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RC71  .W69  A  handbook  of  medica 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/handbookofmedicaOOwils 


A   HANDBOOK  OF 

MEDICAL  DIAGNOSIS 


IN  FOUR  PARTS 

I.   MEDICAL  DIAGNOSIS  IN  GENERAL  III.   SYMPTOMS  AND  SIGNS 

II.   THE  METHODS  AND  THEIR  IMME-  IV.   THE  CLINICAL  APPLICATIONS 

DIATE  RESULTS 


FOR   THE   USE  OF  PRACTITIONERS 
AND   STUDENTS 


BY 

J.  C.  WILSON,  A.M.,  M.D. 

Professor  of  the  Practice  of  Medicine  and  Clinical   Medicine  in  the  Jefferson   Medical  College,  and  Physician 

to  its  Hospital  ;  Physician  to  the  Pennsylvania  Hospital  ;  Physician  in  Chief 

to  the  German  Hospital,  Philadelphia. 


408  TEXT  ILLUSTRATIONS  AND    14  FULL  PAGE  PLATES 


*'T/ie  whole  Art  of  Medicine  is  in  Observation.'" 


PHILADELPHIA   l^  LONDON 

J.  B.  LIPPINCOTT    COMPANY 


Copyright,  1909 
By  J.  B.  LippiNCOTT  Company 


ELECTROTYPED    AND    PRINTED    BY    J.     B.     l,lPPINCOTT    COMPANY 
THE      WASHINGTON    SQUARE    PRESS,     PHILADELPHIA,    U.S.A. 


To 

THE     MEMORY    OF    MY 
FATHER 

ELLWOOD  WILSON,  A.M.,  M.D. 


PREFACE 


This  volume  has  been  written  partly  in  response  to  the  wishes  of  some 
of  my  professional  colleagues,  partly  to  meet  the  urgent  demands  of  many 
successive  classes  of  pupils,  but  chiefly  in  the  hope  that  at  this  time  a  con- 
venient and  practical  presentation  of  the  subject  of  Medical  Diagnosis  will 
prove  useful  to  the  profession  at  large. 

The  treatment  of  the  subject-matter  under  four  main  headings  has 
been  adopted  with  the  view  of  simplifying  the  arrangement  of  the  topics 
in  a  department  of  medicine  which  has  attained  large  scope  and  insistent 
importance.  It  is  the  confident  expectation  of  the  author  that  this  plan 
will  fulfil  the  twofold  requirement,  that,  within  the  compass  of  a  single 
book,  clinical  phenomena,  on  the  one  hand,  and,  on  the  other,  those  com- 
plexes of  clinical  phenomena  which  constitute  diseases,  are  brought  into 
correlation  in  such  a  manner  that  the  practitioner  who  seeks  information 
upon  an  obscure  case  may  at  once  turn  to  the  discussion  of  the  methods 
available  to  clear  it  up,  and  the  student  may  find  the  definite  clinical  appli- 
cations of  the  same  methods  and  their   results  in  descriptive  medicine. 

Practical  rather  than  theoretical  considerations  have  been  held  con- 
stantly in  view  alike  in  the  treatment  of  the  clinical  and  the  laboratory 
subjects.  To  attain  this  end  a  degree  of  positiveness  of  assertion  not 
warranted  under  other  circumstances  and  the  avoidance  of  the  discussion 
of  moot  and  unsettled  questions  have  seemed  proper. 

The  Medical  Diagnosis  of  J.  M.  Da  Costa  was  pubhshed  in  1864.  That 
brilliant  contribution  to  the  literature  marked  an  epoch  in  the  progress 
of  internal  medicine.  From  the  time  of  its  appearance  the  traditional 
conception  of  diagnosis  by  intuition — a  gift  of  the  favored  few — ceased  to 
occupy  the  thoughts  of  medical  men,  and  the  subject  ranged  itself  among 
the  arts  based  upon  scientific  facts.  It  maintained  in  successive  editions 
during  the  life  of  its  distinguished  author  its  position  in  the  forefront  of 
the  progress  of  applied  medicine  during  a  period  of  extraordinary  advance- 
ment in  the  collateral  sciences  upon  which  the  practice  of  medicirie  rests. 
The  continuing  rapid  development  of  knowledge  relating  to  the  facts  of 


vi  PREFACE. 

medicine  in  the  last  decade  has  rendered  necessary  fresh  presentations  of 
the  subject,  and  from  time  to  time  excellent  works  have  appeared.  These 
differ  greatly  among  themselves,  according  to  the  views  of  their  several 
authors,  in  method  and  detail.  To  add  to  this  honorable  list  demands  the 
justification  of  something  different  in  method,  new  arrangement  of  detail,  and 
the  presentation  of  the  whole  subject  in  accordance  with  the  requirements 
of  contemporary  medicine.  It  is  hoped  that  in  the  present  volume  these 
demands  are  fulfilled.  It  is  the  outcome  of  many  years  devoted  to  work 
in  the  wards,  with  the  controlling  side-lights  upon  bedside  diagnosis  afforded 
by  the  clinical  laboratory,  revelations  at  the  hands  of  surgical  colleagues 
in  the  operating  theatre  and  confreres  in  pathology  in  the  post-mortem 
room,  the  frequent  opportunity  of  seeing  unusual  and  grave  cases  in  con- 
sultation, and  long  experience  as  a  teacher.  Such  a  career  arouses  enthu- 
siasm but  begets  caution.  It  does  not  encourage  in  any  way  the  belief 
that  diagnosis  in  medicine  is  an  easy  matter,  but  forces  the  conclusion  that 
it  is  often  difficult  and  in  rare  instances  impossible.  For  this  reason  and 
because  we  are  always  eager  to  extend  the  boundaries  of  our  knowledge, 
this  art  is  as  absorbing  as  it  is  useful. 

In  the  making  of  a  handbook  of  this  kind  it  is  necessary  to  draw  at 
every  step  upon  the  great  fund  of  acquired  information  which  has  become 
the  common  property  of  the  profession.  To  those  whose  contributions 
have  formed  that  fund  and  to  those  who  are  daily  adding  to  it  I  tender 
grateful  acknowledgment  for  its  use.  I  have  mentioned  by  name  those 
to  whose  work  I  have  especially  referred,  but,  as  a  general  rule,  it  has  been 
impracticable  for  want  of  space  to  append  systematic  references  to  the 
literature. 

The  illustrations  are  in  large  part  drawn  from  personal  observations. 
They  have  been  selected  solely  with  the  view  to  elucidate  the  subject  in 
hand.  Diagrams  have  been  employed  when  this  method  of  presentation 
has  appeared  desirable,  and  the  free  use  of  clinical  charts  constitutes  an 
important  feature  of  the  work. 

To  the  friends  and  fellow-workers  who  have  rendered — some  small, 
some  larger,  but  all  generous  and  willing — assistance,  I  desire  to  express 
my  thanks.  The  list  includes  many  colleagues  in  the  hospitals  with  which 
I  am  connected,  some  who  were  and  others  who  still  are  resident  physi- 
cians.    It  includes  also  Mr.  Wilbert  and  Drs.  Bachman,  Manges,  Rosen- 


PREFACE.  vii 

berger,  Rowntree,  Royer,  White,  W.  R.  Wilson,  and  J.  Leslie  Davis.  To 
Drs.  de  Schweinitz,  Welch  and  Schamberg,  T.  M.  Rotch,  Packard,  JPiersol, 
Young,  Emerson,  Dudley  Fulton,  and  many  others,  together  with  their 
publishers,  I  am  indebted  for  permission  to  use  illustrations.  The 
pages  on  the  diagnosis  of  diseases  of  the  eye  were  written  by  Dr. 
Sweet;  those  on  the  stomach  and  intestines  mainly  by  Dr.  Gwyn; 
those  on  the  nervous  system  by  Drs.  James  Hendrie  Lloyd  and  the  late 
William  Pickett;  those  on  X-ray  diagnosis  by  Dr.  Moore,  and  those  on 
the  examination  of  the  blood,  urine,  sputum,  and  other  fluids  by  Dr.  J. 
F.  Kaltej^er.  The  excellent  drawings,  plates,  and  other  illustrations  made 
by  Messrs.  Schmidt  and  Faber  add  much  to  the  usefulness  of  the  book. 
I  am  under  special  and  lasting  obligation  to  Dr.  Kalteyer  for  his  most 
able  and  untiring  aid  while  the  work  was  in  press,  and  to  the  publishers  for 
their  generous  cooperation  at  every  stage  in  its  making. 

J.  C.  Wilson. 

Philadelphia,  September,  1909. 


CONTENTS. 

PART  I. 

OF  MEDICAL  DIAGNOSIS  IN  GENERAL. 

I.  General  Considerations 1 

II.  Medical  Topography , 8 

III.  The  Examination  of  the  Patient,  and  Case-taking 39 

PART  II. 
OF  THE  METHODS  AND  THEIR  IMMEDIATE  RESULTS. 

I.  Medical  Thermometry 53 

^11.  Physical  Diagnosis.    General  Considerations;   Inspection;    Palpation; 

Mensuration;  Percussion;  Auscultation 61 

III.  The  Examination  op  the  Stomach  and  Intestines 194 

IV.  The  Examination  of  the  Upper  Air-passages  and  the  Ear.    Rhinoscopy; 

Laryngoscopy;  Otoscopy 221 

V.  The  Examination  of  the  Blood 229 

VI.  The  Examination  of  the  Urine 264 

VII    The  Examination  of  the  Sputum 296 

VIII.  The  Examination  of  Transudates,  Exudates,  and  the  Contents  of  Cysts  300 
IX.  The  Examination  of  the  Nervous  System.  Preliminary  Considerations; 
Motor  Symptoms;  Sensory  Symptoms;  Regional  Diagnosis  of  Cere- 
bral Disease;  Aphasia  and  Other  Defects  of  Speech;  Spinal  Local- 
ization; Combined  Degenerations;  the  Reflexes;  Electrodiagnosis; 
Trophic  Disturbances;  Pain  and  Temperature;  the  Muscular  Sense; 

'  the  Stigmata  of  Degeneration 306 

X.  The  Examination  of  the  Eye 351 

XI.  The  Examination  by  X-rays 377 

PART  III. 
OF  SYMPTOMS  AND  SIGNS. 

I.  General  Considerations 339 

II.  Appearance;   Temperament  and  Diathesis;   Facies;   Weight,  Form  and 

Nutrition 390 

III.  Bones;   Joints;   Musculature;    Posture,   Attitude   and   Gait;    Posture 

and  Movements  of  Infants 402 

IV.  Temperature;    Heat  Mechanism;    Fever;    Hypothermia;    Significance 

OF  Abnormal  Temperatures 419 

V.  Respiration;     Modified   Respiratory   Movements;     Cough   and   Allied 
Phenomena;  Significance  of  Cough  in  Diagnosis;   Expectoration  or 

Sputum 436 

VI.  Circulation;  Pulsation;  Radial  Pulse;  Anomalies  of  the  Pulse;  Venous 

Pulse;    Pulsation  of  the  Liver;    Centripetal  Venous  Pulse 460 

VII.  The  Digestive  System.    The  Mouth;    Lips;    Teeth;    Gums;   Tongue 477 

VIII.  The  Digestive  System,  continued.    The  Palate;  Tonsils;  Pharynx 490 

ix 


X  CONTENTS. 

IX.  The  Digestive  System,  continued.     The  QCsophagus 495 

X.  The    Digestive    System,    continued.    General    Symptoms.     Appetite; 

Thirst;  Eructations;    Regurgitation;  Nausea;  Vomiting;   The  Vom- 
iTUs;    Defecation;     Constipation;     Diarrhcea;     Tenesmus;    Painful 

Defecation;    Fecal  Incontinence;    Character  of    the    Discharges  500 
XI.  The  Skin.     Physiological  AjStd  Pathological  Changes  and  Their  Sig- 
nificance;   CEdema;    Dropsy;    Superficial  Vascular  Changes;  Skin; 

Nails;    Hair 524 

XII.  Genito-ueinaey  System.    Micturition;    Urinary  Changes;  the  Repro- 
ductive Organs 54S 

XIII.  General  Symptomatic  Disorders  of  the  Nervous  System.    Pain;  Ten- 

derness; Par.esthesia  .  .    558 

XIV.  General   Symptomatic   Disorders   of    the    Nervous    System,    contin- 

ued.   Vertigo;  Convulsions;  Tremor;  Fibrillary  Twitchings 586 

XV.  Psychical    Conditions;    Emotional    States;    Derangements    of    Con- 
sciousness;  Insomnia  and  Other  Disorders  of  Sleep 593 

PART  IV. 
OF  THE  CLINICAL  APPLICATIONS. 

I. 

THE    DIAGNOSIS    OF    THE    SPECIFIC    INFECTIONS. 

I.  Enteric  or  Typhoid  Fever 605 

II.  Typhus  Fever 641 

III.  Relapsing   Fever 644 

IV.  The  Variolous  Diseases 647 

A.  Variola  vera;  Smallpox 651 

(a)  V.  DISCRETA 651 

(b)  V.  CONFLUENS 653 

(c)  V.  H,EMORRHAGICA    656 

B.  Variola  modificata;  Varioloid 657 

C.  Vaccinia — Vaccination 663 

V.  Varicella 668 

VI.  Scarlet  Fever 670 

VII.  Measles 681 

VIII.  Rubella 687 

The  Fourth  Disease 689 

IX.  Whooping-cough 689 

X.  Mumps 694 

XL  Inlfuenza 697 

XII.  Dengue 702 

XIII.  Diphtheria 705 

XIV.  Vincent's  Angina 713 

XV.  Croupous  Pneumonia 714 

XVI.  Cerebrospinal  Fever 730 

XVII.  Erysipelas 737 

XVIII.  Sepsis 742 

Toxemia 744 

Septicemia 744 

Cryptogenetic  Septicemia 744 

Septicopyemia 744 

Terminal  Infections 744 

XIX.  Rheumatic  Fever 746 


CONTENTS.  xi 

XX.  Yellow  Fever 750 

XXI.  Cholera 752 

XXII.  Bacillary  Dysentery 756 

XXIII.  The  Plague '.• 757 

XXIV.  Malta  Fever 759 

XXV.  Beri-beri 761 

XXVI.  Tetanus 763 

XXVII.  Hydrophobia 767 

XXVIII.  Glanders 771 

XXIX.  Actinomycosis 773 

XXX.  Anthrax 776 

XXXI.  Leprosy 780 

XXXII.  Tuberculosis 784 

(A)  Acute  Miliary  Tuberculosis 788 

(B)  Tuberculosis  of  the  Lymph-nodes 792 

(C)  Tuberculosis  of  Serous  Membranes 794 

(D)  Tuberculosis  of  the  Alimentary  Canal 797 

(E)  Tuberculosis  of  the  Brain  and  Spinal  Cord 800 

(F)  Tuberculosis  of  the  Genito-urinary  Organs 800 

(G)  Tuberculosis  of  the  Lungs 802 

(a)  Acute  Pneumonic  Phthisis 803 

(b)  Chronic  Ulcerative  Phthisis 805 

(c)  Fibroid  Phthisis 819 

XXXIII.  Syphilis 821 

XXXIV.  Gonorrhcea 831 

XXXV.  Ephemeral  Fever 833 

XXXVI.  Rocky  Mountain  Spotted  Fever;  Tick  Fever 834 

XXXVII.  Icterus  Infectiosus;   Weil's  Disease 836 

XXXVIII.  Glandular  Fever 837 

XXXIX.  Miliary  Fever 838 

XL.'Foot-and-Mouth  Disease 839 

XLI.  Erysipeloid  of  Rosenbach 840 

XLII.  Erythema  Infectiosum 841 

II. 

THE    DIAGNOSIS    OF    DISEASES    CAUSED     BY    ANIMAL    PARASITES. 

A.  Diseases  due  to  Protozoa 842 

i.  Psorospermiasis 842 

ii.  Amcebic  Dysentery 842 

iii.  Trypanosomiasis 844 

iv.  Dum-dum  Fever 845 

V.  The  Malarial  Fevers 846 

(a)  Regularly  Intermitting  Fever  of  Tertian  or  Quar- 

tan Type 850 

(b)  Irregular,    Remittent,    Continued,    and    Pernicious 

Fevers 852 

(c)  Malarial  Cachexia 854 

B.  Diseases  due  to  Flukes:   Distomiasis 855 

C.  Diseases  due  to  Cestodes 858 

i.  Intestinal  Cestodes:   Tapeworms 858 

(a)  T^NiA  Solium 859 

(b)  TiENiA  Saginata 860 

(c)  T^NiA  Cucumerium 860 


xii  CONTENTS. 

(d)  T.ENIA  Nana , 860 

(e)  T^NiA  Flavopunctata 861 

(f)  T^NiA  Lata:   Bothriocephalus  Latus 861 

ii.  Visceral  Cestodes 862 

(a)  Cysticercus  Cellulose 862 

(b)  EcHiNococcus  Disease 862 

D.  Diseases  due  to  Nematodes 866 

i.  AscARiAsis 866 

ii.  Trichiniasis 867 

iii.  Uncinariasis 870 

iv.  FiLARiAsis 872 

V.  Dracontiasis 875 

III. 

THE    DIAGNOSIS    OF    THE    CHRONIC    INTOXICATIONS. 

I.  Alcoholic  Intoxication;  Alcoholism 876 

II.  Opium  Poisoning;  Morphinism 879 

III.  Cocaine  Poisoning;  Cocainism 881 

IV.  Lead  Poisoning;  Plumbism 881 

V.  Poisoning  by  Arsenic 884 

VI.  Poisoning  by  Mercury 887 

VII.  Poisoning  by  Phosphorus 889 

VIII.  Poisoning  by  Illuminating  Gas 890 

IV. 
THE    DIAGNOSIS    OF    FOOD    POISONING. 

I.  Fish  Poisoning;  Ichthyismus 893 

II.  Meat  Poisoning;  Botulismus 894 

III.  Poisoning  by  Milk  and  Milk  Products 894 

IV.  Grain  and  Vegetable  Poisoning 895 

V. 

THE    DIAGNOSIS    OF    AUTOINTOXICATIONS. 

I.  The  Gastro-intestinal  Autointoxications 896 

II.  The  Retention  Autointoxications 898 

III.  Autointoxication  from  Extensive  Abolition  of  the  Function  of  the 

Skin 898 

IV.  Acidosis 898 

V.  Gout 898 

VI.  Glycosuria  and  Diabetes 898 

VI. 

the  diagnosis  of  heat-stroke  and  electric   stroke. 

Heat-stroke 899 

Electric  Stroke 900 

VII. 

THE    DIAGNOSIS    OF    PREGNANCY. 

The  Diagnosis  of  Pregnancy 901 


CONTENTS.  xiii 
VIII. 

THE    DIAGNOSIS    OF    CONSTITUTIONAL    DISEASES. 

I.  Gout 904 

II.  Arthritis  Deformans 908 

III.  The  Rheumatoid  Affections 910 

A.  Chronic  Rheumatism 911 

B.  Myalgia:  Muscular  Rheumatism 911 

iv.  Diabetes 912 

A.  Diabetes  Mellitus 913 

B.  Diabetes  Insipidus 921 

V.  Nutritional  Diseases ■ 922 

A.  Scurvy 922 

B.  Infantile  Scurvy 925 

C.  Rickets 927 

D.  Obesity 930 

Adiposis  Tuberosa  Simplex   931 

Adiposis  Dolorosa 932 

VI.  Amyloid  Disease  932 

IX. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    DIGESTIVE    SYSTEM. 

(Diseases  of  the  Mouth,  Tongue,  Gums,  Sahvary  Glands,  Pharynx,  Tonsils,  and  (Esophagus 
are  considered  in  Part  III.) 

I.  Diseases  of  the  Stomach 935 

i.  Acute  Gastritis 935 

1.  Toxic  Gastritis 935 

2.  Phlegmonous  Gastritis 936 

3.  Diphtheritic  Gastritis 936 

4.  Parasitic  Gastritis 936 

5.  Dietetic  Gastritis 937 

ii.  Chronic  Gastritis — Chronic  Gastric  Catarrh 938 

iii.  Dilatation  of  the  Stomach — Gastrectasis 939 

iv.  Gastric  Ulcer 942 

V.  Cancer  of  the  Stomach — Carcinoma  Ventriculi 944 

vi.  Hypertrophic  Stenosis  of  the  Pylorus 945 

vii.  Tuberculous  Ulceration  of  the  Stomach 946 

viii.  The  Gastric  Neuroses 946 

ix.  G ASTROPTOSIS 950 

II.  Diseases  of  the  Intestines 952 

i.  Enteritis 952 

Catarrhal  Enteritis 952 

Phlegmonous  Enteritis 953 

Diphtheritic  Enteritis 953 

ii.    DiARRHCEAL  DISORDERS  OF  CHILDREN 954 

iii.  Ulceration  of  the  Intestines 956 

iv.  Intestinal  Stenosis  and  Obstruction 958 

V.  Dilatation  of  the  Intestines — Idiopathic  Dilatation  of  the  Colon  963 

vi.  Appendicitis 964 

vii.  Enteroptosis 972 

viii.  Intestinal  Indigestion 973 

ix.  Intestinal  Neuroses 974 

X.  Intestinal  Neoplasms 975 


xiv  CONTEXTS. 

III.  Diseases  of  the  Liver 977 

i.    A^^ATOIIICAL  AxOlL^UxLES  OF  THE   LiVER 977 

ii.  Movable  Liver 978 

iii.  Jaundice  :  Icterus ,  979 

iv.  Icterus  Xeoxatorum 981 

V.  Acute  Yellow  Atrophy 982 

vi.  Diseases  of  the  Bile  P.^sages  and  Gall-bladder 983 

Catarrhal.  Jauxdice 983 

Chronic  Angiocholitis 985 

Various  Lesions  of  the  Bile  Passages 986 

Inflammation  of  the  Gall-bladder:   Cholecystitis 987 

Caxcee  of  the  Bile-ducts  and  Gaxl-bladder 989 

Cholelithiasis:   Gall-stone  Disease 989 

vii.  Affections  of  the  Blood-vessels  of  the  Liver 997 

Anemia 997 

hyper.emia    997 

DiSE.IlSES  of  THE  PoRTAL  VeIN 998 

Diseases  of  the  Hepatic  Artery  and  Veins 999 

viii.  Abscess  of  the  Liver:   Suppurative  Hepatitis 999 

ix.  Fatty  Liver 1003 

X.  CHRON^c  Interstitial  Hepatitis:   Cirrhosis  of  the  Liver 1005 

xi.  New  Growths  in  the  Li\t:r 1009 

rV.  Diseases  of  the  Pancreas 1013 

i.  Hemorrhage  into  the  Pancreas 1013 

ii.  Acute  Pancreatitis 1013 

iii.  Chronic  P.\ncreatitis 1017 

iv.  P.4^^CREATIC  Calculi 1018 

V.  P.\NCREATic  Cysts 1018 

vi.  Tumors  of  the  P.\ncreas 1020 

V.  Diseases  of  the  Peritoneum 1021 

i.  Ascites — Abdomin.^x  Dropsy — Hydroperitoneum 1021 

ii.  Acute  General,  Peritonitis 1024 

iii.  Acute  Circumscribed  Peritonitis 1029 

iv.  Chronic  Peritonitis 1031 

V.  Tuberculous  Peritonitis — Tuberculosis  of  the  Peritoneum 1032 

vi.  Xew  Growths  in  the  Peritoneum 1032 

vii.  Retroperitoneal  Sarcoma 10.34 

X. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    RESPIRATORY    SYSTEM. 

I.    DiSE.iSES  OF  THE  XOSE 1035 

i.  Acute  Xasal  Catarrh 1035 

ii.  Chronic  Xas.u.  Catarrh 1036 

iii.  Autumnal  Cat.\rrh — Hay  Fever 1037 

iv.  Epistaxis 1039 

II.  Diseases  of  the  Lary^cx 1040 

i.  Acute  Cat.^rrhal  Laryngitis 1040 

ii.  Acute  Laryngitis  of  Children — Spasmodic  Croup 1041 

iii.  Subacute  L.aryngitis  1042 

iv.  Chronic  Laryngitis 1042 

V.  GEdematous  Laryngitis — Acute  Laryngeal  (Edema 1043 

vi.  Pseudomembranous  Laryngitis 1044 

\'ii.  Tuberculous  L.\ryngitis 1045 


CONTENTS.  XV 

viii.  Syphilitic  L.^eyngitis 1046 

ix.  Laryngismus  Stridulus 1047 

X.  Chronic  Infantile  Stridor 1048 

xi.  Paraly'Sis  of  the  Laryngeal  Muscles 1048 

III.  Diseases  of  the  Bronchi 1051 

i.  Bronchitis 1051 

(a)  Acute  Bronchitis 1051 

(b)  Chronic  Bronchitis 1053 

(1)  Dry  Bronchitis 1053 

(2;   Bronchorrhcea 1054 

(3)  Putrid  Bronchitis 1054 

(c)  Fibrinous  Bronchitis 1054 

ii.  Bronchiectasis 1055 

iii.  Tracheobronchial  Stenosis 1057 

iv.  Bronchial  Asthma 1058 

IV.  Diseases  of  the  Pulmonary  Tissue 1061 

i.  Circulatory  Derangements 1061 

(a)  Pulmonary  Congestion 1061 

(b)  Pulmonary  Oedema 1062 

(c)  Pulmonary  Hemorrhage 1063 

ii.  Diseases  Characterized  by  Changes  in  the  Vesicular  Structure 

of  the  Lungs 1066 

(a)  Pulmonary  Emphysema 1066 

Vesicular  Emphy'Sema:    Substantive  Emphysema:    Pseudo- 
hypertrophic EMPHYSEM.-V 1066 

Acute  Vesiculak  Emphy'Sema 1069 

Compensatory  Emphysema:    Vicarious  Emphysema 1069 

Atrophic  Emphy'Sema 1069 

Interstitial  Emphysema 1069 

(b)  Pulmonary  Atelectasis:   Collapse  of  the  Lung 1070 

Congenital  Atelectasis 1070 

Acquired  Atelectasis 1070 

(c)  Bronchopneumonia:  Lobular  Pneumonia:   Catarrhal  Pneu- 

monia: So-called  Capillary  Bronchitis 1071 

iii.  Diseases  of  the  Lungs  Ch.-uracterized  by  Interstiti.al  Inflammation  1075 

(a)  Chronic  Interstitial  Pneumonia:   Cirrhosis  of  the  Lung  ...  .    1075 

(b)  Pneumonoconiosis 107S 

iv.  Diseases  of  the  Lungs  due  to  Suppuration  and  Necrosis 1079 

(a)  Pulmonary  Abscess 1079 

(b)  Pulmonary  Gangrene 1080 

V.  New  Growths  in  the  Lungs 1082 

V.  Diseases  of  the  Mediastinum 1083 

VI.  Diseases  of  the  Pleura 1088 

i.  Pleurisy 1088 

(a)  Fibrinous  or  Plastic  Pleurisy:    Pleuritis  Sicca lOSS 

(b)  Pleurisy  with  Effusion:    Pleuritis  Exudativa  1091 

Serofibrinous  Pleurisy 1091 

Purulent  Pleurisy:   Empyema 1096 

Hemorrhagic  Pleurisy 1097 

Chyliform  Pleural  Effusions:     Hydrops  Adiposis 1098 

ii.  Morbid  vStates  Characterized  by  the  Transudation  of  Serum  or 
Chyle,  or  the  Eruption  of  Pus,   Blood,  or  Air  into  the 

Pleural  Sac 1102 


xvi  CONTENTS. 

(a)  Hydrothorax 1102 

(b)  Chylous  Pleural  Effusion:   Hydrops  Chylosus 1103 

(c)  Pyothorax 1103 

(d)  Hemothorax 1104 

(e)  Pneumothorax:  Hydropneumothorax:   Pyopneumothorax.  .  .  1104 

XI. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    KIDNEYS. 

I.  Anatomical  Anomalies  of  the  Kidneys 1107 

II.  Movable  Kidney 1108 

III.  Circulatory  Derangements. 1110 

(a)  Aneivha 1110 

(b)  Congestion 1110 

(c)  Hemorrhagic  Infarct 1110 

IV.  Uremia : HH 

V.  Inflammation  of  the  Kidneys 1114 

(a)  Acute  Nephritis 1114 

(b)  Chronic  Nephritis;  Chronic  Bright 's  Disease 1117 

1.  Chronic  Parenchymatous  Nephritis 1117 

2.  Chronic  Interstitial  Nephritis 1118 

VI.  Pyelitis 1121 

VII.  Perinephric  Abscess 1123 

VIII.  Nephrolithiasis 1 124 

(a)  Renal  Infarct 1124 

(b)  Renal  Calculus 1124 

IX.  Hydronephrosis 1127 

X.  Cysts  of  the  Kidney 1 129 

XI.  Tumors  of  the  Kidney 1131 

XII. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    BLOOD    AND    DUCTLESS    GLANDS. 
DISEASES    OF    THE    BLOOD. 

I.  Anemia 1 133 

i.  General  Considerations 1133 

ii.  Primary  Anemia 1134 

(a)  Chlorosis 1134 

(b)  Pernicious  Anemia 1137 

(c)  Splenic  Anemia 1141 

iii.  Secondary  or  Symptomatic  Anemia 1141 

II.  Leukemia 1143 

i.  Myelogenous  Leukemia 1144 

ii.  Lymphatic  Leukemia 1146 

III.  Hodgkin's  Disease 1149 

IV.  Diseases  Characterized  by  Hemorrhage 1153 

(a)  Purpura 1153 

Purpura  Simplex 1154 

Purpura  Hemorrhagica 1154 

Purpura  Rheumatica 1155 

Henoch's  Purpura 1156 

Symptomatic   Purpura 1157 


CONTENTS.  xvu 

(b)  HEMOPHILIA 1158 

(c)  Hemorrhagic  Diseases  of  the  New-born 1160 

Acute  Fatty  Degeneration 1160 

Infectious  Hemoglobinuria 1160 

Morbus  Maculosus  Neonatorum 1161 

DISEASES    OF    THE    DUCTLESS    GLANDS. 

I.  Diseases  of  the  Spleen 1161 

i.  Anatomical  Anomalies 1161 

ii.  Movable  Spleen 1162 

iii.  Acute  Splenic  Tumor 1162 

iv.  Chronic  Splenic  Tumor 1163 

V.  Splenic  Tumor  with  Anemia 1165 

vi.  Splenic  Tumor  with  Polycythemia  and  Cyanosis 1165 

vii.  Splenic  Capsulitis 1166 

viii.  Hemorrhagic  Infarct  of  the  Spleen 1166 

ix.  Abscess  of  the  Spleen 1166 

X.  Rupture  of  the  Spleen 1167 

II.  Diseases  of  the  Thymus  Gland 1167 

III.  Status  Lymphaticus:  Lymphatism 1168 

IV.  Diseases  of  the  Thyroid  Gland 1169 

i.  Acute  Thyroiditis 1169 

ii.  Goitre:    Bronchocele 1170 

iii.  Exophthalmic  Goitre 1171 

iv.  Myxcedema 1174 

1.  Cretinism 1175 

2.  Myxoedema  of  Adults 1176 

3.  Post-operative  Myxcedema:    Cachexia  Strumipriva 1177 

4.  Hypoparathyreosis:   Status  Parathyreoprivus 1177 

V.  Diseases  of  the  Adrenal  Bodies 1178 

i.  General  Considerations 1178 

ii.  Addison's  Disease 1178 

VI.  Acromegaly 1181 

XIII. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    CIRCULATORY    SYSTEM. 

DISEASES    OF    THE    HEART. 

I.  Abnormal  Positions  of  the  Heart 1183 

II.  Diseases  of  the  Myocardium 1183 

i.  Acute  Myocarditis 1183 

ii.  Chronic  Myocarditis 1185 

iii.  Hypertrophy  and  Dilatation 1190 

(a)  Hypertrophy  of  the  Heart 1190 

(b)  Dilatation  of  the  Heart 1 192 

iv.  Fatty  Heart 1193 

v.  Various  Degenerations,  New  Growths,  and  Parasites  of  the  Heart  1195 

vi.  Wounds  and  Foreign  Bodies 1195 

vii.  Rupture  of  the  Heart 1195 

viii.  Aneurism  of  the  Heart 1196 

ix.  Atrophy  of  the  Heart 1 197 


xviii  CONTENTS. 

III.  Diseases  of  the  Pericakdium 1197 

i.  Pericarditis 1197 

(a)  Fibrinous,  Plastic,  or  Dry  Pericarditis 1198 

(b)  Pericarditis  with  Effusion 1200 

ii.  Adherent  Pericardium     1205 

iii.  Hydropericardium 1206 

iv.    H^MOPERICARDIUM    1207 

V.  Pneumopericardium 1207 

vi.  Calcification  of  the  Pericardium 1207 

IV.  Diseases  of  the  Endocardium 1207 

i.  Endocarditis  1207 

(a)  Acute  Endocarditis 1208 

(b)  Chronic  Endocarditis 1212 

V.  Chronic  Valvular  Disease 1214 

i.  Aortic  Insufficiency • 1214 

ii.  Aortic  Stenosis 1217 

iii.  Mitral  Insufficiency 1220 

iv.  Mitral  Stenosis 1224 

V.  Pulmonary  Insufficiency  and  Stenosis 1226 

vi.  Tricuspid  Insufficiency  and  Stenosis 1227 

vii.  Physical  Signs  of  Uncombined  Valvular  Lesions  of  the   Left 

Heart,  Compensation  being  Maintained 1228 

viii.  Combined  Valvular  Lesions 1229 

VI.  Congenital  Lesions  of  the  Heart 1230 

VII.  Heart  Block:  The  Stokes-Adams  Syndrome 1231 

VIII.  Angina  Pectoris 1233 

IX.  Functional  Affections  of  the  Heart:   The  Cardiac  Neuroses 1235 

DISEASES    OF    THE    ARTERIES. 

I.  Arteriosclerosis 1239 

II.  Aneurism ' 1244 

i.  Aneurism  of  the  Aorta 1244 

(a)  Aneurism  of  the  Thoracic  Aorta 1246 

(b)  Aneurism  of  the  Abdominal  Aorta 1257 

ii.  Aneurism  of  the  Cceliac  Axis  and  its  Branches 1258 

iii.  Arteriovenous  Aneurism 1259 

iv.  Periarteritis  Nodosa:   Congenital  Aneurism 1259 

XIV. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    NERVOUS    SYSTEM. 
DISEASES    OF    THE    BRAIN. 

I.  Meningitis '■'^^ 

II.  Acute  Hemorrhagic  Encephalitis 1261 

III.  Purulent  Meningo-encephalitis  and  Brain  Abscess 1262 

IV.  Sinus  Thrombosis 1265 

V.  Cerebral  Hemorrhage 1267 

VI.  Cerebral  Softening 1271 

VII.  The  Cerebral  Palsies  of  Children 12/3 

VIII.  Hydrocephalus  ^277 

IX.  Intracranial   Aneurisms 1278 

X.  Tumors  of  the  Brain 12'9 


CONTENTS.  xix 

XI.  Parasites  in  the  Brain 1283 

XII.  Syphilis  of  the  Brain 1284 

XIII.  General   Paresis 1285 

XIV.  Senile  Degeneration 1287 

XV.  Acute  Delirium 1288 

XVI.  Multiple  Sclerosis 1289 

XVII.  Diseases  of  the  Mid-brain 1290 

XVIII.  Nuclear  Ophthalmoplegia 1291 

XIX.  Diseases  of  the  Cerebellum 1295 

XX.  Diseases  of  the  Pons 1296 

XXI.  Bulbar  Palsy 1298 

XXII.  Pseudobulbar  Palsy 1300 


DISEASES    OF    THE    CRANIAL    NERVES. 

I.  First  Nerve 1303 

II.  Second    Nerve 1304 

III.  Third,  Fourth,  and  Sixth  Nerves — Motor  Nerves  of  the  Eye 1306 

IV.  Fifth   Nerve 1307 

V.  Seventh    Nerve 1310 

VI.  Eighth  Nerve 1312 

VII.  Ninth  Nerve 1314 

YIII.  Tenth  Nerve 1315 

IX.  Eleventh  Nerve 1316 

X.  Twelfth  Nerve 1317 


DISEASES    OF    THE    SPINAL    CORD. 

I.  Spinal  Meningitis 1318 

II.  Myelitis 1319 

III.  Anterior  Poliomyelitis 1322 

IV.  Acute  Ascending  Paralysis  (Landry) 1324 

V.  Progressive  Muscular  Atrophy 1325 

VI.  Amyotrophic  Lateral  Sclerosis 1327 

VII.  Primary  Lateral  Sclerosis 1328 

VIII.  Locomotor  Ataxia 1328 

IX.  Ataxic  Paraplegia 1333 

X.  Hereditary  Ataxia  (Friedreich) 1334 

XI.  Syringomyelia 1335 

XII.  Syphilis  of  the  Spinal  Cord 1337 

XIII.  Tumors  of  the  Spinal  Cord 1339 

XIV.  Injuries  of  the  Spinal  Cord 1341 

XV.  Hemorrhage  in  the  Spinal  Cord 1343 

XVI.  Softening  of  the  Spinal  Cord 1345 

XVII.  The  Caisson  Disease 1346 

XVIII.  Diseases  of  the  Cauda  Equina 1347 

XIX.  Spina  Bifida 1349 


DISE.\SES    OF    THE    SPINAL    NERVES. 

I.  Multiple  Neuritis 1349 

II.  The  Cervical  Plexus 1353 

III.  The  Phrenic  Nerve 1354 

IV .  The  Brachial  Plexus 1355 


XX  CONTENTS. 

V.  The  Anterior  Thoracic  Nerves 1356 

VI.  The  Posterior  Thoracic  Nerve 1356 

VII.  The  Circumflex  Nerve 1357 

VIII.  The  Musculospiral  Nerve 1358 

IX.  The  Median  Nerve 1359 

X.  The  Ulnar  Nerve 1360 

XI.  The  Intercostal  Nerves 1361 

XII.  The  Lumbar  Plexus 1362 

XIII.  The  Anterior  Crural  Nerve 1363 

XIV.  The  Obturator  Nerve 1364 

XV.  The  Sacral  Plexus ■ 1364 

XVI.  The  Sciatic  Nerves • 1365 

XVII.  The  Internal  Popliteal  Nerve 1367 

XVIII.  The  Peroneal  Nerve 1368 

GENERAL    NERVOUS    DISEASES. 

I.  Chorea 1369 

Choreiform  Affections ■  ■  ■  •  1372 

II.  Epilepsy 1374 

III.  Hysteria 1380 

IV.  Hypnotism 1385 

V.  Neurasthenia 1386 

VI.  Occupation  Neuroses 1388 

VII.  Migraine 1390 

VIII.  Paralysis  Agitans 1393 

IX.  Tetany 1395 

X.  The  Tics 1396 

VASOMOTOR    AND    TROPHIC    DISEASES. 

I.  Raynaud  's  Disease 1397 

II.  Erythromelalgia 1399 

III.  Angioneurotic  (Edema 1400 

IV.  Hemifacial  Atrophy 1401 

V.  Osteitis  Deformans 1402 

VI.  Achondroplasia 1405 

XV. 

THE    DIAGNOSIS    OF    DISEASES    OF    THE    MUSCLES. 

I.  Myositis 1406 

II.  The  Myopathies 1407 

III.  Thomsen's  Disease:  Myotonia 1409 

IV.  Paramyoclonus  Multiplex 1410 

V.  Myasthenia  Gravis 1410 

Index 1413 


LIST   OF   PLATES 


PLATE 

I,     General   Anatomical    Outlines   and   Relations   of  the  Thoracic  and 

Abdominal  Organs 12 

II.     General  Anatomical    Outlines   and    Relations  of    the  Thoracic  and 

Abdominal  Organs 14 

III.  Positions  of  the  Vocal  Cords 226 

IV.  Blood  Corpuscles 258 

V.     1.  Neutrophile     Leukocytosis.       2.  Eosinophilia.       3.  L'I'mphocytosis. 

4.  Myel^mia 262 

VI.     Tubercle  Bacilli  in  Sputum 298 

VII.     Connection     between     Sympathetic    Nerves    Supplying    Viscera    and 

Spinal  Nerves  Supplying  Muscles  of  Abdominal  Walls 331 

VIII.     Varieties  in  the  Normal  Fundus 352 

IX.     Changes  in  Arteriosclerosis 376 

X.     Changes  in  Retinal  Vessels 376 

XI.     Inflammation  in  the  Retina 376 

XII.     Typical  Vaccination 664 

XIII.  Tertian  and  Quartan  Malarial  Parasites 847 

XIV.  iEsTivo-AUTUMNAL  Malarial  Parasites 849 


A    HANDBOOK 

of 

MEDICAL  DIAGNOSIS 


PART   I. 

OF  MEDICAL  DIAGNOSIS  IN  GENERAL. 


I. 

GENERAL  CONSIDERATIONS. 

Diagnosis  in  medicine  is  the  art  or  process  of  distinguishing  between 
different  diseases.  It  occupies  a  position  related  on  the  one  hand  to  eti- 
ology— that  science  which  has  for  its  object  the  study  of  the  causes  of 
disease — and  on  the  other  to  therapeutics — the  art  of  healing.  To  recog- 
nize a  disease  involves  the  consideration  of  its  causes,  and  if  they  can  be 
corrected  or  removed,  points  the  way  to  a  cure — causa  suhlata  tollitur 
effectus.  Even  when  the  causes  are  beyond  our  control  or  the  lesions 
which  they  have  produced  are  permanent,  a  knowledge  of  the  true  nature 
of  the  malady  may  enable  us  to  select  judiciously  the  therapeutic  meas- 
ures by  which  are  brought  about  those  adjustments  which  relieve  suffer- 
ing and  prolong  life.  There  is  truth  in  the  ancient  maxim,  '^  qui  bene 
diagnoscit  bene  curat."  Finally,  a  correct  diagnosis  is  essential  to  a  rea- 
sonable prognosis,  since  by  this  means  only  can  we  foretell  the  probable 
course  of  a  disease,  whether  it  tends  to  recovery,  to  continuing  disability, 
or  to  death. 

Diagnosis  is  of  fundamental  importance  in  scientific  medicine.  The 
prevention  of  disease  and  the  healing  of  the  sick  constitute  the  goal  of 
medicine,  but  diagnosis  is  the  course  by  which  that  goal  is  to  be  reached. 
Empirical  systems  ignore  alike  the  causal  and  the  pathological  basis  of 
disease  and  content  themselves  with  the  stud}^  and  treatment  of  symptoms, 
and  all  practice  tends  to  degenerate  into  charlatanism  in  proportion  as 
it  allows  itself  to  be  betrayed  into  this  delusion.  Rational  medicine,  on 
the  other  hand,  regards  symptoms  primarily  as  clues  to  a  diagnosis,  only 
secondarily  as  indications  for  treatment;    and  treatment  itself  as  efficient 

r 


2  MEDICAL  DIAGNOSIS. 

when  it  is  causal  or  radical,  and  as  a  makeshift  when  it  is  simply  pallia- 
tive or  symptomatic.  When  pain  is  present  we  seek  by  the  methods  of 
diagnosis  to  find  the  cause  of  it  and  to  relieve  it  by  the  removal  of  the 
cause,  and  are  not  content  simply  to  relieve  the  pain  without  regard  to 
the  underlying  condition  which  produced  it. 

The  art  of  diagnosis  is  important  not  only  because  of  its  practical 
utility,  but  also  because  it  deals  with  the  facts  of  nature.  Hypotheses 
and  theories  in  regard  to  disease  come  and  go,  nosological  arrangements 
change  and  shift  like  the  colors  in  the  kaleidoscope,  therapeutic  fashions 
rise  and  fall,  but  the  facts  gained  by  close  and  constant  observation  belong 
to  science  and  are  changeless,  and  these  are  the  facts  with  which  diagnosis 
is  concerned.  It  has  been  said  that  the  whole  art  of  medicine  is  in  obser- 
vation. It  is  certainly  true  that  the  art  of  diagnosis  is  in  observation. 
Errors  occur  far  more  commonly  from  incomplete  observation  than  from 
want  of  knowledge.  A  systematic,  patient,  painstaking  study  of  the  facts 
is  essential  to  success. 

The  requirements  of  this  branch  of  medicine  are  most  varied  and 
exacting.  A  knowledge  of  anatomy,  and  especially  of  visceral  and  regional 
anatomy,  is  essential.  The  variations  in  the  size  and  position  of  the  organs 
within  the  Hmits  of  health  must  be  known.  The  structure  and  relation 
of  the  parts  entering  into  the  formation  of  the  nervous  system  must  be 
mastered.  The  physiological  functions  of  the  complex  human  organism 
are  to  be  familiar  knowledge.  The  causes  of  disease,  both  those  belonging 
to  the  outside  world  and  those  developed  within  the  body  itself,  and  the 
susceptibilities  which  vary  at  different  periods  of  hfe  and  under  different 
circumstances,  must  be  thoroughly  understood.  Changes  produced  by 
pathogenic  factors  must  be  clearly  known.  In  truth,  the  facts  of  pathology 
and  semeiology  and  the  natural  history  of  the  diseases  constitute  the 
basis  of  diagnosis. 

Hence,  in  the  arrangement  of  medical  studies,  diagnosis  is  properly 
taken  up  after  the  student  has  made  advanced  progress  in  the  funda- 
mental branches,  and  the  success  of  the  practitioner  in  this  field  of  medicine 
is  dependent  upon  close  habits  of  observation,  accurate  knowledge,  and 
large  experience.  A  judicial  temperament  and  the  ability  to  weigh  evi- 
dence and  assign  due  relative  value  to  the  factors  in  clinical  problerris 
are  essential.  Not  less  important  are  patience  and  a  systematic  pro- 
cedure in  all  cases.  Equally  essential  are  correct  habits  of  reasoning, 
since  without  these  a  faulty  conclusion  may  follow  accurately  observed 
facts.  The  diagnostician  in  the  broad  field  of  clinical  medicine  must 
frequently  turn  for  assistance  to  his  professional  colleague,  who  is  familiar 
with  the  facts  of  the  more  restricted  specialties  and  has  mastered  their 
technic,  and  he  is  becoming  with  advancing  knowledge  more  and  more 
dependent  for  accurate  results  ujjon  instruments  of  precision  and  the 
clinical  laboratory.  Finally,  the  diagnostician  shoulcl  not  be  without 
imagination.  Making  use  of  his  knowledge  of  anatomy  and  morbid  anatomy 
he  should  cultivate  the  habit  of  picturing  to  himself  the  changes  in  the 
organs  of  the  body  by  which  clinical  phenomena  are  brought  about,  such 
as  the  consolidated  lung  in  pneumonia,  the  fibrinous  exudate  or  effusion 
in  pleurisy,  the  impacted  gall-stone  in  bihary  fever,  the  thrombus  in  phle- 


GENERAL  CONSIDERATIONS.  3 

bitis,  the  clot  and  its  location  in  cerebral  apoplexy;  and  in  order  that  this 
habit  of  forming  at  the  bedside,  by  a  process  of  projective  imagination, 
mental  pictures  of  structural  conditions  hidden  from  the  eye  may  be 
developed  to  the  greatest  extent,  he  should  avail  himself  of  every  oppor- 
tunity of  witnessing  operations  involving  the  cranium,  thorax,  and  abdo- 
men, and  of  being  present  at  post-mortem  examinations. 

The  object  of  diagnosis  is  not  merely  to  find  a  name  for  a  morbid 
condition  or  symptom-complex.  This  it  does,  it  is  true,  but  in  doing  so 
it  determines  the  condition  of  the  patient  as  an  individual,  the  intensity 
of  the  pathological  process,  the  importance  of  prominent  symptoms,  the 
presence  or  absence  of  complications  or  intercurrent  diseases,  and  in  acute 
maladies  the  ability  of  the  organism  to  withstand  the  attack.  A  correct 
diagnosis  enables  us  to  determine  whether  the  condition  of  the  patient 
is  due  to  causes  still  operative  or  the  result  of  influences  that  have  ceased 
to  act;  whether  or  not  his  malady  is  self-limited,  and,  by  collating  the  facts 
of  any  given  case  with  the  general  knowledge  of  the  profession,  to  form  an 
opinion  as  to  the  probable  duration  of  the  sickness  and  its  ultimate  out- 
come. It  informs  us  whether  the  prominent  symptoms  are  the  direct 
manifestation  of  an  independent  morbid  process,  as  in  gonorrhceal  arthritis, 
the  expression  of  a  constitutional  susceptibility,  as  in  rheumatic  fever,  or 
an  acute  outbreak  of  a  persistent  condition,  as  in  podagra.  It  enables  us 
to  recognize  primary  and  secondary  morbid  processes  and  to  distinguish 
between  them,  as  in  appendicitis  and  peritonitis,  and  to  perceive  the  rela- 
tion between  associated  visceral  lesions  due  to  the  same  cause,  or  to  an 
extension  to  the  neighboring  organs,  as  in  the  case  of  left-sided  pleurisy 
with  pericarditis.  It  takes  into  consideration  the  hereditary  tendencies 
of  the  patient,  his  age,  surroundings,  occupation,  mode  of  life  and  habits. 
Diagnosis  is  clearly  the  only  basis  for  rational  therapeutics  and  reasonable 
prognosis.  The  medical  sciences  deal  with  diseases,  the  art  of  diagnosis 
with  individuals.  Disease  is  not  an  entity,  but  the  sum  of  the  phenomena 
of  the  reaction  of  the  organism  to  pathogenic  influences. 

There  are  various  methods  of  diagnosis,  all  of  which  may  be  included 
under  the  two  general  groups  of  direct  and  indirect  diagnosis. 

Direct  Diagnosis. 

A  direct  diagnosis  is  made  when  the  history  of  the  case  and  the  clin- 
ical phenomena  are  sufficient  to  warrant  a  positive  conclusion.  The  his- 
tory of  a  violent  prolonged  chill,  followed  by  high  fever  and  pain  in  the 
chest,  with  cough,  rusty  sputum  containing  pneumococci,  dulness  upon 
percussion  in  the  affected  area,  crepitant  rales,  and  bronchial  breathing, 
justify  a  direct  diagnosis  of  croupous  pneumonia.  The  previous  history 
of  the  attack  is  not  always  necessary,  the  foregoing  associated  symptoms 
and  signs  being  sufficient  for  the  diagnosis  of  pneumonia  even  when  the 
patient  is  delirious  or  too  ill  to  give  an  account  of  himself. 

The  direct  method  is  sometimes  described  as  the  semeiological  method. 
The  diagnosis  is  based  upon  the  clinical  phenomena  of  the  disease  and  is 
reached  by  analysis  and  induction.  When  the  data  are  adequate  it  is 
altogether  the  most  scientific  and  satisfactory  method. 


MEDICAL  DIAGNOSIS. 


Indirect   Diagnosis. 


The  indirect  method  must  be  employed  when  the  cHnical  phenomena  are 
obscure  or  insufficient  for  a  direct  diagnosis.  The  results  are  not  always 
conclusive  and  the  diagnosis  may  remain  for  a  time  one  of  probability. 
This  method  includes  differential  diagnosis  and  diagnosis  by  exclusion. 

The  differential  method  is  based  upon  the  recognition  of  the 
essential  phenomena  by  which  one  disease  may  be  discriminated  from 
others  of  a  group  presenting  similar  manifestations.  A  young  person 
may  present  himself  complaining  of  the  following  symptoms:  Loss  of 
flesh  and  strength,  occasional  irregular  chills,  followed  by  fever  and  sweat- 
ing, shortness  of  breath  upon  exertion,  cough  and  pain  in  the  chest  with 
scanty  expectoration.  Upon  inspection  the  respiratory  movement  of  the 
right  side  is  diminished.  The  right  thorax  is  found  to  be  enlarged  and 
altered  in  contour.  There  is  faint  cyanotic  discoloration  with  oedema  in 
the  infra-axillary  region.  The  heart  is  displaced  to  the  left  and  the  lower 
border  of  the  liver  downward.  Vocal  fremitus  is  enfeebled.  There  is 
marked  dulness  upon 'percussion  over  the  lower  part  of  the  chest,  con- 
tinuous with  the  liver  dulness,  while  the  percussion  note  over  the  upper 
portion  has  a  sHghtly  tympanitic  quality.  Upon  auscultation  the  ves- 
icular murmur  is  faint  and  distant.  Neither  rales  nor  friction  sounds  are 
heard.  The  greater  number  of  these  symptoms  and  physical  signs  may  be 
encountered  in  (a)  abscess  of  the  right  lobe  of  the  liver,  (b)  mahgnant 
disease  of  the  pleura,  (c)  serofibrinous  pleurisy,  (d)  empyema. 

(a)  Abscess  of  the  right  lobe  of  the  liver  is  compai-atively  rare.  There 
is  frequently  a  history  of  dysentery  or  other  disease  of  the  abdominal 
viscera.    The  pus  collection  is  rarely  sufficiently  large  to  displace  the  heart. 

(b)  Mahgnant  disease  of  the  pleura  is  Hkewise  a  rare  affection.  It 
usually  develops  insidiously  without  pain.  It  is  not  attended  by  chills 
or  fever  and  does  not  displace  the  heart  or  Hver  until  the  growth  has 
attained  unusual  proportions.  It  produces  a  profound  cachexia  and 
usually  involves  rather  than  compresses  the  lung,  so  that  tympany  in  the 
upper  part  of  the  lung  is  absent  and  irregular  patchy  dulness  is  elicited 
over  the  seat  of  the  growth. 

(c)  Serofibrinous  pleurisy  does  not  usually  give  rise  to  fever  or,  even 
when  massive,  to  disturbance  of  the  circulation  of  the  wall  of  the  chest  or 
oedema. 

(d)  The  essential  phenomena  by  which,  when  present,  empyema  may 
be  discriminated  from  the  foregoing  affections,  in  addition  to  the  signs  of 
compression  of  the  lung  and  displacement  of  adjacent  organs,  are  chills, 
fever,  sweating,  and  cyanosis  and  csdema  of  the  chest  wall. 

Diagnosis  by  exclusion  differs  from  differential  diagnosis  only  in 
its  scope.  It  seeks  to  estabhsh  the  nature  of  the  disease  by  the  negative 
process  of  showing  what  it  is  not.  The  various  diseases  presenting  similar 
cHnical  phenomena  are  compared  in  turn  with  the  case  under  consideration, 
and  one  after  another  excluded,  the  diagnosis  of  that  disease  being  finally 
made  to  which  the  malady  most  closely  conforms.  In  the  above  example 
we  should  first  set  aside  abscess  of  the  liver,  then  mahgnant  disease  of  the 
pleura,  then  serofibrinous  pleurisy,  and  by  exclusion  arrive  at  the  diagnosis 


GENERAL  CONSIDERATIONS.  5 

of  empyema.  Diagnosis  by  exclusion  is  a  tedious  and  inconvenient  method, 
not,  however,  without  value  in  difficult  and  obscure  cases.  It  may  be 
employed  with  advantage  in  clinical  teaching.     Other  methods  are: 

Causal  or  Etiological  Diagnosis.  —  The  nature  of  an  obscure 
malarial  disease  with  or  without  fever  may  be  determined  by  the  dis- 
covery of  the  sestivo-autumnal  parasite  in  the  blood,  or  the  tuberculous 
basis  of  impaired  health  with  cough  and  obscure  physical  signs  may  be 
revealed  by  an  examination  of  the  sputum.  When  such  a  diagnosis  con- 
cerns germ  diseases  it  is  spoken  of  as  Bacteriological  Diagnosis. 

H-*:matological  Diagnosis. — This  may  depend  upon  (a)  the  specific 
agglutinating  properties  of  the  serum,  as  in  enteric  fever  or  dysentery;  (b) 
the  morphology,  as  in  pernicious  anaemia  or  leukaemia;  (c)  the  presence  of 
parasites,  as  in  malaria  or  trypanosomiasis;  or  (d)  the  result  of  cultures,  as 
in  enteric  fever  or  septic  conditions. 

A  PROVISIONAL  DIAGNOSIS  is  that  which  best  accords  with  the  sum  of 
the  probabilities  when  the  data  are  insufficient,  or  pending  a  further  inves- 
tigation of  the  facts.  Such  a  diagnosis  may  serve  as  a  working  hypothesis 
for  therapeutic  purposes  and  the  general  management  of  the  patient. 
It  can  be  revised  or  confirmed. 

A  SURGICAL  DIAGNOSIS  is  made  from  the  stand-point  of  the  surgeon, 
and  may  in  proper  cases  be  confirmed  or  set  aside  during  the  life  of  tlie 
patient  by  an  exploratory  operation. 

Functional  diagnosis  is  the  determination  of  the  degree  of  the 
impairment  of  the  functions  of  organs  caused  by  local  affections  or  the 
extent  of  the  interference  with  physiological  processes  resulting  from 
general  disease,  and  the  bearing  of  such  impairment  or  interference  upon 
the  future  of  the  individual  as  regards  health  and  prolongation  of  life. 
Functional  diagnosis  is  closely  allied  to  prognosis. 

A  THERAPEUTIC  DIAGNOSIS  is  that  procedure  by  which  in  obscure 
cases  the  nature  of  the  disease  is  determined  by  the  results  of  treatment. 
This  method  is  of  very  limited  application.  A  provisional  diagnosis  of 
malaria  having  been  reached  by  the  process  of  exclusion,  the  patient  may 
be  put  at  rest  and  quinine  administered  in  proper  doses. '  Should  the 
symptoms  promptly  disappear,  the  diagnosis  of  malaria  becomes  probable. 
A  similar  diagnosis  of  syphilis  having  been  reached  by  analogous  methods, 
the  subsidence  of  symptoms  upon  the  administration  of  mercurials  or  the 
iodides  may  in  some  cases  confo-m  the  diagnosis.  In  almost  all  such  cases 
there  are  other  and  better  methods  of  diagnosis  which  may  be  employed 
concurrently  with  the  treatment.  In  grave  or  urgent  cases  it  is,  however, 
better  to  give  the  patient  at  once  the  benefit  of  the  doubt. 

Clinical  diagnosis  is  the  diagnosis  made  at  the  bedside. 

Anatomical  diagnosis  is  the  diagnosis  made  by  the  pathologist  in 
the  post-mortem  room. 

It  is  not  in  all  cases  possible  to  make  a  positive  diagnosis  at  once. 
Time  may  be  required  for  a  more  thorough  investigation  of  the  history  of 
the  case,  a  closer  study  of  the  patient's  surroundings,  repeated  observation, 
or  for  the  report  of  examinations  conducted  in  the  clinical  laboratory. 
Information  bearing  upon  the  previous  history  of  the  patient  or  the  be- 
ginning of  his  illness  cannot  always  be  obtained.     He  may  be  delirious, 


6  MEDICAL  DIAGNOSIS. 

unconscious,  or  may  have  lost  the  power  of  speech.  The  history  com- 
municated by  his  friends  is  often  uncertain  and  misleading.  Persons  of 
the  lower  classes  are  very  commonly  indifferent  to  symptoms  which  are 
not  painful  or  disabling  and  lack  the  ability  to  describe  their  sensations. 
Many  persons,  on  the  other  hand,  often  intentionally,  sometimes  uncon- 
sciously, make  false  statements  in  regard  to  their  past  life  and  present 
symptoms.  Some  parts  of  the  narrative  are  exaggerated,  others  suppressed. 
Symptoms  may  be  imitated  and  superficial  lesions  artificially  produced. 
Hence  a  group  of  feigned  diseases,  against  which  the  physician  must  be 
upon  his  guard. 

Malingering. — The  term  malingerer  is  used  to  describe  one  who  in- 
tentionally simulates  a  disease.  Malingering  occurs  in  every  grade  of  life 
and  under  various  circumstances.  It  is  to  be  suspected  when  a  simulated 
disease  lacks  essential  symptoms  or  its  picture  is  overdrawn,  and  when 
there  is  lack  of  correspondence  between  the  alleged  symptoms  and  the 
actual  signs  or  the  obvious  general  health;  it  is  to  be  detected  by  close 
study  of  the  case  under  various  conditions,  by  the  use  of  instruments  of 
precision,  and  in  some  cases  by  the  application  of  powerful  faradic  currents 
or  an  examination  under  anaesthesia.  The  over-indulged  child,  to  avoid 
his  lessons  or  escape  punishment,  may  feign  an  illness;  an  older  person, 
to  excite  compassion  or  from  mere  love  of  deception.  It  is  common  among 
beggars,  sailors  and  soldiers,  those  improperly  seeking  pensions,  and  claim- 
ants against  corporations  for  accidental  damages.  The  simulation  of 
disease  is,  however,  not  always  intentional.  Hysterical  and  neurasthenic 
individuals  sometimes  exaggerate  symptoms  or  imitate  the  manifestations 
of  disease  without  purpose  or  intention — the  unconscious  mimicry  of 
disease.  There  are  those,  on  the  other  hand,  who  from  motives  of  delicacy 
or  shame,  or  in  consequence  of  natural  reserve,  or  from  fear  of  having 
their  apprehensions  confirmed,  refuse  to  consult  the  physician,  or  when 
forced  to  do  so  give  a  garbled  and  incomplete  history  of  their  sickness. 
This  may  occur  among  those  suffering  from  venereal  diseases  or  chronic 
diseases  popularly  regarded  as  incurable,  as  tuberculosis  and  cancer. 

The  diagnosis  of  an  obscure  case  occasionally  demands  an  investiga- 
tion of  the  surroundings  of  the  patient  at  the  time  of  the  development 
of  the  illness.  Time  may  be  required  to  ascertain  etiological  conditions 
relating  to  his  food,  drink,  occupation,  endemic  influences,  or  exposure  to 
transmissible  diseases  locally  epidemic.  Questions  of  this  kind  frequently 
arise  at  a  period  like  the  present,  when  facilities  for  commercial  intercourse 
are  increasing  and  when  military  operations  and  the  exigencies  of  trade 
have  greatly  extended  travel  to  all  parts  of  the  world. 

Repeated  examinations  may  be  necessary  in  order  to  obtain  accurate 
impressions  when  the  physical  signs  are  obscure  or  ill  defined.  Excessive 
subcutaneous  fat,  local  oedema,  or  general  anasarca  may  interfere  with  the 
physical  exploration;  or  local  tenderness,  intense  pain,  great  restlessness, 
or  an  unwilhngness  on  the  part  of  the  patient  to  submit  to  an  examination 
may  give  rise  to  delay.  In  other  cases  the  unusual  character  of  the  symp- 
toms or  an  association  of  clinical  phenomena  not  previously  encountered 
may  render  repeated  examinations  necessary.  During  the  stage  of  invasion 
in  the  acute  febrile  infections  a  positive  diagnosis  is  often  impossible. 


GENERAL  CONSIDERATIONS.  7 

The  advances  of  modern  medicine  have  enormously  increased  our 
knowledge  of  diseases  and  the  precision  of  diagnosis.  In  all  departments 
of  clinical  medicine,  scientific  accuracy  has  taken  the  place  of  probability. 
The  every-day  routine  examinations  of  the  clinical  laboratory  cannot  be 
made  off-hand.  The  more  elaborate  investigations  involved  in  obscure 
cases  demand  technical  skill  and  a  reasonable  time.  The  reports  are 
necessary  to  a  final  diagnosis.  An  immediate  diagnosis  is  not  only  not 
necessary,  it  is  very  often  not  possible.  Haste  involves  the  risk  of  error. 
Conclusions  cannot  be  reached  until  the  premises  are  established.  A 
provisional  diagnosis  may  serve  to  meet  the  immediate  requirements  of 
the  situation.  Treatment  may  be  instituted  in  response  to  urgent  indica- 
tions. When  in  the  period  of  invasion  of  an  acute  illness  there  is  reason  to 
suspect  a  transmissible  disease,  such  as  scarlatina  or  variola,  the  same 
measures  of  prophylaxis  should  be  instituted  pending  the  evolution  of  the 
process  that  would  be  employed  if  the  suspected  disease  were  actually 
present. 

There  are  cases  in  which  diagnosis  in  a  broad  sense  is  impossible. 
A  name  may  be  given  to  some  prominent  symptom  or  group  of  symptoms, 
"but  the  essential  pathological  process  may  remain  obscure  until  its  nature 
is  revealed  upon  the  post-mortem  table. 

When  possible  a  positive  diagnosis  should  be  made  at  once;  in  all 
cases  as  soon  as  practicable.  The  student  is,  however,  warned  against 
making  any  but  a  provisional  diagnosis  upon  insufficient  data.  To  ask 
for  delay  is  by  no  means  a  confession  of  ignorance;  on  the  contrary,  it  is 
the  course  dictated  by  knowledge  and  experience.  Intelligent  people, 
who  seek  the  best  professional  advice,  fully  understand  this.  It  is  only 
the  ignorant  who  are  satisfied  with  a  phrase  for  diagnosis,  a  prescription 
dashed  off  at  sight  and  no  directions  whatever,  who  insist  upon  being 
told  what  is  the  matter  at  once. 


II. 

MEDICAL  TOPOGRAPHY. 

Medical  topography  is  that  branch  of  diagnosis  which  has  for  its 
object  the  consideration  of  the  boundaries  and  relations  of  the  external 
parts  and  internal  organs  of  the  bod}^  Various  points,  Hnes,  and  regions 
or  areas,  some  artificial,  others  natural,  serve  the  purposes  of  this  method 
of  clinical  investigation. 

THE  HEAD. 

The  head  is  divided  by  anatomists  into  two  parts,  the  cranium  and 
the  face. 

The   Cranium. 

The  skull  encloses  and  protects  the  brain.  It  is  divided  into  regions 
corresponding  with  the  superficial  bones  which  enter  into  the  formation 
of  the  skull, — namely,  occipital,  parietal,  frontal,  and  temporal.  These 
regions  are  separated  by  the  cranial  sutures.  Opposite  the  angles  of  the 
parietal  bones  are  spaces  called  fontanelles,— /ons,  a  fountain, — which 
remain  unossified  after  the  bony  growth  of  the  skull  is  elsewhere  completed. 
Of  these,  two  in  the  median  hue,  the  anterior  and  posterior  fontanelles, 
are  important. 

The  regions  of  the  skull  serve  for  the  locahzation  of  subjective  sensa- 
tions, as  pain  or  headache,  and  superficial  lesions,  as  craniotabes,  nodes, 
ngevi,  injury,  or  suppuration.  The  mastoid  process  of  the  temporal  bone  is 
an  important  landmark,  as  indicating  the  extension  of  middle-ear  disease. 
The  greatest  convexity  in  the  frontal  region  on  either  side  is  known  as  the 
frontal  eminence.  It  is  separated  by  a  sHght  depression  below  from  the 
superciliary  ridge,  at  the  level  of  which  in  the  median  line  is  the  nasal 
eminence  or  glabella.  About  the  inner  third  of  the  orbital  arch  is  the 
supra-orbital  notch  or  foramen,  a  point  of  tenderness  in  supra-orbital 
neuralgia. 

Sutures. — Failure  on  the  part  of  the  cranial  bones  to  unite,  with 
persistent  wide  sutures,  may  be  due  to  hydrocephalus,  cretinism,  or  in 
very  rare  instances  to  antenatal  rickets. 

Fontanelles. — Variations  in  Prominence. — Bulging  of  the  fonta- 
nelles is  a  common  symptom  in  infants  and  young  children.  It  is  much 
more  marked  in  the  anterior  fontanelle.  When  persistent  it  indicates 
organic  diseases  of  the  brain,  as  hydrocephalus,  meningitis,  or  intracranial 
hemorrhage,  which  is  in  infants  far  more  commonly  meningeal  than  cere- 
bral. When  transient  it  is  usually  pulsating  and  associated  with  high 
temperature  and  other  symptoms  of  an  acute  febrile  infection. 

Retraction  of  the  fontanelles  occurs  in  chronic  wasting  diseases,  as 
tuberculosis,  infantile  atrophy  or  marasmus,  and  colitis,  and  in  acute 
diarrhoeal  affections,  as  enterocolitis  and  cholera  infantum. 


MEDICAL  TOPOGRAPHY.  9 

Variations  in  Size. — The  posterior  fontanelle  is  normally  obliterated 
about  the  sixth  week.  The  anterior  remains  patulous  as  at  birth  or  even 
shghtly  increases  in  size  up  to  about  the  ninth  month,  and  closes  before 
the  end  of  the  second  year.  Delay  in  closing  beyond  this  period  is  com- 
monly associated  with  wide  and  ununited  sutures  and  occurs  in  rickets 
and  hydrocephalus.  The  diameter  of  the  anterior  fontanelle  at  the  end 
of  the  first  year  is  normally  about  2.5  centimetres.  A  greater  width  occurs 
in  rickets  and  some  cases  of  congenital  syphilis.  A  very  wide  fontanelle 
is  characteristic  of  hydrocephalus. 

The   Face. 

The  regions  of  the  face  are  the  orbital,  nasal,  buccal,  and  oral.  They 
contain  the  muscles  of  expression  and  are  of  great  importance  in  the  diag- 
nosis of  local  and  constitutional  disease,  as  well  as  in  the  recognition  of 
mental  and  emotional  conditions.  The  facies  in  various  conditions  will 
be  described  in  a  later  chapter.  Changes  caused  by  nervous  and  ocular 
disorders  will  be  considered  under  their  appropriate  headings. 

DEFORMITIES  OF  THE   HEAD   IN   THE   NEWBORN. 

Caput  Succedaneum. — A  swelling  of  the  scalp   caused   by  pressure 
during  parturition.     The  lesion  consists  of  passive  congestion  with  extrav- 
asation of  blood  and  oedema  of  the  tissues  of  the  scalp  at  the  area  of 
absence  of  pressure,  namely,  the  part  of  pres- 
entation.     The   tumor  is  irregularly  circum- 
scribed and  does  not  fluctuate.    It  disappears 
without  treatment  in  the  course  of  a  few  days. 
This  condition  is  to  be  distinguished  from — 

Cephalhaematoma.  —  A  tumor  formed 
during  labor  by  hemorrhage  into  the  space 
between  (a)  the  occipitofrontalis  aponeu- 
rosis and  the  periosteum,  or  between  the 
periosteum   and   the  skull  —  external  cephal- 

hgematoma  —  or    (b),   between  the  skull  and      ^  '  ,^ 

the  dura  mater  —  internal  cephalhaematoma. 

/    \     T71  r^  rr-M  FiG.  1.— Caput  succedaneum.     Male,  2 

(a)  External  Cephalhematoma. — The  hours  old.— Rotch. 
most    common   variety  is   subperiosteal.     It 

occurs  in  the  form  of  an  irregular,  circular,  flat  tumor  over  one  or.  in 
rare  instances,  both  parietal  bones.  There  is  distinct  fluctuation,  but  the 
overlying  skin  is  not  discolored.  Slight  elevation  of  the  bone  at  the 
border  of  the  swelling  may  be  felt  in  a  few  days,  with  obscure  crepitus. 
The  condition  is  to  be  distinguished  from  caput  succedaneum  by  its 
location,  fluctuation  upon  palpation,  and  the  examination  of  fluid  with- 
drawn by  aspiration.  The  bony  rim  is  diagnostic  at  a  later  period.  It 
is  not  to  be  confounded  with  a  depressed  fracture,  which  is  irregular  in 
outline  and  lacks  the  distinct  tumor  formation  with  fluctuation  and  the 
rim-like  bony  circumference  characteristic  of  hsematoma. 

(b)  Internal  Cephalhaematoma. — A  very  rare  condition  which  ends 
in  the  death  of  the  child.  There  are  pressure  symptoms.  It  is  sometimes 
associated  with  the  external  form.    It  has  occurred  in  breech  presentations. 


10 


MEDICAL  DIAGNOSIS. 


Fluctuating  tumors  arising  from  the  course  of  the  cranial  sutures  are 
usually  situated  in  the  occipital  region  or  at  the  glabella.  Three  varieties 
are  described. 

Meningocele.— This  term  is  used  to  designate  a  hernial  protrusion  of 
the  meninges  through  an  opening  in  the  bony  cranium  resulting  from 
defective  ossification  or  failure  in  suture  formation.     It  may  result  from 

intra-uterine  hydrocephalus.  The  tu- 
mors usually  contain  cerebrospinal  fluid, 
and  are  translucent,  with  large  veins 
upon  the  surface.  In  some  instances 
an  impulse  may  be  felt  upon  crying 
and  the  tumor  can  be  reduced  by  gentle 
pressure. 

Encephalocele. — This  form  of  cere- 
bral hernia  is  more  common.  The 
tumor  contains  brain  substance  in  addi- 
tion to  the  membranes. 

l1ydro=encephalocele.  —  The  her- 
nial contents  consist  of  the  membranes, 
brain  tissue  surrounding  one  of  the  ventricles,  and  a  portion  of  the 
ventricle  itself  distended  with  cerebrospinal  fluid.  These  tumors  vary 
in  size  from  a  walnut  to  a  large  orange  and  tend  to  increase  in  size. 
They  are  usually  pedunculated.  The  prognosis  is  unfavorable,  though 
remarkable  recoveries  have  occurred  after  operation. 

Anencephalia. — This  developmental  defect  is  rarely  complete.  Par- 
tial anencephalia  is  the  usual  form.  In  accordance  with  a  recognized 
pathological  law,  the  deficiency  of  contents  causes  microcephalic  deformity 
of  the  skull. 

Hydrocephalus. — Congenital  internal  hydrocephalus  is  a  common 
cause  of  deformity  of  the  skull  in  the  newborn.  The  head  is  markedly 
enlarged;    the  cranial  bones  are   thinned    and    displaced  outwards;    the 


Fig.   2.— Hydro-encephalocele. — Rotch. 


Fig.  3.— Congenital  internal  hydrocephalus.     Male,  7  months  old. — Rotch. 

sutures  widely  separated  and  the  fontanelles  prominent  and  fluctuating. 
In  marked  cases  the  temporal  and  parietal  bones  flare  outward  so  that  the 
cranium  is  more  or  less  pear-shaped,  the  greatest  diameter  being  in  the 
upper  part.  The  face  is  usually  normal  in  size,  but  it  looks  abnormally 
small,  being  dwarfed  by  the  great  size  of  the  head. 


MEDICAL  TOPOGRAPHY.  11 

THE  NECK. 
Length   and   Thickness. 

In  early  infancy  the  neck  appears  short  on  account  of  the  large  size 
of  the  head  and  its  tendency  to  fall  forward,  and  the  relatively  high  posi- 
tion of  the  sternum  and  clavicles.  The  neck  appears  to  be  broad  in  com- 
parison with  its  length  also  by  reason  of  the  large  amount  of  sub- 
cutaneous fat.  In  fact  at  all  periods  of  life  the  thick  neck  of  obese  persons 
appears  short,  an  appearance  heightened  by  the  accumulation  of  fat 
known  as  the  double  chin. 

A  short  thick  neck  and  stout  plethoric  body  constitute  the  chief 
structural  factors  in  the  so-called  habitus  apoplecticus.  On  the  other 
hand,  a  long  slender  neck  with  a  prominent  larynx,  and  narrow  fiat  chest 
with  projecting  scapulae,  are  characteristic  of  the  habitus  phthisicus.  But 
both  these  designations  are  misleading,  since  apoplexy  is  dependent  upon 
a  condition  of  the  arteries  and  frequently  occurs  in  spare  persons  with 
long  thin  necks,  and  pulmonary  tuberculosis  is  the  result  of  infection  and 
not  rarely  selects  its  victims  among  those  who  have  well-formed  chests 
and  necks,  and  occasionally  among  those  who  are  stout,  with  short  thick 
necks. 

Contour. 

Larynx. — In  lean  persons  the  larynx  is  prominent  and  forms  the 
projection  anteriorly  in  the  median  line  known  as  the  Adam's  apple.  In 
fat  persons  this  organ  is  much  less  noticeable.  Descent  of  the  larynx  upon 
inspiration  occurs  in  all  forms  of  severe  dyspnoea,  and  especially  in  the 
spasmodic  respiration  which  often  precedes  death  in  respiratory  diseases 
attended  with  stenosis  of  the  larynx  or  oedema,  collapse  or  extensive  con- 
sohdation  of  the  lungs.  Pressure  displacements  of  the  larynx  and  trachea 
sometimes  result  from  the  presence  of  aneurismal  or  other  tumors  of  the 
neck.  They  are  usually  lateral.  Some  degree  of  lateral  displacement  may 
also  result  from  pleural  adhesions  and  the  traction  of  a  contracting  lung 
in  neglected  pleurisy  or  fibroid  phthisis.  Moderate  bilateral  prominence 
and  enlargement  of  the  neck  without  spastic  contraction  occur  in  the 
habitual  dyspnoea  of  severe  chronic  bronchitis,  emphysema,  bronchial 
asthma,  cardiac  disease  and  certain  cases  of  chronic  uraemia — so-called 
renal  asthma.  Rigidity  of  the  neck  is  sometimes  due  to  myalgia  of  the 
cervical  muscles,  spondylitis  deformans  involving  the  cervical  vertebrae, 
or  caries.  It  may  be  caused  by  painful  inflammatory  processes,  as  acute 
adenitis,  parotid  bubo,  mumps,  boils,  or  carbuncles. 

Thyroid  Body. — This  gland  is  situated  in  the  lower  part  of  the  neck 
and  embraces  the  trachea  in  its  upper  part,  reaching  up  to  the  larynx  on 
each  side.  It  consists  of  two  lateral  lobes  united  by  an  isthmus.  The  right 
lobe  is  usually  slightly  longer  and  wider  than  the  left.  Both  the  larynx 
and  the  thyroid  body  which  is  in  relation  with  it  rise  with  the  act  of  swallow- 
ing. Enlargement  of  the  thyroid  body  usually  affects  the  isthmus  and 
both  lobes,  but  one— very  often  the  right— to  a  greater  extent  than  the 
other.      The    enlargement    may    be    vascular,    parenchymatous,    fibroid, 


12 


MEDICAL  DIAGNOSIS. 


cystic,  or  due  to  adenoma,  carcinoma,  tuberculosis,  or  gumma.  Vascular 
enlargement  of  the  thyroid  body  may  be  physiological,  occurring  during 
menstruation  or  pregnancy  and  subsiding  at  the  termination  of  these 
events,  or  pathological,  as  in  exophthalmic  goitre,  when  it  is  often  variable 
in  size  and  attended  with  marked  pulsation,  thrill,  and  murmur.  Venous 
hyperaemia  may  be  due  to  the  pressure  of  an  aneurism  or  mediastinal 
tumor.    Parenchymatous  enlargement  or  simple  goitre  may  be  of  moderate 

size,  but  in  some  instances  attains 
enormous  dimensions,  protruding 
beyond  the  chin  and  hanging  over 
the  sternum.  Cystic  goitre  when 
multiple  may  be  recognized  by  the 
smooth,  hemispherical,  close  set, 
elastic  nodules  upon  the  surface; 
when  single  and  larger,  by  fluctua- 
tion. Thyroid  abscess  is  rare  and 
usually  accompanied  by  local  inflam- 
matory oedema  and  grave  constitu- 
tional symptoms.  Cancer,  tubercu- 
losis, and  gumma  rarely  involve  the 
thyroid  and  may  be  recognized 
by  their  local  characters  and  the 
associated  constitutional  phenomena. 
An  underlying  aneurism  or  medias- 
tinal growth  may  displace  the  thy- 
roid upwards  and  forwards  or  to 
either  side.  In  aneurism  of  the 
innominate,  the  displacement  is  to- 
wards the  left.  An  aneurism  some- 
times imparts  its  movements  to  the 
overlying  thyroid.  Atrophy  of  the 
thyroid  may  give  rise  to  flattening  of  the  surface.  More  commonly  it  can 
be  recognized  only  upon  palpation.  It  is  usually  accompanied  by  the 
symptoms  of  cretinism  or  myxoedema. 

Muscles. — One  or  both  sternomastoid  muscles  may  be  hypertrophied 
and  prominent.  In  torticolHs  or  wry-neck  the  contraction  is  usually 
unilateral,  and  the  neck  is  rotated  so  that  the  mastoid  is  drawn  towards 
the  inner  end  of  the  clavicle,  the  chin  raised  and  the  face  turned  towards 
the  unaffected  side.  In  rare  cases  wry-neck  is  bilateral, — retrocollic  spasm, 
— the  head  retracted  and  the  face  turned  upward.  The  spasm  in  both 
forms  of  torticollis  may  be  tonic  or  clonic.  The  disease  is  sometimes 
congenital. 

The  Clavicles. — The  position  of  these  bones  has  much  to  do  with  the 
appearance  of  the  neck  as  regards  length.  They  are  high  in  deep-chested 
persons  with  large  lungs  and  in  emphysema;  low  in  flat-chested  indi- 
viduals with  small  lungs  and  in  phthisis  and  pulmonary  fibrosis  from  any 
cause.  These  bones  are  deformed  after  fracture  and  sometimes  present 
nodes  and  irregularities  of  the  surface  caused  by  syphilitic  periostitis. 
Prominence  in  the  retroclavicular  space  sometimes  occurs  in  emphysema 


Fig.  4. — Cystic  goitre. 


PLATE  I. 


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V    I        1 


General  anatomical  outlines  and  relations  of  the  thoracic  and  abdominal  organs. 


MEDICAL  TOPOGRAPHY.  13 

of  high  grade,  but  as  a  rule  the  clavicles  in  this  condition  are  prominent 
and  both  the  retro-  and  infraclavicular  spaces  are  retracted.  The  sub- 
cutaneous fat  pads  of  myxoedema  are  frequently  seen  above  the  clavicles 
and  sometimes  at  the  root  of  the  neck  posteriorly.  The  neck  is  occasionally 
the  seat  of  extensive  inflammatory  oedema  with  violaceous  discoloration — 
collar  of  brawn — especially  in  scarlet  fever,  erysipelas,  and  infected  wounds, 
and  sometimes  much  distorted  by  subcutaneous  emphysema,  such  as 
follows  rupture  of  the  pleura  or  wounds  or  operations  involving  the  upper 
air-passages. 

THE  THORAX. 

The  thorax  is  of  conical  shape  with  convex  walls.  Its  truncated  upper 
end  is  narrow  and  bounded  by  the  first  dorsal  vertebra,  the  first  pair  of 
ribs,  and  the  manubrium  of  the  sternum.  Its  expanded  base  is  filled  in 
by  the  vault  of  the  diaphragm.  The  anterior  border  of  the  base  curves 
downwards  and  backwards  on  each  side  from  the  xyphoid  cartilage  to  the 
twelfth  rib.  Its  transverse  diameter  greatly  exceeds  its  anteroposterior 
diameter,  which  is  further  shortened  in  the  middle  line  by  the  projection 
of  the  spinal  vertebrae  forwards  into  the  cavity  of  the  thorax.  This  space 
contains  the  heart  and  great  vessels  together  with  the  pericardium,  the 
lungs  and  pleurae,  the  trachea,  the  greater  part  of  the  cesophagus,  and  the 
thymus  gland  or  its  remnant. 

Anatomical  Landmarks  of  the  Thorax. 

ANTERIOR  SURFACE. 

The  Chest. — The  clavicles,  sternum,  ribs,  and  interspaces  constitute 
natural  surface  conformations  to  which,  for  purposes  of  study  and  de- 
scription, clinical  phenomena  may  be  referred. 

The  Clavicles.  —  The  part  immediately  above  these  bones  on  either 
side  is  known  as  the  supra-  or  retroclavicular  space;  that  immediately 
below  them  as  the  infraclavicular  space.  Into  the  supraclavicular  spaces 
the  apex  of  the  lung  enters  to  a  slight  extent,  usually  a  little  further  on  the 
right  than  on  the  left  side.  In  well-developed  lungs  these  spaces  are  not 
retracted,  but  in  ill-developed  lungs  and  in  pathological  states  character- 
ized by  contraction  of  lung  tissue  they  are  more  or  less  strongly  depressed. 

The  Sternum. — The  upper  border  of  this  bone  is  marked  by  a  large 
incurvation  known  as  the  episternal  notch,  which  limits  the  root  of  the 
neck  anteriorly  and  in  which  can  be  felt  at  times  the  pulsating  aorta — 
dilatation,  dynamic  pulsation,  aneurism  of  the  transverse  arch.  At  the 
line  of  juncture  of  the  manubrium  and  gladiolus  or  body  is  a  more  or  less 
prominent  transverse  line  or  prominence,  better  developed  in  the  male — 
the  angle  of  Ludovicius.  At  the  lower  end  is  the  xyphoid  or  ensiform 
appendix,  variable  in  size  and  shape  and  sometimes  having  its  tip  everted 
in  such  a  manner  as  to  form  an  infrasternal  depression  or  fossa. 

The  Ribs  and  Intercostal  Spaces. — The  Ribs. — In  spare  persons  the 
ribs  may  be  counted  with  ease.  When,  however,  there  is  much  subcu- 
taneous fat,  the  recognition  of  any  particular  rib  is  sometimes  difficult. 
The  first  rib  may  be  known  by  the  articulation  of  its  cartilage  with  the 


14  MEDICAL  DIAGNOSIS. 

sternum  at  a  point  immediately  below  the  articulation  of  the  clavicle. 
The  articulation  of  the  second  costal  cartilage  is  directly  opposite  the 
junction  of  the  first  and  second  pieces  of  the  sternum — angulus  Ludovici. 
The  ribs  slope  downwards  from  their  spinal  articulations  in  such  a  manner 
that  their  chondrosternal  articulations  lie  at  a  much  lower  level,  the  artic- 
ulation of  the  first  rib  anteriorly  being  in  quiet  breathing  on  the  horizontal 
plane  of  the  fourth  rib  at  the  back  and  so  on  to  the  seventh  rib.  In  the 
expiratorj^  type  of  chest  this  oblique  position  of  the  ribs  is  somewhat 
increased;  in  the  inspiratory  type  it  is  much  diminished. 

The  Intercostal  Spaces. — These  spaces  correspond  to  the  ribs  and 
cartilages  immediately  above  them — that  is,  the  first  space  lies  immediately 
below  the  first  rib.  They  are  wider  in  front  than  behind.  In  expiration 
the  upper  spaces  are  increased  in  width  and  the  lower  narrowed,  while  in 
inspiration  these  conditions  are  relatively  reversed.  It  is  in  accordance 
with  this  fact  that  the  upper  spaces  are  wider  and  the  lower  narrower  in 
the  expiratory,  while  the  upper  are  narrower  and  the  lower  wider  in  the 
inspiratory  form  of  chest.  In  fat  persons  the  intercostal  spaces  cannot 
be  made  out,  but  in  those  who  are  lean  they  appear  as  shallow,  parallel, 
oblique  furrows  symmetrically  arranged  upon  each  side  of  the  chest. 
They  are  deeper  upon  inspiration  than  on  expiration  or  quiet  breathing, 
and  conspicuously  so  in  obstructive  dyspnoea.  These  furrows  are  oblit- 
erated in  massive  pneumonia  and  in  pleural  effusions  and  the  spaces  may 
actually  bulge  in  old  cases  of  large  empyema.  Local  protrusion  of  the 
chest  wall  such  as  occurs  in  large  hypertrophy  of  the  heart  in  early  life 
causes  widening  of  the  overlying  intercostal  spaces.  The  unilateral  flatten- 
ing of  the  chest  which  accompanies  fibroid  phthisis  or  follows  a  neglected 
pleural  effusion,  crowds  the  ribs  together,  even  in  some  instances  to  over- 
lapping, and  in  this  manner  obliterates  the  spaces  in  whole  or  in  part. 

Normal  Cardiac  Pulsation. — The  apex  beat  is  seen  in  the  fifth  inter- 
costal space  to  the  left  of  the  parasternal  line,  while  undulatory  pulsation  in 
several  spaces  occurs  in  dilatation  of  the  heart,  and  heaving  pulsation  over 
a  large  area  in  marked  h3^pertrophy  of  that  organ.  In  rare  instances  inter- 
costal pulsation  is  due  to  a  neglected  empyema.  The  pulsation  is  almost 
always  in  the  anterolateral  aspect  of  the  chest  upon  the  left  side.  In  mitral 
and  aortic  stenosis,  aortic  insufficiency,  cases  of  congenital  malformation 
of  the  heart,  and  aneurism  of  the  aorta,  thrills  may  be  felt  upon  palpation. 

The  Nipple. — This  organ  is  not  without  value  as  a  topographical 
landmark  in  children  and  spare  males,  but  in  women  and  obese  persons  of 
both  sexes  its  position  is  extremely  variable.  When  there  is  httle  fat  and 
the  mammae  are  undeveloped  the  nipple  is  situated  about  the  fourth  inter- 
costal space,  sometimes  over  the  fourth,  sometimes  over  the  fifth  rib,  and 
in  a  vertical  line  intersecting  the  middle  of  the  clavicle — the  mammillary 
line.  It  is  obvious  that  the  nipple  —  mammilla  —  is  not  a  satisfactory 
anatomical  landmark.     The  midclavicular  line  is  much  more  useful. 

POSTERIOR   SURFACE.— THE    BACK. 

The  Spine. — In  children  and  lean  persons  the  spinous  processes  are 
prominent.  In  muscular  adults  and  fat  people  they  are  situated  in  the 
middle  of  a  shallow  longitudinal  groove  formed  by  the  prominence  of  the 


PLATE  11. 


. 


J 


General  anatomical  outlines  and  relations  of  the  thoracic  and  abdominal  organs. 


MEDICAL  TOPOGRAPHY. 


15 


erector  spinse  muscles  on  either  side.  They  become  more  prominent 
when  the  patient  bends  strongly  forward.  Owing  to  the  denseness  of 
the  overlying  musculotendinous  tissues,  the  spines  of  the  upper  five 
cervical  vertebrae  cannot  as  a  rule  be  recognized  upon  palpation.  The 
sixth  may  be  felt  and  seen  in  many  persons,  and  the  seventh — vertebra 
prominens  —  is  usually  con- 
spicuous and  forms  a  point 
of  departure  from  which  the 
thoracic  and  lumbar  spines 
may  be  counted.  The  eighth 
and  ninth  thoracic  spines 
are  normally  somewhat  more 
prominent  than  the  others. 
Marked  prominence  of  one  or 
more  vertebral  spines,  with 
tenderness  upon  pressure  and 
pain  upon  rotary  movements 
of  the  spine  or  jarring,  is  sig- 
nificant of  spinal  caries,  usu- 
ally tuberculous,  rarely  syph- 
ilitic. There  is  frequently 
angular  curvature. 

Kyphosis. — The  curvature 
is  in  the  sagittal  plane  with 
the  concavity  anterior.  It 
is  chiefly  thoracic,  sometimes 
cer^dcothoracic,  and  may  con- 
stitute nothing  more  than  one 
of  the  skeletal  changes  due  to 
old  age.  It  occurs  also  in 
those  who  habitually  carry 
heavy  burdens  on  the  head  and  shoulders,  in  emphysema,  rickets,  osteitis 
deformans,  and  acromegaly.  This  rounded  curvature  is  to  be  distinguished 
from  the  sharper,  often  angular  curvature  of  vertebral  caries  or  mollities 
ossium. 

Scoliosis.  —  A  rotary-lateral  curvature  usually  involving  the  upper 
thoracic  spine  with  compensating  curvature  in  the  lower  thoracic  and 
lumbar  regions.  Less  commonly  it  affects  the  cervical  or  lumbar  regions. 
Scoliosis  is  very  common  in  school-girls  in  consequence  of  poor  muscular 
development  and  faulty  desk  attitudes.  It  may  result  from  the  habitual 
carrying  of  heavy  weights  on  the  same  arm,  inequalit}^  in  the  length  of 
the  legs,  deformity  of  a  foot,  tilting  of  the  pelvis,  old  sciatica,  the  arrested 
gi'owth  of  a  limb  following  infantile  palsy,  hemiplegia,  and  mollities  ossium. 
The  deformity  of  the  chest  following  long-neglected  pleural  effusion,  sero- 
fibrinous or  purulent,  includes  dorsal  scoliosis,  the  concavity  looking  towards 
the  affected  side. 

Lordosis. — An  exaggeration  of  the  normal  lumbar  curve  occurs  in  ad- 
vanced pregnancy,  large  abdominal  tumors  and  ascites,  progressive  mus- 
cular atrophy,  and  pseudohypertrophic  muscular  paralysis.      The  attitude 


Fig.  5. — Spinal  caries.     Lumbar  region. — Young 


16 


MEDICAL  DIAGNOSIS. 


in  the  last  condition  is  characteristic.  The  legs  are  separated,  the  head  is 
thrown  back,  the  spine  strongly  curved,  and  the  abdomen  thrust  forward. 
Spina  Bifida. — This  is  a  developmental  fault  consisting  of  failure  on 
the  part  of  the  laminae  of  the  vertebrae  to  unite.  The  usual  site  is  in  the 
lumbar  or  lumbosacral  region.  The  protruding  tumor  is  in  the  middle 
line,  sometimes  covered  with  normal  skin,  sometimes  with  a  thin,  trans- 
lucent membrane.     There  are  two  varieties: 


Fig.  6. — Kyphosis. 


Fig.  7. — Senile  kyphosis. 


Spina  bifida  occulta,  in  which  the  sac  is  walled  off  from  all 
connection  with  the  spinal  canal,   and — 

Spina  bifida  vera,  in  which  the  cyst  is  filled  with  cerebrospinal 
fluid  and  increases  in  size  during  violent  crying,  and  can  be  diminished 
by  gentle  pressure. 

Three  subvarieties  are  recognized: 

Spinal  Meningocele. — The  protruding  membranes  contain  onl}^  cere- 
brospinal fluid. 

Meningomyelocele. — The  sac  contains  not  only  fluid  but  also  sub- 
stance of  the  cord.     This  is  the  most  common  form. 


Fig.  8. — Primary  left  dorsal  scoliosis. — ^Young. 


Fig.    10 — Spina     liilida     (.f     liiiiiliar     region 
Male,  5   years   uld. — Rulch. 


Fig.  9. — Extreme  lordo.'si.';  in  progressive 
muscular  atrophy. — Young. 


MEDICAL  TOPOGRAPHY.  17 

Syringomyelocele . — The  sac  is  formed  of  the  membranes  and  a  pro- 
truding portion  of  the  cord,  the  central  canal  being  dilated  to  form  the 
cavity  of  the  tumor. 

This  group  of  deformities  is  commonly  associated  with  other  develop- 
mental defects.  Exceptionally  spina  bifida  occurs  in  children  otherwise 
healthy  and  well  developed. 

The  Scapulae. — These  flat,  triangular,  trowel-like  bones  are  placed 
symmetrically  upon  the  upper  and  back  part  of  the  thorax  and  extend, 
when  the  arms  hang  by  the  sides  in  the  erect  posture,  from  the  second  to 
the  seventh  ribs.  They  are  attached  to  the  skeleton  by  the  clavicle  and 
the  humerus  and  are  therefore  freely  movable.  When  the  arms  are  folded 
and  the  body  is  bowed  forward,  the  interscapular  space  is  much  increased, 
an  important  fact  in  physical  diagnosis.  The  inner  borders  of  the  scapulae 
project  in  consequence  of  muscular  weakness,  palsy,  and  changes  in  the 
contour  of  the  chest.  Combinations  of  these  causative  conditions  may 
occur  in  the  same  case.  Both  inner  borders  project  in  the  alar  or  ptery- 
goid chest  and  in  the  progressive  muscular  dystrophies  affecting  the  shoulder 
girdle.  The  abnormal  mobility  of  the  shoulder-blades  arising  from  loss  of 
muscular  tone  permits  the  inner  borders  to  project  like  budding  wings. 
The  inner  border  stands  out  upon  the  affected  side  in  contraction  of  the 
chest  from  pulmonary  fibrosis;  in  associated  serratus  and  trapezius  paraly- 
sis, especially  when  the  arms  are  held  out  in  front  in  the  horizontal  plane; 
in  scoliosis  due  to  various  causes,  and  sometimes  upon  the  left  side  in 
large  aneurism  of  the  descending  portion  of  the  arch  of  the  aorta. 

Immobility  of  the  Spine.— Flexion,  extension,  and  lateral  and  rotary 
movements  may  be  restricted  or  wholly  prevented  by  various  patho- 
logical conditions,  as  (1)  those  giving  rise  to  pain  in  movement,  among 
which  the  more  common  are  traumatism,  myalgia — lumbago — abscess, 
carbuncle,  meningeal  hemorrhage;  (2)  those  involving  spasm,  as  cerebro- 
spinal fever  and  the  spastic  form  of  myalgia;  (3)  those  affecting  the  joints 
and  bones,  most  of  which  terminate  in  ankylosis,  as  traumatic,  gonor- 
rhoeal,  or  tuberculous  disease  and  spondylitis  deformans;  and  (4)  certain- 
neuroses,  as  many  of  the  cases  of  so-called  typhoid  spine,  railway  spine, 
hysterical  spine,  irritable  spine,  and  so  on. 

LATERAL   SURFACES. 

The  landmarks  are  the  axilla — armpit — above,  the  anterior  and  poste- 
rior axillary  folds,  the  ribs  and  interspaces  and  the  upper  border  of  hepatic, 
on  the  right,  and  of  splenic  dulness  on  the  left  side,  below.  Enlarged  lymph- 
nodes,  which  frequently  undergo  suppuration  or  may  be  tuberculous,  carci- 
nomatous, leuksemic  or  pseudoleukaemic,  are  common  in  the  axillary  space. 

Artificial   Lines   and   Spaces  of  the  Thorax. 

The  following  conventional  imaginary  lines  and  spaces  serve  a  useful 
purpose  in  the  examination  and  description  of  thoracic  lesions.  For 
convenience  of  demonstration  the  lines  may  be  marked  upon  the  surface 
with  a  dermatographic  pencil.  The  subject  is  in  the  erect  posture  with 
his  arms  symmetrically  disposed. 
2 


18 


MEDICAL  DIAGNOSIS. 


A.   Vertical   Parallel   Lines.  —  With   the    exception   of   the    first 
and  last  they  are  double — bilateral. 

(a)  The  mesial  or  mid  sternal  Hne. 

(b)  The  line  of  the  sternal  border. 

(c)  The  parasternal  line,  midway  between  the  line  of  the  ster- 

nal border,  and — 

(d)  The  midclavicular  linC;  sometimes  spoken  of  as  the  mammil- 

lary  line  because  in  individuals  with  undeveloped  mammae 
it  passes  through  or  near  the  nipple. 


Fig.  11. — Lines  of  reference  :  Anterior. — m,  middle  line; 
s,  s',  right  and  left  lines  of  the  sternal  border;  ps,  ps',  para- 
sternal lines;  c,  c',  midclavicular  or  mammillary  lines. 


Fig.  12. — Lines  of  reference  :  Lat- 
eral.— aa,  anterior  axillary  line;  ma,  mid- 
axillary  iine;  pa,  posterior  axillary   line. 


B. 


(e)  The  line  of  the  anterior  axillary  fold. 

(f)  The  midaxillary  line. 

(g)  The  line  of  the  posterior  axillary  fold. 

(h)   The  scapular  line,  passing  vertically  through  the  inferior  angle 
of  the  scapula — a  very  movable  and  uncertain  landmark, 
(i)  The  posterior   mesial  line,   corresponding  to   the  line   of  the 
spinous  processes. 
Horizontal  Parallel  Lines. — These  are  anteriorly: 

(a)  A  line  touching  the  lower  border  of  the  cricoid  cartilage. 

(b)  A  line  passing  through  the  clavicles. 

(c)  A  line  passing  through  the  third  chondrosternal  articulation. 

(d)  A  line  passing  through  the  sixth  chondrosternal  articulation. 


MEDICAL  TOPOGRAPHY.  19 

And  posteriorly: 

(a)  A  line  touching  the  upper  border  of  the  scapulae, 

(b)  A  line  passing  through  the  spines  of  the  scapulae. 

(c)  A  line  passing  through  the  inferior  angles  of  the  scapulae. 

(d)  A  line  touching  the  upper  border  of  the  spine  of  the  twelfth 

dorsal  vertebra. 

Regional   Divisions  of  the    Thorax. 

By  the  intersection  of  certain  of  the  above-described  lines  the  follow- 
ing arbitrary  regions  are  formed: 

(a)  The  Suprasternal  Region.  —  This  region  overlies  the  thyroid 
body,  the  trachea,  and  more  deeply  the  oesophagus.  The  transverse  aorta, 
when  dilated,  extends  into  it  and  may  be  felt  pulsating  above  the  level 
of  the  sternal  incisura. 

(b)  The  Upper  Sternal  Region.- — Beneath  the  breastbone  lie  the 
remnants  of  the  thymus,  the  mesial  borders  of  the  upper  lobes  of  the  lungs, 
and  more  deeply  the  transverse  arch  of  the  aorta. 

(c)  The  Lower  Sternal  Region. — Within  the  limits  of  this  space 
lie  the  mesial  border  of  the  right  lung,  the  termination  of  the  fissure  form- 
ing the  upper  boundary  of  the  middle  lobe,  and  that  part  of  the  right  heart 
which  constitutes  the  area  of  superficial  dulness. 

On  each  side: 

(d)  The  Supraclavicular  Region. — This  space  lies  above  the  upper 
edge  of  the  collar-bone  and  contains  the  apex  of  the  corresponding  lung. 

(e)  The  Clavicular  Region. — A  space  of  no  great  moment  in  diag- 
nosis. It  corresponds  to  the  boundaries  of  the  inner  half  of  the  bone. 
The  clavicle  may  be  used  as  a  pleximeter  in  direct  percussion. 

(f)  The  Infraclavicular  Region. — A  most  important  area  of  the 
chest.  It  is  bordered  above  by  the  line  of  the  clavicles,  internally  by  the 
line  of  the  sternal  border,  externally  by  the  line  of  the  anterior  axillar}'- 
fold  projected  upward  to  the  acromion  process,  and  below  by  the  hori- 
zontal line  passing  through  the  third  chondrosternal  articulation.  It 
contains  on  either  side  that  part  of  the  upper  lobe  of  the  lung  in  which 
tuberculous  bronchopneumonia  is  as  a  rule  first  recognizable. 

(g)  The  Mammary  Region. — From  the  lower  border  of  the  preceding 
to  the  line  passing  through  the  sixth  chondrosternal  articulation.  This 
space  contains  on  the  right  side  a  part  of  the  upper  and  middle  lobes  and 
the  fissure  separating  them,  together  with  the  right  auricle  near  the  sternal 
border,  and  more  deeply  in  the  vault  of  the  diaphragm  the  convexity  of 
the  right  lobe  of  the  liver.  It  overlies  on  the  left  side  the  extrasternal 
area  of  superficial  dulness,  the  apex  of  the  right  and  of  the  left  ventricle, 
and  the  mesial  border  of  the  left  lung  with  the  lingula.  Into  the  mammary 
region  on  each  side  extend  the  interlobar  fissures  of  the  lungs. 

(h)  The  Inframammary  Region. — This  area,  which  extends  from  a 
horizontal  line  through  the  sixth  chondrosternal  articulation  downwards, 
overlies  the  liver  on  the  right  side,  and  upon  the  left  a  portion  of  the  left 
lobe  of  the  liver,  the  fundus  of  the  stomach,  the  transverse  colon,  and  the 
spleen.     On  the  left  is  Traube's  semilunar  space. 


20 


MEDICAL  DIAGNOSIS. 


fi)  The  Axillary  Regiox. — This  space  is  bounded  by  the  lines  of 
the  axillary  folds  and  the  armpit  above.  It  is  a  diagnostic  territory  of 
some  importance. 

(j)  The  Infra-axillary  Region. — The  upper  boundary  is  the  line 
which  passes  through  the  sixth  chondrosternal  articulation;  its  lower  is 
the  base  of  the  chest.  In  this  region,  upon  the  left,  the  upper  border  of 
splenic  dulness  may  be  demonstrated  upon  percussion.  The  interlobar 
fissure  traverses  the  axillary  and  infra-axillary  spaces. 

(k)  The  Suprascapular  Region. — An  area  of  importance  on  ac- 
count of  the  early  manifestations  of  phthisis. 


Fig.    13. — Regional    divisions    of    the    thorax:  Fig.  14. — Regional  divisions  of  t"he  chest:  Pos- 

Anterior. — a,  suprasternal  region;  6,  upper  sternal;  terior. — a,a\  .supraclavicular  regions;  6,6',  supraspi- 

c,  lower  sternal;  d,d',  right  and  left  supraclavicular;  nous;    c,c',    infraspinous;    d,d',    infrascapular;    e.e', 

e,e',  right  and  left  infraclavicular;   /,/',  mammarj-  interscapular  regions. 
ff.fl'i  inframammary. 

(1)  The  Supraspinous  Region. — That  space  lying  between  the  upper 
border  of  the  scapula  and  the  spine  of  the  scapula,  and  occupied  by  the 
thick  supraspinous   muscle.     , 

(m)  The  Infraspinous  Region.  —  From  the  spine  of  the  scapula 
to  the  level  of  the  inferior  angle.  The  infraspinous  and  infrascapular 
regions  are  traversed  by  the  interlobar  fissures.  This  fact  is  of  importance 
in  the  recognition  of  the  signs  of  the  extension  of  a  tuberculous  infiltra- 
tion to  the  apex  of  the  lower  lobe. 

(n)  The  Infrascapular  Region. — From  the  angle  of  the  scapula, 
namely,  about  the  level  of  the  seventh  rib,  to  the  base  of  the  chest. 

(o)  The  Interscapular  Region. — The  space  lying  between  the 
inner  borders  of  the  two  scapulae.  It  extends  across  the  spinal  column 
and  is  much  widened  when  the  arms  are  folded  and  the  body  bent  forward. 


MEDICAL  TOPOGRAPHY.  21 


THE  ABDOMEN. 

The  abdomen  is  the  great  cavity  of  the  body  extending  from  the 
diaphragm  above  to  the  levator  muscles  of  the  anus  below.  It  is  sub- 
divided by  an  oblique  plane  at  the  brim  of  the  pelvis  into  two  portions, 
the  abdomen  proper  and  the  pelvis.  For  the  purpose  of  exact  reference 
to  the  position  and  condition  of  the  organs  contained  in  the  cavity  of 
the  abdomen  in  health  and  disease,  certain  lines,  as  in  the  case  of  the 
thorax,  are  recognized  upon  the  surface.  These  dividing  lines  are  natural, 
and  artificial  or  conventional. 

The  Natural   Lines  of  the  Abdomen. 

(a)  The  linea  alba  in  the  middle  line  from  the  ensiform  cartilage  to 
the  symphysis  pubis. 

(b)  The  line^  semilunares,  one  upon  either  side,  passing  from 
the  ninth  costal  cartilage  to  the  pubic  bone  and  following  the  outer  border 
of  the  rectus  abdominis  muscle. 

(c)  The  line^  transversa,  of  which  there  are  three,  the  upper 
being  at  the  level  of  the  tip  of  the  ensiform  cartilage,  the  middle  at  a 
level  midway  between  the  first  and  the  navel,  and  the  third  at  the  level 
of  the  navel. 

(d)  In  fat  persons  a  deep  transverse  sulcus  or  furrow  crosses  the 
abdomen  a  short  distance  above  the  pubic  arch  and  a  second  similar  but 
less  marked  groove  is  sometimes  seen  about  the  level  of  the  umbihcus. 
These  grooves  vary  in  depth  according  to  the  amount  of  fat  in  the  belly 
wall  and  are  deeper  in  the  erect  than  in  the  recumbent  posture. 

The   Imaginary  or  Conventional   Lines. 

(a)  The  mesial  line,  passing  through  the  tip  of  the  ensiform  car- 
tilage, the  umbilicus,  and  the  symphysis  pubis,  and  corresponding  to  the 
linea  alba. 

(b)  The  prolongation  downward  of  the  midclavicular  line,  which 
passes  through  the  eighth  costal  cartilage  to  the  middle  of  Poupart's 
ligament  upon  each  side. 

(c)  The  infracostal  line,  passing  around  the  body  in  the  horizon- 
tal plane  of  the  tenth  costal  cartilages. 

(d)  The  bi-iliac  line,  which  corresponds  to  the  plane  of  the  most 
prominent  part  of  the  iliac  crests. 

These  two  lines  (c)  and  (d)  divide  the  abdominal  surface  into  three 
zones:  an  upper  or  epigastric,  a  middle  or  umbilical,  and  a  lower  or  hypo- 
gastric. The  two  vertical  lines  dropped  from  the  middle  of  the  clavicle 
to  the  middle  of  Poupart's  ligament  again  divide  each  of  those  zones  into 
three  regions,  as  follows: 

(a)  An  Epigastric  Region  or  Upper  Central  Region. — This  over- 
lies a  portion  of  the  right  and  left  lobes  of  the  liver  and  a  large  part  of  the 
anterior  wall  of  the  stomach,  with  the  pylorus,  the  aorta,  the  coeliac  axis, 
the  semilunar  ganglia,  and  at  a  greater  depth  the  pancreas. 


22 


MEDICAL  DIAGNOSIS. 


(b)  A  Right  and  Left  Hypochondriac  Region. — The  right  hypo- 
chondriac region  overlies  the  right  lobe  of  the  liver  and  the  gall-bladder, 
the  duodenum,  the  hepatic  flexure  of  the  colon,  and  the  upper  part  of 
the  right  kidney;  the  left  the  greater  curvature  of  the  stomach,  the  spleen, 
the  tail  of  the  pancreas,  the  splenic  flexure  of  the  colon,  and  the  upper  part 
of  the  left  kidney. 

(c)  An  Umbilical  or  Middle  Central  Region. — In  this  space  lie 
the  greater  curvature  of  the  stomach,  the  mesentery,  the  great  omentum, 
coils  of  the  small  intestine,  and  the  transverse  colon. 


Fig.  15. — Regional  divisions  of  the  abdomen:  Fig.  16. — Quadrants  of  the  abdomen. 

a,  epigastric  or  upper  central  region;  6,6',  right 
and  left  hypochondrium;  c,  umbilical  or  middle 
central  region;  d,d',  right  and  left  lumbar  regions; 
e,  hypogastric  or  middle  lower  region. 

(d)  A  Right  and  Left  Lumbar  Region. — The  right  contains  the 
lower  part  of  the  right  kidney,  the  ascending  colon,  and  coils  of  small 
intestine;  the  left  the  lower  part  of  the  left  kidney,  descending  colon, 
and  small  intestine. 

(e)  A  Hypogastric,  Suprapubic,  or  Middle  Lower  Region. — 
This  space  overlies  coils  of  the  small  bowel,  at  its  lower  portion  the  fundus 
of  the  urinary  bladder  when  distended,  and  the  gravid  womb. 

(f)  A  Right  and  Left  Iliac  or  Inguinal  Region.  —  The  right 
contains  the  caecum  and  the  base  of  the  appendix  or  frequently  the  whole 
of  it,  the  ileocsecal  valve  and  the  right  ureter;  the  left  the  descending  colon 
and  left  ureter. 


MEDICAL  TOPOGRAPHY.  23 

The  Quadrants  of   the  Abdomen. 

A  simpler  division  of  the  surface  of  the  abdomen  into  regions  may 
be  made  by  a  vertical  and  a  transverse  line  intersecting  at  the  umbilicus. 
The  four  spaces  thus  defined  are  known  respectively  as  the  right  and 

LEFT   UPPER    and    LOWER    QUADRANTS. 

The  Visceral   Regions. 

Certain  important  viscera  give  their  names  to  the  surface  areas  cor- 
responding to  the  situation  in  which  they  are  normally  found.  Thus 
we  speak  of: — 

(a)  The  Precordial  Area;  the  Precordia. — That  part  of  the  chest 
wall  which  overlies  the  heart,  including  the  areas  of  superficial  and  deep 
dulness  and  increasing  in  extent  in  cardiac  dilatation  and  hypertrophy. 

(b)  The  Region  of  the  Apex. — A  more  circumscribed  space  imme- 
diately above  and  around  the  normal  apex  and  shifting  as  the  apex  shifts 
in  enlargement  and  displacement  of  the  heart. 

(c)  The  gastric  area,  which  corresponds  to  the  normal  situation 
of  the  stomach.  The  limits  of  this  region  are  not  strictly  defined,  since  the 
organ  varies  in  size  when  empty  or  distended  with  food  or  gas,  and  has 
some  degree  of  mobility. 

(d)  The  Hepatic  Area. — The  lower  border  of  this  region  is  usually 
sharply  defined  both  in  normal  and  pathological  conditions.  Its  upper 
border  rounds  away  from  the  chest  wall  from  which  the  upper  surface  of 
the  liver  is  separated  by  the  edge  of  the  lung,  and  its  left  border  is  obscured 
by  the  tympany  of  the  stomach  and  colon. 

(e)  The  Region  of  the  Gall-bladder. — The  notch  for  the  gall- 
bladder lies  in  the  under  border  of  the  liver,  slightly  internal  to  the 
ninth  right  costal  cartilage  and  near  the  outer  border  of  the  right 
rectus  muscles.  The  fundus  of  the  organ  when  distended  and  enlarged 
occupies  a  considerable  area  on  both  sides  of  this  point  as  well  as 
below  it. 

(f)  The  Ileocecal  Area. — The  part  of  the  abdominal  surface  lying 
in  the  right  lower  quadrant  of  the  abdomen  and  the  seat  of  the  local 
manifestations  in  appendicitis.  Here  lies  the  spot  of  focal  tenderness 
described  as  McBurney's  point. 

(g)  The  Splenic  Area. — The  region  which  occupies  the  left  hypo- 
chondrium  extending  towards  the  infra-axillary  region.  An  enlarged 
spleen  frequently  transcends  the  normal  borders  of  the  splenic  area, 
and  a  dislocated  spleen  occupies  an  entirely  different  position,  in  such 
a  manner  that  the  normal  dulness  in  the  splenic  area  is  replaced  by 
tympany, 

(h)  The  Sigmoid  Area. — The  left  inguinal  region  and  the  parts 
bordering  upon  it  toward  the  median  line,  which  are  so  designated 
because  new  growths  and  other  pathological  conditions  involving  the 
sigmoid  flexure  of  the  colon  give  rise  to  tumors  or  other  clinical  mani- 
festations in  this  portion  of  the  abdomen.  It  corresponds  with  the  left 
lower  quadrant. 


24  MEDICAL  DIAGNOSIS. 

(i)  The  Pelvic  Area. — The  designation  sometimes  employed  to  de- 
scribe the  suprapubic  area  because  it  is  the  region  of  the  abdomen  in  which 
enlargements  and  new  growths  of  the  pelvic  viscera  are  frequently  manifest. 

The  extent  of  the  various  regions  of  this  group  is  neither  constant 
nor  well  defined.  Their  borders  are  often  shifting  and  overlapping.  Nev- 
ertheless they  serve  a  useful  purpose  in  the  diagnosis  of  diseases  of  the 
abdominal  organs. 

Large  accumulations  of  fat  in  the  belly  wall  or  within  the  peritoneal 
cavity,  pregnancy,  meteorism,  dropsy  and  ascites,  visceral  displacements 
and  enlargements,  new  growths  and  extra-  and  intraperitoneal  cysts  and 
abscesses  distend  the  abdomen,  modify  its  contour,  and  disarrange,  often 
to  an  extreme  degree,  the  relations  between  the  above-described  areas  and 
the  internal  organs. 

The  foregoing  anatomical  and  conventional  lines  and  areas  enable  us 
definitely  to  fix  the  position  of  clinical  phenomena  for  purposes  of  descrip- 
tion and  record. 

The  signs  or  symptoms  of  a  lesion  may  be  referred  to  a  given  region, 
as  episternal  pulsation,  infraclavicular  dulness,  or  precordial  pain.  More 
exactly  the  location  of  a  given  phenomenon  may  be  indicated  by  the  rib 
or  interspace  in  which  it  is  found  and  the  distance  from  the  midsternal 
line  or  its  relation  to  one  of  the  other  vertical  lines  described,  as,  for  example, 
the  signs  of  a  small  cavity  in  the  second  interspace,  a  measured  distance 
to  the  right — or  left — of  the  median  line;  a  presystolic  thrill  in  the  fifth 
interspace,  to  the  left  of  the  left  parasternal  line;  an  undulatory  impulse 
in  the  fourth,  fifth,  and  sixth  interspaces,  extending  to  a  point  midway 
between  the  left  midclavicular  line  and  the  line  of  the  anterior  axillary  fold. 

A  tumor  or  painful  spot  in  the  abdomen  may  be  located  in  one  of  the 
nine  regions  described  as  the  epigastric,  right  iliac,  hypogastric,  and  so  on, 
or  in  one  of  the  quadrants  of  the  abdomen. 

If  greater  accuracy  is  desired,  the  position  of  a  lesion,  physical  sign, 
or  tender  spot  may  be  stated  to  be  a  measured  distance  to  the  right  or 
left,  as  the  case  may  be,  of  the  middle  line  at  the  level  of  the  umbilicus, 
or  a  measured  distance  above  or  below  the  level  of  the  umbilicus.  Or, 
again,  the  anterior  superior  spine  of  the  ilium  may  be  taken  as  the  point 
of  departure  for  similar  measurements. 

In  the  back  the  spinous  processes  may  be  taken  as  points  of  departure 
for  the  measurements.  Thus  a  lesion  may  be  a  measured  distance  from 
the  middle  line  on  a  level  with  the  eighth  dorsal  spine  or  over  a  numbered 
interspace  or  rib. 

The  unit  of  measurement  may  be  the  centimetre,  or  the  inch,  if  pre- 
ferred, or  the  finger's  breadth  which  equals  about  2  centimetres  or  %  inch, 
or  the  hand's  breadth,  which  varies  from  about  9  to  11  centimetres  or 
3^  to  4:h  inches. 

It  is  customary  to  indicate  the  extent  of  a  lesion  or  the  size  of  a  tumor 
by  less  accurate  but  significant  anatomical  measurements;  thus  we  say 
of  a  splenic  tumor  that  it  extends  to  the  crest  of  the  iUum  or  to  the  sym- 
physis pubis  or  beyond  the  median  line,  or  of  a  distended  bladder  or  en- 
larged uterus  that  it  reaches  halfway  from  the  pubis  to  the  umbilicus  or 
to  the  level  of  that  anatomical  landmark. 


MEDICAL  TOPOGRAPHY.  25 

THE  TOPOGRAPHICAL  ANATOMY  OF  THE 
THORACIC  ORGANS. 

The  Thymus  Gland  and  its  Remnants. 

This  temporary  organ  attains  its  maximum  development  about  the 
end  of  the  second  year.  It  then  undergoes  a  gradual  involution  process 
until  it  is  reduced  to  a  mere  vestige.  When  fully  developed  it  appears 
as  a  narrow  elongated  body  lying  in  the  anterior  mediastinal  space  imme- 
diately behind  the  manubrium  sterni  and  extending  into  the  episternal 
region  of  the  neck.  Its  size  varies  according  to  the  degree  of  development. 
At  birth  it  is  about  6  centimetres  in  length,  2.5  centimetres  in  width,  and 
.75  centimetre  in  thickness.  The  thymus  is  occasionally  persistent  and 
may  then  undergo  hypertrophy.  In  this  case  and  when  enlarged  as  the 
result  of  tuberculous,  syphilitic,  or  cancerous  disease,  or  hemorrhagic  or 
purulent  infiltration,  pressure  symptoms,  namely,  paroxysmal  dyspnoea — 
so-called  thymic  asthma — persistent  dyspnoea,  spasm  of  the  glottis,  or 
venous  hyperaemia  and  local  cfidema  arise. 

The  Trachea  or  Windpipe. 

This  tubular  organ  extends  in  the  median  line  from  the  larynx  to  a 
point  opposite  the  third  dorsal  vertebra,  where  it  is  crossed  in  front  by  the 
arch  of  the  aorta,  and  there  or  immediately  below  this  level  it  bifurcates  into 
the  right  and  left  bronchi.  Its  length  is  variable,  being  in  the  adult  about 
9  to  11  centimetres,  its  width  from  2  to  2.5  centimetres.  It  is  both  wider 
and  longer  in  the  male  than  in  the  female.  The  trachea  is  movable  and 
may  be  displaced  as  well  as  compressed  by  an  aneurism  or  a  new  growth. 
Its  posterior  membranous  part  is  in  relation  with  the  oesophagus  behind, 
and  the  recurrent  laryngeal  nerves  ascend  in  the  groove  between  these 
two  organs.  The  manubrium  sterni  overlies  the  trachea,  which  traverses 
the  posterior  mediastinum. 

The  Primary  Bronchi. 

The  right  and  left  bronchi  arise  at  the  bifurcation  of  the  trachea  and 
diverge  to  the  corresponding  lung  upon  each  side,  which  they  respectively 
enter  at  the  root  to  form  by  successive  subdivisions  the  ramifications  of 
the  bronchial  tree.  The  right  bronchus — the  wider  and  shorter  of  the  two — 
passes  obhquely  downwards  and  outwards  to  the  lung  at  the  level  of  the 
fourth  dorsal  vertebra,  and  behind  the  aorta;  the  left,  smaller  in  diameter 
but  much  greater  in  length,  runs  obhquely  downwards  and  outwards 
below  the  arch  of  the  aorta  to  the  root  of  the  left  lung,  into  which  it  passes 
at  the  level  of  the  body  of  the  fifth  dorsal  vertebra.  The  length  of  the 
right  bronchus  is  about  2.5,  that  of  the  left  nearly  5  centimetres. 

Irregular  stenosis  of  the  trachea  or  a  main  bronchus,  from  an  aneu- 
rismai  or  neoplastic  tumor  or  from  a  tenacious  and  adherent  exudate,  causes 
tracheal  stridor  and  the  accumulation  of  an  abundant  liquid  exudate,  as 
in  some  forms  of  bronchitis,  and  the  pulmonary  oedema  that  precedes 
death  gives  rise  to  coarse  tracheal  rales. 


26  MEDICAL  DIAGNOSIS. 

Elasticity  of  the  Tracheobronchial  Structures. — That  these  organs 
have  a  high  degree  of  phabihty,  analogous  to  that  of  the  vesicular  structure 
of  the  lung,  is  shown  by  the  manner  in  which  they  accommodate  them- 
selves to  the  displacing  and  distorting  pressure  of  effusions,  aneurism,  and 
new  growths  of  various  kinds  without  great  impairment  of  their  function. 
That  they  possess  equally  remarkable  capacity  of  elongation  and  contrac- 
tion has  been  recently  demonstrated  by  X-ray  examination  and  the 
bronchoscope  of  Chevalier  Jackson. 

The  CEsophagus:    Gullet. 

This  tubular  organ  extends  from  the  pharynx  at  the  lower  border  of 
the  fifth  cervical  vertebra — the  level  of  the  cricoid  cartilage — along  the 
anterior  surface  of  the  borders  of  the  vertebrae,  to  pass  through  the  dia- 
phragm about  the  level  of  the  ninth  dorsal  vertebra  and  end  in  the  cardiac 
orifice  of  the  stomach.  Its  length  is  about  23  centimetres.  In  the  thorax 
it  lies  posterior  to  the  lower  part  of  the  trachea,  the  upper  part  of  the  left 
bronchus,  and  the  posterior  surface  of  the  pericardium.  The  oesophagus 
may  be  the  seat  of  simple  or  syphilitic  cicatricial  stricture;  stenosis  from 
cancerous  growth  involving  its  wall  or  pressing  upon  it  from  without  or 
from  the  external  pressure  of  an  aneurism.  Spasmodic  stricture  occurs  in 
neurotic  and  hysterical  persons,  and  the  impaction  of  a  foreign  body,  as  an 
artificial  denture,  a.  large  piece  of  meat,  or  a  bone,  may  cause  mechanical 
obstruction,  an  accident  that  occasionally  occurs  among  the  insane.  It  is 
sometimes  the  seat  of  a  diverticulum.  The  oesophagus  is  accessible  to  exam- 
ination by  the  sound,  the  oesophagoscope,  and  X-rays.  The  time  occupied  in 
swallowing  and  the  nature  of  the  accompanying  sounds  may  be  studied  by 
auscultation. 

The  Lungs  and  Pleurae. 

The  lungs  occupy  the  greater  part  of  the  cavity  of  the  chest,  enclosing 
between  their  concave  inner  surfaces  the  heart  and  great  vessels.  Each 
lung  is  attached  to  the  inner  wall  of  the  thorax  in  the  region  of  the  bodies 
of  the  fourth  and  fifth  dorsal  vertebrae  by  a  comparatively  small  pedicle 
called  the  root,  and  a  narrow  membranous  fold  continued  downwards 
from  it.  Elsewhere  the  surface  of  the  lung  is  free  and  covered  by  a  serous 
membrane,  the  pleura,  which  is  also  reflected  upon  the  inner  wall  of  the 
chest.  The  root  of  each  lung  is  composed  of  the  respective  main  bronchus 
together  with  large  blood-vessels,  lymphatic  vessels,  chains  of  lymphatic 
glands,  held  together  by  connective  tissue  and  enclosed  in  the  pleura. 

THE  PLEURA. 

Each  pleura  is  a  closed  serous  sac,  lining  the  lateral  cavity  of  the 
thorax  to  which  it  belongs,  enclosing  the  lung  and  its  root  and  forming 
by  the  aid  of  its  fellow  of  the  opposite  side  the  mediastinum.  That  part 
of  the  pleura  which  encloses  and  covers  the  lung  and  its  root  is  called 
the  visceral  or  pulmonary  pleura;  that  which  is  reflected  upon  the  ribs 
and  intercostal  spaces,  covers  the  upper  convex  surface  of  the  diaphragm, 
and  passes  to  the  sides  of  the  pericardium,  thus  forming  the  mediastinum, 


Fio.  17. — Semidiagiuinmalic  reconstruction,  showing  relations  of  pleural  sacs  (blue)  and  lungs  (led)  to 

thoracic  wall;    anterior  aspect. 


Fig.  18. — Semidiagrammatic  reconstruction,  showing  relations  of  pleural  sacs  (blue)  and  lungs  (red)  to 

body-wall:    posterior  aspect. 


Fig.   ]9. — Semidiagrammatic  reconstruction,  showing  relations  of  right  pleural  sac  (blue)  and  lung  (red 

to  thoracic  wall;  lateral  aspect. 


Fig.  20. — Semidiagrammatic  reconstruction,  showing  reliitions  of  left  pleural  sac  (blue)  and  lung  (red)  to 

thoracic  wall;  lateral  aspect. 


MEDICAL  TOPOGRAPHY.  27 

is  called  the  parietal  pleura,  or  —  as  to  its  different  parts  —  the  costal, 
diaphragmatic,  and  mediastinal  pleura;  and  these  two  parts — namely, 
the  visceral  and  the  parietal  pleura — are  continuous  with  each  other  at 
the  root  of  the  lung. 

The  upper  part  of  the  pleura  on  each  side  passes  upward  beyond  the 
clavicle  into  the  neck,  and  contains  the  apex  of  the  lung,  which  reaches 
from  2.5  to  4  centimetres  above  the  margin  of  the  first  rib,  usually  a  little 
higher  upon  one  side  than  upon  the  other,  but  not  constantly  higher  upon 
the  right  side  as  is  often  stated.  Beneath  the  sternum  the  pleural  sacs  of 
the  two  sides  come  nearly  or  quite  into  contact  in  the  upper  part,  but  in 
the  lower  part  the  right  pleura  passes  to  or  even  beyond  the  middle  line 
and  the  left  pleura  recedes  from  it  to  a  variable  distance  beyond  the  sternal 
border.  At  the  base  of  the  chest  the  pleurae  do  not  reach  to  the  attachments 
of  the  diaphragm,  but  they  are  reflected  from  the  inner  wall  of  the  chest  to 
the  rising  vault  of  the  diaphragm  in  such  a  manner  that,  on  quiet  respira- 
tion or  on  full  expiration,  the  parietal  and  visceral  pleurae  are  not  in  apposi- 
tion,'but  the  costal  and  diaphragmatic  surfaces  of  the  parietal  pleura  are 
opposed.  The  higher  position  of  the  right  diaphragmatic  vault,  due  to  the 
high  position  of  the  right  lobe  of  the  liver,  renders  the  right  pleura  somewhat 
shorter  than  the  left,  while  the  smaller  portion  of  the  heart  upon  the  right 
side  of  the  median  line  renders  the  right  pleura  somewhat  wider  than  the  left. 

THE   LUNGS. 

Each  lung  is  cone-shaped — with  its  blunt  apex  extending  into  the 
root  of  the  neck,  its  anterior  surface  flattened,  its  lateral  and  posterior 
convex  surfaces  strongly  convex,  and  its  inner  and  inferior  surfaces 
concave.  The  contour  resulting  from  this  conformation  gives  rise  to 
sharp,  well-defined  anterior  margins,  the  horizontal  sections  of  which  are 
acutely  angular,  and  to  a  similar,  sharply  angular,  circumferential  border 
at  the  base,  which  fits  into  the  corresponding  re-entrant  angle  between  the 
thoracic  wall  and  the  diaphragm — a  fact  of  no  little  importance  in  physical 
diagnosis.  Each  lung  is  divided  by  a  long,  deep  fissure,  beginning  about 
the  level  of  the  spine  of  the  scapula  and  proceeding  obliquely  downward 
and  outward  to  the  sixth  rib  in  the  midaxillary  line,  into  an  upper  and 
a  lower  lobe.  The  right  lung  is  further  divided  by  a  second,  shorter  fis- 
sure, which  passes  inward  and  upward  through  the  anterior  margin,  thus 
forming  a  third  or  middle  lobe.  Upon  the  inner  anterior  border  of  the 
left  lobe  is  situated  a  deep  notch  into  which  the  heart,  enveloped  in  its 
pericardium,  is  received,  and  at  the  inferior  part  of  this  border  of  the 
lung  is  situated  a  tongue-hke  projection  which  passes  in  front  of  the  apex 
of  the  heart — lingula. 

The  lungs  completely  fill  the  chest,  and  the  surfaces  of  the  visceral 
and  parietal  pleurae  are  accurately  in  contact  except  along  the  ante- 
rior and  inferior  margins  of  the  lungs.  In  these  situations  the  sharp 
wedge-like  borders  of  the  lung  advance  between  the  reflected  layers  of 
the  parietal  pleura  during  inspiration  and  recede  during  expiration,  as 
above  stated. 


28  MEDICAL  DIAGNOSIS. 

The  Mediastinum. 

This  space  lies  between  the  layers  of  an  anteroposterior  septum 
formed  by  the  inner  or  mesial  portions  of  the  right  and  left  plem^ae  which 
pass  upon  the  surface  of  the  pericardium  from  the  anterior  and  posterior 
walls  of  the  chest  to  the  root  of  the  lung  upon  either  side.  It  is  subdivided 
into  an  anterior,  middle  and  posterior  mediastinum. 

The  anterior  is  narrow  and  of  little  depth,  lying  directly  behind  the 
inner  surface  of  the  sternum.  At  its  upper  part  it  contains  the  atrophied 
thymus.  Behind  the  gladiolus  the  right  and  left  pleurae  are  in  contact, 
and  the  anterior  mediastinum  consists  merely  of  the  connective-tissue 
layer  by  which  they  are  joined.  Lower  down,  while  still  shallow,  it  is 
widened,  by  the  departure  of  the  left  pleura  from  the  midsternal  line,  into 
a  triangular  space  which  lies  between  the  anterior  portion  of  the  right 
ventricle  and  the  wall  of  the  thorax — the  area  of  superficial  cardiac  dulness. 

The  middle  mediastinum  is  the  large  space  between  the  mesial  layers 
of  the  two  pleurae  which  contains  the  pericardium  and  its  contents. 

The  posterior  mediastinum  lies  in  front  of  the  vertebral  bodies  and 
contains  the  trachea,  the  oesophagus,  the  thoracic  duct,  the  descending 
aorta,  the  azygos  vein,  lymphatic  vessels  and  the  pneumogastric  nerves. 

THE  PERICARDIUM. 

This  membranous  sac,  which  occupies  the  middle  mediastinum  and 
contains  the  heart  and  the  roots  of  the  great  blood-vessels,  is  conical 
in  shape,  its  base  resting  upon  the  diaphragm  and  its  apex  extending 
upwards  upon  the  walls  of  the  blood-vessels  as  far  as  their  first  sub- 
divisions. It  consists  of  two  layers,  an  external  fibrous  layer,  which 
is  attached  below  to  the  central  tendon  of  the  diaphragm,  and  above 
to  the  surface  of  the  large  blood-vessels  which  it  embraces;  and  an  inner 
serous  layer,  which  lines  the  fibrous  sac  in  which  the  heart  is  contained  and 
is  reflected  upon  the  surface  of  that  viscus  in  such  a  manner  as  to  form  a 
parietal  and  a  visceral  portion.  The  latter  is  sometimes  described  as  the 
epicardium.  The  fibrous  pericardium  is  furthermore  firmly  attached  to  the 
structures  by  which  it  is  surrounded,  namely,  the  sternum  in  front,  the 
mediastinal  pleurae  laterally,  and  the  trachea,  oesophagus,  and  main  bronchi 
behind. 

The  Heart  and  Great  Vessels. 

THE  HEART. 

This  central  organ  of  the  circulation  is  situated  in  the  cavity  of  the 
thorax  in  the  middle  mediastinum.  It  lies  unattached  within  the  peri- 
cardium except  by  the  great  vessels  which  spring  from  its  cavities  at  the 
base,  and  it  rests  upon  the  convexity  of  the  diaphragm.  Its  base  is  directed 
upward,  backward,  and  toward  the  right,  and  extends  from  the  level  of  the 
fourth  to  that  of  the  eighth  dorsal  vertebra,  while  its  apex  points  down- 
ward, forward,  and  toward  the  left,  coming  into  relation  with  the  chest  wall 
in  the  fifth  intercostal  space  a  little  to  the  left  of  the  parasternal  line.  It 
projects  farther  to  the  left  of  the  median  line  than  to  the  right  in  the 
average  ratio  of  nearlv  2  to  1. 


MEDICAL  TOPOGRAPHY. 


29 


Orthodiagraphic  measurements  have  shown  that  the  average  oblique 
diameter  of  the  heart  from  the  true  apex  to  the  angle  at  the  upper  right 
border  of  the  auricle  and  the  great  vessels  is  between  13  and  14  centimetres; 
the  horizontal  distance  from  the  midsternal  line  to  the  most  distant  point 
of  the  border  of  the  heart  on  the  right;  3.5  to  4.5  centimetres;  to  the  most 
distant  point  on  the  left,  7.5  to  8.5  centimetres. 

The  Relation  of  the  Heart  to  the  Anterior  Wall  of  the  Chest. — In 
general  the  normal  heart  in  the  adult  may  be  said  to  extend  from  the  level 
of  the  second  intercostal  space  on  the  right  side  to  the  fifth  interspace  on 
the  left.  Investigations  conducted  to 
ascertain  the  exact  relations  of  the 
viscus  to  the  chest  wall  by  thrusting 
long  needles  through  it  immediately 
after  death,  by  means  of  sections  of 
frozen  bodies,  and  by  the  X-rays  have 
not  yielded  constant  nor  concurrent 
results.  The  discrepancies  are  doubt- 
less due  to  differences  existing  natu- 
rally among  individuals  and  to  variable 
conditions,  in  themselves  equally  in- 
capable of  exact  determination:  for  ex- 
ample, the  position  of  the  diaphragm, 
the  amount  of  residual  air  in  the 
lungs,  the  quantity  of  gas  in  the  stom- 
ach and  intestines,  and  the  volume  of 
blood  in  the  chambers  of  the  heart  at 
the  time  of  examination.  For  clinical 
purposes  it  is  possible  to  be  over- 
exact  in  variable  matters  of  this  kind. 

The  greater  part  of  the  anterior 
surface  of  the  heart  is  not  directly  in 
relation  with  the  inner  chest  wall,  but 
separated  from  it  by  the  wedge-like 
anterior  borders  of  the  lungs.  The 
superior  border  of  the  heart  closely 
corresponds  to  a  transverse  line  drawn 
about  the  level  of  the  upper  edges  of 
the  third  costal  cartilages  and  extending  from  a  point  two  centimetres  from 
the  right  border  of  the  sternum  to  the  third  left  costochondral  articula- 
tion. This  line  constitutes  the  chnical  base  of  the  heart  and  subdivides 
the  precordia  into  the  cardiac  area  and  the  area  of  the  great  vessels. 

The  inferior  border  is  indicated  by  a  line  drawn  from  a  point  on 
the  upper  border  of  the  sixth  rib,  directly  below  the  outer  limit  of  the 
impulse,  obliquely  upward  and  to  the  right,  across  the  base  of  the  ensi- 
form  cartilage,  and  terminating  at  the  middle  of  the  fifth  right  interspace 
near  its  junction   with   the   sternum. 

The  right  border  nearly  coincides  with  a  hne  drawn  from  the  point 
at  which  the  superior  border  terminates  on  the  right,  convex  to  the  right, 
to  the  middle  of  the  fifth  interspace  as  above,  namely,  about  2  centimetres 
to  the  right  of  the  right  sternal  border. 


Fig.  21.  —  Outline  of  heart  and  lines  indi- 
cating the  auriculoventricuJar  groove  and  the 
anterior  interventricular  groove. 


30  MEDICAL  DIAGNOSIS. 

The  left  border  is  marked  by  a  line  joining  the  apex  and  the  articula- 
tion of  the  third  left  rib  with  its  cartilage. 

A  line  joining  the  third  left  chondrosternal  articulation  and  the  seventh 
right  chondrosternal  articulation  corresponds  fairly  well  with  the  hne  of 
the  auriculoventricular  septum. 

A  line  joining  the  apex  and  the  third  left  costochondral  articulation 
corresponds  closely  with  the  interventricular  septum. 

The  gi-eater  part  of  the  anterior  surface  of  the  heart  is  formed  by  the 
right  ventricle  and  constitutes  a  triangle  included  between  the  above  hues 
and  the  inferior  border  of  the  heart.  The  apex  of  this  triangle  is  occupied 
by  the  conus  arteriosus  and  the  tip  of  the  left  auricular  appendix. 

The  upper  third  of  the  right  auricle  lies  behind  the  sternum,  while 
its  two  lower  thirds  extend  to  the  right  of  the  sternal  edge  and  are  bounded 
by  the  curved  right  border  of  the  heart. 

The  left  auricle  is  deeply  seated  and  is  completely  covered  by  the 
body  of  the  heart  and  the  left  lung. 

The  left  ventricle  is  likewise  deeply  seated  and  wholly  retired  from 
the  surface  of  the  chest  with  the  exception  of  a  narrow  longitudinal  strip 
which  forms  the  left  border  of  the  heart  and  presents  anteriorly,  and  of 
which  the  lower  end  constitutes  the  true  or  anatomical  apex  of  the  heart, 
and  is  separated  from  the  chest-wall  by  the  Hngula,  the  clinical  apex  to 
which  the  impulse  is  due  being  the  apex  of  the  right  ventricle. 

That  portion  of  the  anterior  surface  of  the  heart  which,  uncovered 
by  the  borders  of  the  lungs,  comes  into  relation  with  the  wall  of  the  chest, 
constitutes  the  area  of  superficial  cardiac  dulness  and  may  be  more  or  less 
accurately  defined  by  percussion;  that  which  recedes  by  its  rounded  sur- 
faces from  the  chest  wall  and  is  covered  by  a  rapidly  thickening  volume 
of  lung  tissue  is  described  as  forming  the  area  of  deep  cardiac  dulness  and 
cannot  be  defined  with  the  nicety  which  some  assume  by  the  ordinary 
methods  of  physical  diagnosis,  though  the  shadow  of  its  borders  may  be  seen 
expanding  and  contracting  with  the  revolutions  of  the  heart  upon  X-ray 
examination. 

THE  GREAT  VESSELS. 

The  ascending  arm  of  the  arch  of  the  aorta  arises  at  the  base  of  the 
left  ventricle  of  the  heart  behind  the  pulmonary  artery.  Its  course  is  at 
first  upward  and  to  the  right  and  slightly  forward  as  it  passes  behind  the 
sternum.  At  the  level  of  the  second  right  costal  or  aortic  cartilage,  the 
vessel  passes  upward,  backward,  and  to  the  left,  forming  the  transverse  por- 
tion of  the  arch,  then  backward  and  downward  to  form  the  descending  arm 
of  the  arch  which  terminates  in  the  descending  portion  of  the  thoracic  aorta. 

The  pulmonary  artery  passes  a  little  more  than  a  centimetre  beyond 
the  left  border  of  the  sternum  in  a  hne  about  the  level  of  the  middle  of 
the  left  third  interspace  upward  to  the  second  costal  cartilage,  behind  which 
it  divides  into  its  right  and  left  main  branches. 

The  descending  vena  cava  extends  from  the  second  interspace  on  the 
right  side  of  the  sternum  to  the  base  of  the  heart,  which  it  enters  at  the 
level  of  the  middle  of  the  third  interspace.  Its  course  is  slightly  curved, 
the  convexity  being  toward  the  right. 


MEDICAL  TOPOGRAPHY. 


31 


These  vessels  are  situated  at  varying  depths  behind  the  manubrium 
sterni  and  in  an  area  extending  beyond  the  right  and  left  sternal  borders. 
This  region  is  sometimes  designated  the  area  of  the  great  vessels. 

The  Relation  of  the  Valves  of  the  Heart  to  One  Another  and  to  the 
Surface  of  the  Chest. — The  hues  of  attachment  of  the  bases  of  the  mitral 
and  tricuspid  valves  correspond  to  the  auriculoventricular  sulcus.  The 
semilunar  cusps  of  the  aortic  and  pulmonary  valve  systems  are  situated 
respectively  at  the  origin  of  each  of  those  vessels  from  the  ventricles. 
The  four  sets  of  valves  lie  in  close  proximity  to  one  another  and  to  some 
extent  overlap.  The  pulmo- 
nary is  most  superficial;  the 
mitral  most  deeply  situated; 
the  aortic  centrally  placed  and 
in  parts  of  its  extent  covered 
by  the  pulmonary;  and  the 
tricuspid  lowest  in  position. 

Their  relations  to  the  sur- 
face of  the  chest  are  as  follows: 

The  pulmonary  valve  lies 
horizontally  immediately  to  the 
left  of  the  sternal  border  at 
the  level  of  the  upper  edges  of 
the  third  left  costal  cartilage. 

The  aortic  valve  is  at  a  level 
slightly  lower  than  the  pulmo- 
nary and  situated  behind  the 
sternum  at  the  level  of  the  third 
left  intercostal  space  and  to 
the  left  of  the  median  line. 
It  is  nearly  horizontally  placed. 

The  mitral  valve  —  left 
auriculoventricula  r — 1  i  e  s 
obliquely  behind  the  sternum 
to  the  left  of  the  median  line 
extending  from  the  level  of  the 
fourth  to  that  of  the  upper  bor- 
der of  the  fifth  costal  cartilage. 

The  tricuspid  valve — right  auriculoventricular — lies  still  more  obliquely 
behind  the  sternum  in  a  line  drawn  from  a  point  in  the  midsternal  line 
on  the  level  of  the  third  interspace  to  the  sixth  chondrosternal  articulation. 

These  four  valve  systems  are  so  close  to  one  another  that  the  sounds 
produced  by  each  cannot  be  studied  by  auscultation  directly  over  the  seat 
of  the  valve,,  but  at  that  point  in  the  precordia  at  which  the  blood  stream 
at  the  moment  directly  affecting  the  particular  valve  mechanism  approaches 
the  surface  of  the  chest  most  closely. 

Puncta  Maxima. — These  areas,  of  which  there  are  four,  corresponding 
to  the  separate  valve  systems,  are: 

1.  The  pulmonary  area — at  the  inner  end  of  the  second  left  intercostal 
space. 


Fig.  22. — Position  of  heart  and  valves  in  relation  to 
anterior  thoracic  wall.  A,  aortic  valve;  P,  valve  of  pul- 
monary aorta;  T,  tricuspid  valve;  M,  mitral  valve;  and 
puncta  maxima  indicated  by  red  circles. 


32  MEDICAL  DIAGNOSIS. 

2.  The  aortic  area — at  the  second  right  costal  cartilage. 

3.  The  mitral  area — at  and  just  above  the  position  of  the  apex-beat. 

4.  The  tricuspid  area — at  the  right  border  of  the  lower  end  of  the  sternum. 

THE  TOPOGRAPHICAL  ANATOMY  OF  THE 
ABDOMINAL  VISCERA. 

The  Stomach. 

The  stomach  is  that  dilated  portion  of  the  alimentary  canal  which 
lies  between  the  cardiac  end  of  the  oesophagus  and  the  pyloric  end  of  the 
duodenum.  It  is  irregularly  gourd-shaped,  the  larger  left  end  being  called 
the  fundus  or  splenic  extremity;  the  smaller  right  end  the  pyloric  extremity. 
The  orifice  by  which  the  CBSophagus  enters  is  called  the  cardia  or  cardiac 
orifice,  that  passing  to  the  duodenum  the  pylorus.  The  former  is  imme- 
diately below  the  central  part  of  the  diaphragm  and  lies  between  the  greater 
and  lesser  curvatures.  The  latter  lies  lower  down,  more  toward  the  anterior 
abdominal  wall,  and  to  the  right.  The  shorter  inner  curvature  of  the 
gourd  is  known  as  the  lesser,  the  longer  outer  curvature  is  the  greater 
curvature  of  the  stomach.  This  hollow  viscus  hes  chiefly  in  the  epigastric 
and  left  hypochondriac  regions,  the  greater  part  of  its  extent  being,  when 
distended,  in  about  the  proportion  of  1  to  5,  to  the  left  of  the  median  line. 
During  physiological  rest  the  healthy  stomach  contains  only  a  little  mucus 
and  a  small  accumulation  of  air  or  gas  which  occupies  its  fundus,  and 
forms  a  narrow  wrinkled  pouch,  the  long  diameter  of  which  is  obhque  from 
the  cardia  downward  and  to  the  right  and  approaches  much  more  nearly 
to  the  vertical  than  to  the  transverse  axis  of  the  body.  Its  superior  border 
is  fixed  at  the  cardia  at  the  point  at  which  the  oesophagus  pierces  the  dia- 
phragm and  is  attached  to  the  overlying  Hver  and  diaphragm  by  the 
gastrohepatic  omentum  and  the  gastrophrenic  ligament.  The  gastrocolic 
omentum  is  attached  to  the  lower,  the  gastrosplenic  omentum  to  the  left 
border.  The  anterior  surface  is  in  relation  with  the  diaphragm  and  under 
surface  of  the  liver  above  and  the  wall  of  the  abdomen  lower  down;  the 
posterior  surface  is  in  relation  with  the  great  vessels  and  pancreas  above 
and  the  transverse  mesocolon  lower  down.  Both  these  surfaces  are  free, 
smooth,  and  invested  with  peritoneum.  When  the  stomach  is  distended, 
it  rotates  upon  its  cardiopyloric  axis  in  such  a  manner  that  the  anterior 
surface  tends  to  look  upward  and  the  posterior  surface  downward.  The 
dimensions  of  the  stomach  vary  according  to  the  degree  of  distention  caused 
by  food,  fluid,  or  gas.  When  moderately  filled,  its  longest  diameter  is  about 
25  centimetres,  its  diameter  between  the  greater  and  lesser  curvature  from 
9.5  to  12  centimetres,  and  the  diameter  between  its  anterior  and  posterior 
walls  about  9  centimetres.  When  much  distended,  a  normal  stomach  may 
reach  to  the  level  of  the  umbilicus. 

The  cardia  is  situated  in  a  direct  line  posterior  to  the  left  seventh 
chondrosternal  articulation  at  a  distance  of  about  10  to  12  centimetres 
from  the  anterior  abdominal  wall.  The  pylorus,  which  has  considerable 
freedom  of  motion,  lies  about  the  level  of  the  tip  of  the  ensiform  cartilage 
and  near  the  outer  border  of  the  right  rectus  muscle.    It  is  in  relation  with 


MEDICAL  TOPOGRAPHY.  33 

the  concave  surface  of  the  Hver  and  may  extend  to  the  neck  of  the  gall- 
bladder. When  the  stomach  is  distended  the  pylorus  assumes  a  position 
further  to  the  right  and  lower  in  the  abdomen.  The  fundus  rises  into  the 
vault  of  the  diaphragm  to  the  level  of  the  fifth  interspace  in  the  midaxillary 
line  and  is  higher  than  the  cardia,  just  as  the  lateral  vault  of  the  diaphragm 
is  higher  than  its  central  aponeurosis.  Its  upper  part  lies  behind  the  anterior 
diaphragmatic  border  of  the  left  lung  and  the  tips  of  the  seventh,  eighth, 
and  ninth  left  ribs  and  their  cartilages.  The  convex  curve  of  Traube's 
semilunar  space  in  this  region  corresponds  with  the  curvature  of  the  fundus 
of  the  stomach. 

The  Intestines. 

A.  The  small  intestine  begins  at  the  pylorus  and  terminates  at  the 
ileocaecal  valve,  at  which  point  it  joins  the  large  bowel.  It  has  an  average 
length  in  the  adult  of  about  six  metres.  Its  convolutions  occupy  the  middle 
parts  of  the  abdomen  and  are  surrounded  by  the  large  intestine.  They  are 
attached  to  the  back  wall  of  the  abdominal  cavity  by  the  mesentery. 
The  small  intestine  is  divided  into  (1)  an  upper  portion,  or  duodenum, 
about  25  to  30  centimetres  in  length,  into  which  in  its  middle  third  the 
common  bile  duct  and  pancreatic  duct  discharge  their  contents;  (2)  a 
middle  portion,  or  jejunum;  and  (3)  a  lower  portion,  or  ileum.  In  the  last 
are  situated  Peyer's  patches.  The  duodenum  is  the  widest  and  least  mov- 
able of  the  three  portions  of  the  intestines.  The  coils  of  the  jejunum  and 
ileum  are  freely  movable  within  the  abdomen  and  among  themselves  and 
bear  no  constant  relation  to  the  regions  of  the  surface. 

B.  The  large  intestine  extends  from  the  termination  of  the  small 
intestine  at  the  ileocaecal  valve  to  the  anus.  Its  average  length  is  between 
1.5  and  2  metres.  Its  diameter  varies  at  different  parts  and  ranges  from 
3.5  to  6  centimetres.  There  is  a  pouch-like  dilatation  of  the  rectum  im- 
mediately above  its  lower  end.    It  is  divided  into  three  parts. 

(1)  The  Caecum  ;  Intestinum  Caecum ;  Caput  Caecum  Coli. — The  shortest 
and  widest  part  of  the  large  intestine.  It  measures  in  length  and  width 
each  about  6  centimetres.  As  a  rule,  there  is  no  mesocsecum,  and  this 
part  of  the  intestine  is  attached  to  the  fascia  covering  the  right  iliacus 
muscle.  The  caecum  is  situated  in  the  right  iliac  fossa  and  is  comparatively 
fixed.  Its  position  determines  that  of  the  ileocaecal  valve  which  lies  between 
6  and  7  centimetres  mesial  to  the  right  anterior  superior  spinous  process. 

(2)  The  appendix  vermiformis  arises  from  the  inner  and  posterior 
aspect  of  the  caecum  near  the  ileocaecal  valve.  It  lies  in  the  right  iliac  region 
and  its  base  is  opposite  McBurney's  point.  Its  dimensions  are  extremely 
variable,  its  width  being  that  of  a  large  quill  and  its  length  from  6.5  to  9  cen- 
timetres. From  its  comparatively  fixed  base,  the  appendix,  being  free,  may 
extend  in  any  direction.  As  a  rule  it  lies  downward  or  inward.  It  may, 
however,  extend  backward,  in  which  case  the  symptoms  of  appendicitis  may 
suggest  renal  colic;  or  upward,  and,  if  inflamed,  suggest  gall-bladder  disease. 

(3)  The  CoIon„ — This  part  of  the  large  intestine  constitutes  its  great- 
est length.  It  occupies  the  peripheral  parts  of  the  abdominal  cavity,  and, 
owing  to  the  lack  of  a  mesocolon  in  its  ascending  and  a  portion  of  its 
descending  course,  maintains   a   comparatively   fixed   position.      In   some 

3 


34  MEDICAL  DIAGNOSIS. 

instances  there  is  a  short  mesocolon  in  these  portions.  It  is  divided, 
according  to  its  course  and  direction,  into  four  parts,  namely,  an  ascend- 
ing, a  transverse,  a  descending  portion,  and  the  rectum. 

(a)  The  ascending  colon,  commencing  at  the  ceecum,  passes  upward 
in  a  vertical  direction  to  the  under  surface  of  the  Hver  near  the  gall-bladder, 
where  it  turns  forward  and  sharply  to  the  left,  forming  the  hepatic  flexure. 
It  is  as  a  rule  fixed  in  its  whole  course  and  overlaid  by  some  coils  of  the 
ileum.     It  is  contained  in  the  right  lumbar  and  hypochondriac  regions. 

(b)  The  transverse  colon  passes  across  the  umbilical  region  from  the 
right  to  the  left  hypochondrium.  It  is  deeply  situated  at  its  right  and  left 
extremities,  but  in  its  intermediate  course  it  bends  forward  and  approaches 
the  anterior  wall  of  the  abdomen— arch  of  the  colon.  It  rises  shghtly  at  its 
left  extremity  to  pass  behind  the  costal  margin  in  relation  with  the  fundus 
of  the  stomach  and  turns  abruptly  downward  to  form  the  splenic  flexure. 

(c)  The  descending  colon  is  continuous  with  the  transverse  colon  at 
the  splenic  flexure.  It  descends  nearly  directly  downward  through  the  left 
hypochondrium  and  lumbar  region  to  the  left  iliac  region,  where  it  curves 
inward  and  then  downward  to  form  the  sigmoid  flexure.  The  descending 
colon  is  covered  only  in  front  and  at  its  sides  by  peritoneum,  but  the  sig- 
moid flexure  has  a  distinct  mesocolon  and  is  freely  movable.  The  latter  lies 
well  toward  the  front  of  the  cavity  of  the  abdomen  in  the  left  ihac  region. 

(d)  The  rectum,  notwithstanding  its  name,  is  not  straight  in  man, 
but  curved  from  its  beginning  at  the  brim  of  the  pelvis  in  front  of  the  left 
sacro-ihac  articulation  obliquely  downward  from  left  to  right  to  the  middle 
line  of  the  sacrum,  then  forward  in  the  hollow  of  the  sacrum  to  the  level 
of  the  prostate  in  the  male  or  the  vagina  in  the  female,  where  it  again  turns 
and  proceeds  downward  and  obHquely  backward  to  the  anus.  This  part 
of  the  large  intestine  lies  entirely  within  the  pelvis,  but  is  accessible  to 
examination  by  the  finger,  the  rectal  bougie,  and  the  proctoscope. 

The  Liver. 

The  Hver  is  the  largest  gland  in  the  body  and  occupies  a  large  space 
in  the  abdominal  cavity.  It  measures  from  22  to  24  centimetres  in  its 
transverse,  about  15  centimetres  in  its  maximum  anteroposterior,  and 
14  to  16  centimetres  in  its  maximum  vertical  diameter.  It  is  large  and 
rounded  in  its  right  extremity;  narrow  and  wedge-shaped  toward  the  left; 
convex  and  smooth  upon  its  upper  surface;  concave,  uneven,  traversed 
by  various  fissures,  and  showing  the  gall-bladder  and  extrahepatic  bile  pas- 
sages upon  its  lower  surface.  The  rounded,  thick  posterior  part  is  the  most 
fixed;  the  thin,  sharp  anterior  margin  the  most  movable  part  of  the  organ. 

The  liver  occupies  the  right  hypochondriac  and  extends  across  the 
epigastrium  into  the  left  hypochondriac  region.  It  is  closely  adapted  to 
the  vault  of  the  diaphragm  and  is  in  relation  with  the  anterior  wall  of  the 
abdomen  on  the  right  side  as  far  down  as  the  margin  of  the  ribs.  The  right 
lobe  reaches  higher  than  the  left — a  fact  in  accord  with  the  shorter  vertical 
diameter  of  the  right  thorax  as  compared  with  the  left.  At  its  highest 
point  the  convex  upper  surface  of  the  right  lobe  of  the  liver  correspondi? 
to   the  fourth  intercostal   space   in   the   midclavicular    line.      The    upper 


MEDICAL  TOPOGRAPHY, 


35 


boundary  gradually  declines  to  the  base  of  the  ensiform  cartilage  in  the 
direction  toward  the  left  and  continues  on  the  right  and  to  the  back  almost 
upon  the  same  level,  crossing  the  midaxillary  line  at  the  level  of  the  seventh 
intercostal  space  and  the  line  of  the  angle  of  the  scapula  about  the  level  of 
the  ninth  rib.  Owing  to  the  dome-like  shape  of  the  upper  surface  of  the 
right  lobe  of  the  liver  and  the  concavity  of  the  base  of  the  lung  into  which 
it  is  adapted,  the  diaphragm  being  interposed,  there  is  a  considerable 
difference  in  the  level  of  the  actual  upper  border  of  the  organ  and  that  of 
the  portion  which  lies  in  contact  with  the  wall  of  the  thorax.     The  latter 


Fig.  23. — Aieas  of  deep  and  superficial  hepatic 
dulness. 


Fig.  24. — Areas  of  deep  aud  superficial 
hepatic  dulness. 


in  the  midclavicular  line  corresponds  with  the  sixth  rib;  in  the  mid- 
axillary  line  with  the  eighth  rib,  and  posteriorly  with  the  tenth  rib.  Upon 
percussion  that  portion  of  the  liver  which  lies  in  relation  with  the  wall  of 
the  chest  yields  well-marked  dulness;  that  which  is  covered  by  the  inter- 
posed border  of  the  lung  modified  dulness.  The  former  is  spoken  of  as  the 
area  of  superficial  hepatic  dulness,  the  latter  as  the  area  of  deep  hepatic 
dulness,  and  these  two  areas  together  constitute  the  area  of  hepatic  dulness. 
The  lower  anterior  margin  corresponds  in  the  midclavicular  line  with 
the  margin  of  the  ribs;  in  the  median  line  it  lies  slightly  above  a  horizontal 
line  midway  between  the  base  of  the  ensiform  cartilage  and  the  umbilicus; 
about  the  left  parasternal  line  at  the  lower  border  of  the  sixth  rib;  in  the 
right  midaxillary  line  at  the  tenth  interspace;  and  at  the  spine  about  the 
level  of  the  eleventh  intercostal  space. 


36 


MEDICAL  DIAGNOSIS. 


The  interlobar  notch  hes  nearly  in  the  median  line.  The  thin  edge 
of  the  left  lobe  reaches  closely  to  the  midclavicular  line.  To  the  right  of 
the  right  midclavicular  line  the  lower  border  corresponds  approximately 
to  the  costal  margin.  In  aged  persons  the  liver  occupies  a  slightly  higher 
level;  in  children  it  is  large  in  proportion  to  the  size  of  the  body  and  extends 
higher,  displacing  the  apex  beat  of  the  heart  to  a  point  behind  the  fifth 
rib  or  in  the  fourth  interspace,  and  causing  the  lower  border  to  fall  below 
the  line  above  indicated  bv  1  or  2  centimetres. 


The  Qall= Bladder  and  Extrahepatic  Bile  Passages. 

THE  GALL=BLADDER. 

This  membranous  sac  is  situated  in  a  fossa  in  the  base  of  the  liver. 
It  is  pear-shaped,  measuring  in  its  long  diameter  from  7  to  10  centimetres 
and  in  its  greatest  transverse  diameter  about  4  centimetres.  It  hes  ob- 
liquely, with  its  fundus,  which  projects  beyond  the  anterior  margin  of  the 

gland,  looking  downward,  forward, 
and  to  the  right.  There  is  often  a 
slight  notch  in  the  margin  of  the  liver 
at  this  point,  which  corresponds  to 
the  outer  border  of  the  right  rectus 
muscle  at  the  level  of  the  inner  edge 
of  the  ninth  costal  cartilage. 

THE  EXTRAHEPATIC  BILE 
PASSAGES. 

The  Cystic  Duct. — The  neck  of 
the  gall-bladder,  which  grows  gradu- 
ally narrower,  forms  a  double  curve 
like  the  letter  S,  and  then  becoming 
much  constricted  it  turns  abruptly 
downward  to  form  the  cystic  duct, 
which  runs  downward  and  to  the  left 
and  unites  with  the  hepatic  duct  to 
form  the  common  duct. 

The  Hepatic  Duct. — This  duct 
is  formed  by  the  union  of  a  right  and 
a  left  branch,  which  issue  from  the 
transverse  fissure  and  unite  at  an 
obtuse  angle.  Its  diameter  is  3  or  4 
millimetres  and  its  length  about  4 
centimetres.  It  unites  with  the  cystic 
duct  to  form  the  common  duct. 
The  Common  Bile  Duct;  Ductus  Communis  Choledochus. — This 
is  the  largest  of  the  bile  passages,  being  5  or  6  millimetres  in  width  and  6 
centimetres  or  more  in  length.  It  runs  downward  and  backward  to  the 
inner  and  posterior  wall  of  the  duodenum,  where,  uniting  with  the  pancre- 
atic duct  to  form  a  dilatation,  known  as  the  ampulla  of  Vater,  it  penetrates 
the  wall  of  the  duodenum  very  obliquely  in  the  course  of  its  middle  third. 


Fig.  25. — Position  of  fundus  of  gall-bladder. 


MEDICAL  TOPOGRAPHY. 


37 


Pathological  conditions  involving  the  ducts,  such  as  cholangitis  and 
gall-stone  disease,  do  not  directly  give  rise  to  physical  signs,  but  they  cause 
serious  symptoms  and,  indirectly,  marked  physical  signs,  and  a  knowledge 
of  the  position  and  size  of  these  ducts  and  their  relations  to  each  other  is 
of  prime  importance  in  the  diagnosis  of  the  diseases  to  which  they  are  liable. 

The  weight  of  the  liver  and  its  direct  relationship  with  the  diaphragm 
render  it  to  a  high  degree  subject  to  the  influence  of  gravity  in  different 
postures  of  the  body,  as,  for  example,,  the  erect  position  as  compared  with  the 
dorsal  decubitus,  and  to  the  influence  of  the  respiratory  movements.  Due 
allowance  for  these  changes  in  the  position  of  the  organ  is  to  be  made  in  its 
physical  examination. 

The  Pancreas. 

This  elongated,  flattened  gland  is  situated  deeply  in  the  abdominal 
cavity  directly  behind  the  stomach  and  at  the  level  of  the  first  lumbar 
vertebra.  The  larger  right  extremity  is  called  the  head  and  is  embraced 
by  the  curvature  of  the  duodenum.  Its  smaller  left 
extremity,  the  tail,  is  situated  in  a  slightly  higher  level 
than  the  head  and  reaches  to  the  spleen,  with  which  it 
is  in  contact.  This  organ  varies  considerably  in  size, 
being  between  15  and  20  centimetres  in  length,  about 
4  centimetres  in  average  breadth,  and  about  2.5  centi- 
metres in  thickness.  It  extends  across  the  epigastric 
region  and  into  the  right  and  left  hypochondrium.  Its 
principal  duct  traverses  the  entire  length  of  the  gland 
and  in  association  with  the  common  bile  duct  enters 
the  duodenum  by  an  oblique  passage  through  its  wall. 
Its  great  depth  in  the  body  renders  it  as  a  rule  inac- 
cessible to  direct  physical  examination.  The  close 
relations  of  the  head  of  the  pancreas  with  the  portal 
vein,  the  inferior  vena  cava,  and  the  ductus  communis 
choledochus  are  of  clinical  importance,  since  malig- 
nant or  other  disease  attended  by  enlargement  of  that 
part  of  the  gland  constitutes  a  not  infrequent  cause 
of  oedema,  ascites,  or  persistent  jaundice. 


The  Spleen. 

This  soft,  vascular  organ  is  situated  in  the  left 
hypochondrium,  opposite  the  ninth,  tenth;  and  eleventh 
ribs,  and  in  the  posterolateral  portion  of  the  upper 
part  of  the  abdominal  cavity.  It  undergoes  consid- 
erable variation  in  size  in  health  and  may  be  enor- 
mously enlarged  in  disease.  It  is  irregularly  oval  in 
shape,  its  upper  and  posterior  borders  being  rounded  and  thick,  its  lower 
and  anterior  borders  sharp  and  the  latter  indented  by  two  or  more  notches. 
Its  convex  outer  surface  is  in  relation  with  the  inner  surface  of  the  left 
side  of  the  diaphragm.  Its  concave  inner  surface  presents  a  vertical  fis- 
sure called  the  hilus,  and  is  in  relation  at  its  posterior  portion  with  the 


Fig.  26.— Position  of 
spleen. 


38  MEDICAL  DIAGNOSIS. 

suprarenal  capsule  and  the  upper  part  of  the  left  kidney,  and  at  its  ante- 
rior portion  with  the  stomach,  the  splenic  flexure  of  the  colon,  and  coils  of 
the  small  intestine.  Its  average  long  diameter  under  normal  conditions 
is  between  8  and  10  centimetres  and  it  cannot  be  felt  upon  palpation. 
Supernumerary  spleens  are  not  uncommon. 

The  Kidneys. 

The  right  and  left  kidneys  are  deeply  seated  in  the  lumbar  region  in 
the  back  part  of  the  cavity  of  the  abdomen  and  behind  the  peritoneum, 
opposite  the  last  dorsal  and  the  first,  second,  and  sometimes  the  third 
lumbar  vertebrae.  The  position  of  the  right  kidney  is  slightly  lower  than 
that  of  the  left.  Each  kidney  is  about  9  centimetres  long,  6.5  centimetres 
in  width,  and  3  centimetres  in  thickness,  the  left  being  usually  longer  and 
thinner  than  the  right.  Their  oblong,  rounded  concavo-convex  shape  is 
characteristic.  The  convexity  of  each  is  directed  outward  and  backward; 
the  concavity  inward  and  shghtly  forward.  Near  the  middle  of  the  con- 
cave surface  is  a  longitudinal  fissure  or  hilus  at  which  the  vessels  and 
nerves  enter  or  emerge  and  the  ureter  arises.  This  excretory  duct  expands 
within  the  hilus  into  the  pelvis  of  the  kidney,  from  which  arise  three  or 
sometimes  two  funnel-shaped  spaces  which  subdivide  into  a  number  of 
smaller  tubes  called  calices  or  infundibula,  similarly  funnel-shaped  but 
into  which  the  papillae  of  the  kidney  project.  The  kidnej^s  are  supported 
by  the  vessels  and  the  perirenal  fat.  The  right  kidney  is  in  relation  with 
the  duodenum  and  colon  in  front  and  the  liver  above;  the  left  with  the 
spleen  above  and  colon  anteriorly.  Both  He  against  the  corresponding 
pillar  of  the  diaphragm,  the  anterior  layer  of  the  lumbar  fascia,  and  the 
psoas  muscle.  The  deep  situation  of  the  kidneys  and  the  thick  layers  of 
muscles  against  which  they  rest,  embedded  in  a  layer  of  fat  behind,  render 
them  under  normal  circumstances  inaccessible  to  the  ordinary  methods 
of  physical  examination.  When  they  are  displaced  or  enlarged  they  present 
characteristic  physical  signs.  The  suprarenal  bodies  are  also  beyond  the 
reach  of  the  usual  procedures  of  physical  diagnosis.  The  ureters  descend 
from  the  hilus  of  each  kidney  to  enter  the  bladder  at  its  base.  When 
dilated — hydronephrosis — they  form  characteristic  abdominal  tumors. 

The  Bladder. 

When  empty  this  organ  lies  below  the  symphysis  pubis;  when  dis- 
tended it  gives  rise  to  a  globular  area  of  dulness  in  the  hypogastrium. 
In  some  neglected  cases  of  urethral  stricture  or  enlarged  prostate  an  over- 
distended  bladder  forms  a  large  fluctuating  tumor,  reaching  as  high  as  the 
umbilicus  and  inclining  somewhat  more  to  one  side  of  the  median  line 
than  to  the  other. 


III. 

THE  EXAMINATION  OF  THE  PATIENT  AND  CASE-TAKING. 

Case=Taking. 

An  accurate  knowledge  of  the  facts  in  the  case  constitutes  the  first 
requisite  to  a  diagnosis.  Those  relating  to  the  medical  life  of  the  patient 
and  his  illness  up  to  the  time  of  his  coming  under  observation  are  known 
as  the  HISTORY  of  the  case,  or  the  anamnesis;  those  relating  to  his 
immediate  circumstances,  alike  subjective  or  objective,  are  described 
under  the  heading  present  condition,  or  status  pr^esens. 

The  examination  to  ascertain  the  necessary  facts  should  be  conducted 
in  an  orderly  and  systematic  manner.  Time  is  thus  saved,  a  general  sur- 
vey of  the  clinical  phenomena  made,  and  those  of  chief  importance  brought 
into  contrast  and  proper  relation  with  those  of  subordinate  value.  Data 
not  otherwise  obvious  are  brought  to  light  and  the  chances  of  oversight 
minimized.  Vague  and  pointless  inquiries  are  omitted.  The  interrogation 
is  precise  and  explicit.  Above  all,  leading  questions  are  to  be  avoided. 
Running  comments  in  the  presence  of  the  patient  produce  an  especially 
unfavorable  effect.  Tact  and  patience  are  necessary.  An  examination 
thus  conducted  has  a  favorable  influence  upon  the  patient,  especially  in 
chronic  and  difficult  cases,  and  always  inspires  confidence.  The  investiga- 
tion should  not  be  unduly  extended  or  minute.  The  examination  of  an 
experienced  and  thoroughly  trained  clinician  stands  in  striking  contrast 
to  the  vague  and  unsystematic  questions  of  the  beginner.  On  the  other 
hand,  the  inquiry  may  be  too  concise  and  brief.  The  former  method  has 
been  spoken  of  as  the  extensive,  the  latter  as  the  intensive.  The  middle 
course  is  the  best. 

There  are  two  principal  modes  of  case-taking,  the  synthetic  and  the 
analytic. 

THE  SYNTHETIC  METHOD. 

In  the  synthetic,  sometimes  spoken  of  as  the  historical  method,  the 
inquiry  begins  with  the  history  of  the  patient,  rather  than  with  his  present 
condition.  His  place  of  birth,  age,  social  state,  occupation,  previous  dis- 
eases, habits,  hereditary  and  constitutional  tendencies  are  first  ascertained, 
then  follows  an  investigation  into  the  beginning  and  progress  of  the  present 
illness.  All  this  constitutes  the  anamnesis.  The  status  praesens  is  then 
considered.  The  condition  of  the  several  physiological  systems,  the  diges- 
tive, the  circulatory,  the  respiratory,  the  genito-urinary,  the  nervous,  and 
so  on,  being  carefully  inquired  into  in  regular  order.  Finally,  the  symp- 
toms and  signs  referable  to  the  organs  or  structures  especially  affected 
are  carefully  studied.  The  next  step  in  the  process  is  the  diagnosis,  upon 
which  the  prognosis,  treatment  and  general  management  of  the  case  depend. 
Case-taking  by  this  method  follows  the  natural  order.     It  is  scientific  and 

39 


40  MEDICAL  DIAGNOSIS. 

useful  in  obscure  cases.  The  chief  objections  to  it  are  the  time  it  consumes 
and  the  fact  that  in  the  progress  of  the  inquiry  unnecessary  attention  must 
be  given  to  facts  which  are  found  later  to  have  little  or  no  bearing  upon 
the  patient's  present  condition. 

THE  ANALYTICAL  METHOD. 

In  the  analytical  method  the  order  of  procedure  is  reversed.  The 
principal  symptoms  are  taken  as  the  point  of  departure  for  the  investiga- 
tion. The  organ  or  region  to  which  these  symptoms  are  referred  is  exam- 
ined by  the  proper  diagnostic  measures.  The  general  condition  of  the 
patient,  his  facies,  the  state  of  nutrition  of  his  body,  his  posture,  his  move- 
ments, are  carefully  observed;  meanwhile  he  is  questioned  as  to  the  dura- 
tion and  progress  of  the  present  illness  and  an  inquiry  is  made  into  such  ■ 
facts  in  his  previous  history  and  antecedents  as  may  bear  upon  the  case. 
The  chnical  study  is  then  extended,  the  condition  of  the  other  organs  inves- 
tigated, the  history  of  the  case  more  systematically  reviewed,  an  opinion 
formed  as  to  whether  the  malady  is  general  or  local  and  a  diagnosis  reached. 
This  is  the  plan  commonly  pursued  in  ordinary  professional  work  where  the 
data  are  sufficient  for  a  diagnosis  by  the  direct  method,  and  is  available 
in  all  cases  except  those  where  the  symptoms  are  obscure  and  ill  defined. 

QUESTIONS. 

Great  care  is  necessary  in  formulating  questions.  It  is  not  sufficient 
to  ask  the  patient  if  the  present  illness  began  with  a  chill  and  be  content 
with  an  affirmative  answer.  Many  patients  regard  the  transient  shivering 
which  so  often  marks  the  onset  of  an  acute  febrile  disease  as  a  chill,  whei-eas 
it  is  a  very  different  matter  from  the  prolonged  and  intense  rigor  that 
attends  the  onset  of  pneumonia  or  the  malarial  paroxysm.  The  physician 
must  be  on  his  guard  also  in  regard  to  statements  made  by  patients  or  their 
friends  concerning  their  previous  illnesses.  Very  often  such  diagnoses  are 
popular  rather  than  professional,  and  questions  must  be  so  framed  as  to 
determine  their  accuracy.  Accounts  of  influenza,  malaria,  catarrh  of  the 
stomach,  rheumatism,  and  the  like  cannot  be  accepted  without  close  inves- 
tigation into  the  symptoms,  course  and  duration  of  the  illnesses  referred  to. 
The  ''stomach  cough"  and  "malaria"  of  the  consumptive  are  familiar  to 
all  practitioners.  In  the  matter  of  hereditary  and  family  tendencies  to 
disease  the  examination  must  be  conducted  with  great  care.  It  is  no 
uncommon  thing  for  patients,  even  those  who  are  well  informed  and  intel- 
ligent, to  deny  the  existence  of  malignant  disease,  chronic  nephritis,  a 
tendency  to  tuberculosis,  and  the  like,  when  careful  inquiry  or  the  inde- 
pendent statements  of  their  friends  render  the  occurrence  of  these  diseases 
in  the  family  in  the  highest  degree  probable.  A  patient  will  affirm  that 
no  case  of  consumption  has  ever  occurred  in  his  family,  and  upon  cautious 
questioning  admit  that  his  father  or  mother  or  other  near  relative  suffered 
from  chronic  cough,  abundant  expectoration,  blood-spitting,  and  progressive 
emaciation.  An  epileptic  will  deny  the  occurrence  of  nervous  diseases, 
and  subsequently  admit  that  near  relations  have  presented  the  symptoms 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  41 

of  hysteria  or  neurasthenia  or  been  insane.  Patients  very  often  withhold 
in  the  presence  of  a  nurse  or  other  attendant  important  facts  that  they 
wilhngly  communicate  to  the  physician  alone. 

RECORDS. 

Records  should  be  kept  m  private  as  well  as  in  hospital  and  dispensary 
practice.  How  full  these  should  be  will  depend  upon  the  physician's 
estimate  of  the  importance  of  the  individual  case.  Their  preparation 
demands  close  attention,  concise  statements,  and  accuracy.  They  consti- 
tute a  permanent  store  of  professional  experience  for  future  reference  and 
study.  They  are  of  great  value  in  the  review  of  the  history  of  patients 
previously  seen,  as  an  aid  in  comparing  one's  personal  observations  with 
those  of  the  profession  at  large,  in  the  preparation  of  articles  for  pubhca- 
tion,  and  not  infrequently  as  bearing  upon  medico-legal  cases.  They  should 
be  preserved  in  accordance  with  a  uniform  plan  in  books  prepared  for  the 
purpose,  or  preferably  upon  cards  of  convenient  dimensions  arranged  in 
cabinets,  in  the  same  manner  as  the  index  catalogues  used  in  hbraries. 
Uniformity  is  important.  It  prevents  the  oversight  of  significant  facts 
and  facihtates  the  comparison  of  cases.  The  following  scheme  is  suggestive; 
it  may  be  modified  in  accordance  with  individual  views: 

SCHEME  FOR  CASE  RECORDS. 

Case  record  number Diagnosis Revise Result 

Admitted Discharged (In  hospital  patients). 

Date  of  examination 

Name. Age Sex Race Place  of  birth.. Present 

abode Former  occupation Present  occupation Social  state 

Married,  single,  widowed. 

Anamnesis. 

1.  Family  History:  Hereditary  tendencies;  health  of  parents,  brothers  and  sisters; 
deaths  in  family — cause,  age. 

2.  Personal  History:  (a)  Diseases  of  childhood;  (b)  menstruation;  (c)  preg- 
nancies, miscarriages,  date  of  last  confinement;  (d)  previous  illnesses  or  injuries;  (e)  habits 
— regularity  of  meals,  kind  of  food,  method  of  eating;  bowels;  sleep;  habitual  or 
occasional  physical  or  mental  overexertion;   tobacco;    alcohol;    narcotics. 

3.  Present  Illness:  (a)  Date  of  onset;  supposed  exciting  cause;  exposure  to  con- 
tagion; prodromes;  initial  symptoms;  course  of  the  attack;  previous  treatment,  (b) 
Antecedent  derangements  of  health  not  amounting  to  positive  disease,  appetite,  pain, 
cough,  disturbances  of  sleep,  headache,  etc. 

Status    Pr^esens. 

A.  General  Appearance:  Expression,  height  and  weight,  musculature,  bony 
structure,  panniculus  adiposus;  posture  in  bed;  movements,  gait  and  station  out  of  bed; 
temperature;  pulse;  respiration;  color  and  condition  of  the  skin;  perspiration;  cedema; 
eruptions;  psychical  condition;  sensations  and  complaints;  delirium;  convulsions; 
stupor;   coma. 

B.  Particular  Phenomena:  Symptoms  and  signs  relating  to  special  structures, 
organs  and  functions. 

1.  The  Digestive  Apparatus:  Inspection  of  the  mouth,  tongue  and  gums;  tonsils 
and  pharynx;  palpation  of  the  abdomen,  its  form  and  contour,  visible  peristalsis,  tender- 
ness upon  pressure,  resistance,  tumors;  percussion  and  palpation  of  the  stomach  and 
intestines,  liver,  gall-bladder,  spleen;   inspection  of  vomited  matters  and  faeces. 

2.  The  Circulatory  Apparatus:  Inspection  and  palpation  of  the  cardiac  area;  visible 
and  palpable  pulsation;  thrill;  precordial  prominence;  position  of  the  apex;  percussion 
and  auscultation  of  the  heart;    the  pulse-frequency,  rhythm,  fulness,  tension;    condition 


42  MEDICAL  DIAGNOSIS. 

of  walls  of  arteries;  venous  pulsation;  capillary  pulse;    liver  pulsation;   auscultation  of  the 
arteries  and  veins;  arterial  pressure,  positive  and  negative;  examination  of  the  blood,  etc. 

3.  The  Respiratory  Apparatus:  Nose,  mouth,  and  larynx;  cough  and  expectora- 
tion; chest  and  lungs — character  of  the  respiration,  dyspnoea,  stridor,  Cheyne-Stokes 
respiration;  contour  of  the  thorax;  local,  lateral  or  bilateral  retraction  or  expansion; 
respiratory  excursus;  fremitus;  local  and  general  physical  signs  obtained  by  percussion, 
auscultation,  and  mensuration;    the  cyrtometer. 

4.  The  Genito-Urinary  Apparatus:  Palpation  of  the  kidneys  and  bladder;  percussion 
of  the  bladder;  retention  of  urine;  suppression;  frequency  of  micturition;  pain;  quantity 
of  urine;  total  amount  for  twenty-four  hours;  disturbance  at  night;  chemical  and  micro- 
scopic examination  of  the  urine;  sexual  organs. 

5.  The  Xerv'ous  System:  InteUigence;  mental  state;  subjective  sensations;  sleep, 
gait,  station,  reflexes,  tremor,  convulsions,  spastic  conditions,  paralysis;  aphasia  and  other 
disorders  of  speech;   derangements  of  sensation;    the  organs  of  special  sense. 

6.  The  Osseous  System — Bones  and  Joints:  General  and  local  changes  in  the  skeleton; 
cranium,  spine,  thorax,  pehis,  long  bones,  extremities;  striking  deformities;  the  joints; 
size  and  shape,  color,  pain,  degree  of  impairment  of  function,  fixation,  disintegration. 

7.  The  Tegumentary  System:  Itchmg,  burning,  tension,  pain,  inflammatory  phe- 
nomena; presence  and  character  of  eruptions,  macular,  papular,  vesicular,  pustular; 
uniformity;  polymorphism;  hypertrophy  and  atrophy;  cicatrices;  pigmentary  changes; 
animal  and  vegetable  parasites;  subcutaneous  structures;  enlargement  or  atrophy  of  thy- 
roid body;  Ijrniph  nodes;  constitutional  disturbances. 

Diagnosis;  Prognosis;  Treatment;  Subsequent  obser\'ations. 

The  results  of  special  clinical  and  laboratory  examinations  are  to  be  in- 
corporated under  the  appropriate  headings.  Among  these  are  rhinoscopic 
and  laryngoscopic,  ophthalmoscopic  and  otoscopic  examinations;  hsemato- 
logic  investigations;  the  chemical  and  microscopic  examination  of  the  gas- 
tric contents,  vomited  material,  and  the  stools;  of  expectorated  matters; 
bacteriologic  examinations  of  the  blood,  sputum,  secretions,  exudates,  etc., 
by  the  methods  of  staining,  culture,  and  inoculation;  examination  of  the 
rectum  by  the  finger,  the  speculum,  and  by  inflation;  cystoscopy;  special 
examination  of  the  genital  organs  in  both  sexes,  examination  of  the  fluids 
obtained  by  exploratory  puncture,  and  examination  by  the  X-rays. 

In  febrile  cases  temperature  charts  should  be  preserved  with  the 
records,  and  superficial  deformities,  as  swelling  or  retraction,  as  well  as 
changes  in  the  viscera  revealed  by  the  various  methods  of  diagnosis,  may 
be  indicated  upon  outline  clinical  diagrams  and  incorporated  in  the  notes. 
Changes  of  contour,  glandular  enlargements  and  topographical  lesions, 
such  as  local  consolidations  and  cavity  formation  in  the  lungs,  cardiac 
dilatation  or  hypertrophy,  pleural  and  pericardial  effusions  and  the  result- 
ing displacement  of  adjacent  viscera,  enlargement  of  the  liver  and  spleen, 
dilatation  of  the  stomach  and  displacement  of  the  abdominal  organs  may 
in  this  manner  be  more  or  less  accurately  delineated.  The  location  of 
tumors  and  circumscribed  exudates  may  also  be  indicated,  and  in  the  case 
of  the  nervous  system  the  extent  and  distribution  of  areas  of  disturbance 
of  sensation  and  other  phenomena. 

Some  further  explanation  of  the  bearing  of  the  facts  noted  in  the 
anamnesis  upon  the  mental  processes  b}'  which  a  diagnosis  is  reached  may 
be  of  service  to  the  student. 

Age The  age  is  important.     Each  period  of  life  has  its  pecuhar 

susceptibility  to  morbid  influences.  In  the  new-born,  congenital  defects, 
the  results  of  the  accidents  of  parturition,  diseases  arising  from  faulty 
management  of  the  cord,  those  directly  transmitted  from  the  mother, 
and  those  produced  by  improper  diet   and  unhygienic  surroundings   are 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING. 


43 


common.  In  childhood,  anatomical  peculiarities  of  the  growing  organism 
and  the  sensitiveness  of  physiological  processes  to  external  impressions 
give  rise  to  special  predispositions  to  disease.  Thus,  the  ready  prolifera- 
tion of  the  lymph  tissues  explains  the  frequent  occurrence  of  respiratory 
obstruction  in  the  nasopharynx  from  adenoid  hypertrophy,  while  the 
narrowness  of  the  larynx  accounts  for  the  gravit}^  of  catarrhal  and  infective 
processes  involving  that  organ,  and  the  great  vascularity  and  rapid  over- 
growth of  the  epithelium  of  the  bronchi  when  irritated  explain  the  peculiar 
liability  of  children  to  bronchitis  and 
bronchopneumonia.    In  the  instability  „.-<^^^^^\^ 


Fig.  27. — Clinical  diagram. 


Fig.  28. — Clinical  diagram. 


of  the  nervous  system  in  children  we  find  a  ready  explanation  of  their 
liability  to  fever,  its  high  range  and  rapid  fluctuations,  and  to  various 
reflex  disturbances,  and  in  the  absence  of  acquired  immunity,  an  explana- 
tion of  the  wide  prevalence  among  them  of  the  transmissible  infections,  as 
the  exanthemata,  which  are  spoken  of  as  the  diseases  of  childhood.  In 
adolescence,  hereditary  predispositions  begin  to  show  themselves,  as  in 
the  occurrence  of  tuberculosis  and  of  epilepsy  or  other  nervous  affections. 
The  late  sequels  of  infantile  diseases,  as  chronic  valvular  trouble  following 
rheumatic  endocarditis,  or  chronic  nephritis  subsequent  to  scarlatina, 
often  now  appear.  Changes  in  the  environment  of  the  individual  subject 
him  to  special  pathogenic  influences,  and  pleurisy  with  or  without  effusion. 


44  MEDICAL  DIAGNOSIS. 

pneumonia,  and  enteric  fever  are  common.  The  middle  period  of  life  is 
especially  prone  to  diseases  that  result  from  occupation,  examples  of  which 
are  lead  intoxication,  caisson  disease,  and  scrivener's  palsy,  to  those  which 
result  from  the  habitual  use  of  narcotics,  as  gastric  catarrh,  hepatic  cir- 
rhosis, and  alcoholic  neuritis,  to  those  resulting  from  the  stress  of  life  and 
anxiety,  among  which  may  be  named  cardiac  hypertrophy,  the  neuras- 
thenias and  other  nervous  diseases  and  insanity.  It  is  in  this  period  that 
hereditary  and  acquired  tendencies  to  sclerotic  changes  in  the  vessels 
and  in  the  nervous  system  begin  to  develop  and  that  diabetes  and  the 
paroxysms  of  gout  commonly  first  show  themselves.  Later  in  life  the 
indications  of  progressive  degenerations  become  more  marked.  The 
wrinkled  skin,  the  failing  sight  and  hearing,  the  feeble  heart,  winter  cough, 
and  renal  inadequacy  are  the  indications  of  sclerotic .  and  nutritive 
changes  which  are  more  apparent  in  the  rigid,  tortuous,  or  atheromatous 
superficial  arteries.  This  is  especially  the  period  of  apoplexy,  chronic 
bronchitis,  diabetes,  cystitis  from  hypertrophiecl  prostate,  Parkinson's 
disease  and  the  special  infections^  erysipelas  and  pneumonia,  which  are 
frequently  terminal  events.  In  general  terms  the  evolution  of  life  is 
the  period  of  infections,  the  involution  the  period  of  degenerations; 
but  in  pathology  age  cannot  be  measured  by  years,  and  the  signifi- 
cant sajang  that  "a  man  is  as  old  as  his  arteries"  has  become  a  modern 
medical  aphorism. 

Physiological  Epochs. — The  epochs  of  life  are  also  marked  by  special 
liability  to  disease.  Thus  at  the  first  dentition  nutritional  diseases  and 
gastro-intestinal  troubles  are  common;  at  puberty,  chlorosis  and  hysteria; 
at  the  menopause,  hysteria,  obesity,  and  arthritis  deformans.  It  is  to  be 
noted,  however,  that  the  maladies  of  these  physiological  epochs  are  not 
the  direct  result  of  functional  changes,  but  are  the  outcome  of  previous 
morbid  conditions  or  tendencies. 

Sex.  —  Sex  is  likewise  important.  In  early  and  advanced  life  the 
sexes  are  equally  liable  to  disease.  Women  between  the  age  of  puberty 
and  the  menopause  are  exposed  to  the  danger  of  many  accidents  and 
diseases  peculiar  to  the  anatomical  and  physiological  development  con- 
nected with  the  sexual  life  and  child-bearing.  Consideration  of  these 
matters  properly  belongs  to  gynaecology  and  midwifery.  Sedentary  living, 
the  monotony  of  the  household,  and  depressing  moral  influences  also  act 
as  causes  of  disease  in  women.  Hysteria,  neurasthenia,  and  special  forms 
of  insanity  occur.  These  peculiarities  do  not,  however,  carry  with  them 
an  exemption  from  other  pathogenic  influences,  and  among  the  peasantry 
of  those  countries  where  the  women  largely  engage  in  the  same  occupations 
as  the  men  they  suffer,  in  addition  to  their  own  peculiar  disorders,  from 
the  maladies  of  the  other  sex  and  practically  to  the  same  extent.  In  more 
enlightened  districts  and  among  the  upper  classes  of  society  women  escape 
many  risks  of  disease  to  which  men  are  exposed.  In  the  male  sex  occupa- 
tion, exposure,  the  strenuous  life,  and  self-indulgence  are  common  causes 
of  disease,  hence  the  more  frequent  occurrence  of  plumbism,  farcy,  pneu- 
monia, chronic  arthritis,  gout,  tabes,  and  alcoholism.  As  a  consequence, 
arteriosclerosis  and  atheroma  are  more  marked  in  men  than  in  women 
at  advanced  age. 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  45 

Race  and  Nationality. — These  points  demand  consideration  in  the 
anamnesis.  The  pecuhar  hability  of  the  Hebrew  to  diabetes  and  neuras- 
thenia; of  the  negro  and  mulatto  to  tuberculosis,  and  the  relative  immunity 
of  the  former  to  malaria  and  yellow  fever;  the  prevalence  of  beriberi 
among  the  oriental  races,  of  leprosy  in  Scandinavia,  the  Sandwich  Islands, 
and  the  West  Indies;  and  the  frightful  ravages  of  tuberculosis,  syphilis, 
and  alcoholism  among  the  Indians  of  North  America  are  well-known  facts. 

Nativity.  —  The  place  of  birth  and  residence  frequently  shed  light 
upon  an  obscure  case,  as  in  ill-defined  malaria,  the  malarial  cachexia, 
goitre,  cretinism,  and  leprosy.  A  knowledge  of  the  district  or  locality  of 
the  patient's  present  residence,  the  situation  of  his  home,  its  sanitary 
conditions  and  surroundings,  the  source  of  the  water  supply,  and  the 
disposition  of  the  sewage   may  shed  light  upon  the  diagnosis. 

Occupation. — The  occupation  of  the  patient  demands  careful  investi- 
gation. The  habitual  over-use  of  certain  muscles,  and  exposure  to  particular 
irritants  or  poisons  or  an  atmosphere  laden  with  minute  mineral  or  metallic 
particles  or  chemicals,  or  to  infections  peculiar  to  certain  crafts,  cause  defi- 
nite diseases.  Examples  of  such  affections  are  writer's  cramp,  anthracosis 
or  miner's  consumption,  chronic  phosphorus  poisoning  among  workmen 
engaged  in  the  manufacture  of  matches,  malignant  pustule  or  wool- 
sorter's  disease,  and  glanders.  It  is  necessary  to  inquire  carefully  into 
former  occupations  as  well  as  the  present;  thus  chronic  bronchitis  with 
bronchiectasis  may  have  had  its  origin  in  the  inhalation  of  the  dust  caused 
by  stone-cutting — an  occupation  long  abandoned  by  the  patient.  In  those 
occupied  in  professional  or  literary  work  functional  derangements  of  the 
stomach,  constipation,  and  insomnia  are  common.  Even  amusements 
may  be  the  cause  of  disease,  as  in  the  golfer's  back  and  the  heart-strain  of 
the  athlete. 

Heredity.  —  The  family  history  has  a  very  important  bearing  upon 
the  diagnosis,  especially  in  chronic  diseases.  It  is  difficult  to  frame  a 
satisfactory  definition  for  heredity,  but  we  know  that  traits  and  lineaments 
are  transmitted  from  parents  to  children  through  the  generations,  and 
we  occasionally  observe  in  a  son  who  has  his  mother's  features  some  trick 
of  expression  that  makes  his  resemblance  to  his  father  for  the  moment 
almost  starthng.  So  too  are  transmitted  from  one  generation  to  another 
tissue  peculiarities  and  constitutional  tendencies  to  disease.  The  inquiry 
into  the  family  history  must  be,  as  has  been  pointed  out  in  a  previous 
paragraph,  conducted  with  tact  and  caution.  Blunt  inquiries  in  regard 
to  "consumption,"  "cancer,"  "  Bright's  disease,"  or  "insanity"  irritate 
the  patient  and  usually  elicit  vague  replies  or  absolute  denials.  A  patient 
should  be  asked  if  his  parents  are  living  and  in  good  health;  if  not  in  good 
health,  the  symptoms  and  duration  of  the  illness;  if  dead,  the  cause  of 
death  and  the  age  at  which  it  occurred.  He  should  be  questioned  as  to 
the  number  of  his  brothers  and  sisters,  their  health,  and  the  cause  of  any 
deaths  that  may  have  occurred  among  them.  It  is  very  important  to  learn 
whether  or  not  deaths  in  the  family  have  been  the  result  of  acute  or  chronic 
disease.  The  inquiry  may  be  extended  to  the  preceding  generation  and 
collateral  branches  of  the  family.  Diseases,  it  is  true,  are  conveyed  by 
hereditary  transmission,  but  their  number  is  comparatively  few.     Hsemo- 


46  MEDICAL  DIAGNOSIS. 

philia  is  a  striking  example.  Syphilis  is  very  commonly  thus  transmitted. 
When  the  mother  has  contracted  an  acute  infection,  as  measles  or  enteric 
fever,  the  child  may  be  born  during  the  period  of  incubation  or  with  the 
symptoms  of  the  disease  already  manifest.  A  number  of  nervous  diseases 
are  clearly  hereditary.  As  examples  may  be  mentioned  progressive  mus- 
cular atrophy,  hereditary  chorea,  Friedreich's  ataxia,  and  migraine.  The 
definite  symptoms  may  not  show  themselves  for  some  years  after  birth, 
in  some  cases  not  until  adult  life.  Much  more  commonly  it  is  the  pre- 
disposition that  is  transmitted.  This  is  especially  the  case  in  tuberculosis. 
The  peculiar  exposure  of  the  young  infant  to  infection  from  a  tuberculous 
mother  and  the  length  of  time  that  the  tuberculous  lesions  in  many  in- 
stances remain  localized  render  it  in  the  highest  degree  probable  that  the 
predisposition  to  tuberculosis  rather  than  the  disease  itself  is  hereditary. 
This  view  is  confirmed  by  the  results  of  pathological  and  bacteriological 
investigations.  The  direct  transmission  of  tuberculosis  from  the  mother 
to  the  foetus  in  the  human  being  is  of  uncommon  occurrence.  The  doc- 
trine of  the  direct  hereditary  transmission  of  tuberculosis,  so  long  enter- 
tained but  now  fortunately  abandoned,  was  a  stumbling  block  in  the  way 
of  the  recognition  of  the  infectious  character  of  this  disease.  That  the 
predisposition  rather  than  the  disease  is  hereditary  is  also  true  of  cancer. 
The  occasional  occurrence  of  chronic  Bright's  disease  in  nearly  every 
member  of  a  family  in  two  or  three  generations,  usually  first  showing  itself 
in  adolescence  or  early  adult  life,  must  be  attributed  to  hereditary  defects 
of  the  renal  and  vascular  tissues,  while  faults  of  metabolism,  the  constitu- 
tional tendency  to  which  is  transmitted  from  father  to  son,  bear  a  direct 
etiological  relation  to  gout  and  its  associated  cardiovascular  and  renal 
changes.  The  development  of  forms  of  insanity  in  successive  generations 
of  a  family,  usually  at  the  physiological  epochs  of  life,  often  not  until  late 
middle  age,  must  likewise  be  attributed  to  hereditary  defects  of  nervous 
and  mental  organization. 

A  further  peculiarity  in  regard  to  the  hereditary  transmission  of 
disease  is  to  be  found  in  its  diverse  manifestations  among  various  members 
of  a  family.  The  radical  defect  or  susceptibihty  may  find  expression  in 
pathological  conditions  which  are  allied  but  which  have  wholly  different 
symptoms.  Thus  the  tendency  to  deranged  metabolism  and  arteriosclerosis 
may  in  one  show  itself  in  contracted  kidney  and  hypertrophied  heart; 
in  another  in  disease  of  the  aorta  or  angina  pectoris;  in  a  third  in  gout^ 
renal  calculus  and  gravel,  or  yet  again  in  early  cerebral  hemorrhage  or 
thrombosis.  The  neuropathic  constitution  may  manifest  itself  in  one 
member  of  a  family  in  forms  of  neuralgia,  neurasthenia,  or  hysteria;  in 
another  in  the  development  of  epilepsy,  and  in  a  third  in  the  guise  of 
hypochondriasis  or  insanity.  The  family  susceptibility  to  certain  infec- 
tions may  reveal  itself  in  different  individuals  in  recurrent  attacks  of 
tonsillitis  or  rheumatism,  chorea  or  chronic  valvular  disease;  or  the  sus- 
ceptibility to  tuberculosis,  on  the  one  hand  in  pulmonary  consumption, 
on  the  other  in  tuberculosis  of  the  bones  and  joints  or  glandular  disease, 
or  finally  in  the  implication  of  the  meninges,  pleura,  or  peritoneum. 

Immunity  may  be  transmitted  by  inheritance  as  well  as  the  pre- 
disposition to  disease.     There  are  families  and  individuals  who  possess  a 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  47 

remarkable  natural  immunity  against  the  exanthemata.  This  is  espe- 
cially true  in  regard  to  scarlet  fever.  When  we  consider  the  wide 
prevalence  of  pulmonary  tuberculosis  an'd  the  diffusion  of  its  cause  in  the 
centres  of  population  and  certain  districts  and  houses,  and  the  fact  that  so 
large  a  proportion  of  individuals  and  famihes  constantly  exposed  to  the 
inhalation  of  an  atmosphere  containing  the  tubercle  bacilh  escape  the 
•disease,,  the  common  existence  of  a  natural  immunity  which  is  frequently 
transmitted  by  inheritance  becomes  evident.  The  predisposition  to  tuber- 
culosis is  far  less  general  than  that  to  scarlatina  and  measles.  The  occur- 
rence of  personal  peculiarities  and  morbid  tendencies  in  an  individual 
which  were  not  manifested  in  his  parents  but  existed  in  their  ancestors  is 
known  as  atavism.  In  rare  instances,  and  especially  in  cases  of  nervous 
disease  and  insanity,  this  condition  is  important  in  the  anamnesis.  Curi- 
ous facts  in  regard  to  the  duration  of  life  are  occasionally  observed. 
There  are  families  in  which ,  in  successive  generations  few  members  survive 
the  early  middle  period  of  life.  In  such  instances  death  is  very  often 
due  to  an  acute  disease  not  always  the  same.  On  the  other  hand,  all  the 
members  of  certain  families  reach  an  advanced  age,  the  exceptions  being 
where  death  is  due  to  accident  or  violence. 

Medical  History. — The  personal  history  is  essential  to  a  diagnosis 
in  the  broad  sense.  A  knowledge  of  the  significant  facts  in  the  past  hfe 
of  the  patient  may  clear  up  a  doubtful  case.  The  present  disease  may  be 
a  late  sequel  of  some  previous  illness,  as  bronchitis  or  emphysema  after 
whooping-cough,  or  an  obscure  manifestation  of  one  of  the  exanthemata 
which  the  patient  escaped  in  childhood,  as  scarlatina  in  the  adult  with 
fever  of  moderate  intensity  and  an  irregular  patchy  eruption,  or  it  may 
be  the  expression  of  a  peculiar  constitutional  susceptibility,  as  tonsillitis, 
rheumatic  fever,  or  chorea,  from  which  the  patient  has  suffered  on  previous 
occasions.  In  this  connection  it  is  to  be  borne  in  mind  that  many  of 
the  acute  infectious  diseases,  and  especially  the  exanthemata,  result  in 
an  acquired  immunity  which  usually  lasts  throughout  life,  hence  second 
attacks  are  exceedingly  infrequent,  while  the  immunity  conferred  by  other 
infections,  for  example  rheumatic  fever,  erysipelas,  -croupous  pneumonia, 
and  diphtheria,  is  incomplete  and  of  limited  duration,  so  that  many  individ- 
uals suffer  from  repeated  attacks  of  these  diseases.  In  acute  febrile  attacks 
and  in  the  presence  of  epidemics  careful  inquiry  as  to  exposure  to  the 
contagion  must  be  made.  The  period  of  incubation  and  the  occurrence  of 
prodromal  symptoms  are  to  be  taken  into  consideration.  In  women 
abnormal  menstruation,  the  accidents  and  diseases  of  pregnancy,  the  occur- 
rence of  miscarriages,  too  frequent  child-bearing  and  prolonged  lactation 
may  be  the  cause  of  serious  impairment  of  health  or  of  actual  disease. 
These  matters  must  be  carefully  inquired  into.  In  exceptional  cases, 
especially  in  aggravated  and  intractable  functional  nervous  diseases,  it 
becomes  necessary  to  inquire  more  closely  into  the  sexual  life  of  the  patient. 
The  investigation  must  be  conducted  with  great  delicacy  and  discretion. 
The  part  played  by  vicious  practices  arid  excesses  in  the  production  of  such 
diseases  must  be  ascertained.  It  is  necessary  also  to  learn  whether  or  not 
the  patient  has  suffered  from  venereal  infection,  the  date  of  its  occurrence, 
the  nature,  character,  and  duration  of  the  primary  symptoms,  the  presence 


48  MEDICAL  DIAGNOSIS. 

or  absence  of  secondary  lesions,  and  the  treatment.  Gonorrhoea  is  not 
always  merely  a  local  affection.  The  frequency  with  which  it  is  followed 
by  stricture  is  well  known,  but  the  symptoms  of  the  latter  condition  may 
first  show  themselves  after  the  lapse  of  years.  Local  abscess  formation, 
acute  and  chronic  cystitis  and  pyelitis  also  occur.  The  immediate 
recognition  of  the  specific  nature  of  gonorrhoeal  ophthalmia,  whether  in 
the  new-born  or  in  the  adult,  is  a  matter  of  overwhelming  importance.  The 
diagnosis  of  many  a  case  of  disabling  and  stubborn  arthritis  is  made 
clear  by  a  knowledge  of  gonorrhoeal  infection.  Nor  is  the  fact  to  be 
overlooked  that  endocarditis,  both  in  its  benign  and  malignant  forms,  may 
be  a  secondary  process.  In  women  the  history  of  primary  gonorrhoea  is 
very  often  obscure.  Tubal  disease  and  other  pelvic  inflammations,  only 
to  be  relieved  by  the  knife  of  the  gynaecologist,  are  common  results  of  the 
extension  of  the  infection.  A  dissolute  life  on  the  part  of  the  patient  is 
presumptive  evidence  of  the  nature  of  the  process.  There  is  also  gonor- 
rhoea insontium;  a  virtuous  wife  may  suffer.  The  protean  manifestations 
of  syphilis  are  to  be  borne  in  mind.  The  symmetrical  arrangement  and 
sequence  of  the  early  cutaneous  lesions,  their  later  polymorphism  and 
irregular  distribution,  the  buccal  and  anal  mucous  patches,  the  ade- 
nopathy, the  obscurity  of  the  visceral  and  nervous  phenomena,  their 
irregularity  and  chronicity,  are  all  to  be  considered  in  the  diagnosis  of  an 
obscure  case.  The  presence  of  the  specific  organism — spirochseta  pallida — 
is  conclusive.  Where  syphilis  is  suspected  in  a  family,  we  must  inform 
ourselves  as  to  whether  or  not  a  mother  has  aborted,  especially  in  her 
early  pregnancies,  or  has  had  later  a  series  of  abortions  or  still-born  children, 
and  as  to  snuffles  and  cutaneous  eruptions,  especially  on  the  buttocks, 
in  her  new-born  children,  and  corneal  opacities,  interstitial  keratitis,  Hut- 
chinson's teeth,  and  arrested  development  or  nervous  diseases  in  those  who  . 
have  survived.  Nor  must  the  physician  overlook  the  fact  that  many 
innocent  persons  contract  syphilis.  Not  only  the  blameless  wife  but  also 
the  unsuspecting  girl,  from  the  kiss  of  her  betrothed,  may  become  the 
victim  to  this  disease,  while  the  methods  of  accidental  inoculation  are 
innumerable.  Familiar  examples  are  to  be  found  in  the  chancre  upon  the 
hand  of  the  surgeon  or  accoucheur,  or  upon  the  hp  or  tongue  of  the 
incautious  borrower  of  a  pipe  from  an  infected  friend.  When  matters 
of  this  kind  concern  members  of  a  family,  the  physician  cannot  be  too 
guarded  in  respect  to  the  way  in  which  his  questions  are  framed  or  in 
his  statements  to  a  husband  or  wife.  Suggestive  questioning  or  injudicious 
statements  may  seriously  aggravate  existing  troubles.  If  definite  communi- 
cations become  necessary,  his  knowledge  of  the  circumstances  will  enable 
him  to  decide  whether  it  is  best  personally  to  assume  the  whole  responsi- 
bility or  to  invite  a  colleague  of  high  reputation  to  share  it  with  him. 

The  history  of  a  surgical  operation  and  the  conditions  which  led  up 
to  it,  as  well  as  its  results,  are  important.  The  patient's  present  condition 
may  be  due  to  a  recurrence  of  the  original  trouble,  or,  as  in  the  case  of  an 
abdominal  operation,  to  the  development  of  adhesions  or  constricting  bands. 

Personal  Habits. — The  habits  must  be  closely  studied.  Important 
information  bearing  upon  the  diagnosis  may  often  be  obtained  by  direct- 
ing the  patient  while  continuing  his  ordinary  method  of  living  to  keep  a 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  49 

record  of  the  hours  at  which  his  meals  are  taken,  the  kind  and  quantity 
of  food  and  drink,  the  action  of  his  bowels,  the  hours  and  character  of 
sleep,  and  his  various  occupations  and  amusements,  which  may  be  sub- 
mitted at  a  subsequent  consultation.  The  causal  relation  of  improper 
clothing  to  bronchopulmonary  affections,  of  badly  regulated  work  and 
sleep  to  neurasthenic  conditions,  of  injudicious  or  irregular  eating  to  gastro- 
intestinal troubles,  of  the  abuse  of  alcohol  to  nervous  diseases  and  cirrhosis 
of  the  liver,  of  excess  in  tobacco  to  irritable  heart  and  amblyopia,  will 
guide  us  in  the  inquiry.  Late  hours  and  dissipation,  in  fact  all  matters 
which  enter  into  consideration  from  the  stand-point  of  the  moral  hazard 
of  the  insurance  companies,  have  a  most  important  bearing  upon  diagnosis. 

Present  Illness. — The  history  of  the  present  illness  must  be  system- 
atically investigated  and  its  symptoms  recorded  in  chronological  order 
from  the  onset  to  the  tim6  of  the  patient's  coming  under  observation. 
It  is  important  to  learn  if  possible  the  effect  of  treatment.  The  disap- 
pearance of  a  rash  after  mercurials  or  the  subsidence  of  headache  after 
continued  large  doses  of  the  iodides  constitutes  presumptive  evidence  in 
favor  of  syphihs.  The  failure  of  quinine  to  prevent  the  recurrence  of  chills 
renders  the  diagnosis  of  malaria  improbable,  or  of  the  proper  administra- 
tion of  suitable  preparations  of  iron  in  full  doses  to  correct  the  pallor, 
breathlessness  upon  exertion,  and  headache  of  a  highly  anaemic  young 
woman  militates  against  the  diagnosis  of  chlorosis.  Much  allowance  must 
be  made  for  the  statements  of  patients  both  as  regards  the  symptoms  of 
the  illness  and  their  reports  of  previous  treatment  and  the  opinions  of 
physicians  whom  they  may  have  consulted.  In  many  cases  the  unravelling 
of  a  diffuse  and  inconsequent  story  can  only  be  accomplished  by  the  exer- 
cise of  skill  and  patience.  On  the  other  hand,  the  history  communicated 
by  intelhgent  persons  is  often  curiously  succinct  and  clear.  Frequently 
by  reason  of  the  patient's  mental  condition  no  account  of  the  illness  can 
be  obtained.  In  some  cases  it  often  happens  that  very  little  information 
can  be  gleaned  from  the  bystanders.  In  hospital  practice  the  admission 
of  ambulance  cases  gravely  ill,  of  whose  previous  condition  nothing 
whatever  can  be  learned,  is  a  matter  of  daily  occurrence. 

Duration. — Of  first  importance  is  a  knowledge  of  the  duration  of 
the  illness,  since  it  enables  us  at  once  to  form  an  opinion  as  to  whether  the 
disease  should  be  referred  to  one  or  the  other  of  the  two  general  groups 
of  acute  or  chronic  maladies.  The  fact  is,  however,  not  to  be  overlooked 
that  acute  symptoms  may  be  the  manifestation  of  an  unsuspected  chronic 
affection,  as  sudden  loss  of  vision  or  convulsions  in  nephritis,  angina  pectoris 
in  disease  of  the  heart  and  aorta,  or  perforation  phenomena  and  peritonitis 
in  peptic  ulcer  of  the  stomach  and  duodenum.  The  mode  of  onset  next 
demands  our  attention.  In  chronic  cases  we  seek  information  as  to  whether 
the  present  illness  developed  insidiously  or  abruptly  upon  a  condition  of 
previous  good  health,  or  followed  an  acute  illness,  and  whether  its  course 
has  been  gradual  and  progressive  or  interrupted  by  periods  of  improve- 
ment; in  acute  cases  whether  the  attack  developed  insidiously,  as  in  the 
case  of  enteric  fever,  or  abruptly,  as  in  influenza  or  typical  croupous  pneu- 
monia, and  whether  or  not  prodromes  occurred.  It  is  next  in  order  to 
ascertain  the  prominent  symptoms  of  the  disease,  the  region  or  organ 

4 


50  MEDICAL  DIAGNOSIS. 

to  which  they  have  been  referred,  whether  they  have  been  continuous, 
intermittent,  or  paroxysmal,  and  any  changes  in  the  patient's  appearance 
or  condition,  of  which  he  may  or  may  not  be  aware,  that  have  attracted 
the  attention  of  his  friends.  Finall)^,  important  information  is  often  reached 
by  due  consideration  of  the  views  of  the  patient  or  others  relating  to  the 
cause  of  his  illness. 

Status  Prsesens. — The  investigation  of  the  present  condition  of  the 
patient  must  also  be  conducted  in  an  orderly  and  systematic  manner. 
The  subjective  sensations  are  carefully  considered.  No  complaint  of  the 
patient,  however  trifling,  is  to  be  wholly  disregarded.  The  objective 
symptoms  must  be  studied  with  equal  care.  Every  fact  is  to  receive  proper 
consideration.  Due  regard  must  be  paid  to  the  feelings  of  the  patient. 
Abruptness  and  all  appearance  of  haste  or  harshness  are  to  be  avoided. 
The  interview  must  not  seem  too  business-like.  The  clothing,  whether 
in  the  consulting  room  or  at  the  bedside,  must  be  so  arranged  as  to  facilitate 
the  examination.  No  physical  exploration  of  the  thoracic  or  abdominal 
organs  can  be  made  without  proper  access  to  the  regions  to  be  studied; 
mistakes  from  a  disregard  of  this  rule  are  of  daily  occurrence.  In  diseases 
of  the  heart,  lungs,  or  great  vessels  it  is  necessary  to  inspect  the  uncovered 
chest;  palpation  must  also  be  performed  upon  the  bare  surface;  per- 
cussion and  auscultation  upon  the  bare  skin  or  more  conveniently  in  most 
cases  through  a  towel  or  the  single  layer  of  a  smooth  under-vest.  In  order 
that  the  influence  of  gravity  upon  the  abdominal  viscera  may  be  learned 
or  to  study  the  station  and  gait,  the  patient  must  rise  from  bed.  If  there 
are  symptoms  referable  to  the  spine,  the  clothing  must  be  removed  and 
the  patient  examined  in  the  erect,  sitting,  or  recumbent  posture,  in  the  last 
instance  not  in  bed  but  upon  the  firm,  smooth  surface  of  a  suitable  table; 
the  effect  of  various  movements  is  studied  and  the  condition  of  the  muscles 
and  joints.  Accurate  measurements  of  parts,  preferably  in  centimetres,, 
are  essential  where  there  is  a  departure  from  normal  standards  or  asym- 
metry. We  measure  and  note  the  circumference  of  the  head  in  hydro- 
cephalus, the  chest  on  quiet  breathing,  on  full  held  inspiration  and  on 
forced  expiration,  its  lateral  circumferences  for  comparison,  its  contour 
by  means  of  the  cyrtometer,  and  we  may  measure  diameters  of  the  head 
and  chest  by  means  of  calipers.  It  frequently,  especially  in  the  case  of 
ascites  and  tumors,  is  desirable  to  take  the  circumference  of  the  abdomen. 
The  muscles  in  relaxation  and  contraction  are  studied  by  the  hand  and 
one  side  is  compared  with  the  other.  Where  necessary  the  circumference 
of  the  limbs  is  measured  at  the  same  point  upon  the  two  sides.  Where 
symptoms  relating  to  the  brain  or  spinal  cord  dominate  the  clinical  picture, 
the  examination  must  be  made  with  especial  attention  to  the  details  bear- 
ing upon  the  localization  of  the  lesions.  Specimens  of  the  urine  must  be 
obtained  for  examination  as  a  matter  of  routine  in  all  cases.  The  diagnosis 
of  obscure  conditions,  the  symptoms  of  which  are  referred  to  the  nervous 
system,  digestive  organs,  or  general  condition  of  the  patient,  frequently 
depends  upon  the  result.  The  discovery  of  chronic  disease  of  the  kidneys 
or  the  presence  of  sugar  in  the  urine  as  the  outcome  of  investigations  made 
upon  application  for  life  insurance  is  a  matter  of  very  common  occurrence 
in  middle-aged  men  who  regard  themselves  as  in  excellent  health. 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  51 

In  general  the  examination  should  be  methodically  conducted  in  accord- 
ance with  the  foregoing  scheme,  prominence  being  given  in  the  record  of 
the  case  to  the  symptom-complex  which  bears  directly  upon  the  diagnosis. 

Abbreviations. — Time  and  space  may  be  saved  in  case-taking  by  the 
use  of  abbreviations.     Thus: 

/  &  m  I  &  w — father  and  mother  living  and  well. 

6  3;  2  din  infancy;  1  I  &  w — three  brothers;  two  dead  in  infancy; 

one  living  and  well, 
s  2;   1  d  at  7  sc  fever;  1  at  10  acute  nephritis, 
w  &  s  till  18  then  ent  fever;    I  crural  phlebitis;    elas  stk  still — well 

and  strong  till  18,  then  enteric  fever;   followed  by  left  crural 

phlebitis;  still  wears  elastic  stocking. 
Epigast  pain  p  c;   occas  v;   blood  12   mos  &  1  mo  ago — Epigastric 

pain    after    food;     occasional    vomiting;     haematamesis    one 

year  and  again  one  month  ago. 
D  r  u  a;  def  expn;    br-vesic  resp;    crep  roles — Dulness  right  side 

upper     lobe,     anteriorly;      deficient     expansion;      broncho- 
vesicular  respiration;     crepitant  rales. 
Tend  r  I  q;   aire  D;   Sd  d  of  attack;   n  &  v;   T.  101° — Tenderness 

in  right  lower  quadrant;    circumscribed  dulness;    third  day 

of  attack;    nausea  and  vomiting. 

Many  similar  abbreviations,  at  once  familiar  to  the  writer  and  intel- 
ligible to  any  trained  clinician,  will  suggest  themselves. 

Murmurs  maj^  be  shown  on  the  clinical  diagrams  (Figs.  27  and  28) 
by  stippling  or  washes,  the  point  of  maximum  intensit}'  being  most 
deeply  colored  and  the  direction  of  propagation  shown  by  an  arrow: 


or  more  simply  by  a  many-pointed  star  to  indicate  the  point  of  maximum 
intensity  and  an  arrow  the  direction;  thus 


These  signs  should  be  drawn  in  a  different  color  from  that  of  the 
ground  plan,  red  if  the  latter  is  black,  or  vice  versa. 

Dulness  may  be  indicated  by  cross  hatching;  its  degree  by  closeness 
of  the  mesh;  thus 


Relative  dulness.  -Marked  dulness 

Flatness  by  solid  color;  thus 


52  MEDICAL  DIAGNOSIS. 

Rales  by  dots,  their  size  and  abundance  corresponding  to  the  phys- 
ical signs;  thus 


/!^^j';  '••:,  ', 


Crepitant.  Subcrepitant.  Small  mucous.  Large  mucous. 

Cavities  by  irregularly  outlined  spaces;  thus 

Friction    sounds    by    zigzags,    the    extent    and    coarseness   of  which 
indicate  the  distribution  and  intensity  of  the  rub;   thus 


-#  4  ifiii^ 


PART   II. 

OF  THE  METHODS  AND  THEIR  IMMEDIATE   RESULTS. 


MEDICAL  THERMOMETRY. 

The  art  of  taking  and  recording  the  temperature  of  the  body  is  called 
medical  thermometry.  The  instruments  used  are  known  as  clinical 
thermometers.  They  are  marked  off  in  degrees  upon  the  glass,  and  each 
degree  is  subdivided  into  fifths,  so  that  the  readings  may  conveniently 
be  recorded  in  fractions  of  the  decimal  system.  The  thermometers  com- 
monly used  in  the  United  States  and  Great  Britain  are  marked  in  degrees 
of  Fahrenheit's  scale;  those  used  in  Europe  are  graduated  according  to  the 
Centigrade  scale.  The  scale  of  Reaumur  is  rapidly  going  out  of  use,  but  is 
still  employed  in  some  parts  of  Europe.  On  the  scale  of  Fahrenheit  the 
distance  through  which  the  mercury  rises  from  zero  to  the  boiling-point  of 
water  is  divided  into  two  hundred  and  twelve  degrees,  of  which  the  thirty- 
second  marks  the  melting-point  of  ice.  Between  the  melting-point  of  ice 
and  the  boiling-point  of  water  there  are  one  hundred  and  eighty  degrees 
(32° +  180°  =  212°  F.).  The  melting-point  of  ice  is  taken  as  zero  in  the 
Centigrade  scale  and  in  that  of  Reaumur,  but  in  the  Centigrade  the  boiling- 
point  of  water  is  at  one  hundred  (100°  C),  while  in  Reaumur's  it  is  at 
eighty  (80°  R.).    The  relation  of  the  three  scales  to  each  other  is,  therefore, — 


R. 

4 


To  convert  recordings  of  the  Fahrenheit  scale  into  Centigrade  degrees, — 
Subtract  32,  multiply  by  5,  and  divide  by  9;  thus:   98.6  —  32  =  66.6x5 

=  333.0  -  9  =  37.     That  is,  98.6°  F.  =  37°  C. 

To  convert  Centigrade  degrees  into  Fahrenheit  degrees, — 

Multiply  by  9,  divide  by  5,  and  add  32;   thus  37X9  =  333-5  =  66.6  + 

32  =  98.6.     That  is,   37°  C.  =  98.6°  F. 

The   Centigrade   scale  is   more   convenient   than   that   of   Fahrenheit, 

and  many  physicians  in  this  country  prefer  to  use  it.     The  following  table 

of  approximate  equivalents  may  prove  of  use: 


96.0°  F. 

=  35.5°  C. 

101.3°  F. 

=  38.5°  C. 

106.7°  F. 

=41.5°  C. 

96.8°  F. 

=  36.0°  C. 

102.0°  F. 

=  38.9°  C. 

107.0°  F. 

=  41.6°  C. 

97.8°  F. 

=  36.0°  C. 

102.2°  F. 

=  39.0°  C. 

107.6°  F. 

=  42.0°  C. 

98.0°  F. 

=  36.6°  C. 

103.0°  F. 

=  39.4°  C. 

108.0°  F. 

=  42.2°  C. 

98.6°  F. 

=  37.0°  C. 

103.1°  F. 

=  39.5°  C. 

108.5°  F. 

=  42.5°  C. 

99.0°  F. 

=  37.2°  C. 

104.0°  F. 

=  40.0°  C. 

109.0°  F. 

=  42.8°  C. 

99.5°  F. 

=  37.5°  C. 

104.9°  F. 

=  40.5°  C. 

109.4°  F. 

=  4.3.0°  C. 

100.0°  F. 

=  37.8°  C. 

105.0°  F. 

=  40.5°  C. 

110.0°  F. 

=  43..3°  C. 

100.4°  F. 

=  38.0°  C. 

105.8°  F. 

=  41.0°  C. 

111.2°  F. 

=  44.0°  C. 

101.0°  F. 

=  :3S.3°  C. 

106.0°  F. 

=  41.1°  C. 

53 


54  MEDICAL  DIAGNOSIS 

Seasoning. — As  thermometers  are  liable  after  a  time  to  give  readings 
that  are  slightly  too  high,  in  consequence  of  the  gradual  contraction  of  the 
glass  of  which  they  are  formed,  it  is  necessary  at  long  intervals  carefully  to 
compare  them  with  a  standard  instrument.  This  is  done  as  a  matter  of 
business  at  the  public  observatories,  to  which  any  instrument-maker  will 
send  them.  This  contraction  of  the  glass  is  called  "seasoning,"  and  goes 
on  very  slowly.  After  two  or  three  years  it  practically  comes  to  an  end, 
and  the  thermometer  is  then  seasoned. 

Description  of  Thermometers. — Clinical  thermometers  as  at  present 
made  are  of  the  kind  known  as  maximum,  or  self-registering;  that  is,  a 
small  portion  of  the  mercury  is  separated  from  the  main  bulk  of  it,  or 
separates  itself  from  it  as  it  contracts,  by  reason  of  a  device  in  the  twist  of 
the  tube,  in  such  a  way  that  it  remains  in  position  in  the  tube  when  the 
temperature  falls,  until  shaken  down,  and  thus  indicates  the  highest  tem- 
perature reached  during  the  observation.  The  separated  portion  of  the 
mercury  is  known  as  the  "index."  The  reading  is  taken  from  the  upper 
end  of  the  index,  which  is  then  shaken  down  bv  a  quick  motion  of  the  wrist, 
such  as  is  made  in  cracking  a  whip,  the  thermometer  being  held  by  its 
upper  end.  Before  taking  the  temperature  the  index  should  be  below 
95°.  The  best  clinical  thermometers  are  now  made  with  a  curved  surface, 
which,  acting  as  a  lens,  magnifies  the  width  of  the  mercury;  and  with  a 
flattened  back,  which  lessens  the  danger  of  breakage  from  rolling. 

Technic.  —  The  object  being  to  measure  the  internal  temperature, 
the  thermometer  must  be  placed  in  such  a  position  that  the  tissues  of 
the  body  completely  surround  its  bulb.  The  positions  available  are  the 
armpit,  or  axilla,  the  mouth,  the  vagina,  and  the  rectum.  The  fold  of 
the  groin,  when  the  thigh  is  bent  up  or  flexed  over  the  abdomen,  is  in 
infants  also  occasionally  used;  but  this  locality  is  less  satisfactory  than 
any  of  the  others. 

The  axilla  is  usually  selected.  If  very  moist,  it  should  be  dried  with 
a  towel  before  the  instrument  is  introduced;  or,  if  dry  and  harsh,  it  must 
be  bathed  with  warm  water  and  then  dried.  There  is  no  difference  in  the 
temperature  of  the  two  armpits  under  ordinary  circumstances.  The  bulb 
of  the  instrument  must  be  placed  deeply  in  the  hollow  and  the  arm  brought 
well  across  the  chest.  Care  must  be  taken  that  no  fold  of  clothing  inter- 
fere with  the  contact  of  the  instrument  with  the  skin.  Some  thermometers 
are  more  sensitive  than  others;  that  is,  they  act  more  quickly.  The  mer- 
cury rises  rapidly  at  first,  then  more  slowly.  Thick  thermometers  require 
five  minutes  to  record  the  maximum  temperature,  but  the  best  instruments 
now  made  reach  the  highest  point  in  about  two  ininutes.  In  the  rectum  or 
vagina  less  time  is  required. 

When  the  temperature  is  taken  in  the  mouth  the  bulb  must  be  placed 
under  the  tongue  and  the  lips  closed  about  the  stem,  the  patient  breathing 
through  his  nose.  It  is  an  excellent  plan  to  dip  the  instrument  in  water 
and  wipe  it  with  a  clean  napkin  in  the  presence  of  the  patient  both  before 
and  after  using  it  in  the  mouth.  It  is  not  safe  to  take  the  temperature  in 
the  mouth  either  in  young  children  or  in  conditions  of  delirium.  When  the 
patient  is  in  an  insensible  state,  or  when  doubts  arise  as  to  the  correctness 
of  an  axillary  observation,  the  rectum  or  the  vagina  may  be  used  for  apply- 


MEDICAL  THERMOMETRY.  55 

ing  the  thermometer,  and  with  self-registering  instruments  this  plan 
involves  no  exposure  of  the  person.  In  European  countries  the  common 
custom  is  to  take  the  temperature  in  the  rectum.  In  restless  children 
care  must  be  taken  to  prevent  the  instruments  being  broken,  and  in  all 
cases  to  prevent  a  short  thermometer  from  slipping  entirely  into  the  bowel, 
from  which  it  might  be  difficult  to  extract  it.  The  temperature  may  be 
rapidly  taken  in  unmanageable  children  by  means  of  an  old-fashioned 
thermometer  which  is  not  self-registering,  by  cautiously  warming  it  until 
the  mercury  reaches  a  very  high  point,  say  108°,  and  then  quickly  placing 
it  in  the  armpit.  The  mercury  falls  rapidly  to  the  temperature  of  the 
patient's  body  and  then  stops. 

Frequency. —  It  is  desirable  to  take  the  temperature  at  least  twice 
daily,  the  best  times  being  between  seven  and  eight  in  the  morning  and 
about  eight  in  the  evening.  The  observations  must  be  repeated  at  the  same 
hours  each  day.  In  cases  characterized  by  great  or  sudden  variations  of 
temperature,  by  very  high  temperature,  or  when  the  influence  of  treat- 
ment upon  the  fever  is  being  closel}^  watched,  observations  must  be  made 
at  shorter  intervals  of  time,  and  it  may  become  necessary  to  take  the 
temperature  as  often  as  every  hour. 

Abnormal  Temperatures. 

The  temperature  in  disease  may  range  below  or  above  the  normal. 
Sudden  falls  of  temperature  in  fever  are  very  significant;  just  as  are 
abrupt  rises  from  the  temperature  of  health.  The  following  terms  are 
used  to  indicate  the  general  condition  of  the  patient  in  abnormal 
ranges   of   temperature: 

Below  the  Normal.  F.  C. 

a.  Temperature  of  collapse Below       96.5°  35.8° 

h.  Subnormal  temperature 96.5°—  98°  35.8°— 36.7° 

c.  Normal  temperature 98°    —  99.5°  36.7°— 37.5° 

Above  the  Normal. 

d.  Subfebrile  temperature 99.5°— 100.5°  37.5°— 38.1° 

e.  Moderate  febrile  temperature f  100.5°— 102°     a.m.    38.1°— 38.9° 

(Mild  pyrexia) \  102.2°— 103°     p.m.  39°    —39.5° 

/.  High  febrile  temperature i  102°    —104°     a.m.  38.9° — 10° 

(Severe  pyrexia) \  104°    —105.8°  p.m.  40°    —41° 

g.  Intense  febrile  temperature 1  jQr  qo 1 1  qo  410    40  00 

(Hyperpyrexia) j 

The  range  of  deviation  from  the  normal  within  the  limits  of  which 
life  can  be  maintained  for  brief  periods  is  comprised  between  92°  F. 
and  110°  F.  A  temperature  of  95°  F.  on  the  one  hand  or  of  106°  F. 
on  the  other,  already  indicates  great  danger,  especially  if  it  be  prolonged, 
and  beyond  these  limits  in  both  directions  the  danger  to  life  speedily 
becomes  extreme. 

(a)  Temperature  of  Collapse  or  Shock.  —  A  considerable  and  rapid 
fall  of  temperature  attends  the  collapse  which  sometimes  occurs  during  or 
towards  the  close  of  some  of  the  essential  fevers.  In  enteric  fever  this 
condition  may  be  produced  by  hemorrhage,  or  by  sudden  peritonitis  due 
to  perforation,  or  in  consequence  of  sudden  failure  of  the  heart.     The  last 


56  MEDICAL  DIAGNOSIS. 

of  these  accidents  is  liable  to  occur  in  any  very  grave  case  of  fever, 
and  occasionally  follows  the  critical  fall  of  temperature  which  occurs  in 
pneumonia,  relapsing  fever,  and  more  rarely  in  other  febrile  diseases. 

Very  low  axillary  temperatures  are  met  with  in  the  stage  of  collapse 
in  the  algid  or  cold  stage  of  cholera,  the  internal  temperature  as  indicated 
by  the  vagina  or  rectum  remaining  high.  Great  depression  of  the  general 
temperature  occurs  in  the  collapse  produced  by  various  poisons,  and  espe- 
cially by  large  quantities  of  alcohol.  The  temperature  is  apt  to  fall 
considerably  below  the  normal  in  ordinary  deep  alcoholic  intoxication, 
especially  if  the  patients  have  been  exposed  to  cold  and  wet. 

(b)  Subnormal  Temperature.  —  This  condition  attends  considerable 
losses  of  blood;  starvation  from  any  cause;  the  wasting  of  certain  of  the 
chronic  diseases,  such  as  cancer  of  various  organs;  some  diseases  of  the 
brain  and  spinal  cord  and  the  later  stages  of  chronic  diseases  of  the  lungs 
and  heart,  especially  when  accompanied  by  dropsy. 

The  temperature  is  very  apt  to  reach  subnormal  ranges  in  the 
morning  for  a  few  days  at  the  termination  of  febrile  disorders. 

(c)  Normal  Temperature. — If  in  the  course  of  a  continued  fever,  as 
enteric,  the  temperature,  which  has  been  elevated  two  or  three  degrees  or 
more,  suddenly  falls  to  normal  or  near  it,  though  not  below,  this  in  itself 
is  significant  of  something  wrong,  and  may  even  acquire  the  importance 
of  the  "temperature  of  collapse,"  as  indicating  internal  hemorrhage, 
perforation,  or  failure  of  the  heart. 

(d)  Subfebrile  Temperature. — Slight  elevations  of  temperature  often 
accompany  trifhng  and  transient  disturbances  of  the  general  health, 
especially  in  children.  They  are  also  observed  at  the  beginning  of 
gradually  developing  fevers,  as  enteric,  and  at  the  close  of  slowly  subsid- 
ing febrile  conditions.  In  obscure  chronic  cases  they  are  of  importance 
as  indicating  the  existence  of  actual  disease  which  may  not  manifest  its 
ordinary  symptoms. 

(e)  Moderate  Febrile  Temperature. — When  the  morning  temperature 
reaches  101°-102°  F.  and  the  evening  shows  a  further  increase  of  one  or 
two  degrees,  we  have  to  do  with  actual  fever.  So  long,  however,  as  the 
temperature  does  not  exceed  these  limits,  there  is  no  serious  danger  from 
the  fever  process  itself. 

(f)  High  Febrile  Temperature. — When  the  temperature  in  the  morning 
is  above  102°-104°  F.  and  in  the  evening  reaches  or  ranges  higher  than 
104.5°,  the  case  becomes  serious  from  the  intensity  of  the  fever  alone, 
and  active  treatment  becomes  imperative.  High  fever  is  unattended  by 
immediate  danger  to  life  if  it  be  transient,  but  when  prolonged  it  is  ominous. 
A  temperature  of  105°  or  even  107°  in  the  hot  stage  of  an  ague,  when  the 
whole  attack  lasts  but  a  few  hours,  is  much  less  dangerous  than  the  same 
temperature  occurring,  even  for  a  short  time,  in  the  course  of  one  of  the 
continued  fevers,  when  the  patient's  powers  of  resistance  are  called  upon 
to  withstand  some  degree  of  fever  for  several  days  or  weeks. 

(g)  Hyperpyrexia,  or  Intense  Febrile  Temperature. — The  temper- 
ature reaches  105.8°  and  continues  to  rise,  or  at  all  events  does  not  fall. 
The  condition  is  one  of  extreme  and  imminent  danger  to  life.  The  resources 
of  the  art  of  medicine  are  put  to  their  severest  test.     Hyperpyrexia  often 


MEDICAL  THERMOMETRY.  57 

supervenes  with  great  suddenness.  Not  a  moment  is  to  be  lost.  The  most 
prompt  and  radical  measures  to  reduce  the  temperature  of  the  body  too 
often  fail  to  avert  the  fatal  result.  This  condition  has  been  encountered 
after  injuries  to  the  brain  and  to  the  upper  part  of  the  spinal  cord;  in  lock- 
jaw; in  sunstroke,  and  very  often  in  the  infectious  diseases,  especially 
scarlet  fever  and  pneumonia.  It  sometimes  occurs  in  rheumatic  fever, 
especially  after  the  intensity  of  the  symptoms  has  begun  to  subside,  or 
even  when  the  patient  is  apparently  almost  well.  Hyperpyrexia  is  often 
one  of  the  indications  of  approaching  death.  Hence,  in  certain  cases  the 
futility  of  treatment.  In  such  cases  a  temperature  of  110°  to  112°  is  some- 
times seen.  The  temperature  sometimes  continues  to  rise  slowly  for  an 
hour  or  two  after  death. 

The  thermometer  may  be  made  to  indicate  a  temperature  much  higher 
than  that  of  the  patient's  body,  by  friction,  or  by  being  slipped  against  a 
poultice  or  hot-water  bag,  or  into  a  cup  of  tea,  when  the  attention  of 
the  nurse  is  given  to  other  duties.  These  tricks  are  sometimes  played  by 
hysterical  girls.  They  are  readily  detected  by  repeated  observations  under 
the  eye  of  the  attendant.  A  number  of  cases  have  been  recorded  in  the 
medical  journals  in  which  excessively  high  temperatures — 120°,  150°, 
even  170°  F. — have  been  noted  and  apparently  verified  by  repeated  and 
most  careful  observations.  Many  of  the  patients  have  subsequently  been 
found  to  be  very  clever  pretenders  and  tricksters,  but  the  method  by 
which  the  high  temperatures  have  been  recorded  has  not  been  explained. 
In  such  cases  the  temperature  should  be  taken  in  several  different  regions, 
axilla,  mouth,  rectum,  etc.,  at  the  same  time,  and  the  temperature  of  the 
urine  when  voided. 

Transitory  Variations. — The  temperature  of  a  fever  patient  may  be 
somewhat  affected  by  excitement,  fatigue,  or  exposure.  Hence  hospital 
patients  often  show  for  a  few  hours  after  admission  a  temperature  higher 
than  subsequently,  or,  if  they  have  been  exposed  to  cold,  lower  than  really 
corresponds  to  their  condition. 

It  is  a  peculiarity  of  the  state  of  convalescence  from  the  acute  fevers 
that  the  temperature,  though  normal,  is  disturbed  by  trifling  causes,  and 
may  be  made  to  rise  two  or  three  degrees  by  the  first  visit  of  a  friend,  the 
first  solid  food,  or  even  by  sitting  up.  Such  rises  are  usually  very  brief, 
the  temperature  quickly  falling  again  to  normal.  They  occasion  uneasiness 
lest  they  be  the  beginning  of  a  relapse.  On  the  other  hand  it  occasionally 
happens  that,  though  all  the  other  symptoms  have  disappeared  and  the 
patient  is  almost  well,  the  temperature  remains  subfebrile,  and  the  patient 
is  for  that  reason  alone  kept  in  bed.  In  such  cases  all  traces  of  fever  vanish 
upon  cautiously  allowing  the  patient  to  sit  up  an  hour  or  so  each  day. 

Surface  Thermometry. 

This  method  is  of  inferior  value  for  diagnostic  purposes.  The 
bulb  consists  of  a  fine  coil  at  right  angles  to  the  tube  and  forming  an 
expanded  base  for  it.  Observations  may  be  taken  at  the  same  time 
in  corresponding  positions  on  both  sides  of  the  body.  The  general 
temperature    must   be   noted. 


58  MEDICAL  DIAGNOSIS. 

Normal  surface  temperature  (Kunkel).     Temperature  of  room  68°  F. — 20°  C. 

F.  C. 

Forehead 93.38-93.92°  34.1-34.4° 

Cheek  under  the  zygoma 93.92°  34.4° 

Tip  of  ear "; 83.84°  28.8° 

Back  of  hand 90.5  -91.76°  32.5-33.2° 

Hollow  of  the  hand  (closed) 94.64-95.18°  34.8-35.1° 

Hollow  of  the  hand  (open) 93.92-94.64°  34.4-34.8° 

Forearm 92.66°  33.7° 

Forearm  (higher) 93.74°  34.3° 

Sternum 93.92°  34.4° 

Pectorales 94.46°  34.7° 

Right  iliac  fossa 93.92°  34.4° 

Left  ihac  fossa 94.28°  34.6° 

Os  sacrum 93.56°  34.2° 

Eleventh  rib  (back) 94.1°  34.5° 

Tuberosity  of  ischium 89.6°  32.0° 

Upper  part  of  thigh 93.56°  34.2° 

Calf 92.48°  33.6° 

The  temperature  of  the  skin  is  slightly  higher  over  an  artery  than  at 
some  distance  from  it.  over  muscle  than  over  sinew,  over  an  organ  in  activity 
than  when  at  rest,  in  the  frontal  than  in  the  parietal  region  of  the  head, 
and  on  the  left  side  of  the  head  than  on  the  right. 

Local  elevation  above  the  general  temperature  has  been  noted  on  the 
surface  of  the  head  in  cases  of  mania  and  meningitis.  Local  elevation  of 
the  temperature  has  also  been  observed  in  cerebral  tumor  and  abscess. 
A  local  rise  of  temperature  also  occurs  over  the  painful  points  in  some 
cases  of  neuralgia  and  in  areas  of  superficial  inflammation.  The  surface 
temperature  is  increased  in  the  region  corresponding  to  the  exudate  in 
croupous  pneumonia.  Irregularly  distributed  areas  of  elevated  surface 
temperature  sometimes  occur  in  hysterical  persons. 

Subnormal  temperature  may  be  observed  in  a  limb  from  which  the 
blood  supply  is  cut  off  by  the  tourniquet  or  obstruction  of  the  main  artery, 
in  an  oedematous  or  cj^anosed  part,  and  in  gangrenous  areas.  Weir  Mitchell 
called  attention  to  the  effect  of  posture  upon  local  temperature.  He  found 
the  surface  of  the  dorsum  and  sole  of  the  foot  0.4°  C.  to  1°  C.  cooler  in  the 
erect  than  in  the  recumbent  posture. 

Charts. — The  temperature  must  be  recorded  at  once.  At  the  same 
time  a  record  of  the  pulse-beats  and  movements  of  respiration  per  minute 
is  to  be  made.  They  are  to  be  carefully  counted  while  the  thermometer 
is  in  position. 

Ruled  sheets,  called  "temperature  charts,"  or  "clinical  charts." 
are  sold  in  the  shops  for  this  purpose.  The  form  here  shown  will  be  found 
very  convenient.  It  may  be  so  kept  with  little  trouble  as  to  preserve  in  a 
compact  form  all  the  important  facts  of  an  acute  case,  and  is  equally  useful 
in  hospital  and  in  private  practice.  The  ruled  space  is  arranged  for  twenty- 
one  days  by  vertical  lines,  the  weeks  being  divided  by  heavy  lines.  The 
space  for  each  day  is  again  subdivided  for  the  morning  and  evening  record, 
as  indicated  by  the  M  and  E.  At  the  left  margin  the  purposes  of  the  spaces 
formed  by  the  transverse  rulings  are  indicated.  At  the  top  the  number 
of  movements  of  the  bowels;  immediately  below  the  quantity  of  urine 
passed,  which  may  be  recorded  in  fluidounces  or  cubic  centimetres;  then 
the  scale  of  Fahrenheit,  with  the  equivalent  Centigrade  opposite  on  the  right 


MEDICAL  THERMOMETRY. 


59 


margin.  The  coarse  horizontal  Une  at  98.4°  F.  indicates  approximately 
the  normal.  At  the  bottom  are,  first,  spaces  for  each  day  of  the  disease, 
then  similar  spaces  cUvided  by  a  diagonal  line  for  morning  (upper,  left 
triangle)  and  for  the  evening  (lower,  right)  pulse-rate;  below  these  again 
corresponding  spaces  for  the  respiration-rate,  and  at  the  bottom  of  the 
chart  spaces  for  the  date  or  day  of  the  month. 

Important  clinical  facts,  as  "hemorrhage,"  "convulsions,"  "sup- 
pression of  urine,"  etc.,  may  be  noted  at  the  time  of  their  occurrence 
between  the  vertical  lines  on  the  right  or  upper  side  of  the  chart  in  the 
position  indicated  by  the  arrows,  under  the  words  "clinical  memoranda." 


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Fig.  29. — Clinical  chart.     Actual  size  28x21  cm. 

While  changes  in  treatment,  and  in  particular  such  temporary  changes  as 
are  made  necessary  by  accidents,  like  hemorrhage,  convulsions,  or  sup- 
pression of  urine,  may  be  noted  at  the  left  or  lower  side  under  the  words 
"details  of  treatment,"  as  shown  by  the  arrows. 

The  previous  history  and  the  condition  of  the  patient  when  first  seen 
may  be  written  on  the  back  of  the  chart. 

The  spaces  corresponding  to  a  degree  of  the  Fahrenheit  scale  are  divided 
into  fifths.  The  temperature,  as  observed,  is  designated  by  a  dot  in  the 
appropriate  position.  These  dots  joined  by  ruled  lines  form  a  zigzag  line, 
called  the  temperature  curve.  It  is  usual  to  form  the  general  curve  of  the 
case  by  means  of  the  regular  morning  and  evening  temperatures,  and  to 
indicate  the  result  of  observations  made  at  other  hours  by  dots  in  the 
appropriate  positions,  with  figures  and  letters  showing  the  hour  at  which 
they  were  made;   thus,  12  noon,  3  p.m.,  or  6  a.m. 


60  MEDICAL  DIAGNOSIS. 

It  is  customary  to  join  the  general  curve  or  range  by  lines  drawn  with 
black  ink;  the  hourly  or  three-hour  observations  by  lines  drawn  with 
red  ink.  If  the  fever  be  prolonged  beyond  three  weeks  two  or  more  charts 
may  be  pasted  together.  These  charts  thus  kept  are  not  only  of  value  for 
preservation:  they  are  also  of  immediate  use  as  showing  at  a  glance  and 
with  precision  the  facts  of  the  case  at  every  period  from  its  coming  under 
observation,  the  course  it  is  running  by  a  comparison  of  the  symptoms 
day  by  day,  and  in  a  general  way  the  effects  of  treatment,  the  changes  of 
which  are  fully  presented.  Especially  are  they  valuable  in  fevers  in  ena- 
bling us  to  watch  the  course  of  the  temperature,  which  is  a  conspicuous 
part  of  the  natural  history  of  the  disease  and  conforms  in  most  of  the  acute 
infections  to  a  type  not  only  in  its  daily  fluctuations  but  also  in  its  duration. 


11. 

PHYSICAL  DIAGNOSIS. 

General  Considerations. — Physical  diagnosis  is  the  method  of  discrim- 
inating diseases  by  the  direct  aid  of  the  special  senses,  namely  the  eye, 
the  ear,  the  touch.  The  diagnostic  criteria  thus  obtained  are  known  as 
physical  signs.  They  depend  upon  the  physical  nature  and  structure  of 
the  organs  or  parts  examined  and  vary  with  the  changes  caused  by  disease. 
Hence  they  are  divided  into  tw^o  groups — normal  or  healthy,  and  abnormal 
or  morbid  physical  signs.  As  they  bear  a  direct  relation  to  the  anatomical 
condition  of  structures,  their  form,  contour,  density,  elasticity,  and  so  forth, 
and  similar  physical  conditions  may  be  present  in  different  diseases,  and  as 
morbid  processes  may  arise  in  the  absence  of  perceptible  alterations  in 
parts,  it  is  evident  that  physical  signs  taken  singly  are  not  diagnostic  of 
particular  diseases.  They  reveal  the  anatomical  condition  but  not  the 
morbid  process  causing  that  condition,  and  attain  their  full  value  in  diag- 
nosis only  when  considered  in  relation  to  other  signs  and  symptoms  and 
the  clinical  history  of  the  case. 

Pathognomonic  signs  are  those  supposed  to  be  diagnostic  of  particular 
diseases.  In  view  of  the  facts  just  mentioned,  the  use  of  the  term  pathog- 
nomonic in  this  sense  is  erroneous  in  theory  and  misleading  in  practice. 
A  physical  sign  is  the  manifestation  of  a  normal  or  morbid  physical  condi- 
tion, not  of  health  or  disease.  It  is  most  important  for  the  student  to  bear 
this  fact  clearly  in  mind.  Signs  at  one  time  regarded  as  pathognomonic, 
as  for  example  the  crepitant  rale  in  pneumonia,  are  now  known  to  occur  in 
other  conditions,  as  oedema  of  the  lungs  and  partial  atelectasis. 

Physical  diagnosis  is  constantly  employed  in  the  study  of  general  mala- 
dies and  in  local  diseases  of  all  parts  of  the  body,  but  it  is  of  special  service 
in  the  investigation  of  diseases  of  the  respiratory  and  circulatory  organs. 

Methods. — The  methods  of  physical  diagnosis  are  inspection,  palp.\- 

TION,  MENSURATION,  PERCUSSION, — including  RESPIRATORY  PERCUSSION, 
PALPATORY  PERCUSSION,  and  AUSCULTATORY  PERCUSSION, — and  AUSCULTA- 
TION. In  the  examination  of  patients  these  methods  are  used  systemati- 
cally and  in  succession,  the  signs  elicited  by  one  serving  to  confirm,  extend, 
or  control  the  knowledge  obtained  by  the  others. 

Technic. — The  physical  examination  must  under  all  circumstances  be 
conducted  in  a  routine  manner.  More  errors  in  physical  diagnosis  arise  from 
want  of  system  than  from  want  of  knowledge.  When  the  patient  is  in  bed. 
the  bared  chest,  abdomen,  and  back  must  be  in  turn  examined  by  the  several 
methods.  Under  some  circumstances  a  towel  or  a  single  thickness  of  rai- 
ment may  be  used  as  a  covering,  especially  in  percussion  and  immediate 
auscultation.     For  inspection  and  jDalpation  the  surface  should  be  bared. 

The  same  rules  apply  to  the  examination  of  ambulatory  patients. 
In  all  cases  the  outer  clothing  should  be  removed.  Physical  signs  cannot 
be  elicited  through  heavy  clothing,   starched  linen,  or  the  corset;  while 

61 


62  MEDICAL  DIAGNOSIS. 

silk,  stiff  shirt  fronts,  and  the  braces  cause  upon  deep  respiratory  move- 
ments crackling  and  friction  sounds  that  have  nothing  to  do  with  the 
organs  within  the  chest.  In  all  cases  the  examination  must  be  conducted 
with  tact,  judgment,  and  due  regard  for  the  sensibilities  of  the  patient. 
The  recognition  of  abnormal  physical  signs  involves  a  familiar  knowl- 
edge of  those  which  are  normal  and  their  variations  within  the  bounds  of 
health  and  of  the  anatomy  and  physiology  of  the  organs  or  parts  examined. 
Equally  necessary  is  a  ready  knowledge  of  the  pathological  changes  upon 
which  abnormal  signs  depend.  The  skilled  diagnostician  cultivates  the 
habit  of  seeing  with  his  mind's  eye  the  changes  in  structure  caused  by 
disease.  A  long  apprenticeship  in  the  post-mortem  room  is  an  essential 
preparatory  course  for  good  work  at  the  side  of  the  bed. 

INSPECTION. 

This  method  of  physical  diagnosis  is  of  the  widest  apphcation  in  the 
study  of  disease.  In  many  cases  a  provisional,  in  some  a  positive  diagnosis 
may  be  made  upon  a  careful  study  of  the  external  clinical  phenomena  by 
inspection  alone.  The  facies  hepatica,  emaciated  neck  and  limbs,  and 
enormously  distended  abdomen  in  cirrhosis  of  the  liver,  the  enlarged  parot- 
ids, disfigured  countenance,  and  projecting  lobule  of  the  ear  in  mumps, 
the  unilateral  flushing  and  jerky  dyspnoea  in  croupous  pneumonia,  and 
the  rash  in  the  eruptive  diseases,  tell  their  own  tale.  In  a  narrower  and 
more  technical  sense  inspection  is  especially  of  value  in  the  diagnosis 
of  diseases  of  the  thoracic  and  abdominal  organs. 

The  clothing  must  be  removed.  The  light  must  be  good.  The  skilled 
diagnostician  makes  use  now  of  direct  light,  by  which  extensive  surfaces 
are  fully  illumined;  now  of  oblique  light,  by  which  local  elevations  and 
depressions  are  accentuated  and  pulsations  are  marked  by  moving  shadows. 

By  inspection  we  obtain  information  in  regard  to  the  size,  form,  or 
contour,  the  appearance  of  the  surface,  and  the  movements  of  the  thorax 
and  abdomen. 

Inspection  of  the  Thorax. 

The  Size. — The  size  of  the  chest  is  determined  by  the  volume  of  its 
contents.  Within  the  limits  of  health  there  are  wide  variations.  A  seden- 
tary life  tends  to  shallow  breathing  and  small  lungs.  The  chest  then  con- 
forms to  the  inspiratory  type.  The  anteroposterior  diameter  is  short, 
the  upper  intercostal  spaces  wide,  the  lower  narrow,  the  costal  angle  acute. 
We  speak  of  such  a  chest  as  shallow.  Active,  out-door  occupations  favor 
habitual  deep  breathing  and  increase  in  the  size  of  the  lungs.  The  chest 
now  conforms  to  the  expiratory  type.  The  anteroposterior  diameter  is 
relatively  long,  the  upper  intercostal  spaces  narrow,  the  lower  wide;  the 
costal  angle  is  obtuse.  Such  persons  are  deep  chested.  Diseases  which 
diminish  the  size  of  the  lungs,  as  chronic  tuberculosis  and  fibroid  phthisis, 
correspondingly  reduce  the  size  of  the  thorax,  while  so-called  pseudo- 
hypertrophic emphysema  greatly  increases  its  size.  But  these  changes 
are  accompanied  by  definite  changes  in  form.  Excessive  subcutaneous 
fat  sometimes  gives  rise  to  an  apparent  increase  in  the  size  of  the  chest. 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


63 


The  Form. — The  form  of  the  chest  varies  with  its  size.  In  infancy 
and  early  childhood  it  is  somewhat  cylindrical, — that  is,  its  anteroposterior 
diameter  and  its  transverse  diameter  are  nearly  the  same, — and  the 
respiration  is  chiefly  diaphragmatic.  In  adults  the  cross  section  of  the 
trunk  is  oval  and  symmetrical.  Upon  deep  inspiration  the  anteroposterior 
diameter   of  the  chest  is  increased;   on  forced  expiration  it  is  diminished. 

Deformities. — The  general 
deformities  in  childhood  are  com- 
monly due  to  respiratory  obstruction 
in  the  upper  air-passages,  as  from 
adenoid  growths  in  the  nasopharynx, 
enlargement  of  the  tonsils;  or  in  the 
lungs,  as  in  bronchopneumonia  or 
phthisis.  Rickets  plays  an  impor- 
tant part.  In  adult  life  they  are 
commonly  caused  by  fibroid  changes 
in  the  lungs,  pulmonary  tuberculosis 
and  emphysema.  Unilateral  and 
local  deformities  are  caused  by  pleu- 
ral effusions,  the  retraction  which 
follows  the  resorption  or  removal  of 
such  effusions,  hypertrophy  of  the 
heart,  and  aneurismal  or  other  intra- 
thoracic tumors.  These  abnormal 
modifications  in  form  are  more 
marked  when  they  occur  early  in 
life.  The  following  deviations  in 
form  are  to  be  considered: 

(a)  The  Alar  or  Pterygoid  Chest. 
— The  chest  is  unnaturally  small  and 
narrow.  The  inner  borders  of  the 
scapulae  project  like  budding  wings, 
the  ribs  are  extremely  oblique,  the 
shoulders  droop,  the  neck  and  chest 
appear  preternaturally  elongated, 
the  head  is  carried  unduly  forward, 
and  the  costal  angle  is  acute.  This 
form  of  chest  is  sometiones  described 
as  the  "paralytic  chest."  Persons  suffering  from  pulmonary  tuberculosis 
frequently  present  this  form  of  chest,  but  it  may  also  occur  in  poorly 
nourished  individuals  who  are  not  phthisical. 

(b)  The  Rhachitic  Chest.  —  The  sternum  may  project,  giving  rise  to 
the  deformity  known  as  pigeon  breast.  The  sides  of  the  chest  are  flattened 
and  curve  forward  to  the  prominent  sternum,  as  the  sides  of  a  boat  to  the 
keel — pectus  carinatum.  From  the  base  of  the  ensiform  cartilage  a  broad 
shallow  depression  or  groove  passes  downward  and  outward  to  the  infra- 
axillary  region — Harrison's  furrow.  In  some  instances  the  cartilages 
of  the  ribs  lose  their  curve  and  become  straight,  causing  the  chest  to  be 
quite  flat  in  front  instead  of  being  rounded.     In  others  there  is  a  shallow 


Fig. 


30.  —  Alar   deformity   of    chest. — German 
Hospital. 


64 


MEDICAL  DIAGNOSIS. 


longitudinal  groove  on  each  side  of  the  front  of  the  chest,  a  little  external 
to  the  sternum  and  nearly  parallel  to  it.  The  remarkable  deformity  known 
as  FUNNEL  BREAST  sometimes  but  by  no  means  always  is  due  to  rickets. 
It  consists  in  a  deep  and  rather  abrupt  crater-like  depression  in  the  region 
of  the  base  of  the  ensiform  cartilage.  Not  rarely  there  may  be  felt  and 
sometimes  seen  a  line  of  nodular  thickenings  along  the  chondrocostal 
articulations  on  each  side,  known  by  the  fanciful  name  of  the  rhachitic  rosary. 

(c)  The  Barrel  Chest.— The 
deformity  characteristic  of  emphy- 
sema is  very  striking.  The  antero- 
posterior diameter  is  greatly 
increased.     The  thorax  is  in  a  state 


Fig.  31.- — Paralji;ic  chest. 


Fig.  32. — Funnel-shaped  deformity  of  chest. 
— JeSerson  Hospital. 


of  distention  greater  than  that  produced  in  health  by  the  deepest  inspira- 
tion. It  is  arched  before  and  behind.  The  manubrium  and  body  of  the 
sternum  are  sometimes  bent  at  an  angle — angulus  Ludovici.  The  shoulders 
are  high,  the  neck  short,  and  the  costal  angle  very  obtuse.  Dorsal  kyphosis 
due  to  the  carrying  of  burdens  upon  the  shoulders,  to  advancing  years,  or 
to  vertebral  caries  may  simulate  the  barrel-shaped  chest  of  emphysema, 
(d)  Deformities  of  the  Spine. — Curvatures  and  twisting  are  very 
common.  The  slighter  forms  are  often  overlooked.  They  may  be  recog- 
nized upon  careful  inspection  of  the  bare  back,  the  spinous  processes  being 
marked  by  a  dermatographic  pencil.  Marked  curvatures  in  which  rotary 
displacements  are  prominent  derange  the  relations  of  the  thoracic  viscera 
to  the  bonv  landmarks  and  render  the  physical  examination  of  the  chest 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


65 


difficult  and  the  signs  uncertain.  The  cardiac  impulse  may  be  displaced 
upward  or  to  the  left;  abnormal  bulging  may  simulate  aneurismal  or  other 
intrathoracic  tumor  and  areas  of  atelectasis  with  compensatory  emphy- 
sema occur.  Abnormal  rigidity  of  the  spine  may  be  due  to  spastic  contrac- 
tion of  the  muscles  in  Pott's  disease  or  to  spondylitis  deformans.  When 
ankylosis  has  developed  the  spine  is  persistently  rigid.  These  signs  may  be 
recognized  upon  attempts  to  bend 
forward  or  backward  or  to  rotate  the 
shoulders  while  the  pelvis  is  held 
fixed.  An  examination  of  the  verte- 
bral column  forms  part  of  every 
routine  examination  of  the  chest. 

Unilateral  changes  in  the  shape 
of  the  chest  consist  in  diminution 
and  enlargement. 

Unilateral  Diminution. — Flatten- 
ing of  one  side  of  the  chest  is  a  sign 
of  chronic  pulmonary  tuberculosis 
of  the  corresponding  lung,  fibrosis 
of  one  lung,  or  a  pleural  effusion 
which  has  undergone  resorption 
or  been  cured  by  operation.  The 
circumference  and  anteroposterior 
diameter  are  diminished;  the  bilat- 
eral diameter  is  increased;  the  side 
is  angular  and  flattened  before  and 
behind;  the  upper  intercostal  spaces 
are  widened,  the  lower  narrowed; 
the  shoulder  is  lowered  and  there 
is  lateral  curvature  of  the  spine,  the 
convexity  being  towards  the  oppo- 
site side.  The  vicarious  enlargenient 
of  the  sound  lung  gives  rise  to 
marked  differences  in  the  circum- 
ference of  the  two  sides.    When  the 

deformity  is  due  to  tuberculous  disease  of  the  upper  lobe,  the  flattening  is 
more  marked  in  the  upper  region  of  the  chest;  when  to  old  pleurisy  it  is 
more  marked  at  the  base.  Unilateral  flattening  of  the  chest  is  attended 
by  pleural  adhesions.  If  obstruction  of  the  main  bronchus  occurs  in  child- 
hood, the  resulting  collapse  of  the  lung  may  cause  an  acute  unilateral 
flattening  of  the  chest.  Lateral  spinal  curvature  may  simulate  diminution 
of  the  chest  from  pulmonary  disease. 

Unilateral  Enlargement. — This  deformity  of  the  chest  is  a  sign  of 
vicarious  enlargement  of  one  lung  as  a  result  of  chronic  disease  of  its  fellow, 
pleural  effusion,  large  hsemothorax,  pneumothorax,  and  rarely  of  rapidly 
growing  malignant  disease.  Pseudohypertrophic  emphysema  may  in 
rare  instances  involve  one  lung  when  the  other  has  undergone  fibroid  changes 
in  consequence  of  previous  di.sease.  The  enlarged  side  is  rounder  than  the 
other;    its  anteroposterior    diameter  longer;    the  intercostal  spaces  wide; 


Fig.  33. — Emphysematous  type  of  chest. — German 
Hospital. 


66 


MEDICAL  DIAGNOSIS. 


the  shoulder  raised  and  the  spine  curved  laterally,  the  dorsal  convexity 
being  towards  the  enlarged  side. 

The  foregoing  alterations  in  the  form  of  the  chest  are  very  obvious 
when  the  physician  stands  behind  the  seated  patient  and  looks  obliquely 
over  his  shoulders  and  the  front  of  his  chest. 

Intercostal  Spaces. — In  large  pleural  effusions  and  in  pneumothorax 
the  normal  depression  of  the  intercostal  spaces  is  obliterated  and  the 
surface  smooth  as  contrasted  with  the  opposite  side.  Bulging  of  the  inter- 
costal spaces  is  rare.  It  may  be  seen  at  the  base  of  the  chest  in  large  em- 
pyema of  long  standing. 


Fig.  34. — Deformity  following  the  resorption  of  a  pleural  effusion. — German  Hospital. 


Local  Changes. — Local  changes  in  shape  consist  in  (a)  circumscribed 
retraction  or  (b)  prominence. 

Local  retraction  is  a  sign  of  the  following  conditions: 

Tuberculous  Consolidation  of  a  Portion  of  the  Lung. — This  is  usual  at  the 
apex  and  most  obvious  in  the  supra-  and  infraclavicular  regions.  It  is 
attended  by  pleural  adhesions. 

A  Superficial  Cavity.  —  Circumscribed  depressions  due  to  this  cause 
are  often  seen  on  the  anterior  surface  of  the  chest  near  the  sternal  border 
and  extending  over  one  or  two  intercostal  spaces.  Flattening  in  the  postero- 
lateral aspect  of  the  chest  opposite  the  spine  of  the  scapula  and  below  its 
level  is  sometimes  seen  in  pulmonary  abscess. 

Old  Pleurisy. — A  broad,  shallow  depression  in  the  anterolateral  region 
at  the  base  of  the  chest  is  common  after  pleural  effusions.  The  funnel 
breast  sometimes  follows  unilateral  pleurisy.  This  deformity  in  shoe- 
makers has  been  attributed  to  the  pressure  of  the  last  against  the  breastbone. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  67 

Local  retraction  in  children  may  follow  croup,  bronchopneumonia,  and 
rickets.  The  deformities  caused  by  these  agencies  are  symmetrical  and 
have  already  been  considered. 

Local  prominence  is  a  sign  of  circumscribed  pleural  effusion,  large 
vomicae  when  distended  with  fluid,  diaphragmatic  hernia  when  congenital, 
tumor  of  the  lung  or  of  the  chest  wall,  mediastinal  tumor,  abscess  of  the 
chest  wall,  and  empyema  necessitatis.  In  a  considerable  proportion  of 
healthy  persons  that  region  of  the  chest  wall  which  overlies  the  heart  ^ — 
the  precordial  space — is  slightly  prominent.  In  children  and  occasionally 
in  adults  prominence  of  the  precordial  space  results  from  cardiac  hyper- 
trophy or  pericardial  effusion.  The  bulging  occupies  the  space  between 
the  third  and  seventh  costal  cartilages  on  the  left  side  and  the  left  mid- 
clavicular line  and  the  sternum.  It  may  extend  to  the  right  nipple.  Aneu- 
rism of  the  arch  of  the  aorta  causes  local  bulging  of  the  chest  wall  and  in 
rare  instances  aneurism  of  the  de- 
scending aorta  may  erode  the  ribs 
and  give  rise  to  a  circumscribed 
tumor  of  the  dorsal  region  to  the 
left  of  the  spine.  Inspection  of  the 
back  frequently  reveals  local  prom- 
inences of  importance  in  diagnosis. 
A  sharp  projection  of  the  spinal 
processes  occurs  in  vertebral  caries. 
The  inner  borders  of  the  scapulae 
stand  out  prominently  in  the  ptery- 
goid chest.  A  congenital  rounded 
tumor  in  the  middle  line,   translu- 

r>on<-  onrl  T-iQrtNT-  rorlnpihlo  ic  fViA  FiG.  35.— Aueurism  of  the  descending  thoracicaorta; 
cent;     ana^    paruy     reaUCipie,     is     tne  perforation  of  chest  wall.—Penna.  Hospital. 

sign  of  spina  bifida.     This  defect  of 

development  is  frequently  associated  with  other  deformities,  as  hydro- 
cephalus or  club-foot.  A  dusky-red,  brawny  swelling,  commonly  in  the 
cervical  region,  discharging  pus  from  several  sinuses,  is  a  carbuncle.  It 
occurs  frequently  in  diabetes  mellitus,  and  in  all  cases  the  urine  should  be 
examined  for  sugar.  Rounded  or  lobulated  elastic  tumors,  painless  and 
usually  movable,  are  fatty.  They  sometimes  so  closely  resemble  abscesses 
as  to  require  aspiration  for  the  differential  diagnosis.  Abscesses  appear 
as  fluctuating  swellings  as  the  result  of  caries  of  the  vertebrae,  usually 
tuberculous,  and  may  burrow  in  various  directions.  I  have  seen  a  large, 
oblong  tumor  to  the  left  of  the  dorsal  spine  formed  by  an  aneurism  of  the 
descending  aorta,  and  a  similar  tumor  in  the  left  lumbar  region  which  ]nil- 
sated  and  was  connected  with  a  left-sided  empyema.  In  disseminated 
sarcoma  of  the  skin  the  lesions  are  common  on  the  back,  appearing  as 
circumscribed  nodular  masses  varying  in  size  from  a  small  shot  to  a  walnut, 
dark  in  color  and  mostly  movable. 

Surface. — The  appearance  of  the  surface  of  the  chest  only  excep- 
tionally yields,  upon  inspection,  physical  signs  of  importance.  We  note 
emaciation  or  an  abundant  panniculus  adiposus,  jaundice,  cyanosis  and 
pigmentation,  the  eruptions  and  scars  of  the  exanthemata  or  of  syphilis 
or  other   chronic    disease,  enlargement  of  the  superficial    lymph-nodes  at 


68  MEDICAL  DIAGNOSIS. 

the  root  of  the  neck  and  in  the  armpits,  patches  and  lines  of  dilated 
venules  and  dilated  and  tortuous  venous  trunks.  The  appearance  of 
linear  patches  of  herpes  in  shingles — zona,  herpes  zoster — in  the  course 
of  the  intercostal  and  lumbar  nerves,  often  clears  up  the  diagnosis 
where  there  has  been  severe  burning  pain  upon  one  side  of  the  chest 
or  abdomen. 

The  Movements  of  the  Chest.  —  Normal  and  abnormal  types  of 
respiration  will  be  considered  in  a  subsequent  section.  Anomalous  move- 
ments that  affect  both  sides  of  the  chest  occur  in  dyspnoea,  inspiratory 
dyspnoea,  expiratory  dyspnoea,  Cheyne-Stokes  respiration,  exaggerated 
thoracic,  exaggerated  abdominal  breathing,  and  so  on. 

Abnormalh^  deep  respiration  in  the  absence  of  any  apparent  difficulty 
either  in  inspiration  or  expiration  is  seen  in  diabetic  coma. 

In  the  emphysema  of  the  aged  and  in  earlier  life  in  some  cases  of 
hereditary  syphilis  and  pulmonary  tuberculosis,  calcification  of  the  costal 
cartilages  and  associated  changes  in  the  ribs  cause  the  walls  of  the  chest  to 
move  through  a  limited  space  as  a  whole — en  cuirasse. 

Unilateral  modifications  of  the  respiratory  movements  may  consist  of 
(a)  diminished  expansion  of  one  side  or  (b)  increased  expansion  of  one  side. 

(a)  Diminished  expansion  of  one  side  may  involve  the  entire  side, 
as  in  large  pleural  effusion,  pneumothorax,  pneumonia  involving  the  whole 
of  one  lung,  tuberculous  consolidation  of  a  lung,  or  tumor  of  the  lung  or 
pleura.  The  afi^ected  side  is  not  only  immobile  but  it  is  also  distended  and 
altered  in  contour.  In  tuberculosis  it  is,  however,  usually  contracted  in 
consequence  of  pleural  adhesions  and  sclerotic  changes  in  the  lung.  In 
massive  pneumonia  it  is  almost  immobile  but  not  enlarged.  Contraction 
also  occurs  in  the  occlusion  of  a  large  bronchus  from  the  presence  of  an 
aneurism  or  other  tumor. 

In  tuberculosis  confined  to  the  apex  of  one  or  both  lungs  there  is  failure 
of  expansion  in  the  corresponding  region  of  the  chest. 

Diminished  unilateral  expansion  may  be  a  sign  of  infradiaphragmatic 
disease — on  the  right  side,  of  an  enlarged  liver  or  hepatic  tumor;  on  the 
left,  of  an  enlarged  spleen  or  tumor  in  the  splenic  region. 

In  rare  instances  a  hemiplegia  or  paralysis  of  one  side  of  the  diaphragm 
or  a  diaphragmatic  hernia  may  be  the  cause  of  diminished  expansion  of 
one  side  of  the  chest. 

Non-expansive  inspiration  is  attended  with  retraction  of  the  inter- 
spaces. This  sign  is  especially  noticeable  in  the  inframammary,  the  infra- 
axillary,  and  the  infraclavicular  regions  in  partial  atelectasis  or  collapse  of 
the  lungs,  in  obstruction  of  the  glottis  as  in  pseudomembranous  laryngitis, 
oedema  of  the  glottis,  or  pseudomembranous  bronchitis  such  as  occurs  in 
infralaryngeal  diphtheria  or  in  the  diffuse  atelectasis  of  bronchopneumonia. 
Under  those  conditions  both  sides  are  involved.  When  a  main  bronchus 
is  occluded  the  sucking  in  of  the  intercostal  spaces  upon  inspiration  is 
limited  to  the  affected  side.  This  phenomenon  is  caused  b}^  intrathoracic 
negative  pressure  during  inspiration,  in  consequence  of  which  the  soft 
parts  of  the  thoracic  wall  yield  to  the  external  pressure  of  the  atmosphere. 

(b)  Increased  expansion  of  one  side  of  the  chest  is  usually  com- 
pensatory.    It  occurs  when  the  respiratory  movement  of  the  opposite  side 


PHYSICAL  DIAGNOSIS:     INSPECTION.  69 

is  interfered  with  by  pathological  conditions  of  the  lung,  as  tuberculosis, 
pneumonia,  fibrosis  and  atelectasis  from  other  causes,  or  by  pleural  effu- 
sion, pneumothorax,  or  tumor,  and  thus  becomes  a  sign  of  tho.se  conditions. 

The  Diaphragm  Phenomenon  —  Litten's  Sign.  —  The  diaphragm  ap- 
proaches the  wall  of  the  thorax  in  expiration  and  comes  into  contact  with 
it  at  the  end  of  the  act.  It  is  separated  or  peeled  off  from  it  in  inspiration. 
These  movements  are  rendered  visible  by  the  procedure  suggested  by 
Litten  in  1892.  The  patient  is  placed  upon  his  back  with  his  chest  bared 
and  his  feet  toward  a  window.  Cross  lights  are  excluded.  If  the  examina- 
tion is  made  at  night,  a  strong  light  held  at  the  foot  of  the  bed  .serves' the 
purpose.  The  observer  stands  at  a  little  distance  and  views  the  surface 
of  the  lower  part  of  the  chest  obliquely.  Upon  deep  inspiration  a  short, 
narrow,  horizontal  shadow  is  seen  to  move  from  the  sixth  intercostal  space 
downward  over  two  or  more  interspaces  upon  both  sides.  During  expira- 
tion this  shadow  moves  up  again  to  the  line  from  which  it  started  but  is 
less  distinct.  It  may  in  some  cases  be  seen  in  the  epiga.strium.  This  phe- 
nomenon is  practically  present  in  all  healthy  persons,  the  only  exceptions 
being  due  to  abnormal  thickness  of  the  chest  walls  and  inability  on  the 
part  of  the  patient  to  make  full,  deep  respiratory  movements.  It  is  best 
observed  in  young,  lean,  muscular  persons.  The  extent  of  the  movement 
of  the  shadow  in  normal  chests  is  about  two  and  a  half  inches;  upon  forced 
breathing  slightly  more  than  this. 

The  descending  shadow  is  due  to  the  undulation  of  the  chest  wall 
caused  by  the  separation  of  the  diaphragm  from  its  contact  with  the  lower 
part  of  the  thorax  and  the  descent  of  the  border  of  the  lung  into  the  wedge- 
shaped  space  between  them  during  inspiration,  and  the  reverse  shadow 
by  the  retraction  of  the  lung  and  the  coming  together  of  the  diaphragm 
and  chest  wall  during  expiration. 

The  shadow  is  absent  upon  the  affected  side  in  pneumonia  of  the 
lower  lobe,  pleural  effusion,  extensive  pleural  adhesions,  intrathoracic 
tumors,  and  marked  emphysema.  In  these  conditions  the  diaphragm 
does  not  approach  and  recede  from  the  chest  wall  and  the  undulations 
which  cause  the  shadow  do  not  occur.  The  extent  of  the  movement  is 
lessened  in  conditions  of  debility,  slight  emphysema,  and  upon  the  affected 
side  in  phthisis.  In  the  latter  condition  there  are  probably  two  factors  in 
restricting  the  movement,  diminished  pulmonary  expansion  and  limited 
pleural  adhesions. 

Litten's  sign  is  present  in  hepatic  and  splenic  enlargements  and  in 
subphrenic  abscess  and  may  be  of  service  in  the  differential  diagnosis 
between  those  conditions  and  pleural  effusion.  In  very  large  ascites  it 
may  be  absent. 

The  Movements  of  the  Heart.  —  Inspection  yields  important  phys- 
ical signs  in  regard  to  the  heart  and  great  vessels  in  health  and  disease. 
These  signs  relate  to  (a)  the  cardiac  impulse;  (b)  other  movements  of 
the  surface  having  the  cardiac  rhythm:  (1)  pulsations  at  the  root  of 
the  neck,  (2)  aneurism.  (3)  tumors  in  contact  with  large  arterial  trunks, 
(4)  pulsating  empyema. 

(a)  The  Cardiac  Impulse.  —  With  the  systole  of  the  heart  tiiere  is 
seen  in  most  norma!  chests  an  outward  movement  or  pulsation  in  a  limited 


70  MEDICAL  DIAGNOSIS. 

area  in  the  fifth  left  intercostal  space  just  beyond  the  parasternal  line — 
the  visible  impulse  or  so-called  apex-beat  of  the  heart.  In  infants  and  young 
children,  owing  to  the  proportionately  greater  size  of  the  liver,  the  impulse 
is  often  visible  as  high  as  the  fourth  interspace,  while  in  aged  persons  it 
may  normally  be  as  low  as  the  sixth  interspace.  It  is  occasionally  absent 
in  healthy  persons,  especially  those  having  deep  chests  and  capacious 
lungs.  It  invariably  takes  place  at  the  time  of  the  contraction  of  the 
ventricles.  The  most  important  factor  in  the  production  of  the  impulse 
is  the  change  in  the  direction  of  the  long  axis  of  the  ventricles  against  the 
resistance  of  the  chest  wall.  It  is  a  mistake  to  speak  of  it  as  a  "blow" 
or  "impact  "  against  the  wall  of  the  chest,  since  that  part  of  the  heart  which 
causes  it,  namely,  the  apex  of  the  right  ventricle,  is  already  in  contact  with 
the  wall  in  diastole  and  simply  becomes  more  tense  and  prominent  during 
systole.  Around  the  point  where  the  soft  parts  are  protruded  by  the  impulse 
they  are  very  slightly  retracted  at  the  time  of  its  occurrence — the  "negative 
impulse."  This  is  clue  to  the  lessening  size  of  the  contracting  ventricles, 
which,  being  air-tight  within  the  cavity  of  the  chest,  must  be  followed 
down  under  the  pressure  of  the  atmosphere  by  the  elastic  and  yielding 
lungs  and  the  somewhat  yielding  intercostal  tissues.  A  clear  conception 
of  this  fact  renders  intelligible  the  systolic  recession  of  the  chest  wall 
occasionally  seen  in  emaciated  persons  in  the  third,  fourth,  or  even  the  fifth 
intercostal  space,  close  to  the  left  border  of  the  sternum. 

Since  the  normal  impulse  is  caused  by  the  apex  of  the  right  ventricle 
and  not  by  that  of  the  left,  which  extends  further  dow^nward  and  is  sepa- 
rated from  the  wall  of  the  chest  by  a  tongue-like  projection  of  the  lower 
lobe  of  the  left  lung,  the  apex  of  the  right  ventricle  is  sometimes  spoken 
of  as  the  "clinical  apex"  and  that  of  the  left  ventricle  as  the  "anatomical 
apex"  of  the  heart. 

The  normal  impulse  is  usually  limited  in  extent,  often  not  exceeding 
an  inch  square.  Its  position  varies  somewhat  with  the  posture.  When 
the  patient  lies  upon  the  left  side,  it  may  shift  an  inch  or  more  towards 
the  axillary  line,  and  a  similar  displacement  to  the  right,  but  less  in  extent, 
takes  place  when  he  lies  upon  the  right  side.  The  impulse  is  less  marked 
and  less  extensive  in  the  recumbent  than  in  the  erect  posture.  These 
changes  in  the  position  of  the  heart  are  caused  by  corresponding  altera- 
tions in  the  position  of  the  apex  under  the  influence  of  gra\dty.  The  posi- 
tion of  the  impulse  is  little  influenced  by  cpiet  breathing,  but  as  the  dia- 
phragm sinks  and  the  lower  ribs  are  elevated  in  inspiration  a  change  in 
the  relation  of  the  apex-beat  to  the  chest  wall,  in  some  instances  amounting 
to  an  interspace,  may  be  observed  upon  forced  breathing. 

The  impulse  becomes  forcible  and  extended  when  the  normal  heart  is 
acting  rapidly  and  with  force  under  physical  or  mental  stress  and  in  thin, 
nervous  persons,  and  it  is  often  extended  in  young  children  even  at  rest. 

The  character  of  the  impulse  and  its  extent  are  best  studied  by  palpa- 
tion, but  inspection  alone  enables  us  in  many  cases  to  determine  that  the 
Impulse  is  extended,  heaving,  tapping,  or  undulatory. 

Displacements  of  the  Impulse  of  the  Heart. — Disflacements  due 
to  Changes  in  the  Heart  Itself. — The  impulse  is  displaced  downward  and 
toward  the  left  in  hypertrophy  and  dilatation  of  the  heart,  and  the  combi- 


PHYSICAL   DIAGNOSIS:     INSPECTION.  71 

nation  of  these  conditions  is  the  most  common  cause.  Enlargement  of 
the  left  ventricle  tends  to  displace  the  visible  impulse  downward,  enlarge- 
ment of  the  right  ventricle  tends  to  displace  the  impulse  to  the  left,  and 
both  of  these  conditions  tend  to  increase  its  extent. 

Pressure  Displacements  are  next  in  Order  of  Frequency. — The  heart  is 
dislocated  upward  in  pressure  from  below  the  diaphragm,  as  in  excessive 
tympany,  ascites,  massive  tumors,  large  cysts,  and  pregnancy.  In  any  of 
these  conditions  the  impulse  may  be  seen  in  the  fourth  interspace  and  to 
the  left  of  the  midclavicular  line.  The  heart  in  pleural  effusion,  pneumo- 
thorax, or  rapidly  growing  malignant  tumors  of  the  pleura,  is  displaced 
towards  the  opposite  side.  When  these  conditions  are  left-sided  the 
impulse  may  disappear  behind  the  sternum  or  become  visible  at  its  right 
border,  or  in  extreme  cases  in  the  right  nipple  line.  In  large  right-sided 
■effusions,  on  the  contrary,  the  impulse  may  be  displaced  as  far  left  as  the 
line  of  the  anterior  axillary  fold.  Cysts  and  abscess  in  the  right  lobe  of 
the  liver  may  displace  the  heart  somewhat  to  the  left  and  shift  the  impulse 
to  a  corresponding  extent. 

The  heart  may  be  displaced  downward  by  an  aneurism  of  the  arch  of 
the  aorta  or  a  mediastinal  tumor.  Under  those  circumstances  the  impulse 
is  not  only  lower  than  normal  but  it  is  also  somewhat  further  to  the  left. 

Traction  displacements  of  the  heart  occur  in  pulmonary  cirrhosis  and 
long-standing  disease  of  the  pleura.  The  displacement  is  toward  the  affected 
side.  Pleuropericardial  adhesions  and  negative  pressure  constitute  the 
mechanical  factors  by  which  this  group  of  displacements  is  brought  about. 
A  cardiac  impulse  may  be  seen  to  the  right  of  the  sternum,  or  to  the  left 
of  the  left  midclavicular  line,  or  if  there  be  great  retraction  of  the  upper 
lobe  on  either  side  there  may  be  visible  cardiac  pulsation  at  the  corre- 
sponding border  of  the  manubrium.  Spinal  curvatures  and  rotations  may 
produce  such  displacement  of  the  heart  as  to  cause  a  wholly  abnormal 
position  of  the  visible  cardiac  impulse  or  its  absence  altogether.  Dextro- 
cardia may  be  the  cause  of  a  right-sided  impulse,  an  anomaly  also  present 
in  complete  transposition  of  the  viscera. 

Systolic  Retraction.  —  I  have  already  spoken  of  the  negative 
impulse  present  under  normal  conditions  in  the  immediate  proximit)''  of 
the  apex-beat  and  the  more  extended  systolic  recession  of  the  interspaces 
occasionally  seen  along  the  lower  sternal  border.  These  are  distinctly 
accentuated  when  a  hypertrophied  and  somewhat  dilated  heart  is  acting 
forcibly.  As  these  forms  of  systolic  recession  are  due  to  atmospheric  pres- 
sure, they  may  be  spoken  of  as  pulsion  recessions  in  contradistinction  to 
those  due  to  the  drawing  in  of  the  surface  in  consequence  of  adhesions, 
which  may  be  called  traction  recessions. 

The  latter  are  seen  in  adherent  pericardium  with  chronic  mediastinitis. 
The  impulse  is  undulatory  and  in  the  region  of  the  apex  there  is  marked  sys- 
tolic retraction.  Owing  to  the  enlargement  of  the  heart  the  precordial  region 
is  prominent  and  the  chest  asymmetrical.    The  impulse  is  greatly  extended. 

Broadbent's  Sign. — When  the  heart  is  extensively  adherent  to  the 
diaphragm,  there  occurs  with  each  pulsation  a  systolic  tug.  This  may  be 
communicated  through  the  diaphragm  to  the  j)oints  of  its  insertion  in  the 
wall  of  the  chest  and  well  seen  in  the  eighth  and  ninth  intercostal  spaces  in 


72  MEDICAL  DIAGNOSIS. 

the  parasternal  line;  but  Broadbent  has  pointed  out  the  fact  that  it 
is  often  also  seen  on  the  left  side  behind,  between  the  eleventh  and 
twelfth  ribs.  Careful  inspection  in  this  region  will  frequently  reveal  a 
systolic  retraction  of  the  chest  wall,  which  becomes  more  evident  upon 
deep  inspiration. 

Visible  Pulsations  of  the  Heart  in  Regions  other  than  the 
Apex. — These  are  mostly  due  to  retraction  of  the  lungs.  In  debilitated 
and  bed-ridden  persons  and  especially  in  the  graver  forms  of  anaemia,  the 
breathing  is  shallow  and  the  lungs  are  not  fully  expanded.  Their  borders 
are  therefore  more  or  less  withdrawn  from  the  space  which  they  normally 
occupy  between  the  heart  and  the  chest  wall.  The  pulsations  of  the  conus 
arteriosus  and  right  ventricle  thus  frequently  become  visible  in  the  second, 
third,  and  fourth  left  interspaces  near  the  sternal  border.  In  some  instances 
these  pulsations  may  also  be  observed  to  the  right  of  the  sternum.  Such 
pulsations  are  also  seen  when  the  borders  of  the  lungs  are  retracted  as  the 
result  of  fibroid  phthisis. 

(b)  Other  Movements  of  the  Surface  of  the  Chest  having  the  Cardiac 
Rhythm. 

1.  Pulsations  at  the  root  of  the  neck  will  be  described  and 
their  significance  as  physical  signs  pointed  out  in  a  subsequent  section. 
They  are  venous  and  arterial. 

Prominence  of  the  veins  of  the  neck  is  observed  in  emaciated  and 
elderly  persons  otherwise  in  health.  These  veins  are  more  or  less  distended 
upon  expiration,  particularly  when  cough  occurs  or  dyspnoea  is  present. 
Transient  engorgement  results  from  efforts  at  lifting  or  from  straining. 
Pathological  conditions  that  give  rise  to  engorgement  of  the  jugulars  are 
aneurism,  mediastinal  tumor,  adhesive  mediastinitis,  and  obstruction  to 
the  pulmonary  circulation  from  any  cause.  Respiratory  engorgement 
and  collapse  of  the  jugulars  are  especially  marked  in  the  dyspnoea  of 
asthma  and  emphysema. 

Collapse  of  the  jugular  upon  one  side,  not  disappearing  when  pressure 
is  made  upon  it  immediately  above  the  clavicle,  is  a  sign  of  thrombosis  of 
the  lateral  sinus. 

Pulsating  Jugulars.  —  The  pulsations  are  best  studied  on  the  right 
side  of  the  neck  and  during  quiet  breathing.  Pulsation  communicated 
from  the  underlying  carotid  may  be  recognized  by  emptying  the  vein  by 
stripping  it  upward  gently  with  the  finger-nail  or  the  blunt  edge  of  the 
tongue  spatula.     It  does  not  refill  from  below. 

The  visible  pulsations  in  the  carotids  often  seen  in  thin,  nervous  persons 
without  disease  of  the  heart  are  without  clinical  importance.  Violent 
throbbing  of  the  carotids  is  common  in  aortic  regurgitation  and  frequently 
occurs  in  simple  hypertrophy  of  the  heart  without  valvular  lesions. 

2.  Aneurism. — Careful  inspection  of  the  anterior  surface  of  the  chest 
must  be  made  in  all  cases  of  suspected  aneurism.  Direct  and  oblique 
illumination  must  be  in  turn  employed,  and  the  examination  must  be  so 
conducted  that  profile  views  are  made  from  above,  the  patient  being  in 
the  sitting  po.sture,  and  from  the  side,  the  patient  being  recumbent.  In 
this  way  slight  pulsations  and  pulsating  prominences  may  be  discovered. 
The  pulsation  of  aortic  aneurism  is  commonly  present  in  the  first  and  second 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


73 


right  interspaces  near  the  sternal  border  and  is  sometimes  accompanied 
by  slight  systolic  elevation  of  the  inner  end  of  the  clavicle.  When  the 
innominate  is  involved  the  pulsation  may  be  seen  at  the  root  of  the  neck 
upon  the  right  side  or  at  the  notch  of  the  sternum.  Aneurismal  pulsations 
sometimes  occur  to  the  left  of  the  manubrium  sterni  and  elsewhere  in  the 
chest  and  are  to  be  sought  for  in  every  doubtful  case.  Aneurisms  that 
have  perforated  the  chest  wall  appear  as  circumscribed  globular  or  irregular 
pulsating  tumors,  the  overlying  skin  being  thinned  and  adherent  and 
ultimately  ulcerated,  so  that  there  is 
superficial  clot  formation  and  more 
or  less  continuous  oozing  of  blood. 
The  tumor  may  be  soft  and  fluctu- 
ating;  more  commonly  in  conse- 
quence of  the  deposition  of  stratified 
fibrin  layers  within  the  sac  it  is  dense 
and  resistant.  In  the  former  case 
the  pulsation  is  expansile;  while  in 
the  latter  case  it  is  apt  to  be  non- 
expansile,  but  forcible  and  heaving. 

3.  Tumors  in  Contact  with 
Large  Arterial  Trunks. —  En- 
larged lymph-nodes,  especially 
when  single,  and  neoplasms  in  the 
neck  overlying  the  carotid  artery 
sometimes  move  synchronously 
with  the  pulsations  of  the  vessel  and 
present  superficial  resemblances  to 
aneurisms.  The  tumor  is  dense, 
the  pulsation  not  expansile,  and 
other  signs  of  aneurism  are  lacking. 

4.  Pulsating  Pleurisy. — In 
neglected  purulent  effusions  a  pul- 
sating movement  synchronous  with 
the  cardiac  rhythm  is  sometimes 
observed.  The  cases  are  not  numer- 
ous. The  phenomenon  is  almost 
always  associated  with  left-sided 
effusions  and  occupies  an  extensive 
area  of  the  lower  anterolateral  sur- 
face of  the  left  chest.  In  cases  where  it  is  circumscribed  and  confined 
to  the  precordial  region  the  differential  diagnosis  relates  to  aneurism 
and  is  attended  with  difficulty.  A  limited  number  of  cases  have  been 
right-sided  and  in  one  or  two  of  the  reported  instances  the  effusion  has 
been  serofibrinous.  Pulsating  empyemata  may  be  intrapleural  or  the 
pulsations  may  occur  in  the  extrapleural  empye7na  necessitatis.  None  of 
the  explanations  of  the  mechanism  by  which  the  cardiac  impulse  in  these 
cases  is  transmitted  through  the  pus  collection  to  the  surface  of  the  chest 
is  satisfactory.  An  important  factor  is  superficial  ulceration  of  the  costal 
pleura  with  loss  of  tone  in  the  intercostal  muscles. 


Fig.  3{). — Aneurism  of  the  thoracic  aorta.- 
Hospital. 


-German 


74  MEDICAL  DIAGNOSIS. 


Inspection  of  the  Abdomen. 

In  the  examination  of  this  portion  of  the  body  the  patient  should  be 
in  the  recumbent  position  and  preferably  in  bed.  The  abdomen  in  exposed 
from  the  arch  of  the  ribs  to  the  suprapubic  region.  The  patient  should 
lie  straight  and  fiat.  The  head  should  be  at  first  low  and  the  lower  limbs 
extended;  later  the  head  should  be  raised  upon  pillows  and  the  thighs  and 
knees  strongly  flexed,  the  heels  being  drawn  up  towards  the  buttocks, 
in  order  to  relax  the  abdominal  wall;  finally  it  is  often  necessary  to  have 
the  patient  assume  the  standing  posture,  in  which  case  the  clothing  or  a 
sheet  is  supported  about  the  hips  by  the  patient  or  an  assistant.  The  light 
must  be  good  and  the  examination  made  from  above,  from  the  sides  and 
obliquely.  Physical  signs  of  importance,  such  as  asymmetry  in  contour 
or  movement  or  slight  local  elevation  or  depression  of  the  surface,  may 
often  be  detected  when  otherwise  not  very  obvious,  if  the  observer  stands 
■Sit  the  patient's  head  and  views  the  abdomen  obliquely  from  above  down- 
wards. Combined  inspection,  palpation,  and  percussion  are  necessary. 
Auscultation  is  of  inferior  value  in  the  examination  of  this  region. 

(a)  The  Normal  Abdomen.  —  In  infants  and  young  children  the 
abdomen  is  relatively  larger  as  compared  with  the  size  of  the  chest  than  in 
adults.  It  is  also  more  protuberant  than  in  well -formed  adults.  It  is 
larger  in  women  than  in  men  and  is  enlarged  and  protuberant  in  obese 
and  elderly  persons.  In  thin  women  who  have  borne  many  children  it  is 
relaxed,  coarsely  wrinkled,  and  pendulous.  Tight  corsets  cause  bulging 
of  its  lower  segment.  Transient  prominence  of  the  upper  segment  may 
sometimes  be  observed  after  a  hearty  meal. 

The  size  of  the  abdomen  in  health  varies  greatly  in  different  individuals 
according  to  the  amount  of  subcutaneous  and  omental  fat  and  the  size  of 
the  intestines,  which  are  apt  to  be  distended  in  persons  who  habitually 
eat  large  quantities  of  coarse  food.  The  physiological  enlargement  of  the 
abdomen  in  pregnancy  is  frequently  enormous. 

The  normal  abdomen  is  symmetrical  in  contour,  slightly  arched  from 
above  downward  and  from  side  to  side,  the  curves  being  more  prominent, 
especially  in  the  lower  part,  in  the  erect  than  in  the  recumbent  posture. 
The  navel  is  shallow  and  marked  by  irregularly  spiral  folds  of  skin  in  thin 
persons  and  deep  and  funnel-shaped  in  those  who  are  fat. 

The  skin  of  the  abdomen  in  healthy  persons  is  opaque  and  the  super- 
ficial veins  are  not  conspicuous.  In  brunettes  regularly  distributed  areas 
of  increased  normal  pigmentation  are  present  in  the  median  line  and 
above  the  flexures  of  the  thighs.  This  coloration  is  deepened  and  con- 
spicuous in  pregnancy — chloasma  uterinum.  The  respiratory  movements 
of  the  diaphragm  are  communicated  to  the  upper  portion  of  the  abdomen, 
the  ensiform  cartilage  and  the  arch  of  the  ribs  being  elevated  and  becom- 
ing more  prominent  with  inspiration.  In  persons  with  very  thin  and 
relaxed  abdominal  walls  the  peristaltic  movements  of  the  stomach  and 
intestines  may  be  occasionally  seen. 

(b)  Inspection  of  the  Abdomen  in  Disease.  —  We  study  the  size  of 
the  belly  as  manifest  in  genei'al  or  local  retraction  or  distention,  alteration 
in  form  and  contour,  the  appearance  of  the  surface  and  abnormal  move- 


PHYSICAL  DIAGNOSIS:     INSPECTION.  75 

merits.  In  this  connection  the  general  rule  that  the  size  of  a  hollow  ana- 
tomical structure  or  viscus  varies  with  the  contents  must  be  borne  in  mind. 

General  Retraction  of  the  Abdomen.  —  When  the  longitudinal  and 
transverse  curves  of  the  surface  are  reversed  and  become  concave  instead 
of  convex,  the  abdomen  is  described  as  scaphoid  or  boat-shaped.  Two 
factors  may  cause  this  condition  and  they  are  frequently  combined,  namely, 
extreme  wasting  and  irritative  tonic  spasm  of  the  abdominal  walls.  The 
former  occurs  in  actual  starvation;  inanition  from  any  cause,  especially 
malignant  disease  of  the  larynx  or  oesophagus,  stricture  of  the  latter  from 
other  causes,  stricture  of  the  pylorus  without  marked  gastric  dilatation, 
diabetes,  phthisis,  cerebrospinal  fever,  cholera,  chronic  diarrhoea,  anorexia 
nervosa, and  the  pernicious  vomiting  of  pregnancy;  the  latter,  in  meningitis, 
cerebral  tumor,  and  lead  colic,  and,  especially  when  combined  with  muscular 
rigidity  and  marked  tenderness,  is  a  most  important  sign  of  early  peritonitis. 

Extreme  retraction  of  the  abdomen  occurs  in  wasting  of  the  subcu- 
taneous and  omental  fat  and  atrophy  of  the  abdominal  organs. 


Fig.  37. — Scaphoid  abdomen  caused  by  starvation  in  a  case  of  cesophageal  carcinoma. — Jefferson  Hospital. 

Local  retractions  of  the  abdomen  are  not  of  importance  as  physical 
signs.  They  are  seen  around  the  base  of  large  hernias,  especially  in  the 
lateral  regions  of  the  abdomen,  in  large  ventral  hernias,  and  in  the  upper 
regions  in  diaphragmatic  hernias.  These  areas  of  depression  disappear 
when  the  hernias  which  cause  them  are  reduced. 

In  moderately  large  peritoneal  effusions  of  some  standing,  when  the 
patient  assumes  the  lateral  decubitus  the  side  of  the  abdomen  which  is 
uppermost  shows  a  concave  retraction  while  the  anterior  and  dependent 
portions  bulge  more  prominently. 

General  Distention  of  the  Abdomen. — This  condition  may  be  caused 
by  subcutaneous  and  intra-abdominal  fat,  the  excessive  accumulation  of 
gas  in  the  stomach  or  intestines,  fluid  in  the  abdominal  wall  or  peritoneal 
■cavity  or  both  combined,  or  a  large  intra-abdominal  tumor. 

Subcutaneous  and  intra-abdominal  fat  accumulations  in  the  obese 
frequently  cause  enormous  distention  of  the  belly.  In  such  cases  there  is 
excessive  and  often  irregular  development  of  the  panniculus  adiposus  else- 
where; while  in  ascites  and  tumor  the  general  nutrition  is  usually  impaired. 
In  cases  where  there  is  reason  to  suspect  pregnancy  or  the  presence  of  an 
abdominal  tumor  a  large  deposit  of  fat  may  render  the  diagnosis  diffi- 
cult. Large  accumulations  of  fat  in  the  omentum,  such  as  sometimes 
occur  in  persons  of  middle  age,  may  simulate  pregnancy  or  a  tumor. 
Fat  in  the  belly  walls  interferes  greatly  with  the  examination  by  means 
of  the   X-rays. 


76  MEDICAL  DIAGNOSIS. 

The  Excessive  Accumulation  of  Gas  —  Meteorism,  Tympanites.  —  The 
distention  is  symmetrical  and  may  be  extreme.  There  is  tympanitic 
percussion  resonance  and  absence  of  fluctuation.  The  association  of  these 
physical  signs  renders  the  diagnosis  easy.  When  extreme  the  condition 
causes  restriction  of  respiratory  movement,  the  disappearance  of  the 
respiratory  excursus  in  the  epigastric  zone,  and  displacement  of  the 
cardiac  impulse  upward  ag  high  as  the  fourth  interspace  and  to  the 
left  of  its  normal  position. 

Moderate  distention  may  result  from  injudicious  eating,  acute  and 
chronic  gastro-intestinal  disorders,  especially  in  neurotic  persons,  and  the 
slight  paresis  of  the  intestines  which  occurs  in  acute  febrile  diseases,  as 
enteric  fever  or  pneumonia.  Nervous  women  are  apt  to  "bloat."  as  it 
is  popularly  called,  after  eating.  Excessive  tympany  occurs  in  grave 
eases  of  the  infectious  diseases,  as  enteric  fever  with  deep  ulceration, 
septic  conditions,  acute  general  peritonitis,  intestinal  obstruction,  after 
the  release  of  a  constricted  loop  of  intestine  after  operation,  as  in 
strangulated  hernia,  and   in   some   cases   of  hysteria. 


Fig.  38. — Ascites,  caused  by  cirrhosis  of  the  liver. — Jefferson  Hospital. 

Free  gas  in  the  peritoneal  cavity  occurs  as  the  result  of  the  perforation 
of  an  air-containing  viscus  into  that  space.  The  abdomen  is  greatly  and 
uniformly  distended,  its  surface  tense  and  smooth,  the  outlines  of  intestinal 
convolutions  and  vermicular  movements  are  not  visible,  and  the  respira- 
tory movement  of  the  upper  part  of  the  abdomen  ceases.  The  most  common 
causal  conditions  are  peptic  ulcer  of  the  stomach  or  duodenum,  a  perforat- 
ing typhoid  ulcer,  and  ulcerative  or  necrotic  appendicitis.  As  the  air  occu- 
pies the  highest  region  of  the  cavity,  it  causes  a  disappearance  of  the  normal 
percussion  dulness  of  the  liver  and  spleen,  which  is  replaced  by  a  tympanitic 
note  in  these  areas,  of  the  same  character  as  that  over  the  abdomen  else- 
where. The  mere  disappearance  of  the  hepatic  dulness  does  not,  however, 
justify  the  diagnosis  of  pneumoperitoneum,  since  the  intestines  and  espe- 
cially the  transverse  colon  may  occupy  the  space  between  the  liver  and 
the  wall  of  the  thorax  and  separate  them  completely.  Moreover,  the  liver 
dulness  may  be  greatly  diminished  in  pulmonary  emphysema  of  high  grade, 
atrophic  cirrhosis  of  the  liver  and  acute  yellow  atrophy.  The  diagnosis  of 
free  air  in  the  peritoneum  may,  however,  be  determined  by  careful  per- 
cussion in  the  axillary  line  according  to  the  following  procedure:  In  the 
dorsal  posture  there  is  dulness  alike  in  the  condition  under  consideration 
and  when  the  liver  is  separated  from  the  wall  of  the  thorax  anteriorly  by 
the  distended  intestine.     When,  however,  the  patient  is  turned  upon  his 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


77 


left  side  there  always  remains  a  limited  area  of  dulness  in  the  axillary 
line  high  up  in  the  case  of  meteorism,  while  the  dulness  wholly  disap- 
pears in  the  case  of  pneumoperitoneum.  The  same  method  of  exam- 
ination is  appHcable  to  the  spleen,  although  the  small  size  of  this  organ 
renders  its  recognition  alike  in  large 
meteorism  and  in  pneumoperitoneum  a 
matter  of  much  greater  difficulty  than 
in  the  case  of  the  liyer. 

Fluid  in  the  Abdominal  Wall  or 
Peritoneal  Cavity. — An  excessiye  dropsy 
of  the  wall  in  some  cases  of  anasarca 
may  cause  distention  of  the  abdomen. 
This  condition  is  encountered  in  acute 
nephritis  and  in  the  later  stages  of 
cardioyascular  disease.  The  abdomen  is 
tense,  doughy,  and  pits  upon  pressure; 
the  more  dependent  parts  of  the  bodj^, 
feet,  ankles,  legs,  thighs,  and  pudenda,  are 
highly  oedematous,  and  the  condition  is 
usually  associated  with  effusion  into  the 
peritoneum  and  sometimes  also  into  the 
other  serous  cavities.  The  pallid  and  puffy 
facies  in  acute  nephritis  is  characteristic. 

Ascites  or  free  fluid  in  the  cavity  of  the 
'peritoneum  }nelds  characteristic  physical 
signs.  The  enlargement  of  the  abdomen 
is  general  and  symmetrical.  Its  degree 
and  outline  depend  upon  the  amount  of 
the  fluid  and  the  fact  that  under  the 
influence  of  gravity  it  changes  its  position  with  changes  in  the  posture 
of  the  patient.  In  moderate  effusions,  in  the  dorsal  decubitus  the  middle 
of  the  abdomen  is  more  or  less  flattened  while  the  lateral  regions  bulge 
outward,  in  the  lateral  decubitus  the  lower  lateral  and  anterior  walls  of  the 


Fig.  39. — Ascites. — German  Hospital. 


Fig.  40. — Pregnancy — ninth  month. 


belly  protrude  while  that  which  is  uppermost  is  slightly  incurved,  in  the 
knee-elbow  posture  the  weight  of  the  fluid  causes  the  abdomen  to  sag 
down  in  an  unusual  manner,  and  in  the  erect  posture  the  lower  segment  of 
the  abdomen  is  especially  prominent.  In  all  these  positions  there  is  dul- 
ness upon  percussion  over  the  dependent  areas  and  tympanitic  resonance 


78 


MEDICAL  DIAGNOSIS. 


over  the  upper,  since  the  fluid  gravitates  toward  the  dependent  regions  of 
the  ca\aty  and  the  air-containing  intestines  float  upon  it  in  the  upper 
spaces.  Ascites  in  a  belly  pre\^ously  relaxed  or  pendulous  causes  in  the 
erect  posture  a  prominent  and  somewhat  conical  symmetrical  protrusion 
of  the  lower  parts.     Massive   ascites   gives  rise  to  uniform   symmetrical 

enlargement  of  the  abdomen,  but  Kttle  influ- 

^^■^  enced  by  change  of  posture. 

•  iPfl^^^  Ascites  results  from  pathological  processes 

»    lii^P  directly  implicating  the  peritoneum,  as  ordinary 

*        "Ir  infections  or  tuberculous  inflammation  or  can- 

cer, or  the  portal  vessels,  as  the  pressure  of  new- 
growths,  gall-stones,  cancerous  invasion,  extreme 
sclerosis  or  pylephlebitis  due  to  other  causes,  or 
disease  of  the  liver.  Cirrhosis  of  the  liver  is  a, 
common  cause  of  ascites.  Tumors  of  the  abdo- 
men and  especially  large  solid  tumors  of  the 
ovary  are  frequently  attended  by  ascites.  The 
foregoing  have  been  spoken  of  as  local  causes. 
The  general  causes  of  ascites  are  those  which 
give  rise  to  anasarca  and  effusion  into  the  other 
serous  sacs.  Peritoneal  effusion  resulting  from 
local  causes  is  not  usually  at  first  associated 
with  oedema  of  the  low^er  extremities.  As  the 
fluid  accumulates  it  exerts  pressure  upon  the 
large  abdominal  veins,  especially  the  iliacs  and 
ascending  vena  cava,  giving  rise  to  dropsy. 

Tumor  as  a  Cause  of  General  Ahdoviinal 
Enlargement. — The  pregnant  uterus,  ovarian, 
pancreatic,  and  hydatid  cysts,  and  large  new 
growths  cause  distention  which  may  simulate 
that  due  to  the  causes  just  considered.  The 
enlargement  caused  by  these  conditions  differs 
from  that  caused  by  fat,  tympany,  or  fluid  in 
being  usually  more  prominent  in  the  anteropos- 
terior than  in  the  bilateral  diameter,  not  so  sj^m- 
metrical,  and  not  yielding  uniform  signs  upon 
palpation  and  percussion.  Other  causes  of  gen- 
eral enlargement  of  the  abdomen  are  fecal  accu- 
mulation, cancer  of  the  bowel,  disseminated  cancer  of  the  peritoneum,  and 
large  peritoneal  or  retroperitoneal  sarcomata  and  lipomata.  To  this  list  must 
be  added  hydronephrosis  and  enormous  dilatation  of  the  stomach  or  colon. 
Local  Prominence  of  the  Abdomen. — Circumscribed  swellings  or  tume- 
faction may  be  caused  by  abnormal  conditions  of  the  belly  wall  or  of 
the  contents  of  the  cavity.  These  changes  in  contour  should  be  carefully 
sought  for  in  all  cases  presenting  symptoms  referable  to  the  abdominal 
viscera.  The  methods  of  especial  value  are  inspection,  palpation,  and  per- 
cussion.     In  thin  persons  radioscopy  yields  important  results. 

The  recognition  of  the  nature  of  local  bulgings  in  the  abdominal  wall 
is  as  a  rule  not  attended  by  great  difficulty,  but  the  diagnosis  of  visceral 


Fig.  41. — Dilatation  of  colon 
Male,  12  years  old. — Rot  eh. 


PHYSICAL   DIAGNOSIS:     INSPECTION. 


79 


tumors  is  frequently  obscure  and  in  many  cases  can  only  be  positively 
determined  by  an  exploratory  operation. 

Local  Prominences  due  to  Changes  in  the  Wall  of  the  Ab- 
domen.— These  comprise  abnormal  conditions  of  the  muscles,  irregular 
collections  of  subcutaneous  fat,  hernia,  abscess,  enlarged  lymph-glands,, 
and  neoplasms,  particularly  sarcomata. 

A  spastnodically  contracted  rectus  muscle  may  simulate  a  tumor.  The 
diagnostician  must  be  on  his  guard  against  the  appearance  and  sensation 
imparted  to  the  touch  by  a  contracted  right  rectus  in  the  pyloric  region. 

Phantom  Tumor. — The  condition  known  as  phantom  tumor,  due  to 
persistent  gaseous  distention  of  a  knuckle  of  gut  with  spasmodic  contrac- 
tion of  the  overlying  muscle,  causes  a  tumor-like  swelling.    Such  swellings 


Fig.  42. — a,  paraumbilical  hernia;  b,  hernia  reduced. 

appear  and  disappear,  with  alterations  in  contour  and  position;  sometimes 
subside  under  gentle  friction  with  the  warmed  hand  and  always  under 
anaesthesia.  They  occur  in  hysterical  persons.  Fitz  has  suggested  that 
in  some  of  the  cases  phantom  tumors  are  symptomatic  of  congenital  or 
acquired  dilatation  of  the  colon. 

Fat.  —  In  very  obese  persons  remarkable  rolls  and  masses  of  sub- 
cutaneous fat  collect  in  the  abdominal  wall.  These  are  usually  but  not 
always  symmetrical  in  arrangement,  and  may  simulate  tumors,  from  which 
they  may  be  differentiated  by  their  continuity  with  the  panniculus  adi- 
posus,  their  consistency  and  want  of  tenderness,  and  the  general  condition 
of  the  patient.  Circumscribed  fatty  tumors — lipomata — are  common. 
They  are  hemispherical  or  egg-shaped,  elastic,  painless,  somewhat  mov- 
able, and  more  common  in  the  lateral  and  posterior  aspects  of  the  trunk 
than  in  the  abdominal  wall.    They  frequently  occur  in  spare  persons. 

Hernia. — No  examination  of  the  abdomen  is  complete  that  does  not 
include  the  sites  of  hernia.    This  is  especially  important  in  cases  attended 


80  MEDICAL  DIAGNOSIS. 

by  intestinal  obstruction  and  vomiting,  or  persistent  pain  in  the  inguinal 
region.  The  inguinal  and  femoral  regions  should  be  examined  by  palpation 
under  the  cover  of  the  sheet  or  clothing  and  if  necessary  by  inspection  as 
well.  Ventral  and  umbilical  hernias  and  scar-hernias  after  operation  may 
be  readily  recognized.  The  tumor  varies  in  consistency  according  as  it 
consists  wholly  of  gut  or  partly  of  omentum.  It  is  usually  soft,  without 
pain  upon  manipulation,  and  reducible.  It  varies  in  size  from  a  mere  nodule 
to  a  sac  containing  a  large  portion  of  the  abdominal  contents.  It  very 
often  disappears  spontaneously  when  the  patient  assumes  the  recumbent 
posture,  or  is  then  readily  reduced.  Strangulated  hernia  does  not,  as  a  rule, 
yield  to  taxis. 

Abscess. — Purulent  collections  in  the  abdominal  wall  may  be  recog- 
nized by  the  signs  of  inflammation,  swelling,  redness,  heat,  and  pain,  by 
their  contour,  and  especially  by  fluctuation.  Pus  may  form  in  any  part 
of  the  wall  or  find  its  way  to  any  point  upon  the  surface.  Appendiceal 
abscess  usually  forms  a  circumscribed,  fluctuating  tumor  in  the  right 
lower  quadrant  of  the  abdomen. 

Lymph-nodes.  —  The  superficial  lymphatic  glands  of  the  groin  do  not 
form  visible  tumors  unless  distinctly  enlarged.  They  are  frequently  pal- 
pable as  small  nodular  bodies  in  adults  who  are  in  good  health.  They  may 
become  enlarged  and  tender  in  injuries  of  the  leg  or  foot,  in  venereal  disease, 
and  in  common  with  the  superficial  lymph  nodules  in  other  parts  of  the 
body  in  some  of  the  acute  infectious  diseases  and  in  particular  in  the  bubonic 
plague.  Slight  enlargement  of  the  inguinal  lymphatics  is  common  in  gener- 
alized malignant  diseases — carcinomatosis,  sarcomatosis.  Massive  enlarge- 
ment of  these  structures  takes  place  in  Hodgkin's  disease.  The  enlarged 
inguinal  glands  in  venereal  disease  and  the  plague  frequently  form  sup- 
purating buboes. 

Neoplasms  of  various  kinds  may  develop  in  the  abdominal  wall.  The 
most  common  variety  is  sarcoma.  In  sarcomatosis  cutis  many  small 
subcutaneous  nodules  appear  scattered  over  the  abdomen.  In  a  recent 
case  a  sarcoma  developed  at  the  umbilicus  and  was  followed,  after  opera- 
tion, in  about  a  year  by  a  small  nodule  in  the  immediate  neighborhood 
and  many  others  in  different  parts  of  the  body. 

Local  Prominences  due  to  Abnormal  Conditions  within  the 
Abdominal  Cavity. — These  conditions  comprise: 

Temporary  Dilatation  of  the  Stomach  from  Excesses  at  Table, 

Gastrectasis, 

Local  Gaseous  Distention  of  the  Bowel, 

Fecal  Accumulations, 

Ectopic  or  Floating  Viscera, 

Visceral  Hypertrophies  and  Enlargements, 

Intra-  and  Perivisceral  Abscess, 

Abscess  from  Caries  of  the  Spine, 

Cysts, 

Extra-uterine  Pregnancy, 

Abdominal  Aneurism, 

Glandular  Enlargements,  and 

Malignant  and  other  New  Growths. 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


81 


Any  of  these  can  exist  without  being  the  occasion  of  prominence 
recognizable  upon  inspection;  but  under  favorable  conditions  this  method 
of  physical  examination  yields  suggestive — even  positive — physical  signs. 
It  is  usually  a  question  of  the  degree  of  their  development  respectively. 

Excessive  fat  and  muscular  rigidity  mask  the  signs  of  these  conditions, 
and  in  the  case  of  great  abdominal  tenderness  a  satisfactory  examination 
is  impossible.  The  plain  recognition  of  an  abdominal  tumor  does  not  in 
all  instances  justify  a  further  diagnosis  of  its  cause  or  nature. 

Gastrectasis. — Temporary  dilatation  of  the  stomach  from  excesses  in 
eating  causes  in  persons  who  are  not  obese  a  visible  prominence  in  the 
epigastric  region.  Substantive  gastrectasis  from  any  cause  shows  a  bulg- 
ing of  the  abdominal  wall  in  the  region  of  the  umbilicus 
or  above  it.  This  bulging  has  downwards  and  to  the 
left  the  outline  of  the  greater  curvature;  if  the  stomach, 
as  is  very  commonly  the  case,  is  displaced  downward 
and  its  longitudinal  axis  more  vertical  than  normal, 
the  outline  of  the  lesser  curvature  may  also  be  visible 
below  the   ensiform   cartilage. 

Intestinal  Obstruction. — The  entire  abdomen  may  be 
distended  or  only  parts  of  it.  If  the  colon  be  distended 
by  hard  fecal  masses  the  course  of  the  bowel  is  marked 
by  an  elongated  eminence,  the  contours  of  which  cor- 
respond to  those  of  the  gut.  If  the  intestinal  stenosis 
be  acute  a  local  area  of  gaseous  distention  without  peri- 
stalsis occurs  above  the  obstruction.  The  obstruction 
may  be  caused  by  fecal  accumulations,  large  gall-stones, 
enteroliths,  or  the  pressure  of  a  tumor.  Any  of  these 
may  give  rise  to  a  distinct,  localized,  asymmetrical 
prominence  of  the  abdominal  wall. 

Intussusception  is  most  common  in  childhood  and 
shows  itself  as  an  elongated  sausage-shaped  tumor  usu- 
ally in  the  region  of  the  caecum  or  at  the  sigmoid  flexure 

Ectopic  or  Floating  Viscera. — General  splanchnop- 
tosis— Glenard's  disease — causes  a  prominence  or  pro- 
trusion of  the  lower  segment  of  the  abdomen  and  is 
common  in  women,  being  favored  by  tight  corsets,  the 
method  of  supporting  the  skirts,  and  the  relaxation  due  to  childbearing. 
Enteroptosis  causes  a  similar  deformity  more  or  less  marked;  gastroptosis 
is  usually  associated  with  dilatation  of  the  stomach.  A  vertical  position 
of  the  stomach  may  be  congenital  or  acquired  as  the  result  of  tight  lacing. 
The  pylorus  then  occupies  a  position  in  the  median  line  or  to  the  left  of 
it,  and  the  greater  curvature  lies  below  the  level  of  the  umbilicus.  In  thin 
persons  these  displacements  of  the  organ  may  sometimes  be  demonstrated 
by  the  methods  of  physical  diagnosis,  especially  if  it  be  inflated  with  gas 
followed  by  the  introduction  of  water  through  the  tube  so  that  the  greater 
curvature  may  be  determined  by  dulness  on  percussion  in  sharp  contrast 
with  the  tympanitic  resonance  of  the  colon. 

Floating  kidney  sometimes  gives  rise  to  an  oval  prominence  plainly 
visible  upon  inspection,  which  may  be  made  to  shift  its  position  or  dis- 
6 


Fir,.  43. — ^'i.■<ce^op- 
tosis.  —  I'eimsylvania 
Hospital. 


82  MEDICAL  DIAGNOSIS. 

appear  upon  manipulation  or  upon  changes  in  the  posture  of  the  patient, 
^he  swelHng  caused  by  a  displaced  kidney  is  usually  upon  its  own  side, 
but  when  very  movable  it  may  sometimes  be  forced  beyond  the  median 
line  to  the  opposite  side.  It  may  occupy  a  position  anywhere  between  the 
ribs  and  the  pelvis  and  is  freely  movable  with  deep  respiration.  Ren 
mobilis  is  much  more  common  in  women  and  upon  the  right  side. 

Floating  Spleen. — The  normal  spleen  which,  in  consequence  of  elonga- 
tion of  the  gastrosplenic  ligament  and  the  splenic  artery  and  veins,  has 
become  dislocated — lien  mobilis — does  not  cause  a  visible  abdominal 
swelling.  When,  however,  the  displaced  organ  is  also  enlarged,  as  is  fre- 
quently the  case,  there  may  sometimes  be  seen  a  rounded  swelling  upon  the 
left  side  in  any  position  from  the  hypochondrium  to  the  pelvis.  This 
swelling,  like  that  caused  by  the  dislocated  left  kidney,  with  which  float- 
ing spleen  is  often  associated,  is  freely  movable  upon  manipulation  and 
change  of  posture. 

Floating  liver  is  among  the  rarest  of  clinical  or  anatomical  findings. 
The  dislocation  of  the  organ  is  usually  slight.  There  is  general  enlarge- 
ment of  the  right  lateral  region  and  a  large  mass  of  characteristic  outline 
which  descends  when  the  patient  assumes  the  erect  posture.  Tympany  in 
the  upper  part  of  the  right  hypochondrium — normal  area  of  liver  dulness — 
disappearing  when  the  organ  is  replaced,  and  the  well-defined  lower  border  of 
the  liver  upon  palpation,  render  the  diagnosis  a  matter  of  comparative  ease. 

Enlargement  of  the  Gall-bladder.  —  This  condition  may  properly  be 
considered  at  this  point,  since  the  position  of  the  enlarged  bladder  is  very 
different  from  that  of  the  normal  gall-bladder.  The  enlargement  is  the 
result  of  cholecystitis,  frequently  associated  with  cholelithiasis,  or  carcinoma. 

The  gall-bladder  is  distended  by  a  serous  fluid  which  gradually  accumu- 
lates in  consequence  of  the  inflammatory  changes  in  its  walls, — dropsy  of 
the  gall-bladder, — the  bile  no  longer  entering,  because  of  obstruction  of 
the  cystic  duct  by  a  calculus,  a  plug  of  tenacious  mucus,  adhesive  cholan- 
gitis, or  a  carcinomatous  nodule.  In  comparatively  rare  instances  infection 
by  pyogenic  organisms  causes  suppurative  cholecystitis  —  empyema  of 
the  gall-bladder.  If  the  gall-bladder  be  sufficiently  distended  and  the 
abdominal  wall  thin,  there  may  be  seen  an  elongated,  smooth  prominence 
in  the  region  of  the  notch  of  the  liver,  projecting  below  the  liver  margin 
and  rising  and  falling  with  the  respiratory  movements.  The  gall-bladder 
may  be  greatly  distended,  reaching  in  some  instances  the  size  of  the 
fist  or  more.  It  is  then  sometimes  pear-shaped,  the  fundus  being  freely 
movable  from  side  to  side  upon  manipulation  and  change  of  posture. 

In  some  instances  when  the  cholecystitis  is  associated  with  cholelith- 
iasis the  gall-bladder  is  distended  by  an  enormous  accumulation  of  calculi; 
in  others  the  tumor  may  be  due  to  primary  or  secondary  carcinoma  ol  the 
gall-bladder. 

Visceral  Enlargements. — The  so-called  corset  fiver  may  give  rise  to  a 
visible  prominence  in  the  right  lateral  region,  reaching  as  low  as  the  crest 
of  the  ilium  and  moving  with  respiration.  In  cases  in  which  the  pressure 
constriction  is  marked  the  portion  of  the  liver  below  it  is  movable  and 
may  simulate,  especially  when  a  loop  of  intestine  occupies  the  groove, 
a  displaced  kidney  or  new  growth  in  the  ascending  colon. 


PHYSICAL   DIAGNOSIS:     INSPECTION. 


83 


Enlargement  of  the  liver,  causing  marked  prominence  in  the  right  h3'po- 
chondrium,  in  some  cases  of  the  entire  abdomen,  may  be  due  to  hypertrophic 
cirrhosis,  carcinoma,  amyloid  disease,  conditions  causing  obstructive  jaun- 
dice, leukaemia,  syphilis,  hypersemia  due  to  cardiac  disease,  and  fatty  liver. 

Enlargement  of  the  spleen  may  attain  a  considerable  degree  before  it 
gives  rise  to  signs  upon  inspection.     Massive  enlargement  may  occur  in 
chronic  malaria— ague  cake,  leukaemia  and  pseudoleuksemia.     The  organ 
may  reach  to  the   pelvis   and  even 
to  the  right  of  the  median  line. 

Enlargement  of  the  Kidneys. — 
Renal  tumors  develop  from  behind 
forward,  tending  to  displace  the 
movable  organs  of  the  abdomen, 
especially  the  intestines,  aside. 

The  anatomical  relations  of  the 
ascending  and  descending  colon  are 
such  that  these  portions  of  the  intes- 
tines, being  attached  to  the  kidneys 
by  connective  tissue,  are  retained  in 
front  of  the  growing  renal  tumor  and 
tend  to  obscure  its  dulness  upon 
percussion.  The  development  of  the 
tumor  from  the  upper  portion  of  the 
kidney  causes  a  prominence  of  the 
hypochondrium  on  the  correspond- 
ing side,  which  extends  as  the  growth 
develops  to  the  iliac  region;  the 
development  of  the  tumor  from  the 
lower  portion  of  the  kidney  causes 
prominence  first  in  the  iliac  region. 
Two  solid  new  growths  of  the  kidney 
only  are  of  clinical  importance  from 
the  stand-point  of  diagnosis,  namely, 
carcinoma  and  sarcoma.  The  for- 
mer is  more  common  in  advanced 
life,  the  latter  in  childhood;  the  for- 
mer is  apt  to  cause  early  cachexia, 
while  in  the  latter  the  general  nutri- 
tion may  be  maintained;  finally,  sarcomatosis  of  the  skin  in  connection 
with  tumor  of  the  kidney  is  highly  suggestive  as  to  the  nature  of  the 
renal  affection.  Renal  adenoma  cannot  be  differentiated  from  carcinoma 
during  the  life  of  the  patient.     Much  more  rare  is  hypernephroma. 

In  the  rare  cases  in  which  both  kidneys  are  involved  the  abdominal 
enlargement  is  of  course  bilateral. 

The  very  rare  primary  malignant  disease  of  the  suprarenal  capsules 
may  give  rise  to  a  tumor  in  the  hypochondrium  of  the  corresponding  side, 
which  differs  in  no  respect  from  the  similar  manifestation  caused  by  a  tumor 
of  the  upper  half  of  the  kidney.  Renal  tumors  move  only  slightly  or  not 
at  all  with  respiration. 


Fig.  44. — Massive  enlargement  of  spleen  in  a  case  of 
splenomedullaryleukfemia. — Jefferson  Hospital. 


84  MEDICAL  DIAGNOSIS. 

Enlargement  of  the  pancreas  is  caused  by  chronic  pancreatitis  and  car- 
cinoma. It  very  rarely  reaches  such  a  size  as  to  occasion  visible  prominence 
in  the  epigastrium. 

Abscess. — Local  bulgings  of  the  surface  may  be  caused  by  suppurative 
inflammation  in  and  around  the  abdominal  viscera. 

Abscess  of  the  Liver. — Multiple  ab«eess  does  not  usually  reveal  itself 
by  changes  in  the  contour  of  the  surface.  Tropical  abscess  commonly 
causes  the  liver  to  enlarge  upward,  especially  upon  the  right  side.  The 
respiratory  excursus  is  diminished  or  absent  and  the  lower  intercostal 
spaces  obliterated.     There  is  often  local  oedema. 

Subphrenic  abscess  occasions  marked  downward  displacement  of  the 
liver  and  a  smooth,  soft  tumor  in  the  epigastrium.  If,  as  is  commonly 
the  case,  there  is  air  as  well  as  pus  in  the  subphrenic  space,  the  diagnosis  is 
not  attended  with  difficulty. 

Abscess  of  the  spleen,  when  of  sufficient  size,  sometimes  reveals  itself 
by  a  splenic  tumor,  upon  the  surface  of  which  a  fluctuating  area  or  areas 
may  be  obscurely  felt  through  a  thin-walled  abdomen. 

Renal  abscess  may  cause  a  circumscribed  tumor  in  the  hypochondrium 
or  iliac  region  of  the  affected  side,  with  obscure  fluctuation,  but  without 
cedematous  swelling  of  the  neighboring  tissues. 

Perinephritic  Abscess. — The  swelling  occupies  the  lumbar  region  and 
there  is  oedema  of  overlying  and  adjacent  parts.  There  is  frequently 
burrowing  of  the  pus  in  a  downward  direction,  so  that  a  second  fluctuating 
tumor  may  be  present  at  a  more  dependent  point. 

Abscess  in  Appendicitis. — The  common  situation  of  the  large,  circum- 
scribed intraperitoneal  abscess  is  in  the  iliac  region  between  the  navel  and 
the  anterior  superior  spine.  The  abscess  may  form  in  the  retroperitoneal 
space  and  burrow  beneath  the  iliac  fascia,  showing  itself  at  Poupart's 
ligament,  or  it  ma}^  accumulate  in  the  retroperitoneal  tissue  in  the  flank, 
forming  a  large  paranephritic  abscess,  with  the  usual  cedematous  condition 
of  the  surrounding  parts. 

Abscess  from  caries  may  follow  enteric  fever  and  show  itself  as  a  small 
fluctuating  tumor  overlying  a  rib  or  costal  cartilage.  Vertebral  caries  may 
cause  an  abscess  in  the  lumbar  region,  or  the  pus  may  follow  the  sheath 
of  the  psoas  muscle  and  point  below  Poupart's  ligament — psoas  abscess. 

Ovarian  or  tubal  abscess  may  give  rise  to  distention  in  the  iliac  region 
of  either  side.  When  upon  the  right  side  these  conditions  may  simulate 
appendiceal  abscess,  with  which  they  are  also  occasionally  associated. 

Cysts.- — Local  as  well  as  general  prominence  may  be  caused  by  cysts 
of  various  kinds.  If  large  the  distention  is  general,  if  small  it  is  local  and 
circumscribed.  From  a  pathologico-anatomical  beginning  wholly  without 
symptoms  and  unrecognizable,  certain  cysts  frequently  attain  enormous 
dimensions.  Among  these  are  especially  to  be  mentioned  cysts  of  the 
pancreas,  hydronephrosis,  and  ovarian  cysts,  which  are  often  of  such  size 
as  to  simulate  ascites.  The  smaller  cysts  do  not  present  physical  signs 
which  differentiate  them  from  abscesses  in  the  same  localities.  It  is  only 
by  a  general  knowledge  of  the  pathological  processes  which  give  rise  to 
cyst-  and  abscess-formation  respectively  and  a  careful  consideration  of 
the  anamnesis  and  associated  symptoms  that  the  differential   diagnosis 


PHYSICAL  DIAGNOSIS:     INSPECTION.  85 

can  in  some  instances  be  made  out,  as  in  dropsy  and  empyema  of  the 
gall-bladder,  echinococcus  and  abscess  of  the  spleen,  or  hydro-  and  pyo- 
nephrosis. Cysts  springing  from  the  liver,  dropsy  of  the  gall-bladder, 
echinococcus  and  pancreatic  cysts  have  their  early  manifestations  in  the 
upper  regions  of  the  abdomen — epigastric  zone — to  the  right  and  left  of 
the  median  line  respectively;  those  springing  from  the  kidney — hydrone- 
phrosis, echinococcus — first  appear  in  the  lateral  regions,  while  those  from 
the  pelvic  organs,  ovarian  cysts,  hydramnion,  arise  from  the  pelvis — hypo- 
gastrium.  Mesenteric  cysts  are  usually  situated  to  the  right  of  the  umbil- 
icus and  below  its  level.  Cysts  connected  with  the  liver  and  spleen  are 
influenced  by  the  respiratory  movements;  those  connected  with  the  pan- 
creas only  slightly  or  not  at  all,  and  those  developing  from  the  kidneys, 
ureters,  and  pelvic  organs  remain  wholly  unaffected  by  the  respiratory 
movements  of  the  diaphragm. 

Aneurism. — Aneurism  of  the  abdominal  aorta  may  cause  a  distinct, 
pulsating  tumor  commonly  in  the  epigastrium  but  occasionally  to  the 
left  of  the  median  line  in  front  or  in  the  lumbar  region.  This  tumor  is  almost 
always  immovable,  but  in  rare  instances  has  been  influenced  by  manipula- 
tion and  change  of  posture,  but  not  by  respiration.  It  presents  the  signs 
of  aneunsm,  and  is  to  be  differentiated  from  tumors  overlying  the  aorta 
and  from  the  so-called  "dynamic  pulsation"  of  the  aorta  which  occurs 
in  neurotic  individuals.  The  distended  urinary  bladder  in  urethral  stric- 
ture, impacted  calculus,  etc.,  gives  rise  to  a  distinct  rounded  oval  tumor  of 
the  hypogastrium,  which  reaches  in  extreme  cases  well  up  towards  the 
umbilicus.  To  a  less  extent  the  retention  of  the  low  fevers  and  comatose 
conditions  gives  rise  to  a  similar  prominence.  In  the  latter  case,  the  incon- 
tinence of  retention — stillicidium  urin(V — prevents  extreme  distention. 
The  anamnesis,  the  oval  outline  of  the  tumor,  its  central  and  symmetrical 
situation,  fluctuation,  and  its  immediate  disappearance  upon  catheterization 
render  the  diagnosis  clear. 

Extra-uterine  Pregnancy.  —  There  is  a  history  of  morning  nausea, 
paroxysmal  colicky  pain  with  faintness,  enlargement  and  hardness  of  the 
breasts,  and  chloasma  uterinum,  together  with  the  presence  of  a  prominence 
to  the  right  or  left  of  the  median  line  above  the  brim  of  the  pelvis.  "S'ery 
often  rupture  of  the  sac  takes  place  before  it  has  attained  sufficient  enlarge- 
ment to  be  recognized  by  the  methods  of  physical  diagnosis.  This  accident 
is  attended  by  collapse  symptoms,  and  upon  vaginal  examination  the  uterus 
is  found  to  be  somewhat  enlarged  and  displaced  downward  and  to  the 
opposite  side. 

Glandular  Erdargements. — Enlargement  of  the  retroperitoneal  glands, 
usually  sarcomatous — Lobstein's  cancer — may  cause  a  visible  tumor  in 
the  epigastric  or  umbilical  region,  usually  tense,  immovable,  and  nodular; 
sometimes  slightly  movable  and  obscurely  fluctuating  and  crossed  by 
the  colon,  which  may  be  recognized  upon  palpation  or  by  its  tympanitic 
resonance,  to  secure  which  artificial  inflation  may  be  necessary.  Tuber- 
culous mesenteric  glands — tabes  mesenterica — cause,  especially  in  children, 
marked  protrusion  of  the  abdomen  with  tympany.  The  enlarged  lymphatic 
glands  may  cause  irregular  local  prominence  in  the  region  of  the  navel  or 
in  the  right  iliac  fossa  and  may  be  recognized  upon  palpation. 


86 


MEDICAL  DIAGNOSIS. 


Malignant  and  Other  New  Growths. — Malignant  diseases  of  abdominal 
organs — carcinoma,  sarcoma — are  of  chief,  while  benign  affections,  fibroma, 
lipoma,  myxoma,  adenoma,  and  gumma,  are  of  subordinate  interest  from  the 
stand-point  of  diagnosis.  This  difference  is  to  be  ascribed  not  only  to  the 
greater  frequency  of  the  former  and  their  disastrous  effects  upon  the  health 
and  ultimately  upon  the  life  of  the  patient,  but  also  to  the  fact  that  at 
some  time  in  their  course  the  diagnosis  becomes  both  practicable  and  ob- 
vious, while  in  the  latter  with  less  significant  symptoms  the  diagnosis  cannot 
be  made  out  and  the  condition  often  remains  unsuspected  during  the  whole 
^  .      course  of  the  patient's  life  and  only 

assumes  pathologico-anatomical 
interest  when  the  case,  death  hav- 
ing resulted  from  an  entirely  dif- 
ferent disease,  at  length  comes  to 
autopsy.  It  is  of  diagnostic  impor- 
tance that  in  visceral  as  well  as  in 
external  cancer,  secondary  implica- 
tion of  adjacent  and  distant  organs 
takes  place  with  characteristic  signs 
and  that  ultimately  in  many  cases 
the  superficial  lymphatic  glands 
become  enlarged,  nodules  appear  in 
the  skin  and  elsewhere— general  car- 
cinomatosis, general  sarcomatosis. 
Cancer  of  the  Stomach. — The 
tumor  can  be  seen  in  some  cases, 
but  is  usually  only  to  be  recognized 
upon  palpation.  It  most  com- 
monly occupies  the  region  of  the 
pylorus  and  may  be  slightly  mov- 
able with  respiration  and  freely  so 
upon  manipulation.  A  visible 
tumor  occupying  the  greater  part  of 
the  epigastrium  and  even  extending 
beyond  its  borders,  irregular,  nod- 
ular, well  defined  at  its  margin, 
immovable  and  very  distinct  through  the  emaciated  wall  of  the  belly,  is 
sometimes  present  in  advanced  cases  of  carcinoma  extensively  involving 
the  anterior  wall  of  the  stomach. 

Cancer  of  the  Liver. — The  volume  of  the  organ  is  usuall}^  greatly  in- 
creased. The  increase  is  rapid  and  may  assume  enormous  dimensions. 
It  may  affect  the  entire  liver  or  the  right  or  left  lobe  to  a  preponderating 
extent.  When  the  right  lobe  is  chiefly  involved,  there  is  a  flaring  out  of 
the  lower  ribs  and  costal  cartilages;  when  the  left,  the  appearance  of  the 
tumor  may  suggest  a  new  growth  involving  the  greater  curvature  of  the 
stomach,  a  cyst  of  the  pancreas,  or  an  enlarged  spleen,  but  these  doubts  are 
immediately  set  at  rest  by  palpation  and  percussion.  The  surface  is  usually 
uneven  and  the  border  irregular,  and  these  signs  may  in  some  cases  be 
clearly  made  out  upon  inspection.     In  the  absence  of  adhesions  the  respira- 


FiG.  45. — Sarcomatosis  cutis, — primary  tumor 
springing  from  a  pigmented  mole  on  the  foreliead; 
metastatic  growths  appeared  in  a  few  months  after 
primary  growth. — Jefferson  Hospital. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  87 

tory  excursus  of  the  liver  may  be  seen,  and  in  one  remarkable  case  in  my 
service  at  the  Philadelphia  Hospital,  when  upon  autopsy  the  entire  right 
lung  was  found  to  be  solidified  by  secondary  carcinomatous  infiltration, 
the  respiratory  movement  of  the  liver,  plainly  seen  through  the  abdominal 
wall,  was  from  left  to  right  upon  inspiration.  When,  as  is  often  the  case, 
extensive  adhesions  are  present,  respiratory  movement  of  the  enlarged 
liver  does  not  take  place  Multilocular  echinococcus  and  gumma  of  the 
liver  present  great  difficulties  in  diagnosis.  Splenic  enlargement  in  the 
former  and  a  history  of  lues  in  the  latter  are  significant.  An  individual 
who  has  syphilis  may  also  be  the  subject  of  echinococcus  disease. 

Cancer  of  the  Gall-bladder. — The  position  of  the  tumor  and  its  respira- 
tory movement  are  important.  It  is  apt  to  be  mistaken  for  cancer  of  the 
pylorus  or  duodenum.  In  the  latter  affections,  when  the  cancer  is  primary, 
free  hydrochloric  acid  may  be  wanting  in  the  gastric  contents,  secondary 
dilatation  of  the  stomach  shortly  appears,  and  the  tumor  may  be  made  out 
to  be  connected  with  the  stomach  or  bowel  by  dilating  the  stomach,  with 
simultaneous  percussion  and  palpation,  while  the  seat  of  the  tumor  in  the 
gall-bladder  becomes  at  the  same  time  more  obvious  by  its  shape  and 
relatively  superficial  situation. 

A  tumor  formed  by  cancer  of  the  head  of  the  'pancreas  cannot  often  be 
positively  differentiated  from  cancer  of  the  pylorus,  duodenum,  transverse 
colon,  or  porta  hepatis.  At  best  in  a  majority  of  cases  the  diagnosis  must 
be  made  by  exclusion. 

Inspection  of  the  Surface  of  the  Abdomen.  Abnormal  Signs.  — 
Moderate  ascites  and  large  tumors  may  be  present  without  changes  in  the 
integument;  but  excessive  distention  causes  nutritive  changes  and  the 
skin  loses  its  natural  appearance,  becoming  tense,  glistening,  and  thinned. 
White  lines  or  strise — linece  albicantes — irregularly  parallel  and  slightly 
depressed  below  the  adjacent  surface  are  produced  by  extreme  or  prolonged 
distention,  as  in  pregnancy,  obesity,  and  ascites.  They  are  seen  upon  the 
abdomen,  flanks,  and  thighs,  and  persist  after  the  condition  which  caused 
them  has  passed  away.  Jaundice  is  often  more  conspicuous  here  than  on 
surfaces  exposed  to  the  air.  Striking  deposits  of  pigment  occur  in  the 
linea  alba  in  pregnancy,  especially  in  brunettes,  and  pigmentation  due  to 
abdominal  growths  and  diseases  of  the  peritoneum,  Addison's  disease, 
melanotic  cancer,  exophthalmic  goitre,  scleroderma,  arteriosclerosis,  and 
chronic  heart  disease  is  often  conspicuous  upon  the  abdomen,  especially 
in  the  lower  quadrants  and  about  the  flexures  of  the  thighs.  The  pigmen- 
tation of  vagabondage  due  to  lice  and  filth  is  usually  characterized  by  the 
parallel  linear  superficial  lesions  of  scratching.  The  haemochromatosis  of 
hypertrophic  cirrhosis  and  diabetes  and  in  rare  instances  scleroderma  are 
attended  by  conspicuous  pigmentation.  The  prolonged  administration 
of  arsenic  frequently  causes  marked  discoloration  of  the  skin.  The  general 
discoloration  of  argyria  is  less  pronounced  upon  the  surface  of  the  trunk 
than  upon  the  face  and  extremities.  The  specific  eruptions  of  the  exan- 
themata, especially  the  initial  rashes  of  variola,  and  the  rose  spots  of  enteric 
fever  are  to  be  sought  for  upon  the  abdomen.  Tache  bleuatres.  tinea 
versicolor,  and  the  symmetrical  diffuse  macular  eruption  of  secondary 
syphilis  are  to  be  seen.     The  scars  of  surgical  operations,  especially  those 


MEDICAL  DIAGNOSIS. 


performed  for  the  relief  of  appendicitis,  gastric  and  gall-bladder  disease, 
and  various  diseases  of  the  pelvic  organs  are  common  nowadays  and  may 
shed  light  upon  many  abdominal  disorders — adhesions  and  the  like — post- 
operative neurasthenia  and  other  obscure   maladies..    Enlarged  inguinal 

glands  and  retracted  cicatrices 
in  the  groins  may  be  significant 
of  venereal  infection. 

Vascular  Changes. — Signs  relat- 
ing to  circulatory  derangements  are 
enlarged  superficial  epigastric 
arteries  and  enlarged  superficial 
veins.  The  former  are  exceed- 
ingly rare  and  indicate  obstruction 
of  the  aorta  or  iliac  arteries;  the 
latter  very  common  and  constitute 
the  evidence  of  collateral  venous 
circulation  in  obstruction  of  the 
portal  system  or  the  inferior  or 
superior  vena  cava.  Among  the 
common  causes  of  such  obstruction 
are,  in  the  portal  circulation,  cir- 
rhosis of  the  liver  and  tumor;  in 
the  general  circulation,  abdominal 
and  mediastinal  tumor,  dilatation 
of  the  stomach  of  high  grade,  and 
ascites  of  long  standing. 

Caput  medusae  is  a  varicose 
arrangement  of  the  dermal  veins 
around  the  umbilicus  with  radiat- 
ing branches.  It  is  made  up  by  the 
dilated  branches  of  the  epigastric 
veins  at  their  juncture  with  a  large 
single  vein  which  passes  from  the 
hilum  of  the  liver  and  follows  the 
course  of  the  round  ligament — 
para-umbilical  vein  of  Sappey. 
Much  more  commonly  the  enlarged 
collateral  veins  are  distributed 
irregularly  over  the  surface  of  the 
abdomen  and  indicate  one  of  the 
courses  towards  the  right  heart 
taken  by  the  blood  in  pressure 
upon  the  inferior  vena  cava.  There  is  engorgement  of  the  blood  from 
the  lower  extremities  in  the  inferior  epigastric  and  internal  mammary 
veins,  with  dilatation  of  the  superficial  abdominal  veins.  In  obstruc- 
tion of  the  portal  system  and  inferior  vena  cava  the  course  of  the 
blood  in  the  dilated  superficial  veins  is  upward;  when  the  superior  cava 
is  obstructed  the  course  of  the  blood  in  the  superficial  veins  of  the  chest 
and  abdomen  is  downward,  the  blood  seeking  its  way  to  the  right  heart 


Fig.  46. — Sarcoma  of  spine,  showing  venous  stasis  and 
metastatic  growtli  in  orbit. — Young. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  89 

by  means  of  the  right  ai^ygos  which  communicates  with  various  tributaries 
of  the  inferior  vena  cava.  Pressure  upon  the  innominate  vein  of  the  right 
or  left  side  may  give  rise  among  other  signs  to  great  cUlatation  of  the 
superficial  veins  of  the  thorax  and  abdominal  wall. 

The  Umbilicus.  —  The  navel  normally  shows  transverse  or  slightly 
spiral  folds  of  the  skin  and  is  moderately  retracted.  It  is  deeply  so  and 
funnel-shaped  in  obese  persons  and  level  with  the  surrounding  surface  or 
protruding  in  large  ascites  and  pregnancy.  It  may  be  the  seat  of  caput 
medusae  or  hernia,  inflammation  or  eczema,  carcinoma  secondary  to  gastric 
carcinoma  or  tuberculous  infiltration  secondary  to  tuberculous  peritonitis. 
A  mole  in  the  region  of  the  umbilicus  may  undergo  sarcomatous  changes. 

Movements  of  the  Abdomen  in  Disease.  —  Inspiratory  retraction 
of  the  epigastrium  is  present  in  stenosis  of  the  upper  air-passages  and 
imperfect  action  of  the  diaphragm.  Diminished  respiratory  movement 
of  the  abdomen  may  be  caused  by  upward  pressure  upon  the  diaphragm, 
as  in  tympany,  ascites,  and  abdominal  tumors  on  the  one  hand,  or  by  mas- 
sive pleural  or  pericardial  effusions  on  the  other.  In  the  early  stages  of 
peritonitis  abdominal  respiratory  movement  is  greatly  impaired  or  wholly 
absent,  on  account  of  the  pain  and  tonic  contraction  of  the  muscles  of  the 
wall;  in  the  later  stages  on  account  of  the  tympany  and  upward  pressure 
upon  the  diaphragm. 

Visible  Peristalsis. — In  thin  persons  the  normal  peristaltic  movements 
may  sometimes  be  seen.  They  appear  as  wave-like,  rounded  elevations  of 
the  surface  which  may  be  attended  by  borborygmi  and  may  be  intensified 
by  gentle  irritation  of  the  skin  by  the  application  of  cold,  brisk  tapping  or 
faradism.  In  some  instances  the  peristaltic  movements  of  the  stomach 
from  left  to  right  are  in  sharp  contrast  to  those  of  the  transverse  colon  from 
right  to  left.  In  the  wide  separation  of  the  recti  occasionally  seen  in  women 
who  have  borne  many  children  these  vermicular  movements  are  very 
conspicuous. 

The  most  important  diagnostic  significance  of  visible  peristalsis  relates 
to  intestinal  obstruction.  The  presence  of  peristalsis  must  be  determined 
and  whether  or  not  it  is  always  in  the  same  direction  and  ceases  at  a  certain 
spot.  If  the  obstruction  is  at  or  above  the  ileocsecal  valve  the  distended 
and  mobile  coils  of  small  intestine  occupy  a  position  in  the  central  portion 
of  the  abdomen,  but  if  the  obstruction  involves  the  lower  part  of  the  large 
intestine — sigmoid  flexure — the  distention  and  movements  of  the  bowel 
may  be  manifest  in  the  region  occupied  by  the  ascending  and  transverse 
colon.  The  inflated  fixed  intestinal  coil  of  acute  stenosis  of  the  gut,  ileus — 
strangulated  hernia — shows  no  peristaltic  movement.  Prior  to  immobility 
there  is  peristalsis.  In  chronic  obstruction,  after  the  muscularis  of  the 
gut  has  become  hypertrophied,  there  is  active  peristalsis,  with  marked 
recurrent  tumor  subsiding  with  coarse  borborygmi,  just  in  advance  of  the 
stenosis.  As  the  gas  in  the  tumor  is  under  tension,  it  does  not  yield  tym- 
panitic resonance  but  dulness  upon  percussion.  Visible  peristalsis  in  the 
left  hypochondrium,  with  the  vermicular  contractions  from  left  to  right, 
has  been  observed  in  extreme  gastrectasis. 

Pulsation  Synchronous  with  the  Cardiac  Systole. — Dynamic  pulsation 
occurs  in  neurotic  persons.    It  is  seen  in  the  median  line  and  is  often  violent 


90 


MEDICAL  DIAGNOSIS. 


but  neither  diffuse  nor  expansile.  The  pulsation  of  abdominal  aneurism 
usually  has  both  these  characters  and  very  often  in  addition  systolic 
thrill    and    bruit.      It   is   mostly   situated    in    the    median   line,   but    may 

be  seen  in  the  left  lateral  region 
of  the  abdomen. 

An  Aid  to  Inspection  in  Cir=. 
cumscribed  Movements  not  Well 
Defined. — I  have  found  the  fol- 
loT\dng  suggestion  of  K.  H.  Beall 
of  much  service: 

"Over  the  area  under  inspec- 
tion there  is  drawn  with  a  skin 
pencil  a  square  plaid  figure,  the 
squares  of  which  are  from  1.5  to 
2.5  cm.  in  diameter  and  from  12 
to  50  in  number,  according  to  the 
size  of  the  area  being  studied. 
Any  slight  movement  of  the  skin 
at  any  point  in  such  a  marked  area 
causes  a  change  in  the  direction  of 
some  of  the  lines  and  a  distortion 
of  the  figure,  and  so  renders  visible  movements  of  the  internal  organs 
which  are  not  to  be  detected  otherwise. " 


Fig.  47. — Beall's  aid  to  inspection. 


PALPATION. 

The  method  of  physical  diagnosis  in  which  the  sense  of  touch  is  em- 
ployed is  known  as  palpation.  It  consists  in  the  systematic  examination 
of  the  surface  of  the  chest  and  abdomen  by  the  la^ang  on  of  the  hand. 
The  physical  signs  elicited  depend  upon  the  condition  and  movements  of 
the  parts  and  the  underlying  structures.  As  in  inspection,  we  study  the 
form,  size,  condition  of  the  surface,  and  movements.  The  method  is  appli- 
cable and  essential  to  the  examination  of  the  thorax  and  abdomen. 


Palpation  in  the  Examination  of  the  Thorax. 

The  chest  should  be  bared,  the  attitude  easy,  the  arms  symmetrically 
disposed,  the  muscles  relaxed.  The  examining  hand  should  be  warm  and 
laid  gently  upon  the  surface.  The  amount  of  pressure  employed  must  be 
determined  in  individual  cases.  Ticklishness,  tenderness,  and  excessive 
fat  constitute  obstacles.  The  first  may  be  overcome  by  care  and  diverting 
the  attention  of  the  patient;  the  others  often  amount  to  insuperable  diffi- 
culties in  the  application  of  this  method  of  diagnosis.  The  palmar  surface 
of  the  whole  hand  is  employed  for  a  general  survey,  as  in  locating  the  posi- 
tion of  the  cardiac  impulse  or  a  thrill;  the  more  sensitive  finger  tips  for  the 
study  of  the  particular  characters  of  such  phenomena,  for  example  the  force 
and  extent  of  the  impulse  or  the  coarseness  or  fineness  and  extent  of  a  thrill. 

By  palpation  we  confirm  and  amplify  the  signs  obtained  by  inspec- 
tion, especially  those  dependent  upon  the  form  and  contour  of  the  chest, 


PHYSICAL  DIAGNOSIS:    PALPATION.  91 

the  width  of  the  interspaces,  the  presence  of  local  swellings  and  deformi- 
ties, and  the  respiratory  and  cardiac  movements.  These  it  is  not  necessary 
at  this  point  to  repeat.  But  there  are  other  physical  signs,  not  always 
recognizable  upon  inspection,  which  we  investigate  by  palpation.  These 
comprise  the  condition  of  the  wall  of  the  chest  as  regards 

Muscular  Tension, 

OEdema, 

Width  of  the  Interspaces, 

Fluctuation, 

Nodes,  Gummata,  and  Periosteal  Thickening, 

Location  and  Character  of  the  Heart's  Impulse. 

Extracardial    Pulsation  and  Diastolic  Shock,   and  in    particular  the 

following  physical   signs  which  are  exclusively  within  the  scope 

of  this  method: 
The  Crepitation  of  Subcutaneous  Emphysema, 
Thrills,  Cardiac  and  Vascular, 
Fremitus,  Vocal,  Friction,  and  Rhonchal, 
Tracheal  Tugging. 

Tension. — The  tension  of  the  muscular  wall  of  the  chest  in  the  inter- 
costal spaces  and  about  the  ensiform  cartilage  is  not  a  sign  of  great  value, 
yet  it  is  to  be  studied  in  doubtful  cases.  The  inspiratory  retraction  of  the 
base  of  the  chest  is  a  sign  of  obstruction  to  the  entrance  of  air,  which  may 
be  at  the  larynx,  as  in  oedema  of  the  glottis,  or  in  the  smallest  bronchial 
tubes,  as  in  bronchopneumonia.  The  slight  normal  furrow  of  the  lower 
intercostal  spaces  may  be  obliterated  by  pleural  or  pericardial  effusion  or 
a  rapidly  growing  new  growth.  In  old  empyemata  there  is  great  relaxa- 
tion and  bulging  and  the  cardiac  pulsations  may  even  be  transmitted  to 
the  surface — pulsating  empyema.  Epigastric  rigidity  and  tenderness  are 
conspicuous  in  tetanus,  and  these  phenomena  are  early  symptoms  in 
peritonitis  beginning  in  the  upper  part  of  the  abdomen. 

(Edema. — Local  oedema  may  indicate  intrathoracic  suppuration  as 
in  empyema  or  hepatic  abscess,  inflammation  of  the  wall  of  the  chest  as 
in  carbuncle,  or  obstruction  to  the  venous  circulation  as  in  mediastinal 
tumor  or  aneurism.  The  puffiness  involves  the  head  and  neck  on  both 
sides  when  the  pressure  involves  the  precava  and  is  unilateral  when  it 
affects  the  right  or  left  innominate  only. 

Spaces. — The  width  of  the  intercostal  spaces  may  be  felt  when  not 
seen  upon  inspection,  and  should  be  carefully  investigated  in  cases  of  pleu- 
ral effusion,  since  they  are  wide  when  the  chest  is  distended  and  become 
narrow  as  the  fluid  undergoes  resorption. 

Fluctuation. — Elasticity  or  fluctuation  in  any  prominence  or  tumor 
upon  the  surface  of  the  chest  is  an  important  sign.  It  may  be  due  to  abscess 
of  the  wall  itself,  empyema  necessitatis,  cyst  formation,  or  sarcoma.  The 
differential  diagnosis  rests  upon  the  associated  clinical  phenomena.  In 
abscess  of  the  wall  the  volume  of  the  tumor  is  not  affected  by  the  respira- 
tory movements;  in  empyema  necessitatis  the  tumor  diminishes  upon 
inspiration  anrl  increases  with  expiration  and  the  physical  signs  of  intra- 


92  MEDICAL  DIAGNOSIS. 

pleural  effusion  are  present;  a  cyst  is  usually  sharply  circumscribed, 
distinctly  globular,  tense,  sometimes  translucent,  and  commonly  movable 
within  a  limited  range. 

Nodes. — Nodes  upon  the  ribs,  cartilages,  or  sternum  or  thickening 
at  the  chondrocostal  or  sternoclavicular  articulations  and  periosteal  thick- 
ening are  important  signs  of  disease.  They  may  sometimes  be  felt  when 
not  obvious  upon  inspection,  and  their  size  and  consistence  can  be  recog- 
nized upon  palpation.  Among  the  earliest  of  the  skeletal  lesions  of  rickets 
is  a  nodular  enlargement  of  the  ribs  at  the  juncture  of  the  bone  with  the 
cartilage.  These  nodules  are  present  upon  the  ribs  of  both  sides  and  are 
symmetrical  in  their  arrangement — the  so-called  rosary  of  rickets.  Gum- 
mata  are  common  upon  the  sternum  and  roughening  and  enlargement  of 
the  clavicles  may  be  a  m'anifestation  of  late  syphilis.  The  clavicles  are 
enlarged  and  the  sternum  deformed  in  acromegaly.  Acute  painful  enlarge- 
ment of  the  sternoclavicular  articulation  is  not  rare  in  gonorrhoeal  arthri- 
tis. A  soft,  elastic,  slightly  fluctuating  tumor  upon  the  upper  part  of  the 
sternum  may  be  a  tuberculous  abscess.  Tender  points  are  found  upon 
palpation.  They  are  not  physical  signs,  but  may  be  mentioned  in  this 
connection  as  symptoms  of  great  value.  They  are  found  in  intercostal 
neuralgia  and  correspond  to  the  points  of  emergence  of  the  intercostal 
nerves ;  in  neurasthenia  tender  points  are  also  found  along  the  dorsal  spine 
and  the  tenderness  is  very  often  present  upon  light  and  absent  upon  firm 
pressure;  in  necrosis  of  a  rib;  in  fibrinous  pleurisy  and  especially  in 
that  form  of  pleurisy  which  occurs  in  pulmonary  tuberculosis,  where  the 
tenderness  is  most  common  and  most  marked  in  the  infraclavicular  region. 

Apex=beat. — The  precise  location  and  character  of  the  impulse  of 
the  heart.  The  palm  of  the  hand  should  be  first  laid  over  the  precordia 
below  the  left  nipple.  The  signs  elicited  by  inspection  are  thus  confirmed 
and  amplified.  We  determine  whether  the  rhythm  of  the  heart  is  regular 
or  irregular  and,  if  irregular,  whether  the  arrhythmia  is  in  time  or  in  force 
or  both,  that  is,  whether  there  are  differences  in  the  intervals  between 
the  ventricular  contractions,  or  in  the  power  with  which  the  heart  con- 
tracts or  these  are  combined.  We  observe  also  in  this  way  the  general 
character  of  the  heart's  action,  that  is,  feeble  or  strong;  heaving  power- 
fully so  as  to  move  the  whole  chest,  as  in  great  hypertrophy  or  the  over- 
action  of  mental  or  physical  excitement — palpitation;  that  it  has  the 
diffuse  slap  often  encountered  in  dilatation  of  the  right  ventricle,  the  sharp 
tap  of  mitral  stenosis  or  the  slow,  heaving,  forcible  impulse  sometimes 
met  with  in  aortic  stenosis. 

The  more  sensitive  tips  of  the  fingers  are  next  brought  into  service. 
They  are  placed  over  the  point  of  maximum  impulse  and  moved  in  vari- 
ous directions.  The  apex  of  the  heart  as  determined  by  finger-tip  palpa- 
tion and  by  percussion  is  usually  two  or  three  centimetres  below  and  to 
the  left  of  the  point  of  maximum  or  visible  impulse.  It  frequently  happens 
that  the  impulse  not  recognized  upon  inspection  may  be  felt  and  rarely 
that  a  visible  impulse  cannot  be  appreciated  by  the  trained  touch.  These 
two  methods  must  be  used  in  all  cases. 

Inspection  and  palpation  yield  the  most  satisfactory  results  in  the 
study  of  the  size  of  the  heart.     The  base  of  the  organ  is  fixed  and  is  as  a 


PHYSICAL  DIAGNOSIS:    PALPATION.  93 

rule  not  greatly  displaced  even  by  the  pressure  of  an  aneurism  or  new- 
growth.  To  fix  the  position  of  the  apex  is  to  determine  the  long  axis  of 
the  heart  and  gain  a  fairly  correct  idea  of  its  size.  The  data  obtained  by 
percussion  are  much  less  definite,  partly  because  of  inherent  difficulties 
in  recognizing  the  limits  of  dulness  in  the  rounded  body  of  the  heart  sur- 
rounded by  resonant  lung  and  partly  because  of  the  modifying  effects  of 
pleural  adhesions  or  effusion,  gastric  dilatation  or  abdominal  tympany. 
When  the  impulse  cannot  be  located  by  inspection  or  palpation,  we  employ 
auscultation  and  consider  the  clinical  impulse  to  be  near  the  point  at  which 
the  first  sound  is  most  distinctly  heard. 

The  changes  in  the  relation  of  the  apex  to  the  wall  of  the  chest  caused 
by  changes  in  the  posture  of  the  patient  have  already  been  considered. 

Extracardiac  Pulsation.  —  Pulsation  beyond  the  limits  of  the 
heart  is  frequently  seen,  but  its  precise  location,  extent,  and  character 
are  best  studied  by  the  sense  of  touch.  A  heaving  impulse  at  the  root 
of  the  neck  occurs  in  hypertrophy,  especially  that  form  associated  with 
aortic  insufficiency  and  in  overaction  from  nervous  causes.  It  occurs 
also  in  anaemia  and  large  hemorrhages,  in  apoplexy,  and  rarely  in  the 
stage  of  onset  of  intense  infections,  as  variola.  It  is  a  conspicuous  phenom- 
enon in  exophthalmic  goitre.  In  neurotic  persons  the  pulsating  dilated 
transverse  aorta  may  in  rare  instances  be  felt  in  the  sternal  notch — 
dynamic  pulsation.  Aneurism  of  the  innominate  artery  or  of  the  trans- 
verse portion  of  the  aortic  arch  may  give  rise  to  similar  pulsation.  Anom- 
alies in  the  distribution  of  the  subclavian  or  thyroid  arteries  may  also  give 
rise  to  pulsation  in  this  region.  In  old  pleural  adhesions  at  the  apex  and 
in  pulmonary  tuberculosis  subclavian  pulsation  is  often  marked  and 
extended.  Pulsation  commonly  to  the  right  of  the  manubrium,  some- 
times to  the  left  of  it,  occurs  in  aneurism  of  the  thoracic  aorta  and  may 
often  be  felt  when  it  is  not  seen.  The  force  and  extent  of  the  impulse  in 
pulsating  empyema  are  best  estimated  by  palpation. 

Epigastric  Pulsation.  —  This  phenomenon  is  generally  regarded  as 
the  sign  of  hypertrophy  of  the  right  ventricle  and  this  view  is  unquestion- 
ably in  some  cases  correct.  The  hypertrophied  and  overacting  right 
heart  communicates  its  movements  to  the  tissues  at  the  tip  of  and  below 
the  ensiform  cartilage.  The  retraction  corresponds  to  time  with  the  ven- 
tricular systole  and  is  due  to  the  negative  pressure  caused  by  the  altera- 
tion in  size  and  diminution  in  the  volume  of  the  ventricles  at  this  moment 
of  the  heart's  revolution.  Epigastric  pulsation  has  been  observed  in  cases 
in  which  no  hypertrophy  of  the  right  ventricle  has  been  found  post  mor- 
tem. Liver  pulsation  is  much  more  frequently  palpable  than  visible,  and 
the  distinction  between  this  condition  and  a  liver  jogged  by  an  overacting 
heart  may  often  be  made  by  bimanual  palpation,  since  a  pulsating  liver 
expands  and  contracts,  a  jogged  liver  merely  moves.  Bimanual  palpation, 
one  hand  upon  the  upper  dorsal  spine  and  the  other  upon  the  manubrium, 
may  detect  the  expansile  pulsation  of  a  deep-seated  aortic  aneurism  which 
presents  no  external  signs.  Diastolic  shock  is  an  important  physical  sign 
of  aneurism.  The  tips  of  the  fingers  upon  the  sac  in  case  erosion  of  the 
chest  wall  has  taken  place,  or  upon  the  surface  directly  overlying  the  sac, 
may  often  detect  a  diastolic  shock,  sometimes  of  considerable  force. 


94  MEDICAL  DIAGNOSIS. 

Crepitation. — In  wounds  and  operations  upon  the  neck  and  chest 
air  may  find  its  way  into  the  subcutaneous  tissues  and  give  rise  to  crepi- 
tation upon  palpation.  In  rare  cases  this  condition  may  result  from  the 
rupture  of  dilated  peripheral  pulmonary  vesicles  in  emphysema. 

Succussion. — When  both  fluid  and  air  are  present  in  a  large  space  with 
rigid  walls,  as  in  pneumohydrothorax  or  pneumopyothorax,  a  distinct  vibra- 
tion or  impulse  may  be  felt  upon  shaking  the  patient  or  causing  him  to 
suddenly  twist  his  body.  This  phenomenon,  which  is  accompanied  by  a 
splashing  sound,  constitutes  the  sign  known  as  Hippocratic  succussion. 

The  arterial  pulse  is  studied  by  palpation.  This  subject  will  be  fully 
considered  in  a  later  section. 

Thrills. — The  palpable  vibrations  of  the  surface  transmitted  from 
the  interior  of  the  heart  or  arteries  are  known  as  thrills.  They  are  usually 
confined  to  limited  areas  and  may  be  easily  overlooked  unless  the  surface 
is  first  searched  with  the  palmar  surface  of  the  open  hand.  They  may 
then  be  studied  with  the  finger-tips.  They  can  frequently  be  felt  only 
upon  the  lightest  pressure,  wholly  disappearing  if  the  pressure  be  increased. 
The  sensation  has  been  compared  to  that  communicated  to  the  hand  by 
the  purring  cat — jremissement  cataire.  Thrills  are  usually  felt  during  a 
portion  of  the  cardiac  revolution  only — presystolic,  systolic,  post-sj^stolic. 
They  may  disappear  when  the  heart  is  acting  feebly  and  become  manifest 
again  when,  with  general  improvement  in  the  condition  of  the  patient, 
the  heart  contracts  with  greater  power.  They  usually  correspond  in  the 
time  of  the  cardiac  cycle  with  audible  murmurs  or  bruits  and  are  signifi- 
cant of  the  same  lesions  and  produced  by  the  same  mechanism,  namely, 
fluid  veins,  the  vibrations  of  which  transmitted  through  tissues  to  the  sur- 
face are  realized  by  the  ear  as  murmurs,  by  the  touch  as  thrills.  In  other 
words  the  thrill  is  the  sensory  equivalent  of  the  murmur.  The  fact  that 
very  coarse  thrills,  especially  the  presystolic  thrill,  sometimes  occur  when  no 
murmur  can  be  heard,  does  not  militate  against  the  foregoing  statement, 
since  regular  vibrations  may  be  palpable  though  not  frequent  enough 
to  produce  sound.  It  is  in  accordance  with  these  statements  that  thrills 
vary  in  the  rapidity  of  their  vibrations — fineness,  coarseness — and  that 
the  finer  thrills  correspond  to  the  higher  pitched  murmurs  and  the  reverse. 
A  thrill  at  the  base  of  the  heart  of  maximum  intensity  in  the  aortic 
area  is  common  in  aortic  stenosis. 

A  thrill  of  coarse  quality,  limited  in  extent,  presystolic  in  time,  more 
marked  during  expiration,  and  most  distinctly  felt  in  the  fourth  or  fifth 
intercostal  space  inside  the  midclavicular  line — mitral  area — is  the  sign 
of  mitral  stenosis. 

A  systolic  thrill  in  the  same  area  is  sometimes  present  in  mitral 
incompetence  and  in  rare  instances  in  aortic  stenosis. 

A  thrill  often  accompanies  the  presystolic  murmur  of  aortic  incompe- 
tency— Flint's  murmur. 

A  thrill  diastolic  in  time  is  occasionally  felt  in  aortic  incompetency^ 
but  is  not  very  common. 

Thrills  are  common  in  congenital  defects  of  the  heart. 
A  thrill  systolic  in  time  at  the  second  left  costal  cartilage  and  inter- 
space— pulmonary  area — is  occasionally  observed  in  exophthalmic  goitre; 


PHYSICAL  DIAGNOSIS:     PALPATION.  95 

very  rarely  it  is  a  sign  of  pulmonary  stenosis.     A  diastolic  thrill  in  this 
area  may  be  the  sign  of  a  rare  condition,  pulmonary  incompetency. 

A  thrill  over  the  lower  portion  of  the  sternum  and  at  its  right  border — 
tricuspid  area — sometimes  occurs  in  dilatation  of  the  right  ventricle  and 
tricuspid  incompetence. 

Systolic  thrills  when  beyond  the  limits  of  the  precordial  space  are 
more  likely  to  be  indicative  of  thoracic  aneurism  than  of  valvular  disease. 
They  are  oftenest  felt  to  the  right  of  the  sternal  border  and  above  the 
fourth  rib,  but  may  be  present  in  the  left  side  in  a  corresponding  region. 
They  are  more  common  in  aortic  dilatation  than  in  sacculated  aneurism. 

It  is  important  to  recognize  the  difference  between  a  thrill  and  the 
slight  shuddering  tremor  which  may  be  felt  in  the  merely  overacting 
heart,  as  in  palpitation  from  any  cause. 

Fremitus. — Fremere,  to  roar  or  murmur  as  a  crowd  or  mob;  techni- 
cally, palpable  vibration.  The  difference  between  a  thrill  and  fremitus 
is  much  more  readily  recognized  than  described.  It  is,  however,  an  essen- 
tial difference  and  depends  upon  the  difference  in  the  mechanism  by  which 
they  are  respectively  produced.  Fremitus  is  usually  much  coarser  than 
thrills,  the  vibrations  are  irregular  and  variable,  the  extent  is  far  wider, 
and  fremitus,  even  when  produced  by  the  movement  of  the  heart  as  in  the 
friction  fremitus  of  pericarditis,  does  not  constantly  conform  to  definite 
movements  in  the  cardiac  cycle.  Fremitus  is  a  tactile  phenomenon  com- 
municated to  the  surface  of  the  chest  by  the  act  of  phonation — vocal 
fremitus;  by  the  friction  of  roughened  surfaces  against  each  other — fric- 
tion fremitus;  or  by  the  respiratory  movement  of  exudates  of  varying 
consistency  within  the  bronchial  tubes — rhonchal  fremitus. 

Vocal  Fremitus. — This  physical  sign  is  of  great  value  in  the  diagnosis 
of  diseases  of  the  respiratory  organs.  It  is  frec[uently  spoken  of  as  tactile 
fremitus,  but  erroneously  so,  since  all  fremitus  is  tactile.  The  hand  is  laid 
upon  the  bared  chest  while  the  patient  counts  "one,  two,  three,''  or  repeats 
some  words,  as  "twenty-one"  or  "ninety-nine."  Under  normal  circum- 
stances the  fremitus  is  more  intense  in  men  than  in  women,  in  adults  than 
in  children,  and  in  persons  whose  voices  are  powerful  and  low-pitched  than 
in  those  whose  voices  are  feeble  and  shrill.  The  patient  should  be  asked 
to  repeat  the  same  phrase  as  the  examining  hand  passes  from  one  part 
of  his  chest  to  another,  and  to  let  his  speaking  be  loud,  low,  and  slow,  always 
as  nearly  as  possible  in  the  same  tone.  This  method  of  physical  diagnosis 
is  without  value  in  persons  suffering  from  aphonia  or  in  those  so  feeble 
that  they  can  only  use  the  whispering  voice.  It  is  practicable  in  young 
infants  who  cry  during  the  examination. 

Vocal  Fremitus  in  Health.  —  The  vibrations  of  the  vocal  cords 
in  phonation  are  transmitted  along  the  walls  of  the  trachea  and  bronchi 
and  the  column  of  air  which  they  contain  to  the  surface  of  the  chest,  which 
is  thus  set  into  vibration  from  within.  These  vibrations  vary  in  different 
regions  normally,  and  are  most  distinct  where  the  large  bronchial  tubes 
approach  the  chest  wall,  less  distinct  where  the  mass  of  intervening  vesicu- 
lar tissue  is  greatest,  and  feeble  or  absent  where  the  lung  tissue  does  not  • 
come  into  contact  with  the  wall,  as  in  the  precordial  space.  Pathological 
conditions  which  increase  the  capacity  of  the  lung  to  conduct  vibrations. 


96  MEDICAL  DIAGNOSIS. 

as  consolidation,  intensify  the  vocal  fremitus;  those  which  separate  the 
lung  from  the  wall,  as  pleural  effusions,  diminish  or  abolish  it,  as  the  case 
may  be.  There  is  normally  considerable  difference  in  the  intensity  of  the 
vocal  fremitus  in  the  two  sides,  especially  in  the  upper  regions.  This 
inequality  is  to  be  constantly  borne  in  mind.  The  vibrations  are  more 
intense  on  the  right  than  on  the  left  side,  in  the  upper  (subclavicular) 
region  than  in  the  lower  (inframammary),  and  in  front  than  behind.  It  is 
feeble  over  the  scapulae,  and  usually  absent  or  very  feeble  in  that  portion 
of  the  precordial  space  which  corresponds  to  the  area  of  superficial  cardiac 
dulness.  A  thick  layer  of  subcutaneous  fat  impairs  the  value  of  this  physi- 
cal sign,  while  a  thin,  elastic  chest  wall  and  deep  voice  render  it  very  useful. 
Vocal  Fremitus  in  Disease  of  the  Respiratory  Organs. — The 
vibrations  are  intensified  by  conditions  which  cause  consolidation  of  the 
lung,  as  tuberculous  infiltration,  croupous  and  bronchopneumonia,  hypo- 
static congestion  and  atelectasis;  they  are  enfeebled  or  absent  altogether 
in  pathological  conditions  which  separate  the  periphery  of  the  lung  from 
contact  with  the  chest  wall,  such  as  pleural  effusion,  pneumothorax,  and 
cysts  or  tumors  in  the  pleural  cavity.  Pleural  thickening  is  usually  attended 
with  enfeeblement  of  the  vocal  fremitus  proportionate  to  its  degree,  and, 
as  a  much  thickened  pleura  gives  rise  to  impairment  of  resonance,  the 
differential  diagnosis  between  a  moderate  effusion  and  pleural  thickening 
may  be  attended  with  difficulty. 

Temporary  disappearance  of  vocal  fremitus  in  pneumonia  in  an  area 
corresponding  to  a  lobe  or  part  of  a  lobe  may  be  caused  by  the  plugging 
of  a  large  bronchus  with  a  mass  of  tenacious  mucus.  In  the  same  manner 
a  foreign  body  may  cause  localized  absence  of  this  sign.  In  infants  and 
less  frequently  in  adults  distinct  vocal  fremitus  is  occasionally  encountered 
upon  the  affected  side  in  large  effusions — a  very  puzzling  phenomenon. 
The  most  probable  explanation  of  this  anomaly  in  children  is  that  the 
intense  fremitus  caused  by  violent  crying  is  transmitted  along  the  elastic 
chest  walls  from  the  sound  to  the  affected  side  of  the  chest;  in  adults,  that 
tensely  stretched  strands  or  bands,  the  result  of  partial  adhesions  caused 
by  a  former  attack  of  fibrinous  pleurisy,  conduct  the  vibrations  from  the 
compressed  lung  to  the  wall  of  the  chest.  In  a  moderate  effusion  under 
favorable  circumstances  the  following  variations  may  be  recognized: 
normal  vocal  fremitus  over  the  apex,  enfeebled  fremitus  in  the  mammary 
region,  and  the  complete  absence  of  this  sign  at  the  base. 

If  the  limitations  of  its  usefulness  be  borne  in  mind,  vocal  fremitus 
is  a  sign  of  very  great  value,  but  it  may  mislead  the  unwary.  In  massive 
pericardial  effusion  it  is  of  great  service  in  the  differential  diagnosis 
between  that  condition  and  large  left-sided  pleural  effusion. 

Friction  Fremitus. — In  health  the  smooth  and  moist  pleural  and  peri- 
cardial surfaces  move  upon  each  other  without  appreciable  sound.  When 
these  surfaces  are  the  seat  of  a  fibrinous  exudate  they  cause  friction  sounds 
which  vary  with  the  arrangement  and  density  of  the  exudate  and  the 
energy  of  the  respiratory  or  cardiac  movements  as  the  case  may  be.  The 
vibrations  which  cause  the  sounds  are  transmitted  to  the  surface  and  con- 
stitute the  tactile  sign  known  as  friction  fremitus.  The  sensation  com- 
municated to  the  examining  finger  is  that  of  grating  or  rubbing  and  varies 


PHYSICAL  DIAGNOSIS:     PALPATION.  97 

from  the  finest  grazing  to  a  coarse  attrition.  It  corresponds  in  location 
and  extent  with  the  friction  sound  which  is  its  auditory  equivalent. 

Pleural  fremitus  is  common  in  the  infra-axillary  region  or  below 
the  nipple  and  is  not  transmitted  beyond  a  limited  area. 

Pericardial  fremitus,  which  is  the  sign  of  fibrinous  or  dry  peri- 
carditis, is  felt  in  the  precordial  space  over  the  right  ventricle.  It  does 
not  usually  correspond  in  time  accurately  with  the  systole  or  diastole, 
gives  the  impression  of  being  very  superficial  and  is  limited  to  a  circum- 
scribed area.  It  differs  from  the  thrills  felt  over  the  heart  in  the  tactile 
qualities  referred  to  in  a  preceding  paragraph. 

Pleural  fremitus  and  pericardial  friction  fremitus  disappear  as 
effusion  takes  place,  separating  the  roughened  surfaces,  and  as  adhesions 
develop,  by  which  the  surfaces  are  united. 

Rhonchal  Fremitus.  —  Coarse  bronchial  rales,  both  dry  and  moist, 
sometimes  communicate  irregular  vibrations  to  the  surface  of  the  chest 
readily  recognized  upon  palpation.  This  form  of  fremitus  is  common  in 
young  children  and  may  occur  in  thin-chested  adults.  It  differs  from  fric- 
tion fremitus  in  being  coarse  and  more  irregular  and  varying  in  intensity 
and  quality  with  the  rales  that  cause  it.    The  sign  is  of  little  diagnostic  value. 

Tracheal  tugging,  a  sign  first  described  by  Oliver,  is  of  great  value 
in  the  diagnosis  of  deep-seated  thoracic  aneurism.  "Place  the  patient  in 
the  erect  position  and  direct  him  to  close  his  mouth  and  elevate  his  chin 
to  almost  the  full  extent;  then  grasp  the  cricoid  cartilage  between  the 
finger  and  thumb  and  use  steady  and  gentle  upward  pressure  on  it,  when, 
if  dilatation  or  aneurism  exists,  the  pulsation  of  the  aorta  will  be  distinctly 
felt  transmitted  through  the  trachea  to  the  hand."  A  better  method  con- 
sists in  the  application  of  the  index  and  middle  fingers  of  the  same  hand 
on  the  sides  of  the  cricoid  cartilage,  or  the  physician  may  stand  behind 
the  patient,  who  is  seated,  and  place  the  forefingers  upon  the  sides  of  the 
cricoid,  with  gentle  upward  pressure.  The  downward  tug  may  be  readily 
recognized.  The  tug  is  due  to  the  fact  that  the  arch  of  the  aorta  passes 
over  the  left  primary  bronchus  in  such  a  manner  that  when  the  aorta  is 
dilated  it  impinges  upon  the  bronchus  with  each  pulsation.  The  tension 
of  the  bronchus  is  communicated  through  the  trachea  to  the  larynx.  A 
downward  tug  felt  only  upon  inspiration  is  frequently  present  in  health 
and  has  no  diagnostic  value.  Pulsation  transmitted  from  the  vessels  of 
the  neck  to  the  cricoid  must  not  be  confounded  with  tracheal  tugging. 
The  movement  of  the  former  is  forward  and  backward;  of  the  latter  a 
distinct  downward  pull  with  release. 

Palpation  in  the  Examination  of  the  Abdomen. 

This  is  the  most  valuable  of  the  methods  of  physical  diagnosis  in 
diseases  of  the  organs  below  the  midriff.  The  patient  should  be  in  bed 
and  the  belly  should  be  bared  as  for  inspection.  The  hand  of  the  physi- 
cian should  be  warmed  and  applied  to  the  surface  -with  gentle  pressure. 
One  or  both  hands  may  be  necessary.  Bimanual  palpation  may  be  from 
side  to  side,  the  wall  of  the  abdomen  being  deeply  folded  between  the 
hands,  or  any  accessible  organ  or  tumor  being  thus  investigated,  or  the 

7 


98  MEDICAL  DIAGNOSIS. 

bimanual  method  may  be  used  in  the  study  of  the  lateral  regions  of  the 
abdomen,  one  hand  being  placed  in  the  lumbar  region,  the  other  in  front. 
In  this  manner  the  border  of  the  liver  may  be  raised  up  against  the 
anterior  wall  or  a  floating  kidney  thrust  forward  for  examination,  or 
deep  fluctuation  elicited  in  paranephritic  or  appendiceal  abscess,  or  a 
hydronephrosis  studied,  or  the  contour  of  an  enlarged  spleen  or  carcinoma 
of  the  sigmoid  flexure  made  out.  When  the  object  of  the  examination  is 
to  localize  and  determine  the  degree  of  tenderness  it  is  better  to  study  the 
face  of  the  patient  than  to  depend  upon  his  statements  or  exclamations.  It 
is  also  important  to  distinguish  between  superficial  tenderness,  as  in  cutane- 
ous hyperaesthesia  and  the  deep  tenderness  of  an  inflamed  or  tumid  organ. 
It  will  frequently  be  found  that  here  as  elsewhere,  in  neurotic  persons, 
more  vivid  expressions  of  pain  are  called  forth  by  a  light  touch  than  by 
firmer  pressure — a  fact  in  itself  of  great  diagnostic  importance. 

Excessive  abdominal  fat,  muscular  tension,  and  ticklishness  are  obsta- 
cles. The  first  often  nullifies  the  results  of  palpation;  the  others  may 
be  overcome.  Muscular  tension  due  to  apprehension,  the  excitement  of 
the  occasion,  or  other  nervous  causes  may  be  overcome  by  elevating  the 
head  upon  pillows  and  causing  the  patient  to  flex  his  thighs  and  knees; 
continuous  deep  or  rapid  breathing  is  also  useful.  Tact  and  address  on 
the  part  of  the  physician  and  suggestion  are  also  to  be  employed.  It  is 
frequently  necessary  to  examine  the  patient  under  general  anaesthesia 
before  expressing  a  final  opinion  as  to  the  nature  of  the  case,  and  finally, 
there  are  serious  cases  of  abdominal  disease  in  which  it  may  become  neces- 
sary to  perform  an  exploratory  operation  to  arrive  at  a  positive  diagnosis. 
Ticklishness  is  an  obstacle  of  minor  importance,  but  it  may  call  for  the 
exercise  of  much  patience  on  the  part  of  both  the  doctor  and  the  patient. 

It  often  becomes  necessary  to  turn  the  patient  from  side  to  side  or 
to  examine  him  in  the  knee-elbow  posture,  or  standing.  A  digital  exami- 
nation by  the  rectum  or  vagina  with  or  without  bimanual  manipulation 
is  frequently  required  in  lesions  of  the  lower  portions  of  the  abdomen. 

The  regions  of  the  abdomen  must  be  in  turn  systematically  explored, 
the  natural  rings  and  accidental  sites  of  hernia  examined,  and  the  general 
outline,  contour,  and  condition  of  the  belly,  particularly  as  to  its  symmetry 
and  elasticity,  carefully  determined.  Large  knowledge  of  the  changes 
caused  by  abdominal  disease  and  wide  experience  are  required  in  this 
field  of  diagnosis.  Here  also  a  delicate  and  well-trained  touch — tactus 
eruditus — is  especially  serviceable. 

The  signs  obtained  by  inspection  are  confirmed  by  palpation.  i\Iuch 
knowledge  is'  obtained  by  the  latter  method.  This  comprises  the  follow- 
ing subjects: 

The  Condition  of  the  Abdominal  Walls, 

General  and  Local  Fluctuation, 

Pulsation,  Thrill  and  Fremitus, 

The  Respiratory,  Postural,  and  Manipulative  Movements  of  Organs 
or  Tumors, 

Peristaltic  and  Fetal  Movements, 

The  Outline  and  Relations  of  Palpable  Tumors, 

Their  Density  and  Elasticity, 

The  Nature  of  the  Surface  of  Tumors. 


PHYSICAL  DIAGNOSIS:     PALPATION.  99 

The  Abdominal  Walls.— In  healthy  young  persons  the  belly  walls 
are  soft  and  elastic  but  neither  tense  nor  relaxed,  and  the  curvature  of 
the  abdomen  as  determined  by  inspection  and  palpation  is  symmetrical 
and  uniform. 

Abnormal  firmness  and  relaxation  are  attended  by  a  loss  of  healthy 
elasticity.  Local  firmness  may  be  caused  by  inflammatory  or  carcinoma- 
tous infiltration,  and  general  hardness  by  the  massive  enlargement  of  the 
liver,  spleen,  uterus,  an  ovary,  or  other  organ,  or  diffuse  malignant  deposits 
in  the  intestines  or  peritoneum.  Muscular  rigidity  is  characteristic  of  the 
early  stage  of  peritonitis.  It  may  be  localized,  as  in  the  right  lower  quad- 
rant in  appendicitis  or  enteric  fever,  or  general.  Local  rigidity  of  the 
bellies  of  the  recti  is  sometimes  observed  in  neurotic  persons  and  ma}'  be 
mistaken  for  a  tumor,  as  a  thickened  or  carcinomatous  pylorus.  Local 
rigidity  with  meteorism  constitutes  phantom  tumor.  A  generalized  inelas- 
tic doughy  sensation  upon  palpation  is  often  observed  in  tuberculous 
peritonitis.  The  general  distention  of  ascites  is  associated  with  dulness 
save  in  the  upper  portions,  where  there  is  tympany,  and  with  fluctuation; 
that  of  meteorism  is  associated  with  tympany  everywhere,  including  the 
dependent  parts,  and  a  balloon-like  elasticity  quite  different  from  that  of 
the  normal  abdomen.  The  anasarcous  abdominal  wall  is  doughy,  inelastic, 
and  pits  upon  pressure;  dropsical  accumulations  are  seen  in  the  flank 
and  elsewhere  in  the  more  dependent  parts. 

Relaxation  follows  the  resorption  of  large  amounts  of  fat  and  repeated 
childbearing.  In  such  cases  the  belly  wall  is  often  pendulous  and  remark- 
ably puckered  and  thrown  into  folds  when  the  patient  lies  upon  her  back. 
Relaxation  also  follows  ascites  of  long  standing  and  the  removal  of  large 
tumors  and  is  usually  present  in  old  age  and  the  advanced  stages  of  wast- 
ing diseases.  In  women  who  have  borne  many  children  wide  separation 
of  the  recti  is  occasionally  seen,  the  connective  tissue  of  the  linea  alba 
being  enormously  stretched  and  thinned  and  the  gastric  and  intestinal 
peristalsis  plainly  seen  and  felt  over  a  large  area  in  the  middle  of  the 
abdomen.  In  such  cases  very  large  ventral  hernia  and  downward  displace- 
ment of  the  abdominal  viscera — Glenard's  disease — are  commonly  present. 

Local  tumors  of  the  abdominal  walls  are  abscess,  attended  by  local 
induration  and  central  softening;  cysts,  oval  or  circular  in  outline,  tense, 
elastic  and  fluctuating;  enlarged  lymph-nodes  in  the  inguinal  region; 
subcutaneous  carcinomatous  and  sarcomatous  tumors,  which  may  be  mov- 
able or  immovable,  and  arranged  in  irregular  masses  as  is  common  in  the 
former,  or  scattered  singly  over  a  wide  area  as  in  sarcoma;  and  hernia. 
The  last  appears  in  definite  locations,  as  the  inguinal  and  crural  rings,  the 
umbilicus,  in  the  linea  alba — ventral  hernia — and  in  the  sites  of  scars  after 
surgical  operations.  Upon  palpation  the  hernial  tumor  is  usually  soft, 
elastic  and  reducible;  omental  hernias  are  doughy  and  irregular  in  outline. 
The  hernia  which  cannot  be  returned  to  the  abdomen  by  manipulation 
is  irreducible,  that  which  is  tightly  constricted  and  is  therefore  likely  to 
become  or  has  already  become  sphacelated  is  strangulated. 

The  umbilicus  that  pouts  in  ascites  or  pregnancy  is  smooth,  stretched, 
and  somewhat  translucent.  In  umbilical  hernia  the  ring  is  usually  dis- 
tinctly felt;    when  omental  the  tumor  at  the  navel  is  often  large,   firm, 


100  MEDICAL  DIAGNOSIS. 

irregular  in  its  surface  and  irreducible  and  may  suggest  a  malignant  growth. 
The  umbilicus,  normally  somewhat  movable,  when  the  seat  of  secondary 
carcinoma,  usually  by  extension  from  the  liver,  becomes  fixed  and  is  indu- 
rated and  nodular.  Tuberculous  infiltration  of  the  tissues  around  the 
navel  has  been  observed  in  tuberculosis  of  the  peritoneum.  A  deeply 
seated,  painful  swelling  of  the  navel  is  usually  an  abscess. 

Fluctuation. ^This  sign  is  elicited  b}"  combined  bimanual  percussion 
and  palpation,  those  methods  being  employed  at  the  limits  of  the  area 
examined,  as  for  example  at  the  right  and  left  lateral  regions  of  the  abdo- 
men in  suspected  ascites  and  at  the  opposite  borders  of  circumscribed 
collections  of  fluid  as  in  pancreatic  or  other  cysts.  To  elicit  general  fluc- 
tuation the  palpating  left  hand  or  finger-tips  are  lightly  laid  upon  the  sur- 
face of  the  right  side  of  the  patient's  abdomen,  while  with  the  fingers  of 
his  right  hand  the  examiner  percusses  or  taps  somewhat  sharply  upon 
the  left  side  of  the  abdomen.  If  there  be  ascites  a  transmitted  wave  cor- 
responding to  each  tap  is  felt  upon  the  opposite  side.  This  wave  is  also 
in  many  cases  visible.  Very  light  percussion  may  bring  out  this  physical 
sign  when  the  wall  of  the  abdomen  is  thin.  The  thin  ulnar  border  of  the 
hand  of  an  assistant  must  be  rather  firmly  pressed  against  the  abdomen 
in  the  middle  line  to  arrest  the  undulatory  transverse  movement  of  the 
wall,  which  very  often  simulates  the  fluctuation  of  peritoneal  effusion. 
This  sign  does  not  arise  unless  the  fluid  is  freely  movable  and  sufficient 
in  amount  to  rise  above  the  pelvis — two  or  more  litres. 

The  method  of  determining  fluctuation  in  circumscribed  collections 
of  fluid,  as  pancreatic  or  other  cysts  within  the  abdomen,  circumscribed 
effusions,  dropsy  or  empyema  of  the  gall-bladder,  etc.,  is  somewhat  differ- 
ent in  technic  and  available  only  in  patients  w'hose  belly  walls  are  com- 
paratively thin.  The  tips  of  the  palpating  fingers  are  lightly  placed  in 
contact  with  the  surface  at  one  border  of  the  area  under  examination  while 
the  opposite  border  is  sharply  but  lightly  flicked  with  the  nail — dorsal 
surface  of  the  tip  of  the  middle  or  ring  finger  suddenly  disengaged  from 
contact  with  the  palmar  surface  of  the  thumb,  as  one  flicks  a  crumb.  By 
this  method  not  only  can  fluctuation  of  limited  extent  be  determined  but 
also  the  limits  of  the  area  in  which  it  is  present  defined. 

Pulsation,  Thrill  and  Fremitus. — Pulsation. — In  thin  persons  the 
normal  pulsation  of  the  aorta  may  be  felt  upon  deep  palpation  in  the  middle 
line  about  the  level  of  the  umbilicus.  Abnormal  pulsation  of  the  abdomi- 
nal aorta  is  of  two  kinds,  the  so-called  dynamic  pulsation  seen  in  neurotic 
persons,  not  expansile  and  not  associated  with  tumor  or  other  signs  of 
dilatation  of  the  vessel,  and  the  expansile  pulsation  of  abdominal  aneurism, 
in  which  a  tumor  that  can  be  grasped  between  the  hands  and  is  the  seat 
of  distinct  expansile  pulsation  may  be  present  together  with  other  signs 
of  aneurism.  The  differential  diagnosis  between  these  two  forms  of  pul- 
sation should  not  be  a  matter  of  doubt.  Pulsation  is  sometimes  trans- 
mitted from  the  aorta  to  a  tumor  overlying  it  in  such  a  manner  as  to 
simulate  aneurism,  especially  as  the  pressure  of  the  tumor  may  cause 
both  bruit  and  thrill.  The  fact  that  the  pulsation  is  not  expansile  and  the 
palpation  of  the  tumor  in  the  knee-elbow  posture,  when  the  movement  of 
the  aorta  is  no  longer  communicated  to  it,  serve  to  render  the  differential 


PHYSICAL  DIAGNOSIS:     PALPATION.  101 

diagnosis  between  such  a  tumor  and  aneurism  a  matter  of  comparative 
ease.  Dynamic  pulsation  of  the  aorta  is  felt  in  the  course  of  the  vessel 
in  the  middle  line  and  slightly  to  the  left  of  it;  that  of  aneurism  is  usually 
more  extended  transversely  and  may  be  felt  some  distance  to  the  left, 
even  reaching  almost  as  far  as  the  iliac  crest,  as  I  saw  in  a  case  verified 
by  autopsy. 

The  liver  pulsation  due  to  tricuspid  incompetency — hepatic  venous 
pulse — may  freciuently  be  recognized  upon  palpation,  especially  bimanual 
palpation,  when  it  is  not  visible  upon  inspection,  and  by  the  former  method 
the  difference  between  the  expansive  movement  of  a  pulsating  liver  and 
the  jogging  due  to  the  communicated  movement  of  the  heart  may  be 
appreciated. 

Thrill. — This  sign  is  sometimes  met  with  in  abdominal  aneurism  and 
tumors  pressing  upon  the  aorta.     It  has  little  diagnostic  significance. 

Fremitus  is  the  sign  of  echinococcus  cysts — hydatid  fremitus  or  thrill. 
The  tumor  is  soft,  elastic,  fluctuating,  and  in  the  majority  of  cases  the  seat 
of  a  peculiar  vibration  or  fremitus,  which  may  be  felt  by  palpation  with 
two  or  three  fingers  of  the  same  hand  or  by  placing  three  finger-tips  widely 
separated  upon  the  surface  and  lightly  percussing  the  middle  finger.  Gall- 
stone fremitus  is  sometimes  elicited  upon  palpation  of  the  gall-bladder 
distended  with  a  large  number  of  calculi.  It  is  a  comparatively  rare  but 
very  important  sign. 

Movements  of  Abdominal  Organs  or  Tumors. — The  movements  of 
intra-abdominal  organs  and  tumors  constitute  physical  signs  of  great 
value  in  diagnosis.  They  may  be  observed  in  some  instances  upon 
inspection  but  very  often  can  be  felt  when  they  cannot  be  seen.  They  are 
respiratory,  postural,  and  manipulative. 

Respiratory  movements  are  communicated  to  the  organs  in  close 
relation  to  the  diaphragm,  especially  the  liver,  spleen,  and  to  a  less  extent 
the  kidneys.  Tumors  of  the  stomach,  owing  to  its  being  a  hollow  viscus, 
are  usually  but  little  if  at  all  influenced  by  the  movements  of  the  dia- 
phragm. When  adhesions  have  taken  place  with  the  diaphragm  itself 
or  the  liver  or  spleen,  tumors  of  the  stomach  share  with  these  organs  in 
the  respiratory  movements.  Conditions  which  hinder  the  respiratory 
movements  of  the  diaphragm,  such  as  pleurisy,  emphysema,  massive 
enlargement  of  the  liver  or  spleen,  advanced  pregnancy,  meteorism  and 
ascites,  restrict  or  wholly  arrest  the  respiratory  movements  of  abdominal 
viscera.  The  anatomical  relations  of  the  pancreas  and  retroperitoneal 
glands  are  such  that  they  are  not  influenced  by  the  movements  of  res- 
piration. Very  large  cysts  of  the  pancreas  may  show  slight  movement 
on  deep  breathing. 

Intra-abdominal  new  growths  which  are  influenced  by  respiratory 
movements  originate  in  the  upper  portion  of  the  cavity;  those  which 
manifest  no  respiratory  movement  upon  careful  palpation  commonly 
but  not  always  develop  from  the  pelvic  organs  or  from  structures  directly 
connected  with  the  spinal  column  behind  the  peritoneum — pancreas, 
retroperitoneal  lymphatic  glands,  aneurism.  It  is  evident  that  the  ante- 
rior portion  of  a  tumor  originating  behind  the  peritoneum,  sufficiently 
large  and  not  too  rigid,  may  be  somewhat  influenced  by  deep  respiration. 


102  MEDICAL  DIAGNOSIS. 

In  determining  such  movements  the  fingers  grasp  the  tumor  or  the  ulnar 
edge  of  the  hand  is  pressed  against  its  upper  border  during  full  inspiration; 
upon  expiration  it  is  felt  to  slip  upwards. 

Postural  Movements. — Free  fluid  in  the  cavity  tends  to  gravitate 
to  the  most  dependent  space  while  the  air-containing  intestines  float  upon 
the  surface  of  the  fluid.  The  importance  of  this  general  fact  has  been 
dwelt  upon  in  a  previous  section.  Small  effusions  may  cause  dulness  in 
the  umbilical  region  when  the  patient  assumes  the  knee-elbow  position. 
Floating  viscera,  kidneys,  sj^leen,  and  in  very  rare  instances  the  liver,  are 
recognized  upon  palpation  by  their  size,  shape,  and  general  relationships. 
The  Uver  when  dislocated  has  but  little  range  of  movement,  but  the  kid- 
ney and  spleen  may  be  found  in  distant  regions  of  the  abdominal  cavity, 
even  at  the  brim  of  the  pelvis. 

The  Technic  of  Palpation  of  the  Kidney. — The  recognition  of 
a  displaced  kidney  is  not  attended  with  difficulty.  Palpation  should  be 
bimanual,  one  hand  pressing  upward  from  the  lumbar  region  while  the 
other  is  gently  moved  over  the  anterior  surface  of  the  abdomen,  which 
should  be  as  relaxed  as  possible.  The  tumor  is  oval,  smooth,  firm,  and  has 
the  oblong  shape  of  the  kidney.  It  is  sometimes  possible  to  recognize  the 
hilum  and  to  feel  the  pulsating  renal  artery.  The  tumor  is  usually  sensi- 
tive to  firm  pressure  and  freely  movable.  In  the  knee-elbow  posture  it 
advances  towards  the  wall  of  the  abdomen,  while  it  sinks  backward  and 
may  be  pressed  into  its  normal  position  when  the  patient  assumes  the 
dorsal  decubitus.  In  the  lateral  and  erect  postures,  it  sinks  to  the  lowest 
point  of  its  range  of  movement.  Except  in  the  case  of  a  much  elongated 
mesonephron,  it  moves  also  with  the  movements  of  respiration.  Wan- 
dering kidney  is  more  common  in  women,  in  multipara,  upon  the  right 
than  the  left  side  and  is  occasionally  bilateral. 

The  Technic  of  Palpation  of  the  Spleen. — The  patient  should 
be  placed  in  a  position  midway  between  right  lateral  and  dorsal,  with 
his  left  hand  upon  his  head.  The  thighs  should  be  flexed  in  order  to  relax 
as  far  as  possible  the  abdominal  wall.  The  head  should  be  slightly 
retracted  and  the  patient  directed  to  breathe  deeply  and  slowly.  The 
physician,  standing  at  the  patient's  right,  exerts  with  his  left  hand  firm 
pressure  upon  the  infra-axillary  region  downwards  and  forwards  while,  with 
his  right  hand,  he  presses  the  soft  belly  wall  below  the  arch  of  the  ribs 
upwards  and  inwards  to  determine  whether  or  not  the  lower  border  of  the 
spleen  can  be  felt  and  in  particular  at  the  end  of  deep  inspiration.  The 
physiological  variations  in  the  size  of  the  organ  should  be  borne  in  mind. 
It  requires  some  skill  to  recognize  slight  increase  in  volume  and  abnormal 
consistency  and  anomalies  in  shape.  Too  much  force  must  not  be  employed 
lest  a,  greatly  softened  spleen,  as  in  enteric  fever,  might  be  ruptured.  The 
data  yieldecl  by  percussion  in  the  examination  of  the  spleen  are  rendered 
uncertain  by,  gastrectasis,  meteroism,  pleural  effusion,  and  fecal  accu- 
mulations in  the  colon  and  new  growths  in  the  splenic  region.  The 
results  of  palpation  in  moderate  enlargement  are  much  more  satisfactory 
and  reliable.  :  ■'■..  .  . 

The  diagjip^is  ;Qf  massive  enUr,gement  of  the  spleen  is  usually  a  matter 
of  .ea?e.and  certainty.    The  contour  of  the  tumor,  upon  which  may  bedis- 


PHYSICAL  DIAGNOSIS:     PALPATION.  103 

tinctly  felt  a  sharply  rounded  inner  border,  often  notched  opposite  the 
hilum,  its  firmness,  its  slight  movement  upon  deep  breathing,  and  the 
smoothness  of  the  surface  are  of  diagnostic  importance. 

Wandering  spleen  is  not  often  difficult  of  recognition.  The  displaced 
organ  is  readily  palpable  below  the  left  hypochondrium,  less  often  in  the 
umbilical  or  left  iliac  region  and  very  rarely  at  the  brim  of  the  pelvis,  as 
a  smooth  oval  tumor  of  the  outline  of  the  spleen,  notched  and  freely  mov- 
able upon  change  of  posture  and  by  manipulation.  If  the  gastrosplenic 
ligament  and  the  splenic  vessels  are  much  elongated,  namely,  if  the  organ 
occupies  a  position  to  which  the  movements  of  the  diaphragm  do  not 
extend,  it  does  not  move  even  upon  the  deepest  respiration. 

In  some  cases  a  tumor  of  the  pylorus  is  extremely  movable  and  may 
show  a  lateral  range  of  several  inches  as  the  patient  turns  from  side  to 
side.  Mesenteric  cysts  are  usually  situated  below  and  to  the  right  of 
the  umbilicus  and  are  often  freely  movable  in  all  directions.  The  same  is 
true  of  omental  tumors. 

Movements  upon  Manipulation.- — All  abnormal  organs  and  tumors 
that  change  their  position  in  response  to  changes  in  posture  are  movable 
upon  manipulation  or  palpation.  The  list  comprises  floating  liver,  spleen, 
and  kidney;  in  the  absence  of  adhesions,  tumors  of  the  pylorus  and  less 
frequently  of  other  parts  of  the  stomach,  as  the  greater  curvature,  new 
growths  in  the  intestines,  excepting  the  ascending  and  descending  colon; 
fecal  accumulations,  gall-stones  and  enteroliths;  mesenteric  and  omental 
tumors.  The  range  of  movement  is  limited  in  tumors  of  the  gall-bladder 
and  pancreatic  cyst,  in  the  upper  regions  of  the  abdomen;  very  limited 
in  tumors  of  the  ascending  and  descending  colon  laterally  and  enlarge- 
ments of  the  uterus  and  ovaries  in  the  lower  segment.  All  malignant  and 
some  benign  tumors  tend  to  contract  adhesions  which  interfere  with  move- 
ment. The  following  are  immovable,  small  tumors  of  the  pancreas,  retro- 
peritoneal growths,  peri-appendiceal  infiltration,  adhesions  and  abscess, 
abdominal  aneurism  and  abscesses. 

Peristaltic  and  Fetal  Movements.  —  The  peristaltic  movements 
may  sometimes  be  felt,  as  they  may  be  seen,  in  thin  individuals  in  health 
and  when  in  obstruction  of  the  bowel  they  become  excessive.  In  chronic, 
slowly  developing  stenosis  of  the  gut  the  musculature  of  the  intestines 
undergoes  hypertrophy  and  the  peristalsis  becomes  proportionately  more 
powerful.  Antiperistaltic  or  reverse  waves  may  sometimes  be  felt.  Pal- 
pable coarse  intestinal  movements  with  the  formation  of  knots  accom- 
panied by  borborygmi  may  be  present  in  colic  and  in  hysteria.  The  gastric 
and  intestinal  movements  are  very  plainly  felt  and  seen  in  cases  of  wide 
separation  of  the  recti  in  women  who  have  borne  man}^  children. 

The  movements  of  the  foetus  may  be  often  plainly  felt  upon  palpation, 
and  in  advanced  pregnancy  the  position  of  the  foetus  may  be  recognized 
by  this  method  of  examination.  All  these  movements  may  be  rendered 
more  active  by  manipulation  and  the  sudden  application  of  cold. 

Tumors  of  the  stomach  and  intestines  when  not  fixed  by  adhesions  fre- 
quently undergo  slight  changes  in  position  with  the  peristaltic  movements. 

Outline. — The  outline  and  relations  of  tumors  as  determined  by 
palpation  constitute  most  important  diagnositic  criteria.     We  thusirtieter- 


104  MEDICAL  DIAGNOSIS. 

mine  whether  an  intra-abdominal  mass  is  round,  oval,  or  irregular  in  out- 
line ;  whether  it  is  rough,  nodular,  or  smooth ;  whether  it  resembles  a  viscus 
as  the  kidney  or  spleen  in  shape  and  has  characteristic  anatomical  features, 
as  the  hilum  or  a  pulsating  artery.  We  ascertain  its  apparent  point  of 
origin,  as  in  the  epigastrium,  the  lateral  regions  of  the  abdomen,  or  the 
pelvis,  and  whether  or  not  it  has  direct  attachments  or  relations  with 
another  organ,  such  as  msLy  be  made  out  between  an  enlarged  gall-bladder 
and  the  liver,  carcinoma  of  the  pylorus  and  the  stomach,  or  a  large  cyst 
in  the  left  hypochondrium  and  the  pancreas. 

Density  and  Elasticity. — The  signs  relating  to  the  consistency  of  an 
intra-abdominal  mass  can  be  ascertained  by  palpation  alone.  We  thus 
determine  whether  it  is  fluctuating  as  in  abscess  or  cyst;  soft  as  in  rapidly 
developing  new  growths  and  aneurism;  moderately  firm  as  in  organs  the 
seat  of  congestion  and  hypertrophy,  or  dense  and  strong  as  in  slowly 
developing  carcinoma  or  interstitial  overgrowths — hepatic  cirrhosis.  We 
note  also  that  in  fecal  accumulations  the  tumor  is  sometimes  hard  and 
firm  and  sometimes  soft  and  doughy  and  can  be  indented  by  the  finger. 

Surface. — Palpation  enables  us  to  determine  the  smoothness  or 
unevenness  of  the  surfaces  of  organs  and  tumors.  The  smooth  surface 
of  an  amyloid  or  fatty  liver,  the  coarse  granular  surface  of  the  liver  in 
atrophic  cirrhosis,  the  nodular  liver  with  its  rounded  isolated  eminences 
at  the  summit  of  which  slight  depressions  may  be  felt — Farre's  tubercles — 
in  cancer,  are  examples  of  surface  changes  of  diagnostic  importance.  The 
smooth  surface  of  the  distended  gall-bladder  stands  in  strong  contrast 
with  the  irregular  outline  of  carcinoma  of  the  pylorus;  the  irregular  multi- 
locular  echinococcus  of  the  liver  can  hardly  be  differentiated  from  hepatic 
cancer,  but  is  wholly  unlike  the  smooth,  elastic,  and  vibrating  single  hydatid 
cyst.  The  smooth,  elastic,  and  fluctuating  cyst  in  hydronephrosis  differs 
altogether  from  the  firm,  nodular  and  irregularly  shaped  mass  in  carcinoma 
of  the  kidney;  and  the  smooth,  ovoid,  nearly  centrally  placed  tumor  of 
early  pregnancy  is  wholly  unlike  the  tumor  formed  by  irregular,  coarsely 
nodular  subperitoneal  uterine  myomata. 

Thayer  of  Galveston  has  suggested  a  method  of  palpating  the  abdom- 
inal organs  which  is  of  practical  value.  The  patient  should  sit  up  in 
bed,  or,  if  a  walking  patient,  upon  a  table,  with  the  knees  widely  separated 
and  the  soles  of  the  feet  together,  and  the  hands  resting  upon  the  calves 
or  the  knees.  The  body  from  the  waist  up  is  then  supported  upon  a  tripod, 
composed  of  the  spine  and  the  arms.  The  elbows  should  be  nearly  or  quite 
extended,  but  ready  to  be  flexed  or  held  entirely  straight,  as  the  physician 
asks  for  more  or  less  space.  Under  ordinary  quiet  breathing  this  posture 
permits  the  viscera  to  come  forward  into  the  field  of  examination  to  the 
full  extent  permitted  by  their  normal  attachments,  the  liver,  stomach, 
and  spleen  coming  down,  and  the  flanks  and  their  contents  coming  for- 
ward, and  the  relaxed  integuments  approaching  the  mid-line,  in  such  a 
manner  that  everything  accessible  in  this  examination  tends  to  approach 
the  anterior  abdominal  wall,  instead  of  receding  from  it. 

The  examiner  sits  behind  the  patient,  his  outer  foot  on  the  floor,  his 
inner  leg  flexed  at  the  knee,  with  the  foot  on  his  other  knee  or  beneath  it. 
This  flexed  knee  is  applied  to  the  lower  lumbar  region,  or  the  sacrum,  of 


PHYSICAL  DIAGNOSIS:     MENSURATION.  105 

the  patient,  and,  since  the  pressure  of  the  tibial  tuberosity  causes  discom- 
fort, he  should  save  the  patient  this  by  putting  a  pillow  between  his  knee 
and  the  subject's  back. 

The  abdominal  wall  is  relaxed  and  the  abdominal  contents  tend  to 
fall  forward  against  the  wall  and  may  be  readily  palpated  b}^  the  hands 
of  the  examiner,  which  are  passed  around  the  sides  of  the  patient  under 
his  arms.  The  organs,  tumors,  exudates  are  examined  in  a  position  cor- 
responding to  that  of  the  body  of  the  examiner.  If  the  patient  is  too  ill 
to  sit  up  he  may  be  moved  to  the  edge  of  the  bed  with  his  back  toward  the 
examiner  and  his  lower  limbs  strongly  flexed,  and  palpation  performed  in  the 
same  manner. 

MENSURATION. 

The  use  of  instruments  of  precision  is  of  great  importance  in  physical 
diagnosis.  Such  appliances  vary  from  a  simple  graduated  tape  to  the 
most  intricate  and  delicate  hae  mo  dynamo  meter  or  polygraph.  The  writer 
holds  the  opinion  that  simplicity  both  of  method  and  of  instruments 
yields  the  most  satisfactory  results  at  the  bedside,  and  that  intricate  and 
costly  mechanical  devices  which  require  great  technical  skill  and  con- 
sume much  time  are  better  suited  to  scientific  research  than  to  every-day 
clinical    work. 

Measurements  of  the  chest — thoracometry — may  be  conveniently 
made  by  a  steel  tape  graduated  upon  one  side  in  centimetres,  on  the  other 
in  inches;   the  diameters  are  taken  by  calipers  made  for  the  purpose. 

The  circumference  and  semicircumferences  are  taken  at  the  level 
of  the  nipples  or  the  fourth  costosternal  articulation  in  quiet  breathing,  in 
full  held  inspiration  and  on  full  expiration.  Care  must  be  taken  that  the 
tape  is  horizontal.  The  normal  chest  is  nearly  but  not  quite  symmetrical, 
the  right  semicircumference  being  in  the  majority  of  individuals  slightly 
larger  than  the  left — an  average  difference  of  about  half  an  inch.  It  is 
well  to  make  a  mark  with  a  dermatographic  pencil  in  the  median  line  in 
front  and  over  a  vertebral  spine  at  the  same  level  and  measure  the  semi-- 
circumference  from  point  to  point  on  each  side  for  comparison.  Two  tapes 
attached  to  a  little  wooden  saddle  which  fits  over  a  vertebra  are  useful  to 
determine  the  semicircumference  on  quiet  breathing  and  the  differences 
on  forced  respiration.  The  average  circumference  in  men  is  34.3  inches 
(87  cm.);  in  women  29.5  inches — (75  cm.).  The  difference  in  forced 
expiration  and  full  held  inspiration  varies  in  normal  individuals  between 
1.5  (4  cm.)  and  5  inches  (12.5  cm.). 

The  main  diameters  of  the  chest  at  the  same  level  as  taken  by  compass 
calipers  with  curved  arms  or  slide  calipers  are :  anteroposterior  (the  depth 
of  the  chest)  average  in  repose  in  men  7.5  inches  (19  cm.);  in  women 
6.9  inches  (17  cm.);  bilateral  or  transverse  (the  breadth  of  the  chest), 
average  in  men  9.9  inches  (25  cm.). 

Spirometry.— Mensuration  may  be  employed  not  only  to  ascertain 
the  size  of  the  chest  and  its  movements  but  also  to  learn  the  volume  of 
the  tidal  air.  The  instrument  used  for  this  purpose  is  the  spirometer. 
Various  forms  are  in  use  but  the  results  are  far  from  satisfactory.  The 
instruments  are  cumbersome  and  require  a  certain  amount  of  training  to 


106  MEDICAL  DIAGNOSIS. 

obtain  constant  results.  The  sex,  age,  weight  and  height  must  be  taken 
into  account.  Thus  for  every  inch  above  five  feet,  eight  cubic  inches  are 
to  be  added  to  the  normal  standard,  which  for  five  feet  is  174  cubic  inches. 
The  estimated  average  lung  capacity  for  height  in  males  between  sixteen 
and  forty  years  of  age  is,  according  to  Otis,  twenty-three  cubic  centimetres 
for  every  centimetre  of  height;  in  females  at  nineteen  years  of  age,  it  is 
fifteen  cubic  centimetres  for  each  centimetre  of  height. 

Waldenburg's  pneumatometer  is  an  apparatus  designed  to  measure  the 
respiratory  energy.  Normally  the  power  exerted  in  expiration  is  greater 
than  in  inspiration  by  from  twenty  to  thirty  millimetres  of  mercury. 
In  emphysema  and  asthma  the  expiratory  pressure  is  greatly  diminished, 
while  in  certain  forms  of  phthisis  the  inspiratory  power  is  much  lessened. 

Cyrtometry. — The  determination  of  the  outline  of  a  cross-section  of 
the  chest  may  be  made  with  an  instrument  called  a  cyrtometer — measure 
of  the  curve.  This  procedure  is  of  no  great  use  in  ordinary  clinical  work 
but  very  suggestive  and  important  in  teaching.  Elaborate  and  costly 
instruments  are  not  necessary  for  this  purpose.  The  best  device  consists 
in  a  little  metal  saddle  made  to  fit  the  spine,  to  each  side  of  which  is  hinged 
a  strip  of  leaden  ribbon  half  an  inch  in  width  and  thick  enough  to  be  easily 
bent  so  as  to  conform  to  the  surface  of  the  chest,  yet  retain  its  form  when 
removed.  The  saddle  is  set  upon  the  spine  at  the  level  selected,  the  leaden 
band  is  carefully  adjusted  to  the  surface  on  each  side  and  made  to  meet 
at  the  median  line  in  front.  It  is  then  released,  opened  at  the  hinges, 
removed  from  the  chest  and  then  laid  upon  a  sheet  of  paper,  the  ends 
being  brought  together  at  the  point  of  meeting  in  the  median  line.  The 
outline  is  controlled  by  the  fixation  of  the  main  diameters  by  means  of 
the  calipers.  A  soft  pencil  is  then  used  to  make  the  tracing  on  the  inside 
of  the  cyrtometer.  The  various  deformities  of  the  chest  described  under 
inspection  may  be  thus  depicted. 

Circumferential  measurements  of  the  abdomen  at  the  level  of  the 
umbilicus  and  vertical  measurements  from  the  ensiform  cartilage  are 
useful,  especially  for  purposes  of  comparison  in  ascites  and  enlargements 
from  tumor  or  other  conditions.  They  are  best  made  with  the  ordinary 
graduated  tape.  Measurements  from  various  fixed  points  upon  the  surface 
of  the  thorax  or  abdomen  are  necessary  for  purposes  of  record. 

The  Sphygmograph. — This  is  an  instrument  for  the  graphic  registra- 
tion of  the  pulse.  There  are  various  forms.  Vierordt's,  1855,  was  the  earli- 
est. Marey's,  1860,  was  more  practical  and  as  modified  by  Mahomed  and 
others  is  still  much  used.  The  instruments  of  Sommerbrodt,  Jaquet  and 
Frey  are  more  recent.  That  of  Dudgeon  has  many  advantages  and  is  in 
general  use.     Dudgeon  makes  the  following  claims  for  his  instrument:. 

That  it  magnifies  the  movements  of  the  artery  in  a  uniform  degree, 
namely,  fifty  times;  that  the  pressure  of  the  spring  can  be  regulated  from 
1  to  5  ounces;  that  it  requires  no  wrist  rest  and  can  be  used  with  equal 
facility  whether  the  patient  be  standing,  sitting,  or  recumbent:  that  a 
tracing  can  be  made  with  it  almost  as  quickly  as  the  pulse  can  be  felt  with 
the  finger;  that  owing  to  its  great  sensitiveness  it  records  the  slightest 
deviation  in  the  form  or  character  of  every  beat;  its  construction  is  so 
simple  th'c.t  any  watchmaker  can  repair  it  if  broken;    that  it  is  so  small, 


PHYSICAL  DIAGNOSIS:     MENSURATION. 


107 


CYRTOMETRIC  TRACINGS. 


Fig.  48. — Outline  of  normal  chest. 


Fig.  49. — Outline  of  emphysematous  chest. 


Fig.  50. — Outline  of  chest  showing  "funnel-shaped"  Fig.  51. — Outline  of  phthisical  chest, 

deformity. 


Fig.  52. — Outline  of  the  chest  in  spinal  curvature. 


Fig.  53. — Outline  of  the  chest  in  rickets. 


108 


MEDICAL  DIAGNOSIS. 


2§  X  2  inches,  and  so  light,  4  ounces,  that  it  msiy  be  carried  in  the  pocket; 
that  it  is  much  less  expensive  than  other  forms  of  the  instrument. 

The  sphygmograph  is  of  great  value  in  clinical  work  but  it  is  rarely 
essential  to  a  diagnosis.  That  which  it  adds  to  the  information  obtained 
by  the  well-trained  finger  relates  to  minutia3  many  of  which  are  still  the 
subject  of  dispute. 

It  is  chiefly  useful  in  making  permanent  records  for  future  compari- 
son, in  the  graphic  representation  of  details  for  purposes  of  discussion  and 
the  teaching  of  students,  and  in  leading  to  close  habits  of  observation.  It 
corroborates  facts  in  regard  to  the  pulse  previously  obtained  by  palpation. 
There  is  no  instrument  of  precision  employed  in  clinical  medicine 
the  results  of  which  are  so  greatly  influenced  by  the  personal  equation. 
A  series  of  sphygmograms  taken  in  succession  in  the  same  case  by  differ- 
ent observers  may  show  variations 
that  are  remarkable  and  inex- 
plicable. The  regulation  of  the 
pressure  is  uncertain  and  the  diffi- 
culties in  the  way  of  securing  a  uni- 
form  pressure  at  different  times 
and  in  different  cases  are  in  the 
present  state  of  development  of 
the  instrument  insurmountable. 
The  time  consumed  in  the  appli- 
cation of  the  instrument  is  in 
ordinary  clinical  work  out  of  pro- 
portion to  the  results.  Neverthe- 
less the  sphygmograph  has  its 
place  and  is  regarded  by  those 
who  have  by  practice  acquired 
the  ability  to  take  rapid  and  accu- 
rate tracings  as  a  valuable  aid  to 
systematic  clinical  work. 
Directions  for  the  application  of  Dudgeon's  sphygmograph: 

(a)  Mark  the  exact  position  of  the  artery  with  a  line  drawn  by  ink  or 
a  dermatographic  pencil  and  prolonged  to  the  ball  of  the  thumb. 

(b)  Wind  up  the  clockwork  used  to  drive  the  smoked  paper  along 
by  means  of  the  milled  button  at  the  back  of  the  clockwork  box. 

(c)  Insert  the  smoked  paper  between  the  rollers  and  under  the  writ- 
ing needle. 

(d)  Place  the  patient  in  a  comfortable  position  with  the  hand  selected 
pointing  towards  you,  the  wrist  exposed,  the  fingers  gently  flexed  and 
the  muscles  relaxed,  and  request  him  to  hold  the  hand  and  arm  per- 
fectly still. 

(e)  Slip  the  band,  the  free  end  of  which  has  been  drawn  through  the 
retaining  clamp,  over  the  patient's  hand.  The  metal  box  should  be  placed 
toward  the  elbow. 

(f)  Adjust  the  instrument  by  placing  the  bulging  button  of  the  spring 
directly  over  the  radial  artery  as  shown  by  the  line  previously  drawn,  and 
close  behind  the  prominence  of  the  os  trapezium. 


Fig.  54. — Dudgeon's  sphygmograph. 


PHYSICAL  DIAGNOSIS  :     MENSURATION.  109 

(g)  Retain  the  instrument  accurately  in  its  place  with  the  left  hand 
and  draw  the  band  through  the  clamp  with  the  right  until  the  writing 
needle  plays  freely  over  the  middle  of  the  smoked  paper;  then  fasten  the 
band  by  screwing  up  the  clamp  with  the  left  hand.  If  the  band  is  not 
used,  place  the  patient's  hand  and  wrist  on  some  proper  support  and 
hold  the  instrument  with  one  hand;  or  the  band  may  be  passed  around 
the  wrist  and  held  from  underneath  without  clamping. 

(h)  Regulate  the  pressure  by  means  of  the  milled  head  of  the  thumb 
screw  until  the  needle  attains  its  greatest  amplitude  of  movement.  The 
pressure  is  graduated  in  ounces  but  the  reading  is  never  reliable. 

(i)  Set  the  smoked  paper  in  motion  by  pushing  toward  the  right  the 
small  lever  at  the  top  of  the  box,  and  either  stop  the  mechanism  by  revers- 
ing this  lever  just  before  the  slip  runs  out  or  catch  the  slip  in  the  free 
hand.  Two  tracings  may  be  taken  at  varying  pressure  or  the  clockwork 
may  be  stopped  about  the  middle 
of  the  slip,  the  pressure  increased 
to  the  maximum  and  the  tracing 
resumed.  The  effect  of  medium 
and  maximum  pressures  is  thus 
obtained.  Strips  of  paper  of  proper 
texture  and  accurate  size  can  be 
obtained  from  the  instrument- 
makers.  They  are  prepared  for  use 
by  passing  them  through  the  smoke 
of  burning  gum  camphor.     For  this 

purpose    a    suitable    holder    is    made  Fig.55.— Diagram  of  normal  pulse  tracing.    a,b, 

frnm     q      atrir-.      r>f     iin      +nrr>orl      r^^Tor  up-stroke,  percussion  stroke;  ascending  or  anacrotic 

ironi     a     strip     OI      tin     turneu     over  jimb.    6,  e,  descending  or  catacroticlimb.    a,  6,  c,  per- 

cit    fVio    onrlo          Tl-    ia    i  i-nnnr-l-Q  nf    +Viq+  cussion  wave;  c,  rf,  e,  predicrotic  or  tidal  wave;  e,f,g, 

at    tne    enaS.        it    is   important    tnat  dicrotic  or  recoil  wave;  6,  c,d,  pretidal  notch;  d,e,f, 

they    be    smoked    as    evenly    as    POS-  the  aortic  notch;  hi,  base  line     The  period  indi- 

.      "^                                                .          .                ^      ,  cated  between  a  and  e  corresponds  to  the  ventncu- 

Slble.        After  the   tracing  is   made   it  lar  systole;  the  period  between  e  and  g  to  the  aortic 

may  be  labelled  with  the  name,  date, 

diagnosis,  etc.,  upon  the  smoked  surface  with  a  coarse  needle,  or  these  facts 
may  be  written  with  ink  on  the  unsmoked  end  of  the  slip.  The  smoke 
upon  the  surface  of  the  paper  is  then  set  by  passing  the  slip  through  a 
quick  drying  varnish,  such  as  photographer's  negative  varnish  or  a  solu- 
tion of  benzoin  in  alcohol  in  the  proportion  of  1  ounce  to  6.  If  the  tracing 
is  to  be  much  handled  a  second  coat  should  be  applied. 

The  Sphygmogram  under  Normal  Conditions. — The  percussion  stroke 
or  ascending  limb  is  caused  by  the  wave-like  transmission  of  the  impulse 
communicated  to  the  blood  in  the  arterial  system  by  the  ventricular  sj's- 
tole.  The  elastic  walls  of  the  suddenly  distended  artery  contract  slightly, 
causing  the  aortic  or  pretidal  notch,  and  again  expand  as  indicated  by  the 
tidal  wave,  after  which  the  pressure  again  diminishes  until  the  closure 
of  the  aortic  valves,  by  which  a  base  of  support  is  presented  to  the  blood 
column  with  a  resultant  recoil  which  is  manifested  in  the  dicrotic  wave. 
Insignificant  undulatory  curves  in  the  lower  part  of  the  descending  or 
catacrotic  limb,  scarcely  shown  in  ordinary  tracings,  are  caused  by  minor 
oscillations  of  the  arterial  walls.  The  intrinsic  movements  of  an  extremely 
delicately  adjusted  and  sensitive  writing  needle  are  to  be  taken  into  account 


110 


MEDICAL  DIAGNOSIS. 


but  cannot  be  determined.  It  is  evident  that  the  excursion  of  the  needle 
will  be  exaggerated  when  the  pulse  is  quick  and  of  large  volume  and  that 
under  these  circumstances  the  tracing  represents  the  qualities  of  the  pulse 
plus  certain  qualities  of  the  instrument  not  shown  in  tracings  of  other  pulses, 
particularly  those  of  small  volume,  high  tension,  and  tardy  development. 

The  Diagnostic  Significance  of  Sphygmograms. — In  the  normal  sphyg- 
mogram  the  up-stroke  is  straight,  almost  vertical,  of  moderate  amplitude 
as  compared  with  the  tracings  of  low  and  high  tension  pulses,  the  apex 
acute  rather  than  obtuse,  the  descent  gradual,  interrupted  by  a  small  tidal 
and  well-marked  dicrotic  wave.     Sphygmograms  are  read  from  left  to  right. 

Minor  departures  from  the  normal  in  any  of  these  particulars  cannot 
be  regarded  as  of  diagnostic  value.  The  tracings  are  much  modified  by  cer- 
tain pathological  conditions  and  the  following  points  deserve  consideration: 


Fig.  56. — Aortic  regurgitation. 

Amplitude. — The  length  of  the  percussion  stroke  varies  considera- 
bly under  normal  conditions.  It  is  dependent  primarily  upon  the  quick- 
ness of  the  pulse,  secondarily  upon  the  relaxation  of  the  peripheral  vessels. 
A  long  up-stroke  indicates  a  pulse  of  low  tension  and  large  volume.  The 
up-stroke  is  elongated  in  pyrexia.  A  striking  character  of  the  tracing  of 
aortic  regurgitation  is  the  long  up-stroke.  On  the  contrarj^  the  percus- 
sion stroke  is  short  when  the  pulse  is  of  small  volume  or  of  high  tension, 
as  is  seen  in  tracings  from  cases  of  arteriosclerosis,  aortic  stenosis,  mitral 
stenosis  and  regurgitation  and  aneurism. 


Fig.  57. — Mitral  stenosis. 

Direction. — The  direction  of  the  percussion  stroke  is  dependent  upon 
the  quickness  of  the  pulse.  It  is  vertical  or  nearly  so  in  tracings  from 
cases  in  which  the  ventricular  systole  is  sharp,  especially  in  cases  of  dilated 
hypertrophy.  The  up-stroke  is  vertical  in  the  tracing  of  pulses  of  low  ten- 
sion and  both  vertical  and  elongated  in  aortic  incompetency.  It  is  oblique 
or  sloping  in  fat  persons,  the  force  of  the  percussion  impulse  being  taken 
up  by  the  thick  tissue  overlying  the  artery.  Tracings  of  this  kind  are 
characteristic  of  cases  in  which  there  is  a  relatively  slow  discharge  of  blood 
from  the  ventricle  into  the  arterial  system,  whether  in  consequence  of 
lesions  of  the  vessels  or  lesions  of  the  heart  itself.     A  sloping  anacrotic 


PHYSICAL  DIAGNOSIS:     MENSURATION. 


HI 


limb  occurs  in  tracings  in  arteriosclerosis,  high  tension  from  any  cause, 
and  aneurism.  It  is  seen  also  where  the  left  ventricle  is  weak,  or  where 
the  mass  of  blood  in  the  ventricle  is  divided,  as  in  mitral  incompetence, 
or  where  there  is  mechanical  obstruction  of  the  flow  of  the  blood  through 
the  heart,  as  in  mitral  and  aortic  stenosis. 

Apex  or  Summit. — The  apex  is  sharp  or  pointed  in  the  great  majority 
of  tracings,  both  normal  and  pathological.     Tracings  in  which  the  apices 


Fig.  58. — Arteriosclerosis. 

are  blunt  or  broad  are  frequently  the  result  of  improper  adjustment  of 
the  sphygmograph  or  too  great  pressure.  Tracings  of  this  kind  are  some- 
times obtained  in  high  tension  pulses,  arteriosclerosis,  aortic  stenosis, 
and  especially  in  aneurism. 

Line  of  Descent. — This  in  a  normal  pulse  tracing  is  gradual  and 
undulatory,  showing  in  succession  the  pretidal  notch,  the  tidal  wave, 
the  aortic  notch,  and  the  dicrotic  wave.  Under  normal  circumstances  the 
blood  takes  some  time  to  flow  from  the  arterial  system  into  the  capillaries 
and  the  subsidence  of  the  pulse  wave  is  gradual  and  the  line  of  descent 
sloping.  The  line  of  descent  is  relatively  abrupt  when  the  outflow  from 
the  arterial  system  into  the  capillaries  is  rapid,  as  in  tracings  from  cases 
of  great  relaxation  of  the  peripheral  circulation  and  in  aortic  regurgita- 
tion in  which  the  arteries  suddenly  collapse  in  consequence  of  the  defect 
in  the  aortic  valves;  it  is  more  gradual  than  normal  when  the  outflow  is 
retarded,  as  is  the  case  in  arteriosclerosis,  during  a  chill  and  in  the  early 
stages  of  peritonitis.  Great  irregularity  in  the  line  of  descent  is  frequently 
seen  in  tracings  of  mitral  disease,  especially  during  impairment  or  rupture 
of  compensation.  All  forms  of  intermittence  and  irregularity  of  the  pulse 
are  graphically  represented  in  properly  taken  sphygmograms. 


Fig.  59. — Pulsus  bisferiens. 


Tidal  Wave.— The  prominence  of  this  curve  indicates  increase  of 
the  arterial  tension  during  the  ventricular  systole.  It  occurs  in  some  cases 
of  arteriosclerosis  and  in  aortic  stenosis.  This  wave  is  sometimes  per- 
ceptible to  the  finger — pulsus  hisferiens.  It  is  small  or  absent  when  the 
heart  is  very  weak,  or  when  with  moderate  systolic  force  there  is  free  per- 


112  MEDICAL  DIAGNOSIS. 

ipheral  circulation.  It  is  absent  in  mitral  and  aortic  incompetency  of  high 
grade.  It  occasionally  happens  that  the  tidal  or  predicrotic  wave  is  pres- 
ent in  some  pulse  curves  of  a  tracing  and  absent  in  others — a  condition 
arising  from  variations  in  the  am.ount  of  blood  discharged  into  the  arte- 
rial system  during  the  ventricular  systole.  Tracings  showing  a  marked 
predicrotic  w^ave  upon  alternate  beats  or  at  other  intervals  indicate 
derangement  of  the  nervous  mechanism  of  the  heart. 

Dicrotic  Wave. — This  w^ave  is  usually  present  in  the  normal  pulse 
tracing.  It  corresponds  to  that  period  of  the  cardiac  revolution  immedi- 
ately following  the  closure  of  the  aortic  valves.  When  the  vasomotor  tone 
is  good  and  the  arterial  tension  high  the  dicrotic  wave  is  feebly  marked 
or  absent.  It  is  absent  or  faintly  indicated  in  free  aortic  regurgitation. 
In  some  cases  of  arteriosclerosis  when  well  marked,  it  may  be  recognized 
by  the  palpating  finger,  and  the  pulse  is  spoken  of  as  dicrotic.  Different 
degrees  of  dicrotism  are  shown  in  tracings.  When  the  dicrotic  wave  is 
well  marked  but  the  aortic  notch  is  above  the  respiratory  or  base  line, 
the  pulse  is  called  dicrotic.  When  the  aortic  notch  falls  to  the  level 
of  the  base  line  the  pulse  is  said  to  be  fully  dicrotic.     When  the  aortic 


Fig.  60. — Dicrotic  pulse. 

notch  falls  below  the  level  of  this  line  the  pulse  is  called  hyperdicrotic. 
If  the  hyperdicrotic  pulse  is  very  rapid  the  second  beat  is  altogether 
lost  and  the  pulse  is  said  to  be  monocrotic. 

Respiratory  or  Base  Line.  —  In  the  normal  sphygmogram  the 
lowest  points  of  the  percussion  strokes  of  successive  pulse  waves  are  on 
the  same  horizontal  plane,  and  a  line  drawn  through  these  points  is  called 
the  base  or  respiratory  line.  The  term  respiratory  is  used  to  designate 
this  line  because  the  inspiration  and  expiration  to  some  extent  in  health, 
but  much  more  in  disease,  exert  a  marked  influence  upon  it.  Full  and  sud- 
den inspirations  reduce  the  arterial  tension  and  lower  the  base  line.  Forced 
expiration  on  the  contrary  increases  arterial  tension  and  raises  the  base 
line.  In  cases  of  severe  dyspnoea  from  any  cause  the  base  line  is  undulatory, 
falling  with  inspiration  and  rising  with  expiration. 

Mackenzie's  Clinical  Polygraph. — By  means  of  this  instrument,  for  a 
description  of  which  the  student  is  referred  to  ''The  Study  of  the  Pulse," 
London,  1902,  graphic  tracings  of  the  venous  pulsations  in  the  neck  or 
liver  are  made  in  connection  with  sphygmographic  tracings  of  the  radial 
pulse.  The  simultaneous  tracings  upon  the  same  strip  of  paper  afford  an 
opportunity  for  accurate  timing  of  the  radial  and  the  venous  pulses  for 
clinical  purposes  by  the  familiar  method  of  laboratory  research.  This 
method  may  be  made  use  of  in  hospital  work  and  under  certain  circum- 
stances in  the  consultation  room,  and,  by  a  modification  of  the  instru- 
ment, the  portable  ink-writing  polygraph  may  be  used  in  private  practice 
at  the  bedside. 


PHYSICAL  DIAGNOSIS:     MENSURATION. 


113 


The  following  tracings  were  made  by  Bach  man  by  means  of  an  in- 
strument supplied  with  Marey's  tambours.  A  rubber  tube  four  feet  in 
length  connects  the  receiver  with  the  tambour.  The  records  were  made 
upon  smoked  paper  with  an  ordinary  laboratory  kymograph. 


Fig.  61. — Normal  carotid  tracing. 


Fig.  62. — Mitral  insufficiency. 


t 
1  -  J     "'"■■•-      ; 

I 

\                t 

S 

'i 

!  \ 

1 
-J 

Curol.ui 

^m 

Cd'/dioclp^'V              "■'" 

llA-SJlAflJuJl-.-lJ. 

.1  Jl  A  f.  ^  .'U  \ 

Tiwf  '/yo" 

Fig.  63. — Mitral  stenosis. 


M    'Iv 

i 

1  A 

IV 

M 

'1/ 

/V 

'  vv     ,   V' 

\ 

;   lA 

;   A 

v\ 

i   lA^ 

1     'vA 

-—'     ^-J 

^X. 

-^ 

"^■-J     ^ 

/                          \^- 

■v_ 

> 

-J 

Carotid 

f] 

/ 

M 

/U 

if\ 

r^, 

,^/^ 

^-^  v^ 

J  \ 

\ 

1.^ 

-^\ 

Cardiac  Apex.        V 

_^ 

v 

/ 

/ 

^■^- 

———  -^^-^-^—^-^-^^             -      -      1 

Fig.  64. — Pulsus  bisferieas — aortic  regurgitation  and  stenosis;   mitral  regurgitation. 


114 


MEDICAL  DIAGNOSIS. 


^.        /  \ 


Cardiao  Apex 


Fig.  65. — Aortic  regurgitation. 


Fig.  66. — Aortic  stenosis — anacrotic  pulse 


Fig.  67. — Pulsus  trigeminus. 


i  r^-^j^  /'^^-^  N-_/^^ 

■   Tv 

/V.^          ;V. 

/\ 

1 — ■             -^  ^"^^ 

'         Carotid                                             * 

V        ' 

~^''~"'  .:^^ 

i^"'V^-^V.,y\^^\f-^^\, 

,,,^ 

Ia^'^'^  V^-^~^\ 

^--y\/^^-' 

Cardirio  Apex. 

' — '                                                             ' — '~ 

1 — 1 

-1 ,           , ,           , r— 

-. — . — , — .- 

Fig.  68. — Mitral  regurgitation  and  stenosis. 


PHYSICAL  DIAGNOSIS:     MENSURATION.  115 


A        A,       \f\        y.        I 

Carotid 


\r 


Cardiac  Apex 
Time  ijlo" 


Fig.  69. — Mitral  and  aortic  regurgitation. 


The  Sphygmomanometer.  —  Instruments  for  measuring  the  blood- 
pressure  in  the  arteries  have  come  into  general  use.  They  not  only 
render  it  possible  to  determine  the  blood-pressure  with  a  reasonable  ap- 
proximation to  accuracy,  due  allowance  being  made  for  variations  inherent 
to  the  instrument  employed,  but  they  also  reveal  changes  in  pressure  not 
recognizable  by  palpation  in  the  ordinary  way.  The  mechanical  principle 
involved  in  the  instruments  thus  far  devised  for  clinical  use  consists  in 
the  transference  of  the  blood-pressure  within  limits  nearly  constant  as 
regards  the  apparatus  to  a  properly  graduated  mercurial  manometer. 
The  essential  parts  comprise  a  compressing  armlet  having  a  breadth  of 
not  less  than  8  cm.,  connections  of  tubing  which  is  practically  non- 
distensible,  an  inflating  apparatus,  and  the  manometer.  For  practical  pur- 
poses such  an  instrument  must  be  capable  of  measuring  both  systolic 
and  diastolic  pressures;  its  application  must  be  simple  and  the  results 
obtainable  within  a  period  not  exceeding  three  minutes;  it  must  be  not 
too  delicate  for  ordinary  clinical  use  and  sufficiently  compact  to  be  readily 
transported  by  hand. 

Two  instruments  meet  these  requirements — Stanton's  and  Janeway's. 
The  method  in  use  consists  in  the  close  application  of  the  armlet  to  the 
arm  at  the  level  of  the  heart,  the  patient  being  either  in  the  sitting  or  the 
recumbent  posture;  the  application  of  the  finger  to  the  radial  pulse,  the 
patient's  arm  being  completely  relaxed  and  the  pressure  being  steadily 
raised  by  the  other  hand  by  means  of  the  inflating  apparatus.  When  the 
pulse  can  no  longer  be  felt,  the  pressure  is  gradually  released  until  it 
is  again  perceptible.  This  manoeuvre  is  repeated  as  a  control  observa- 
tion. The  height  of  the  mercury  at  which  the  pulse  is  again  felt  indicates 
the  systolic  blood-pressure.  As  the  pressure  is  gradually  released  the 
lowest  point  at  which  the  maximum  oscillation  of  the  mercury  occurs 
indicates  the  diastolic  pressure. 

Technic. — The  following  practical  suggestions  of  Dr.  Stanton  will 
be  found  useful:  "It  is  wise  to  form  a  method  by  which  all  pressures  are 
taken.  This  diminishes  the  time  required  and  eliminates  error.  The 
muscles  of  the  arm  should  always  be  relaxed:  hence,  if  the  patient  is  in  a 


116 


MEDICAL  DIAGNOSIS. 


sitting  posture,  the  elbow  and  forearm  should  be  supported,  as  muscular 
contractions  show  themselves  on  the  mercury  column.  Preferably,  the 
pressures  should  be  taken  with  the  patient  recumbent.  For  most  observers 
it  is  easier  to  take  the  pressure  from  the  left  arm,  as  the  necessary  manipu- 
lations of  the  manometer  are  more  easily  done  with  the  right  hand.  In 
nearly  all  cases  the  first  estimation  will  be  found  10  to  20  millimetres  higher 
than  subsequent  estimations.  This  is  probably  due  to  excitement  arising 
from  fear  that  the  examination  will  cause  pain.  Several  estimations  should 
be  made  until  the  level  normal  to  the  individual  is  obtained.  In  cases 
with  a  very  rapid  pulse-rate  the  diastolic  pressure  is  hard  to    determine 


Fig.  70. — Dr.  Stanton's  sphygmomanometer. 

because  of  the  inertia  of  the  mercury.  Repeated  observations  may  be 
necessary.  With  a  very  slow,  strong  pulse  the  oscillations  may  be  so  large 
that  it  is  hard  to  distinguish  the  largest  ones.  In  these  cases,  by  leaving 
the  valve  A  open,  some  of  the  oscillation  is  absorbed  by  the  elastic  rubber 
bulb,  and  the  reading  becomes  easier.  In  cases  showing  threatened  circu- 
latory failure,  especially  in  cases  of  high  pressure,  it  will  be  found  almost 
impossible  to  get  a  clear-cut  high  or  low  pressure.  That  is,  in  spite  of 
repeated  estimations,  the  high  pressures  will  vary  from  5  to  15  millimetres. 
These  cases  may,  at  times,  show  a  condition  in  which  an  occasional  beat 
comes  through  at  a  much  higher  level  than  that  at  which  all  the  beats  can 
be  detected.  Often  this  is  due  to  the  action  of  respiration.  This  should  be 
noted  in  the  estimation  thus:  High  pressure,  occasional  beat  at  170;  all 
other  beats  at  155.  Diastolic  level  with  increasing  pressure:  Where  the 
diastolic  level  is  hard  to  obtain,  it  is  of  help  to  get  the  greatest  oscillation 


PHYSICAL  DIAGNOSIS:     MENSURATION. 


117 


with  increasing  pressure  as  well  as  with  decreasing  pressure.  With  the 
valve  A  at  right  angles  (shut  off  from  the  syringe)  blow  up  the  syringe 
until  a  good  pressure  is  established  in  the  second  bulb.  Now  open  A  very 
slowly  and  the  air  can  be  made  to  enter  at  any  desired  rate  of  speed.  As 
the  mercury  column  rises  the  oscillations  begin,  grad- 
ually increase  in  size  until  the  maximum,  and  then 
diminish.  By  shutting  off  A  completely,  the  behavior 
of  the  oscillations  under  diminishing 
pressure  can  be  noted.  Point  of 
disappearance  and  reappearance  of 
pulse:  Where  it  is  desirable  to  com- 
pare the  point  at  which  the  pulse 
disappears  with  the  point  at  which 
it  reappears,  this  can  readily  be 
accomplished  as  follows:  Blow  up 
the  apparatus  until  the  pulse  is 
nearly  gone;  then,  dropping  the  syr- 
inge portion,  gently  compress  the 
second  bulb  until  the  pulse  com- 
pletely disappears;  a  relaxation  of 
the  bulb  allows  it  to  reappear." 

The  modification  of  the  Riva- 
Rocca  sphygmomanometer  by  Beall 
and  Mason  is  portable  and  compact. 
The  accompanying  illustrations 
show  the  instrument  ready  for  use 
and  closed  for  transporting.  The 
manometer  tube  is  in  two  sections, 
connected  by  a  rubber  cuff,  and  the 
scale  is  hinged,  the  break  occurring 
at  the  195  mm. 

The  elaborate  studies  of 
Theodore  Janeway  ^  show 
the   upper  limit   of   noi 
blood-pressure  in 
young  adults  is 
about  145  mm.  and 
the  lower  limit 
about  80  mm.    In 
the   great   major- 
ity of  young  males 
the  upper  limit  is 
100    mm.    to    130 
mm.     In  females  it 

is  about  10  mm,  lower.  In  infants  the  pressures  are  lower.  After  fifty 
they  are  higher.  Blood-pressures  above  160  mm.  or  180  mm.  are  almost 
always  associated  with  disease.  Janeway  places  the  normal  diastolic  pres- 
sure at  25  to  40  mm.  below  the  systolic  pressure  in  the  same  individual, 

1  The  Clinical  Study  of  Blood-pressure.     New  York,  1904. 


1= 

y 

= 

j^ 

= 

335 

=. 

J20 

3 

310 

=• 

JOS 

S- 

ISi 

= 

7B1 

=. 

275 

= 

= 

JbU 

=- 

255 

=3. 

m 

111 

nn 

=• 

m 

=■ 

fe 

S 

1~ 

= 

= 

195 

^ 

IBS 

lEU 

= 

ifi 

1. 

% 

105 

- 

135 
HO 

- 

l?S 

ll>i 

_ 

lOD 

_ 

bU 

= 

— 

75 

= 

70 

_ 

fiS 

2 

BO 
SB 

I 

—-3S 


No.l 


Portable  blood-pressure  apparatus. — Beall  and  Mason. 


118  MEDICAL  DIAGNOSIS. 

that  is  to  say,  between  65  and  110  mm.  In  the  aged  a  difference  of 
50  mm.  is  common.  A  difference  of  less  than  20  mm.  between  the 
systoUc  and  diastolic  pressure  indicates  an  abnormally  small  pulse;  a 
difference  of  more  tlian  50  mm.  an  abnormally  large  pulse. 

The  readings  are  much  influenced  by  the  breadth  of  the  armlet  and 
by  exertion,  attitude  and  other  physical  conditions  and  by  psychical  states. 

The  Blood=pressure  in  Disease. — High  BIood=pressure — Hypertension. 
— The  highest  recorded  arterial  pressures  have  occurred  in  acute  compres- 
sion of  the  brain,  such  as  is  caused  by  intracranial  hemorrhage  or  fracture 
of  the  base  of  the  skull.  A  permanently  high  blood-pressure  accompanies 
persistence  in  the  peripheral  resistance  with  hypertrophy  of  the  left 
ventricle,  in  arteriosclerosis  and  renal  disease. 

Low  Blood=pressure — Hypotension. — This  condition  is  present  in  wast- 
ing diseases  and  cachectic  states,  various  infections  and  toxaemias,  espe- 
cially when  severe,  profuse  hemorrhage,  collapse  and  shock,  and  terminal 
states — agonal  hypotension. 

Nephritis.- — Permanent  high  pressure  is  a  conspicuous  phenomenon 
in  chronic  interstitial  nephritis.  Systolic  pressures  of  200  mm.  and  more 
are  common.  Diastolic  pressures  are  usually  60  to  SO  mm.  lower.  The 
facts  have  great  value  in  diagnosis.  There  are  cases  of  interstitial  nephritis 
in  which  high  arterial  pressure  as  shown  by  the  sphygmomanometer  does 
not  occur.  They  are  those  with  associated  severe  wasting  diseases,  those 
in  which  there  is  late  cardiac  insufficiency,  and  those  tliat  have  reached 
the  terminal  stages  of  the  disease. 

In  chronic  parenchymatous  nephritis  high  tension  also  occurs,  but 
is  by  no  means  so  constant  as  in  the  interstitial  form.  In  amyloid  dis- 
ease blood-pressure  is  inconstant,  sometimes  high,  sometimes  subnormal. 

Uraemia. ^The  s3'mptoms  of  this  condition,  especially  in  its  chronic 
form,  are  associated  with  increased  blood-pressure  and  become  more  marked 
as  the  tension  rises,  less  marked  as  it  falls.  Persistent  lower  tension  has 
followed  improvement  under  treatment.    A  gradual  fall  has  preceded  death. 

Arteriosclerosis.^ — When  the  larger  superficial  arteries  onh'  are 
involved  the  blood-pressure  is  not  markedly  affected.  Arteriosclerotic 
processes  generally  involving  the  smaller  vessels  are  accompanied  by 
increased  blood-pressure,  the  systolic  pressure  being  increased  much  more 
than  the  diastolic. 

Apoplexy.- — As  a  general  rale  patients  who  become  hemiplegic  either 
in  consequence  of  thrombosis  or  hemorrhage  have  previously,  if  examined, 
manifested  sclerosis  of  the  peripheral  vessels  with  elevation  of  blood- 
pressure. 

Diseases  of  the  Heart.— In  primary,  uncomplicated  cardiac  insuf- 
ficiency from  myocardial  changes  high  normal  pressures  appear  to  be  the 
rule.  When  the  cardiac  insufficiency  is  due  to  failing  compensatory  hyper- 
trophy in  arteriosclerosis  and  renal  disease,  the  blood-pressure  is  high. 
As  the  myocardium  becomes  feebler  the  arterial  tension  falls. 

Valvular  Disease. — In  aortic  insufficienc}'  the  sphygmomanom- 
eter, to  use  the  words  of  Janeway,  "gives  a  numerical  value  to  the  well- 
known  pulsus  celer.  which  expresses  perfectly  the  mechanical  effect  of 
the  lesion  in  the  systemic  arterial  circulation."    The  systolic  pressures  are 


PHYSICAL  DIAGNOSIS:     MENSURATION.  119 

high,  the  diastolic  pressures  low.  In  combined  aortic  insufficiency  and 
stenosis  the  blood-pressure  determination  is  of  value  in  indicating  the 
preponderating  lesion,  a  high  degree  of  stenosis  being  accompanied  by  a 
proportionately  lower  systolic  pressure.  In  associated  aortic  and  mitral 
insufficiency  the  degree  of  the  latter  defect  may  be  estimated  by  the  sys- 
tolic as  compared  with  the  diastolic  blood-pressure.  In  disease  of  the 
aortic  valves  the  systolic  pressure  is  frequently  variable  in  the  absence  of 
obvious  cause,  while  the  diastolic  pressure  is  more  constant.  Sphygmoma- 
nometric  measurements  are  of  less  value  in  other  forms  of  valvular  disease. 

Angina  Pectoris. — Hypertension  is  an  important  condition  in  this 
syndrome.     It  is  not,  however,  constant. 

The  Acute  Infectious  Febrile  Diseases. — The  type  of  this  group, 
namely,  enteric  fever,  shows  with  great  constancy  low  pressure.  System- 
atic observations  at  regular  and  frequent  intervals  have  shown  that  hypo- 
tension is  first  apparent  toward  the  end  of  the  first  or  early  in  the  second 
week  and  increases  as  the  attack  goes  on.  The  daily  oscillations  are  not 
significant.  Crile's  statistics,  quoted  by  Janeway,  are  ver}^  suggestive. 
The  mean  pressure  by  weeks  in  all  cases  was,  first  week,  115  mm.;  second 
week,  106  mm.;  third  week,  102  mm.;  fourth  week,  96  mm.;  and  fifth 
week,  98  mm.  Other  observers  have  confirmed  these  results.  A  grad- 
ually progressive  fall  indicates  increasing  failure  of  vasomotor  tonus; 
a  sudden  fall  actual  collapse  or  hemorrhage.  A  sharp  rise  in  pressure 
attends  the  occurrence  of  perforation.  If  the  observations  hitherto  recorded 
should  be  confirmed  by  further  clinical  studies  the  sphygmomanometer 
will  prove  of  great  value  in  the  differential  diagnosis  between  collapse  from 
hemorrhage  or  other  cause  in  enteric  fever  and  intestinal  perforation.  The 
importance  of  continuous  records  in  this  connection  is  obvious.  In  the 
terminal  stage  of  the  consecutive  peritonitis  hypotension  becomes  extreme 
— agonal  fall  of  pressure.  Pneumonia  stands  alone  among  the  complica- 
tions of  enteric  fever  in  causing  hypertension.  The  favorable  influence  of 
treatment  by  systematic  cold  bathing  is  manifest  in  a  rise  of  pressure. 

Pneumonia. — Uniform  tendencies  in  blood-pressure  have  not  been 
observed  in  this  disease.  The  reports  are  at  variance.  Subnormal  pres- 
sures are  common;  in  severe  cases  the  rule.  A  rapid  fall  may  precede 
collapse  or  the  fatal  issue. 

Chronic  Diseases  — Tuberculosis  pulmonum  in  its  advanced  stages 
gives  low  pressures.  In  the  early  stages  of  syphilis  when  there  is  fever 
and  the  condition  is  analogous  to  an  acute  infectious  process,  there  is 
hypotension.  Diabetes  is  apparently  without  direct  influence  upon  the 
blood-pressure.  When  associated  with  arteriosclerosis  or  chronic  renal 
disease  it  may  show  hypertension,  and  in  advanced  cases  hypotension  is 
common  in  consequence  of  emaciation  and  cardiac  insufficiency.  The 
secondary  anaemias  are  attended  by  low  blood-pressures.  The  derange- 
ment of  pressure  in  chlorosis  is  neither  marked  nor  characteristic.  Chronic 
bronchitis,  emphysema  and  asthma  are  frequently  attended  with  high 
arterial  tension.  Pleural  effusions  are  attended  by  hypertension  which 
falls  upon  aspiration. 

Diseases  of  the  Nervous  System. — In  locomotor  ataxia  the  light- 
ning pains  are  attended  by  a  fall  in  blood-pressure;    in  the  gastric  crises 


120  MEDICAL  DIAGNOSIS. 

the  pressure  is  greatly  increased.  Arteriosclerosis  of  the  cerebral  vessels 
may  exist  without  similar  changes  in  the  general  vascular  system  Blood- 
pressure  estimations  are  therefore  without  value  as  indicating  the  exist- 
ence of  intracranial  vascular  lesions.  When  there  is  reason  to  suspect 
their  presence,  increased  arterial  pressure  due  to  cardiac,  vascular,  or  renal 
causes  affords  important  data  for  prognosis  and  treatment.  With  high 
pressure  there  is  danger  of  hemorrhage,  with  low  pressure  danger  of  throm- 
bosis. Cerebral  hemorrhage  is  attended  by  marked  hypertension  which 
continues  to  rise  as  the  hemorrhage  increases,  and  remains  stationary  or 
falls  when  the  hemorrhage  ceases.  In  uraemic  coma  the  pressure  is  also 
greatly  increased. 

In  epilepsy,  owing  to  the  difficulty  of  making  observations  during  the 
attack,  there  is  some  uncertainty.  During  the  attack  there  is  said  to  be 
a  sudden  rise  in  the  blood-pressure,  followed  by  a  rapid  fall  to  normal  as 
the  paroxysm  ceases.  In  coma  following  an  attack  of  general  convulsions 
the  fact  that  in  epilepsy  the  blood-pressure  falls  while  in  urssmia  it  remains 
high  is  of  diagnostic  importance.  In  tic  douloureux  there  is  a  rise  of  pres- 
sure during  the  pain  proportionate  to  the  intensity  of  the  attack.  Insom- 
nia may  be  associated  with  increased  tension  on  the  one  hand  or  norma) 
or  diminished  tension  on  the  other.  In  the  former  condition  the  pressure 
falls  during  sleep.  In  hysteria  and  neurasthenia  the  pressures  are  variable. 
Some  observers  have  observed  high  pressures  in  neurotic  and  excitable 
persons,  but  this  condition  is  not  constant. 

Mental  Diseases. — In  melancholia  the  pressure  is  abnormally  high 
and  shows  rises  and  falls  corresponding  to  the  intensity  of  the  mental  symp- 
toms.   In  mania,  on  the  other  hand,  the  pressure  tends  to  subnormal  levels. 

PERCUSSION. 

Percussion  in  ph^'sical  diagnosis  is  the  art  of  striking  or  tapping  upon 
the  surface  of  the  body  in  such  a  manner  as  to  call  forth  sounds,  from  the 
nature  of  which  conclusions  are  drawn  as  to  the  structure  of  the  underly- 
ing parts. 

This  art  was  first  described  and  systematically  employed  in  the  latter 
part  of  the  eighteenth  century  by  Auenbrugger,  a  physician  of  Gratz,  who 
published  his  observations  in  a  little  book  entitled  Inventum  Novum. 
The  subject  was  widely  brought  to  the  attention  of  the  profession  by 
Corvisart  in  the  beginning  of  the  following  century. 

The  practice  of  this  method  demands  nice  training  both  of  the  hands 
and  ear  in  order  to  secure  its  best  results.  Careless  and  inexact  methods 
yield  not  only  unsatisfactory  but  also  positively  misleading  results.  It  is 
especially  true  of  percussion  that  they  find  it  most  useful  who  most 
clearly  realize  its  limitations  as  an  art  in  diagnosis.  Unfortunately  too 
many  practitioners,  otherwise  well  trained,  fail  to  acquire  proficiency  in 
percussion  and  equally  fail  to  appreciate  its  limitations. 

Neither  percussion  nor  auscultation  requires  the  possession  of  much 
technical  knowledge  of  acoustics  nor  a  cultivated  musical  ear.  It  is,  how- 
ever, necessary  to  be  able  to  discriminate  differences  in  the  character, 
intensity,  and  pitch  of  sounds. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  121 

The  Theory  of  Percussion.— Reduced  to  its  simplest  terms  the  theor}^ 
of  percussion  depends  upon  the  differences  in  the  vibrations  produced  by 
blows  delivered  upon  structures  which  do  not  and  those  which  do  contain  air, 
and  in  the  latter  case  upon  cUfferences  in  the  mechanical  arrangement  under 
which  the  air  is  present.  There  is  nothing  a  priori  in  the  matter.  Our 
whole  knowledge  in  regard  to  the  signs  elicited  is  the  result  of  observation 
and  experience.  It  has  been  found  that  direct  percussion,  that  is,  percus- 
sion without  the  intervention  of  a  finger  or  other  form  of  pleximeter,  prac- 
tised upon  the  thigh,  which  does  not  contain  air,  produces  a  minimum  of 
sound  which  has  a  peculiar  quality,  technically  described  as  dull.  The 
interposition  of  a  pleximeter  increases  the  intensity  of  the  sound  and 
slightly  alters  its  other  acoustic  properties.  From  this  we  infer  that  in 
percussion  the  vibrations  of  the  pleximeter  itself  constitute  a  certain  factor 
in  the  general  result.  It  has  further  been  found  that  percussion  over  the 
liver  and  spleen,  organs  which  do  not  contain  air,  produces  a  similar  dull 
sound,  but  that  the  quality  of  dulness  is  modified  according  to  the  force 
with  which  the  act  is  performed.  Upon  light  percussion  over  the  spleen 
or  centrally  over  the  liver  the  dulness  is  much  hke  that  of  the  thigh,  but 
upon  powerful  percussion  over  these  organs  the  dull  sound  is  modified, 
the  quality  of  resonance  being  added.  This  fact  in  connection  with  others 
presently  to  be  mentioned  leads  us  to  infer  that  by  light  percussion 
a  limited  region  of  the  wall  of  the  body  is  set  into  vibration,  but  that  the 
area  is  extended  by  forcible  percussion,  so  that  the  sound  produced  partakes 
of  qualities  due  to  the  sound-producing  mechanism  of  adjacent  organs  or 
structures,  and  that  if  we  desire  to  obtain  the  percussion  phenomena  pecu- 
liar to  an  organ  we  must  content  ourselves  with  well-defined  but  light 
percussion  of  the  surface  overlying  the  viscus  immediately  in  question.. 
Experience  amply  confirms  this  inference.  It  has  been  further  established 
that  percussion  over  the  distended  bladder  or  a  cyst,  or  any  considerable 
collection  of  fluid,  as  a  serofibrinous  or  purulent  pleural  effusion,  produces 
a  dull  sound,  and  that  there  are  degrees  in  the  dulness  just  as  we  find 
differences  upon  light  and  heavy  percussion  over  the  spleen  and  liver, 
the  sign  having  a  certain  quality  of  resonance  at  some  parts  of  the  border 
or  edge  of  the  effusion  and  wholly  lacking  resonance  over  the  mass  or 
base  of  the  effusion.  The  recognition  of  these  differences  led  to  the  very 
proper  employment  of  such  terms  as  relatively  dull,  dull,  and  absolutely 
dull  or  fat.  To  return  to  the  liver  and  the  flatness  upon  light  percus- 
sion and  the  development  of  some  degree  of  resonance  upon  forcible 
percussion  especially  near  the  borders  of  the  dull  area,  we  have  attrib- 
uted the  latter  to  the  vibrations  of  adjacent  organs.  Pursuing  our 
investigations  we  find  that  as  we  proceed  in  lines  upwards  the  sign 
changes  somewhat  abruptly  from  dull  to  a  distinctly  resonant  sound,  hav- 
ing qualities  hereafter  to  be  pointed  out,  which,  with  modifications  of 
intensity  and  so  on,  but  not  of  quality,  is  everywhere  present  over  the 
chest  where  the  surface  or  periphery  of  the  lung  comes  into  contact  with 
the  wall.  For  this  reason  the  percussion  sound  elicited  over  the  chest,  and 
having  the  peculiar  resonant  quality  spoken  of,  is  known  as  pulmonary 
resonance,  or  briefly  and  technically  as  clear.  Again,  when  we  extend  our 
percussion  in  lines  proceeding  downwards  from  the  liver,  we  pass,  under 


122  MEDICAL  DIAGNOSIS, 

normal  circumstances,  quite  abruptly,  about  the  margin  of  the  ribs,  to  a 
region  which  yields  upon  percussion  a  note  of  high  resonance  having 
likewise  peculiar  qualities  of  its  own,  which,  because  of  its  being  produced 
by  a  mechanism  remotely  analogous  to  that  of  a  drum,  is  called  tympanitic. 
A  very  important  fact  in  connection  with  these  three  fundamental 
qualities  of  the  signs  elicited  upon  percussion,  namely,  dulness,  clearness, 
and  tympany,  is  this,  that  they  are  constantly  related  to  and  dependent 
upon  the  absence  or  presence  of  air  in  the  examined  structures  and  upon 
the  mode  of  arrangement  of  the  air  when  it  is  present.  The  constant 
correspondence  between  the  clinical  and  post-mortem  percussion  signs  and 
the  post-mortem  conditions  justifies  us  in  formulating  the  following  dicta: 
Upon  percussion: 

1.  Airless  viscera  and  hollow  viscera  distended  with  fluid  yield  dulness, 
flatness. 

2.  The  normal  lungs  contained  in  the  chest  under  conditions  of  norynal 
tension  yield  a  clear  note. 

3.  Air  contained  in  hollow  viscera,  as  the  intestines,  the  walls  of  which 
are  not  tense,  yield  tympanitic  resonance. 

These  physical  signs — namely,  clearness,  dulness,  and  tympany — are 
normal.  The  percussion  sound  clearness  as  such  is  always  normal.  It 
cannot  be  elicited  anywhere  save  over  the  chest,  and  there  is  no  condition 
of  structures  other  than  the  lungs  by  which  the  physical  arrangement 
essential  to  its  production  can  be  brought  about.  With  dulness  and  tym- 
pany the  case  is  different.  The  modifications  or  absence  of  clear  or  pul- 
monary resonance  in  regions  normally  occupied  by  the  lungs  constitute 
morbid  physical  signs.  Dulness  in  regions  normalh^  clear  or  tj^mpanitic 
and  the  extension  of  dulness  beyond  the  limits  of  airless  viscera  constitute 
morbid  physical  signs,  and  this  statement  is  also  true  of  the  presence  of 
tympany  in  regions  in  which  the  physical  conditions  essential  to  its 
production  do  not  normally  exist. 

The  foregoing  facts  also  warrant  the  following  statements: 
Upon  percussion: 

1.  There  is  no  difference  in  the  physical  signs  by  which  a  distinction  can 
be  made  between  an  airless  viscus  and  a  collection  of  fluid. 

2.  The  signs  do  not  enable  us  to  determine  the  line  of  contact  between 
two  airless  viscera  or  an  airless  viscus  and  a  collection  of  fluid,  or  betiveen 
collections  of  fluid  separated  by  a  membrane. 

Percussion  is  the  application  of  an  every-day  art  to  diagnosis  in  medi- 
cine. The  woodsman  taps  with  his  axe  upon  the  trunk  of  a  tree  to  learn 
whether  or  not  it  is  hollow,  the  ganger  upon  the  cask  with  his  mallet  to 
find  the  level  of  the  wine,  and  the  carpenter  with  his  hammer  upon  the 
plastered  wall  to  fix  the  position  of  a  stud  into  which  he  can  drive  his  nail. 

The  Technic  of  Percussion. — The  patient  may  be  examined  in  the 
recumbent,  sitting,  or  erect  posture.  The  outer  clothing  should  be  removed. 
The  air  contained  in  thick  garments  or  in  several  layers  of  clothing  seri- 
ously modifies  the  results  of  percussion.  A  single  under-garment  or  a 
towel  is  preferable  to  the  bare  skin.  The  limbs  should  be  symmetri- 
cally disposed  and  the  muscles  relaxed.  Errors  may  arise  from  forcible 
percussion  when  the  patient  is  resting  upon  a  feather  bed  or  very  elastic 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  123 

mattress.  In  general  terms  much  display  of  energy  on  the  part  of  the 
physician  is  to  be  avoided.  It  not  only  yields  misleading  results  but  it 
also  alarms  and  may  even  hurt  the  patient. 

Two  methods  are  employed,  immediate  or  direct,  and  mediate  or 
indirect  percussion. 

Immediate  or  Direct  Percussion. — The  blow  is  struck  directly  upon  the 
surface  with  the  palm  of  the  slightly  flexed  hand,  or  upon  the  clavicles  or 
sternum  with  the  tip  of  the  second  or  third  finger,  or  upon  the  abdomen 
with  the  dorsal  surface — nail — of  the  second  finger  flicked  off  from  the 
thumb  as  one  flicks  a  crumb.  The  first  two  of  these  methods  were 
originally  employed.     The  last  is  a  modern  refinement. 

With  the  Palm  of  the  Hand. — The  whole  hand  slightly  flexed  or  the 
palmar  surface  of  the  fingers  held  closely  together  may  be  employed.  The 
blow  is  delivered  chiefly  from  the  wrist,  very  slightly  from  the  elbow,  care 
being  taken  to  avoid  too  much  force  and  the  over-production  of  noise. 
This  method  is  available  for  a  rapid  preliminary  survey  and  class  demon- 
stration of  gross  differences  between  the  sides  of  the  chest,  or  the  upper 
and  lower  part  of  one  side,  especially  posteriorly.  It  cannot  often  be 
employed  satisfactorily  in  the  examination  of  the  abdomen.  The  objec- 
tions to  it  are  that  it  demands  too  much  force  and  that  the  vibrations 
caused  are  too  extensive.    It  lacks  the  nicety  of  good  clinical  work. 

Direct  finger  percussion  over  the  clavicles  and  sternum  is  often  prac- 
tised, but  is  here  mentioned  only  to  condemn  it  as  mostly  inexact,  often 
misleading,  and  at  best  yielding  results  obtained  much  more  satisfactorily 
by  other  methods.  The  results  are  unsatisfactory  because  of  the  elasticity 
and  extensive  vibrations  of  long  and  flat  bones.  The  resonance  produced  is 
that  of  an  elongated  or  very  large  pleximeter — so-called  bone  or  osteal  reso- 
nance, well  illustrated  upon  percussion,  in  the  same  manner,  of  the  head  with 
the  finger-tip.  As  there  is  no  intracranial  air,  it  is  evident  that  the  reso- 
nance is  due  to  the  vibrations  communicated  by  the  bone  to  the  external  air. 

Direct  Percussion  or  Finger- flicking.  —  In  this  procedure  the  skin 
should  be  bared.  Very  exact  and  satisfactory  results  may  be  obtained, 
especially  in  the  examination  of  circumscribed  regions  in  a  thin-walled 
abdomen.  It  is  by  far  the  most  satisfactory  method  of  mapping  out  the 
limits  of  the  splenic  dulness. 

Mediate  or  Indirect  Percussion  —  Pleximetry.  —  The  blow  is  delivered 
not  directly  upon  the  surface  of  the  body  but  upon  an  interposed  plate  or 
disk  of  ivory  or  hard  rubber — a  pleximeter,  literally,  measurer  of  the  blow. 
This  instrument  should  be  quite  flat  with  rounded  edges,  about  an  inch 
and  three-quarters  in  length  and  five-eighths  of  an  inch  in  width,  so  that  it 
may  be  closely  applied  to  the  surface  in  the  intercostal  spaces.  There 
should  be  at  each  end  a  little  flange  or  ear  by  which  it  is  held  in  position. 
The  percussing  instrument  or  hammer  is  called  a  plexor,  and  consists  of  a 
suitable  head  of  soft  rubber,  or  metal  tij^ped  with  soft  rubber,  and  a  light, 
stiff  handle.  The  plexor  of  Wintrich  has  a  handle  or  shaft  nearly  corre- 
sponding in  length  to  a  human  hand  from  the  wrist-joint  to  the  first  pha- 
langeal joint  and  a  head  corresponding  in  length  from  the  last  named  joint 
to  the  tips  of  the  fingers.  Instrumental  pleximetry  is  much  used  among 
European  physicians. 


124  MEDICAL  DIAGNOSIS. 

Finger  Pleximetry — Finger  Percussion. — This  method  is  almost 
exclusively  used  by  American  physicians.  A  finger  of  the  left  hand  is  used 
as  the  pleximeter  and  the  right  hand  as  the  plexor,  the  fingers  being  flexed 
as  nearly  as  possible  at  a  right  angle  at  the  first  phalangeal  joint  to  form 
the  head  of  the  hammer,  and  the  hand  from  this  joint  to  the  wrist  forming 
its  handle  or  shaft.  The  blow  is  delivered  from  the  wrist  and  not  from  the 
elbow,  and  the  head  of  the  plexor,  made  up  of  the  last  two  phalanges,  must 
fall  at  a  right  angle  upon  the  dorsum  of  the  middle  or  terminal  phalanx  of 
the  finger  used  as  the  pleximeter,  the  palmar  surface  of  which  is  closely 
applied  to  the  part  examined.  It  is  scarcely  necessary  to  add  that  in  left- 
handed  persons  the  fingers  of  the  right  hand  are  used  as  pleximeters  and 
the  left  hand  becomes  the  plexor. 

The  advantages  of  finger  percussion  are  (a)  that  the  soft  palmar  under- 
surface  of  the  pleximeter  can  be  closely  applied  to  the  part  to  be  examined 
and  the  danger  of  a  thin  layer  of  air  between  them  wholly  avoided;  (b) 
that  the  finger  used  as  a  pleximeter  is  also  a  palpating  finger  and  receives 
sensory  impressions  concerning  the  firmness  or  elasticity  of  the  underlying 
part  which  supplement  the  auditory  impressions  caused  by  the  vibrations 
occasioned  by  the  blow;  (c)  that  the  pleximeter  is  composed  of  tissues 
corresponding  in  physical  composition  with  the  wall  of  the  body,  which  it 
protects  from  the  blow  without  the  interposition  of  an  instrument  of  wholly 
different  composition,  and  (d)  that  the  instruments  are  always  at  hand. 

Flicking  percussion  may  also  be  intermediate,  a  finger  of  the  left 
hand  being  used  as  the  pleximeter. 

Superficial  and  Deep  Percussion. — These  terms  indicate  in  general 
the  degree  of  force  employed.  In  superficial  percussion  the  blow  is  light 
and  the  vibrations  are  limited  in  extent  and  depth.  This  method  is  essen- 
tial in  the  study  of  conditions  in  which  the  percussion  signs  involve  limited 
areas,  as  in  the  heart  and  spleen,  or  in  which  we  have  to  deal  with  thin 
wedges  of  tissues  yielding  different  signs  which  overlie  each  other,  as  the 
lung  surrounding  the  cardiac  ventricles,  or  dipping  down  between  the  wall 
of  the  chest  and  the  liver  or  the  wedge-shaped  anterior  lower  border  of  the 
liver  occasionally  seen.  Superficial  percussion  enables  us  to  determine 
the  nature  of  the  structure  immediately  beneath  the  surface,  and  is 
necessary  where,  by  reason  of  the  thinness  and  elasticity  of  the  walls, 
wide  areas  of  tissue  are  set  into  vibration  by  the  blow,  as  in  children 
and  emaciated  persons,  and  in  elderly  persons  whose  costal  cartilages 
have  undergone  calcification.  Only  superficial  percussion  should  be 
employed  in  the  examination  of  the  chest  after  recent  hemorrhage. 

Deep  percussion  excites  vibrations  in  wide  areas  and  to  a  considerable 
depth.  It  is  employed  where  the  chest  walls  are  very  muscular  or  fat  and 
to  ascertain  the  dulness  or  resonance  of  the  deeper  structures,  as  the  actual 
limits  of  cardiac  dulness,  the  upper  border  of  liver  dulness,  pneumonic 
consolidation  not  reaching  to  the  periphery  of  the  lung,  or  a  deep-seated 
aneurism.  In  the  case  of  a  wedge-shaped  anterior  lower  border  of  the 
liver  superficial  percussion  enables  us  to  demonstrate  the  actual  limits 
of  dulness,  while  deep  percussion,  by  acting  upon  the  underlying  intestine 
through  the  thin  wedge  of  liver,  yields  a  most  misleading  tympanitic 
resonance. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  125 

The  following  directions  must  be  carefully  observed: 

1.  Apply  the  second  or  ring  finger  of  the  left  hand  accurately  and 
firmly  but  without  undue  pressure  to  the  surface  to  be  examined. 

2.  Raise  the  other  fingers  and  palm  from  the  surface  to  avoid  muffling 
the  vibrations.  The  finger  used  as  the  pleximeter  only  should  at  the 
moment  be  in  contact  with  the  surface. 

3.  Deliver  a  quick,  rebounding  blow,  with  the  tip  of  the  percussing 
finger  or  fingers  perpendicularly  upon  the  finger  used  as  a  pleximeter, 
upon  the  middle  phalanx  or  the  terminal  phalanx  above  the  nail.  The 
quicker  the  rebound  of  the  plexor  the  better  and  more  significant  the  result. 

4.  Let  the  blow  be  delivered  from  the  wrist  held  perfectly  loose  and 
not  from  the  elbow.  The  force  must  be  moderate  and  equal  at  correspond- 
ing points  upon  the  two  sides  of  the  chest;  lighter  where  the  chest  wall  is 
thin,  as  in  lean  persons  and  in  the  infraclavicular  and  axillary  and  infra- 
axillary  regions,  and  more  forcible  in  the  examination  of  the  back  of  a  very 
muscular  man  or  the  mammary  regions  of  one  who  is  fat. 

5.  The  attitude  of  the  patient  is  important.  It  must  be  easy  and 
unconstrained.  Rigid  and  fixed  positions  are  to  be  avoided.  Muscular 
tension  modifies  percussion  resonance.  The  arms  must  be  symmetrically 
arranged.  In  the  examination  of  the  anterior  surface  of  the  body  let  them 
lie  loosely  at  the  sides  in  the  recumbent  posture  or  hang  relaxed  if  the 
patient  is  erect;  in  the  examination  of  the  back  the  patient  should  bend 
forward  and  gently  fold  his  arms.  I  do  not  like  the  hands  to  be  placed 
each  upon  the  opposite  shoulder,  since  it  involves  an  undesirable  degree 
of  muscular  tension;  while  in  the  examination  of  the  lateral  regions  of  the 
chest  the  hands  should  be  placed  together  upon  the  top  of  the  head  with 
the  fingers  lightly  interlocked. 

6.  The  patient  must  breathe  gently  and  regularly.  If  changes  in  the 
percussion  signs  upon  full  held  inspiration  and  forced  expiration  are  to 
be  studied — respiratory  percussion — give  the  necessary  directions. 

7.  Perform  percussion  systematically  and  in  a  routine  manner,  exam- 
ining corresponding  parts  upon  the  two  sides  of  the  chest  above  and 
below,  anteriorly,  laterally,  and  posteriorly,  comparing  and  noting  the 
signs  at  each  step  in  the  proceeding.  Comparison  and  contrast  are  essential 
alike  in  percussion  and  auscultation.  It  is  often  useful  to  apply  two  or 
more  fingers  widely  separated  to  the  surface  and  lightly  percuss  one  after 
the  other.  In  this  way  the  border-line  between  dulness  and  clearness  or 
tympany  can  be  defined  and  demonstrated  with  great  exactness. 

8.  Deliver  two  or  three  percussion  strokes  and  then  examine  the  cor- 
responding point  upon  the  opposite  side  in  the  same  manner.  This  ma- 
noeuvre may  be  repeated  as  often  as  is  necessary.  Dexterity  and  close 
attention  to  the  sounds  render  a  wearisome  prolongation  of  the  exami- 
nation unnecessary. 

9.  To  determine  the  borders  of  areas  of  dulness,  clearness,  or  tympany 
percuss  in  parallel  or  radiating  lines  and  note  the  points  in  such  lines  at 
which  the  quality  of  the  percussion  signs  changes.  Repeated  light  per- 
cussion is  often  necessary.  These  points  may  be  fixed  by  touches  with  the 
dermatographic  pencil,  which  when  joined  by  a  line  indicate  the  borders 
of  the  areas  studied. 


126  MEDICAL  DIAGNOSIS. 

Practitioners  gradually  develop  modifications  of  percussion  methods 
to  suit  themselves.  There  are  many  different  methods,  but  not  every  one 
of  them  is  right.  •  Those  not  based  upon  a  knowledge  of  the  principles  upon 
which  this  method  of  physical  diagnosis  rests  and  those  which  are  slovenly 
or  careless  are  positively  wrong.  It  is  like  playing  a  musical  instrument. 
Knowledge,  aptitude,  and  training  are  essential,  and  there  are  good  per- 
formers, poor  performers,  and  those  who  cannot  play  at  all. 

Sources  of  error  especially  to  be  avoided  are: 

1.  Failure  to  apply  the  pleximeter  accurately  to  the  surface.  A  thin 
stratum  of  air  modifies  the  result  and  may  render  it   wholly  misleading. 

2.  Applying  the  other  fingers  or  the  palm  of  the  hand  to  the  surface 
in  such  a  manner  as  to  dampen  the  vibrations  and  muffle  the  sound. 

3.  Awkwardness,  slowness,  and  the  use  of  too  much  force  in  deliver- 
ing the  blow.  These  may  all  be  readily  avoided  if  the  percussion  stroke 
is  from  the  wrist  as  a  centre  of  movement  rather  than  the  elbow. 

4.  A  false  attitude  on  the  part  of  the  patient.  Many  persons  on  being 
examined  assume  rigid  and  fixed  postures  with  the  muscles  in  tension  and 
the  arms  in  constrained  positions. 

5.  Too  much  clothing,  and  setting  the  air  contained  in  the  pillow,  bed, 
or  mattress  into  vibration  by  powerful  percussion. 

6.  A  want  of  system  in  conducting  the  examination.  More  errors 
arise  from  carelessness  than  from  ignorance. 

THE  SIGNS  ELICITED  UPON    PERCUSSION. 

The   sounds   differ   among  themselves,    as  already   seen,   as  follows: 

A.  Quality:    (1)   Clear,   (2)  dull,  and  (3)  tympanitic. 

A  structure  containing  no  air  yields  upon  percussion  a  minimum  of 
sound  due  to  vibrations  in  the  surrounding  air  and  is  said  to  be  completely 
dull  or  flat. 

Changes  in  such  a  structure  by  which  it  becomes  air-containing  or  the 
contiguity  of  air-containing  structures  modify  the  percussion  sign,  which 
acquires  resonance,  and  the  dulness  is  no  longer  flat  or  complete,  but  marked, 
and,  as  it  is  a  question  of  degree,  moderate  or  merely  slight  or  relative. 

The  physical  signs  by  which  these  modifications  of  flatness  are  brought 
to  pass  are  (a)  in  the  direction  of  the  conditions  which  underlie  tympany, 
namely,  collections  of  air  contained  in  spaces  the  walls  of  which  are  not 
too  tense,  as,  for  example,  the  intestines;  and  (b)  in  the  direction  of  the 
arrangement  of  the  air  in  the  lung  under  normal  conditions  which  involve 
a  certain  tension  as  to  the  vesicles  and  as  to  the  whole  lung  within  the 
thorax — clearness. 

The  terms  used  to  designate  (a)  modifications  of  dulness  in  the  direc- 
tion of  tympany  are  slight  tympany,  dull  tympany,  moderate  tj^mpany,  and 
tympany. 

Special  modifications  of  tympany  are  cracked-pot  resonance  and 
amphoric  resonance. 

Cracked-pot  Resonance:  the  Cracked-metal  Sound.  —  This  per- 
cussion sign  requires  for  its  development  a  rather  forcible  abrupt  stroke 
while  the  mouth  of  the  patient  is  open.     The  physical  condition  is  an  air- 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  127 

containing  cavity  communicating  freely  with  a  bronchus  and  sufficiently 
near  the  surface  of  the  chest  to  be  compressed  by  the  sudden  blow.  It 
may  also  be  elicited,  in  the  absence  of  cavity  formation,  in  conditions  in 
which  by  reason  of  yielding  chest  walls  a  certain  amount  of  air  contained 
in  the  lungs  or  in  the  pleural  cavity  is  suddenly  forced  by  strong  percussion 
into  the  large  bronchi.  We  may  encounter  the  cracked-pot  sound  therefore 
in  infants  not  suffering  from  disease  of  the  lungs,  especially  when  percus- 
sion is  performed  at  the  time  of  the  full  inspiration  of  crying,  in  pleurisy, 
above  the  level  of  an  effusion,  over  lung  relaxed  by  the  pressure  of  a  large 
pericardial  effusion,  sometimes  in  emphysema  and  in  certain  cases  of  pneu- 
mothorax. This  modification  of  tympanitic  resonance  may  be  imitated 
by  sharply  percussing  the  cheek  while  the  mouth  is  open  or  by  striking 
the  two  hands  held  together  against  the  knee  in  such  a  way  as  to  cause  a 
sound  like  that  produced  when  coins  are  rattled  in  the  hands.  For  this 
reason  the  cracked-pot  sound  is  sometimes  called  the  money-jingle  sound. 
This  sound  is  in  many  cases  only  to  be  heard  when  at  the  moment  of  per- 
cussion the  patient's  open  mouth  is  turned  directly  toward  the  ear  of  the 
physician  or  when  the  patient  holds  the  bell  piece  of  a  double  stethoscope 
just  in  front  of  his  open  mouth.  As  sudden  compression  of  the  cavity  is 
essential  the  blow  must  be  of  some  force  and  as  the  walls  of  such  a  cavit}^ 
are  not  always  highly  resilient  the  peculiar  phenomenon  in  question  is  often 
produced  only  upon  the  first  two  or  three  strokes  of  percussion  and  suf- 
ficient time  must  elapse  for  the  full  redistention  of  the  cavity  before 
the  cracked-pot  sound  can  again  be  heard. 

Amphoric  or  Metallic  Resonance.  —  This  sign  has  the  quality 
characteristic  of  the  sound  produced  by  percussing  a  large  vessel  with  a 
wide  mouth — amphora,  a  jar.  It  is  a  ringing  tympanitic  sound  and  denotes 
a  cavity  of  considerable  size  with  firm  elastic  walls  which  do  not  vibrate 
in  unison.  The  pitch  varies  with  the  shape  and  size  of  the  cavity  and  the 
degree  of  tension  of  its  walls.  A  closed  cavity  distended  with  air  or  gas 
under  pressure  so  that  its  walls  vibrate  in  unison  yields  dulness  on  percus- 
sion. Amphoric  resonance  frequently  occurs  without  the  cracked-pot 
quality,  but  the  cracked-pot  sound  is  usually  also  amphoric. 

(b)  Modifications  of  dulness  in  the  direction  of  clearness  are  slight 
or  relative  dulness,  impaired  resonance,  clearness. 

But,  leaving  dulness  altogether  out  of  the  question,  we  find  that  changes 
in  the  physical  condition  in  the  lung  by  which  the  normal  or  vital  tension 
is  relaxed  frequently  occur.  This  takes  place,  for  example,  in  congestion, 
in  oedema  and  atelectasis  from  compression,  in  both  of  which  the  residual 
air  is  diminished,  and  the  normal,  clear  or  vesicular  resonance  acquires  the 
tympanitic  quality  to  a  varying  degree — vesiculot^^mpanitic  resonance — 
and  as  the  lesions  upon  which  vesiculotympanitic  resonance  depend-s 
undergo  resolution  this  sign  is  gradually  replaced  by  the  normal  or  clear 
resonance  again.  These  changes  can  occur  only  in  regions  in  which  we 
normally  find  the  clear  or  vesicular  percussion  resonance,  namely,  over 
the  lungs.  It  has  been  demonstrated  experimentally  that  the  extreme 
distention  of  a  hollow  viscus,  as  a  bladder,  with  air  so  that  its  opposite 
walls  upon  percussion  do  not  vibrate  independently,  but  as  a  whole,  does 
away  with  the  tympanitic  sound,  and  causes  it  to  be  replaced  by  dulness. 


128  MEDICAL  DIAGNOSIS. 

B.  Volume  or  Intensity. — This  acoustic  property  is  of  minor  impor- 
tance in  percussion.  It  depends  upon  the  volume  of  air  contained  in  the 
structures  examined,  the  elasticity  of  the  enclosing  walls  and  energy  of 
their  vibrations,  and  the  force  of  the  blow.  This  term  has  reference  to  the 
loudness  or  degree  of  sonority  of  percussion  sounds,  which  may  be  on  the 
one  hand  so  great  as  to  obscure  their  value  or  on  the  other  so  faint  as  to 
be  without  any  significance  whatever.  The  duration  of  percussion  sounds 
usually  corresponds  to  their  volume  or  intensity. 

C.  Pitch. — The  distinction  between  sounds  and  musical  tones  must 
be  borne  in  mind.  In  percussion  we  have  to  do  with  the  former.  Never- 
theless the  pitch  of  percussion  sounds  is  of  great  importance.  Pitch  indi- 
cates in  music  the  relative  position  of  notes  upon  the  scale  and  depends 
upon  the  frequency  of  the  vibrations  by  which  tones  are  produced.  In 
physical  diagnosis  we  find  that  large  air-containing  spaces  with  slight  or 
moderate  tension  yield  percussion  resonance  of  low  pitch,  while  small 
spaces  with  high  tension  yield  resonance  of  higher  pitch,  and  that  the  vibra- 
tions of  the  pleximeter  upon  the  thigh  or  over  an  airless  viscus  yield  a 
sound  of  slight  intensity  and  high  pitch. 

Percussion  over  the  abdomen  reveals  great  variations  in  the  pitch 
of  sounds  having  the  quality  of  tympany,  as  over  the  stomach  and  large 
and  small  intestines.  These  variations  are  of  some  value,  but  cannot  be 
relied  upon  in  mapping  out  the  positions  of  those  viscera.  They  serve  a 
purpose  in  indicating  the  border-line  between  contiguous  organs,  as  the 
stomach  and  transverse  colon  and  coils  of  intestines  under  different  degrees 
of  tension. 

The  quality  of  a  sound  is  that  property  which  enables  us  to  recognize 
it  whenever  heard  without  seeing  the  mechanism  by  which  it  is  produced, 
as  the  sound  of  a  bell,  a  drum,  and  so  on;  the  volume  or  intensity  of  a 
sound  relates  to  the  energy  and  the  mass  of  the  material  by  which  it  is 
produced,  as,  for  example,  in  great  and  little  bells,  the  sound  of  which  has 
the  same  quality  and  may  have  the  same  pitch  while  differing  greatly  in 
intensity  or  volume;  the  pitch  depends  upon  the  rapidity  of  the  vibrations 
by  which  sound  is  produced,  as  in  the  long  strings  of  the  piano  which  pro- 
duce low  notes,  and  the  short  strings  which  send  forth  the  high  notes. 

The  Lung  Reflex  (Abrams).  —  It  has  been  observed  that  local 
irritation  of  the  skin  of  the  chest  as  by  cold  or  the  application  of  mustard 
has  been  followed  by  the  evidences  of  a  temporary  circumscribed  emphy- 
sema of  the  underlying  lung.  These  signs  of  dilatation  of  the  air-vesicles 
have  in  some  instances  been  confirmed  by  X-ray  examination.  Cabot 
has  referred  to  this  observation  in  explanation  of  the  fact,  well  known  to 
teachers  of  physical  diagnosis,  that  the  repeated  demonstration  of  an  area 
of  moderate  dulness,  as,  for  example,  in  incipient  tuberculosis,  is  followed 
by  a  modification  of  the  percussion  sign,  which  graduall}'  becomes  more 
resonant.  The  repeated  percussion  apparently  acts  as  a  local  irritant. 
If  the  consolidation  is  dense  and  extensive  this  change  cannot  occur. 

Respiratory  Percussion. — Differences  in  the  sound  are  noted  upon 
quiet  breathing  and  full  held  inspiration.  The  contrast  between  the  two 
sides  of  the  chest  in  slight  consolidation,  as  in  beginning  phthisis  or  pleural 
thickening,  is  thus  accentuated,  the  dulness  upon  the  affected  side  remain- 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  129 

ing  the  same,  while  the  resonance  upon  the  sound  side  is  increased.  This 
method  is  serviceable  in  determining  the  presence  or  absence  of  slight 
degrees  of  relative  dulness,  especially  in  the  infraclavicular  regions  in 
incipient  pulmonary  tuberculosis. 

Palpatory  Percussion. — As  has  been  pointed  out  in  the  general  con- 
sideration of  percussion,  palpation  is  an  essential  though  subordinate 
factor  in  finger  percussion,  which  is  gradually  taking  the  place  of  other 
methods.  Palpatory  percussion  is  a  method  in  which  the  attention  is 
especially  directed  to  the  resistance  and  elasticity  of  the  tissues  over  which 
the  percussion  is  performed.  It  consists  in  the  combined  use  of  palpation 
and  percussion  in  a  modified  form,  and  is  applicable  (a)  to  the  determina- 
tion of  the  outlines  and  boundaries  of  the  solid  viscera  under  various  con- 
ditions, but  especially  to  the  study  of  the  deep  dulness  of  the  heart  both 
when  the  lungs  are  normal  and  when  they  are  emphysematous;  (b)  to 
the  examinations  of  solid  organs  of  limited  size  surrounded  by  air-contain- 
ing and  resonant  structures,  as  the  spleen,  and  particularly  when  there  is 
tympanitic  distention  of  the  abdomen;  and  (c)  to  the  recognition  of  the 
extent  and  the  horizontal  levels  of  fluid  exudates  in  the  abdominal  and  tho- 
racic cavities  in  different  postures.  The  physical  signs  depend  to  a  greater 
extent  upon  the  sensation  of  resistance  imparted  to  the  percussion  finger 
than  upon  the  character  of  the  sounds  perceived,  though  both  have  value. 
Various  methods  have  been  described.  Delicacy  of  touch,  a  light  stroke, 
and  a  lingering  rather  than  a  momentary  contact  with  the  surface  under 
examination  are  essential  to  success  in  all  of  them. 

The  direct  methods  of  palpatory  percussion  are: 

1.  That  of  the  Writer.  —  This  consists  in  flicking  the  surface 
with  the  nail  of  the  middle  finger  in  the  manner  described  under  the 
caption  direct  or  immediate  percussion.  This  method  is  painless  to  the 
patient  and  yields  very  accurate  results.  The  nail  should  strike  the  surface 
percussed  flatly  and  linger  for  an  instant. 

2.  Maguire's  Method. — The  palmar  cushion  of  the  tip  of  one  finger 
is  employed  as  the  plexor.  The  stroke  is  not  short  and  quick  but  prolonged 
and  combined  with  a  certain  movement  of  pressure  or  palpation. 

3.  Method  of  Hein. — The  first  and  middle  fingers  are  employed, 
the  tip  of  one  resting  upon  the  surface  while  the  other,  used  as  a  plexor, 
delivers  a  light  tap  upon  the  adjacent  surface,  palpation  and  percussion 
being  literally  performed  at  the  same  time.  The  fingers  are  alternately 
used  and  the  whole  surface  is  gradually  examined.  Very  accurate  results 
may  be  obtained  by  this  method. 

The  Indirect  Methods  Are:  1.  The  finger  used  as  a  pleximeter  is 
struck  lightly  with  the  fingers  of  the  other  hand,  which  are  slightly  flexed 
in  such  a  manner  that  the  blow  is  delivered  by  the  pulps  rather  than  the 
extreme  tips.  The  stroke  is  not  sharp  and  rebounding,  but  prolonged 
and  pushing,  the  so-called  palpating  stroke,  and  the  percussing  fingers 
remain  a  moment  upon  the  plexor  finger  before  the  blow  is  repeated. 

2.  That  of  Ebstein.  A  glass  pleximeter  4  centimetres  in  length  and 
1.3  centimetres  in  width,  with  a  projecting  bar  1.5  centimetres  in  height 
is  used.  This  is  held  firmly  in  place  while  the  finger  held  as  in  ordinary 
finger  percussion  delivers  a  gentle  but  pushing  or  pressing  percussion  stroke 

9 


130  MEDICAL  DIAGNOSIS. 

upon  the  flat  upper  surface  of  the  bar.  The  pleximeter  devised  by  Sansom 
consists  of  a  slender  rod  of  square  section  having  at  one  end  attached  at 
right  angles  a  thin  plate  and  at  the  other  end  a  similar  plate  parallel  to 
the  first.  The  measurements  are  about  the  same  as  those  of  the  glass 
pleximeter  of  Ebstein,  but  all  the  parts  are  made  of  hard  rubber.  In  use 
the  larger  plate  is  applied  to  the  surface  of  the  chest  and  held  in  position 
by  the  tips  of  two  fingers,  one  on  each  side  of  the  rod.  Percussiou  is  then 
made  upon  the  upper  plate,  the  finger  of  the  other  hand  being  employed 
as  a  plexor.  Greater  attention  is  paid  to  the  vibrations  perceived  by  the 
fingers  than  to  the  sound.  This  special  pleximeter  enables  the  observer 
who  has  acquired  skill  in  its  use  to  recognize  slight  modifications  of  the 
vibrations  produced  by  percussion  and  to  map  out  more  closely  than  by 
other  methods,  but  not  absolutely,  the  limits  of  the  deep  dulness  of  the 
heart  and  the  great  vessels. 

Auscultatory  Percussion.  —  The  chest  piece  of  a  binaural  stetho- 
scope is  applied  to  the  surface  over  the  body  of  an  organ,  as  the  heart, 
liver,  stomach,  etc.,  and  held  in  place  by  an  assistant  or  the  patient  him- 
self. Using  finger  pleximetry  with  very  light  strokes,  percussion  is  per- 
formed in  radiating  lines  towards  or  away  from  the  stethoscope  as  a  centre. 
Direct  percussion  with  the  finger-tips  may  be  employed  especially  in  case 
the  observer  himself  for  any  reason  is  obliged  to  use  one  hand  to  hold  the 
stethoscope  in  place,  or  a  light  stroking  touch  or  scratching  of  the  skin 
will  serve  the  purpose.  A  stiff  brush  may  be  used  for  this  purpose.  The 
sounds  are  greatly  intensified  and  changes  in  their  quality,  volume,  and 
pitch  are  readily  appreciated.  Of  especial  importance  are  the  abrupt 
changes  that  take  place  as  the  line  of  percussion  passes  over  the  border 
of  the  organ  over  which  the  stethoscope  is  placed.  The  points  at  which 
the  change  occurs  being  marked  and  these  points  being  joined  by  lines, 
an  approximate  outline  of  the  organ  is  obtained.  The  observation  must 
be  controlled  and  errors  eliminated  by  percussing  in  segments  of  widening 
circles  and  by  the  employment  of  the  ordinary  methods  of  percussion. 
This  method  is  much  more  useful  in  the  examination  of  the  abdominal 
than  of  the  thoracic  viscera.     It  should  be  acquired  by  every  student. 

Percussion  Signs  in  the  Chest. 

THE  EXAMINATION  OF  THE  NORMAL  CHEST  BY  PERCUSSION. 

Pulmonary  Resonance. — The  sounds  elicited  vary  in  different  regions. 
The  anterior  and  lateral  surfaces  are  more  resonant  than  the  posterior 
by  reason  of  the  greater  thickness  of  the  walls  of  the  last.  The  resonance 
in  the  former  is  known  as  normal,  pulmonary,  or  vesicular.  The  portion  of 
the  apex  of  the  lung  above  the  clavicle  yields  a  sound  which  acquires  the 
tympanitic  quality — vesiculotympanitic — as  the  trachea  is  approached. 
Some  difficulty  in  the  application  of  the  finger  or  pleximeter  renders 
percussion  less  satisfactory  in  this  region  than  in  other  parts  of  the  chest. 
Over  the  clavicle  the  sound  has  the  peculiar  quality  known  as  osteal  reso- 
nance; is  dull  towards  the  scapular  extremity  and  acquires  a  distinctly 
tympanitic  quality  with  heightened  pitch  at  its  sternal  end  of  the  bone. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  131 

In  the  infraclavicular  region,  that  is,  as  far  downward  as  the  fourth 
rib,  the  pulmonary  or  vesicular  resonance  is  characteristic.  There  is  usually, 
however,  a  slight  disparity  in  the  two  sides,  the  sound  of  the  right  being 
somewhat  less  resonant,  shorter  in  duration,  and  of  higher  pitch  than  the 
left.  The  recognition  of  this  fact  is  of  cardinal  importance.  From  the 
fourth  rib  downwards  on  the  right  side  the  resonance  upon  strong  per- 
cussion is  slightly  diminished,  owing  to  the  presence  of  the  dome  of 
the  right  lobe  of  the  liver.  About  the  sixth  rib  the  pulmonary  reso- 
nance ceases.  During  full  inspiration  the  liver  is  pushed  downwards 
to  the  extent  of  an  inch  or  more  and  the  line  of  dulness  is  depressed 
to  a  corresponding  degree. 

On  the  left  side  the  vesicular  resonance  is  impaired  by  the  presence 
of  the  heart  between  the  fourth  and  sixth  ribs  and  to  the  left  as  far  as  the 
mamillary  or  midclavicular  line.  The  extent  of  this  area  is  diminished 
under  any  conditions  in  which  a  larger  wedge  of  the  border  of  the  lung  is 
interposed  between  the  wall  of  the  chest  and  the  heart,  as  upon  deep 
inspiration  and  in  those  who  have  deep  chests  and  voluminous  lungs.  At 
the  base  anteriorly  the  clear  resonance  passes  into  the  tympanitic  reso- 
nance of  the  fundus  of  the  stomach — Traube's  semilunar  space;  laterally 
into  the  dulness  of  the  spleen. 

In  the  lateral  regions,  axillary  and  infra-axillary,  percussion  yields 
vesicular  resonance  modified  in  the  direction  of  higher  pitch  and  dimin- 
ished intensity  towards  the  base  of  the  chest  by  the  presence  of  the  liver 
on  the  right  and  the  spleen  on  the  left  side. 

Posteriorly  the  sound  varies  markedly  according  to  the  region  per- 
cussed. The  greater  thickness  of  the  muscles  and  the  presence  of  the  scap- 
ulae are  to  be  considered.  The  resonance  is  everywhere  diminished  as 
compared  with  the  anterior  and  lateral  regions.  It  has  the  quality  of 
clearness  but  is  muffled  and  merges  into  dulness  over  the  scapulae.  The 
percussion  sound  is  clear  over  the  apices  but  usually  slightly  less  so  on 
the  right  side  than  on  the  left;  and  in  the  interscapular  regions,  which  are 
widened  when  the  patient  bends  forward  and  folds  his  arms.  It  is  also 
clear  from  the  angle  of  the  scapula  on  each  side  to  the  base  of  the  chest, 
namely,  about  the  level  of  the  tenth  rib,  where  on  the  right  side  the  liver 
dulness  begins.  On  the  left  side  the  clear  percussion  sound  may  be  found 
a  little  lower  than  upon  the  right;  while  the  resonance  upon  deep  percus- 
sion is  somewhat  diminished  on  the  right  by  the  convexity  of  the  liver 
and  on  the  left  to  a  less  extent  by  the  spleen. 

In  children  and  emaciated  persons  the  resonance  in  the  back  is  often 
very  good  and  percussion  yields  results  scarcely  less  satisfactory  than  in 
the  front  of  the  chest. 

Normal  Tympanitic  Areas  in  the  Chest. — These  are  at  the  sternal 
ends  of  the  clavicles,  over  the  manubrium  sterni  and  at  the  left  base  anteri- 
orly. The  first  and  second  of  these  regions  owe  their  tympanitic  resonance 
to  the  proximity  of  the  trachea  and  main  bronchi  and  their  osteal  quality 
to  the  large  proportion  of  bone  entering  into  the  wall  of  the  chest.  In 
elderly  persons  with  calcification  of  the  costal  cartilages  this  osteal  quality 
is  widely  present  and  when  combined  with  tympany  as  is  often  the  case 
greatly  impairs  the  value  of  the  percussion  signs. 


132 


MEDICAL  DIAGNOSIS. 


Percussion  directly  over  the  trachea  at  the  episternal  notch  and  that 
over  the  larynx,  ^.e.,  over  the  plates  of  the  thyroid  cartilage,  yields  amphoric 
resonance.  The  normal  tympany  at  the  left  base  anteriorly  is  due  to 
the  presence  of  the  fundus  of  the  stomach  when  distended  with  air  and 
the  adjacent  transverse  colon.  The  curved  upper  border  of  this  space,  the 
convexity  of  which  corresponds  with  the  convexity  of  the  diaphragm,  is  of 
special  diagnostic  A^alue.    The  degree  of  distention  of  the  stomach  increases 

this  curve,  which  is  flattened 
or  may  even  become  concave 
in  large  left-sided  pleural  effu- 
sions. Traube's  semilunar 
space  is  bounded  to  the  right 
by  the  left  lobe  of  the  liver 
— dull;  above  by  the  lung — 
clear ;  to  the  left  by  the  spleen 
— -dull  upon  light  percussion 
and  is  itself  tympanitic,  the 
tympany  being  continuous 
with  that  of  the  stomach  and 
transverse  colon.  It  often 
requires  nice  work  in  percus- 
sion to  map  out  the  border- 
line between  the  clear  vesic- 
ular resonance  which  forms 
the  upward  limit  of  this  space 
and  the  tympanitic  resonance 
of  the  space  itself. 

Dull  Areas  in  the  Nor- 
mal Chest. — These  are  found 
to  correspond  to  the  scapulse 
with  their  large  muscular 
masses  in  the  chest  wall,  the 
liver  and  spleen  reaching  up 
into  the  chest  in  the  vault  of 
the  diaphragm  and  the  heart  within  the  chest  itself.  The  scapular  dul- 
ness  has  already  been  described.  The  hver  dulness  extends  in  the  right 
midclavicular  Hne  from  about  the  sixth  rib  to  the  border  of  the  ribs  and 
shifts  downwards  an  inch  or  more  on  full  inspiration;  the  dulness  of  the 
left  lobe  is  continuous  vertically  with  the  cardiac  dulness,  from  which  it 
cannot  be  distinguished  by  ordinary  percussion,  although  the  border-line 
between  them  is  sufficiently  indicated  for  clinical  purposes  by  the  upper 
border  of  liver  dulness  on  the  right  side  and  the  position  of  the  cardiac 
impulse  on  the  left.  In  doubtful  cases  auscultatory  percussion  may  be 
employed.  The  heart  rests  upon  the  central  tendon  of  the  diaphragm  and 
the  upper  curvature  of  the  liver  fits  into  the  vault  of  the  diaphragm. 

The  area  of  the  splenic  dulness  extends  from  the  upper  border  of  the 
ninth  to  the  lower  border  of  the  eleventh  rib  and  from  a  point  slightly 
anterior  to  the  midaxillary  line  backward  towards  the  spine.  It  varies 
normally  with  the  physiological  changes  in  the  size  of  the  organ. 


Fig. 


-Normal  tympany. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  133 

Cardiac  Dulness. — The  cardiac  dulness  is  divided  into  the  superficial 
and  the  deep. 

Superficial. — The  superficial  cardiac  dulness  corresponds  to  that 
part  of  the  organ  constituted  by  the  anterior  surface  of  the  right  ventricle, 
which  uncovered  by  lung  lies  in  relation  with  the  chest  wall.  It  begins 
above  about  the  level  of  the  fourth  costal  cartilage  and  extends  to  the  apex, 
being  bounded  below  by  the  dulness  of  the  left  lobe  of  the  liver  and  on  the 
right  by  the  resonance  of  the  anterior  border  of  the  right  lung  at  the  middle 
line.  This  irregularly  quadrilateral  area  varies  in  size  according  to  the 
expansion  of  the  borders  of  the  lungs,  especially  the  left.  It  is  smaller 
upon  inspiration  than  upon  expiration  and  in  active  individuals  with  volu- 
minous lungs  than  in  sedentary  persons  with  small  and  narrow  chests.  It 
yields  upon  superficial  percussion  a  flat  and  upon  deep  percussion  a  dull  note. 

Deep. — The  deep  cardiac  dulness  corresponds  to  the  borders  of  the 
heart  itself  beneath  the  overlapping  margins  of  the  lung  and  extends  beyond 
the  area  of  superficial  dulness.  Upon  deep  percussion  over  this  area  the 
note  is  dull,  but  the  rounded  receding  surface  of  the  heart  renders  a  liter- 
ally exact  determination  of  its  limits  impracticable.  Even  the  most  skilful 
percussion  yields  only  approximate  results.  The  difficulties  in  determin- 
ing the  upper  and  right  border  of  the  heart  by  percussion  are  increased 
by  the  fact  that  the  organ  is  covered  in  those  regions  not  only  by  the 
borders  of  the  lung  but  also  by  the  sternum,  which  modifies  to  a  high  degree 
the  percussion  sound  of  the  structures  underlying  it. 

Enlargement  of  the  heart  gives  rise  to  increase  in  the  diameters  of 
both  these  areas,  the  deep  area  of  cardiac  dulness  being  increased  by  the 
enlargement  of  the  heart  itself;  the  superficial  area  by  the  pushing  aside 
of  the  margins  of  the  lungs.  The  determination  of  the  superficial  area  of 
cardiac  dulness  is  a  relatively  easy  matter,  but  the  knowledge  thus  obtained 
relates  rather  to  the  position  of  the  margins  of  the  lungs  than  to  the  size 
of  the  heart ;  the  determination  of  the  deep  area  in  so  far  as  it  is  practica- 
ble would  indicate  the  actual  size  of  the  heart,  but  the  difficulties  in  reach- 
ing exact  data  are  in  many  cases  insuperable.  For  these  reasons  we  cannot 
regard  percussion  as  the  best  method  of  ascertaining  the  size  of  the  heart. 
It  has  a  value  as  a  control  method,  but  the  position  of  the  apex-beat,  as 
determined  by  inspection,  palpation,  or  auscultation,  and  the  extent  of  the 
impulse,  with  associated  clinical  phenomena,  constitute  diagnostic  criteria 
at  once  more  convenient  of  application  and  far  more  precise. 

The  resonance  of  the  normal  chest  is  modified  within  narrow  limits 
by  a  variety  of  conditions,  among  the  more  important  of  which  are  the 
following: 

1.  Change  of  Posture. — In  the  lateral  decubitus  the  resonance  of  the 
lower  lung  is  slightly  less  than  that  of  the  upper  by  reason  of  the  greater 
amount  of  air  in  the  latter.  On  exchanging  the  recumbent  for  the  erect 
posture  the  pitch  of  the  percussion  sound  is  raised  (Da  Costa).  If  the 
patient  turns  upon  the  left  side,  the  heart,  under  the  influence  of  gravity, 
swings  outwards  towards  the  left  axilla,  with  a  corresponding  change  in 
the  position  of  the  apex  and  the  cardiac  dulness. 

2.  Respiration. — The  general  resonance  of  the  chest  is  greater  upon 
full  held  inspiration  than  on  quiet  breathing  simply  because  of  the  increase 


134  MEDICAL  DIAGNOSIS. 

of  ait  within  its  cavity.  This  increase  of  resonance  may  be  noted  on  quiet 
respiration  after  great  muscular  exertion,  which  is  accompanied  by  a 
temporary  physiological  distention  of  the  vesicular  structure  of  the  lungs. 

The  increase  in  the  volume  of  the  lungs  upon  full  inspiration  not  only 
augments  the  resonance  but  also  extends  its  borders  in  certain  directions, 
especially  over  the  heart  so  that  the  superficial  area  of  cardiac  dulness  is 
diminished,  and  at  the  base  of  the  chest  so  that  the  liver  and  spleen  are 
carried  downwards  with  the  descending  diaphragm,  and  areas  at  the  base, 
dull  on  expiration  or  quiet  breathing,  yield  a  clear  note.  This  respiratory 
excursus  of  the  lower  margin  of  the  lungs  is  observed  posteriorly  as  well 
as  anteriorly,  but  not  to  the  same  extent.  It  varies  in  different  individuals 
in  health  just  as  the  inspiratory  expansion  varies  and  is  diminished  by  the 
presence  of  pleural  adhesions. 

3.  Gaseous  Distention  of  tlie  Stomach  and  Colon. — This  condition  may 
displace  the  upper  crescentic  convexity  of  Traube's  half-moon-shaped 
space  and  cause  tympanitic  resonance  in  the  lower  part  of  the  left  chest 
or  impart  a  tympanitic  quality  to  the  vesicular  resonance — vesiculo- 
tympanitic resonance.  It  may  also  to  some  extent  displace  the  diaphragm 
upwards,  thus  causing  the  lower  margins  of  the  lungs  to  assume  a  position 
slightly  higher  than  normal  with  a  corresponding  upward  displacement 
of  the  limit  of  pulmonary  resonance. 

Age. — In  children  the  lungs  are  relatively  small  and  the  dull  areas 
of  the  heart  and  liver  correspondingly  greater.  In  old  age  the  borders  of 
the  lungs  are  usually  emphysematous,  even  in  persons  otherwise  in  normal 
condition.  Hence  the  area  of  superficial  cardiac  dulness  is  encroached 
upon  and  the  upper  border  of  liver  dulness  is  slightly  lower  than  at  earlier 
periods  of  life.  Under  this  circumstance  the  vesicular  resonance  acquires 
a  faintly  tympanitic  quality. 

The  Condition  of  the  Chest  Wall. — The  obvious  part  in  this  respect 
played  by  great  muscular  development  and  obesity  has  already  been 
spoken  of.  There  are  persons  in  whom  percussion  on  account  of  these 
obstacles  yields  negative  results,  ffidema  of  the  chest  wall  is  also  an 
important  obstacle.  Highly  developed  mammae  likewise  interfere  with  the 
application  of  this  method  of  examination;  so  also  do  the  tenderness  of 
inflammation  of  the  chest  wall  and  hypersesthesia. 

PERCUSSION    IN    DISEASE   OF   THE   THORACIC   ORGANS. 

Percussion  in  the  different  regions  of  the  normal  thorax  yields  (1) 
vesicular  resonance,  the  sign  of  normal  lung  tissue  under  normal  intra- 
thoracic tension;  (2)  diminished  resonance  or  dulness  over  the  scapulae 
and  the  area  of  deep  cardiac  dulness;  (3)  absence  of  resonance  or  flatness 
over  the  lower  ribs  on  the  right  side  anteriorly;  (4)  vesiculotympanitic 
resonance  towards  the  base  of  the  chest  anteriorly  on  the  left;  (5)  tym- 
panitic resonance  over  Traube's  semi-space  and  over  the  manubrium  and 
the  sternal  ends  of  the  clavicles;  (6)  amphoric  resonance  over  the  trachea 
and  cracked-pot  resonance  sometimes  in  the  crying  infant.  While  these 
sounds  are  normal  when  obtained  in  the  particular  regions  of  the  chest 
above  indicated,  they  become  abnormal  or  morbid  signs  in  other  positions. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  135 

Thus  vesicular  resonance  in  the  area  of  superficial  cardiac  dulness  may 
indicate  dextrocardia  or  some  other  form  of  malposition  of  the  heart; 
diminished  resonance  or  dulness  in  the  infraclavicular  or  mammary  regions 
may  be  significant  of  tuberculous  infiltration  or  at  the  bases  of  broncho- 
pneumonia; absence  of  resonance  or  flatness  over  a  large  area  on  either 
side  which  is  normally  clear  denotes  pleural  effusion,  a  tumor,  or  some  other 
airless  condition;  vesiculotympanitic  resonance  is  the  sign  of  a  moderate 
degree  of  atelectasis  due  to  compression  of  the  lung  and  of  emphysema; 
when  of  high  degree  it  constitutes  the  percussion  sign  known  as  skodaic 
resonance;  tympanitic  resonance  elsewhere  than  normal  is  the  sign  of  a 
cavity,  pneumothorax,  or  pneumopericardium;  and  amphoric  resonance 
save  over  the  trachea  and  the  cracked-pot  sound  except  in  crying  children 
must  in  all  instances  be  looked  upon  as  pathological  conditions. 

The  changes  which  modify  the  normal  resonance  affect  (a)  the  borders 
of  the  lungs;  (b)  the  structure  and  tension  of  the  lungs,  and  (c)  adjacent 
organs.     They  may  be  general,  unilateral,  or  local. 

Changes  in  the  Relation  of  the  Borders  of  the  Lung  to  the  Wall 
of  the  Thorax. 

The  Apices. — The  lungs  normally  reach  about  an  inch  and  a  half  to 
two  inches  above  the  clavicles,  the  right  apex  being  usually  somewhat 
higher  than  the  left.  Normal  pulmonary  resonance  is  obtained  therefore 
in  both  retroclavicular  spaces.  If  absent  in  one  or  both  and  especially 
when  replaced  by  dulness  there  is  consolidation  and  retraction  of  the  apex 
or  apices.  This  sign  is  significant  of  tuberculous  disease,  fibroid  phthisis,  or 
local  adhesive  pleurisy.  It  is  often  stated  that  bulging  of  the  retroclavicular 
space  with  tympanitic  resonance  occurs  in  emphysema.  This  is  not  always 
true.  Owing  to  the  skeletal  changes  in  the  thorax  in  emphysema  of  high 
grade  there  is  usually  retraction  of  the  spaces  immediately  above  and  below 
the  clavicles.  Transient  prominence  with  vesiculotympanitic  resonance 
occurs  in  the  acute  emphysema  of  asthma  and  pertussis. 

The  Anterior  Borders. — The  resonance  is  marked  by  the  osteal  quality 
of  the  percussion  sound  oyer  the  sternum  and  the  signs  are  uncertain. 
Below  the  level  of  the  fourth  costal  cartilage  the  border  of  the  left  lung 
sweeps  downward  and  to  the  left,  and  is  readily  made  out  by  percussion, 
forming  the  upper  and  left  lateral  boundary  of  the  area  of  superficial  cardiac 
dulness.  Below  the  clinical  apex  of  the  heart  and  between  the  anatomical 
apex  and  the  chest  wall  a  tongue-like  projection  of  the  anterior  border  of 
the  lower  lobe  called  the  lingula  gives  rise  to  a  clear  percussion  sound  over 
a  limited  wedge-shaped  space.  The  anterior  border  of  the  left  lung  is 
pushed  aside  by  an  hypertrophied  heart  or  large  pericardial  effusion  so 
that  the  area  of  superficial  cardiac  dulness  is  increased.  An  increase  in 
diameter  is,  however,  much  more  frequently  due  to  diminution  in  the 
volume  of  the  lung  as  in  tuberculous  or  fibroid  disease  and  consequent 
retraction  of  its  borders.  In  substantive  chronic  emphysema  and  the  acute 
emphysema  of  asthma  and  whooping-cough  the  left  border  of  the  lung  is 
advanced  and  in  extreme  cases  to  such  an  extent  as  to  obliterate  the  area 
of  superficial  cardiac  dulness. 

The  Lower  Borders. — Due  allowance  must  be  made  for  the  changes 
caused  by  posture,  exertion,  age,  etc.  (p.  133).    The  borders  are  lowered 


136  MEDICAL  DIAGNOSIS. 

in  pathological  conditions  in  which  the  volume  of  the  lungs  is  increased 
and  they  occupy  a  position  higher  than  normal  when  it  is  diminished. 

In  advanced  cases  of  emphysema  the  lower  border  of  the  lung  as 
marked  by  the  transition  to  liver  dulness  on  the  right  side  and  to  tympany 
on  the  left,  may  reach  the  ninth  rib  and  a  corresponding  level  in  the  lateral 
and  posterior  regions.  The  respiratory  excursus  of  the  border  is  very 
limited  in  this  disease.  It  is  likewise  much  restricted  by  old  pleural 
adhesions.  Permanent  upward  displacement  with  restricted  respiratory 
movement  is  a  sign  of  tuberculous  or  fibroid  shrinking,  chronic  broncho- 
pneumonia, or  pulmonary  collapse.  The  lung  border  ma}'  be  pushed  up 
by  a  distended  abdomen,  or  drawn  up  by  its  own  elasticit}^  in  paralysis  of 
the  diaphragm.  It  is  also  displaced  upward  and  rendered  immovable  by 
fluid  or  air  in  the  pleural  cavity — hydro-pyo-hsemo-pneumothorax. 

Impaired  Resonance;  Dulness;  Flatness. — The  resonance  is  dimin- 
ished in  proportion  as  the  amount  of  air  is  decreased  in  the  part  percussed. 
It  is  modified  according  to  the  changes  in  the  physical  structure  of  the 
spaces  containing  the  air  caused  by  the  lesions  of  disease.  Consolidation  of 
the  lung  from  exudate  within  its  substance,  compression,  infarct,  collapse, 
renders  the  percussion  sound  over  the  affected  area  less  resonant  in  pro- 
portion to  the  extent  of  the  lesion.  In  disseminated  lesions,  as  those  of  the 
common  forms  of  ordinary  or  tuberculous  bronchopneumonia,  there  is  usu- 
ally a  local  compensatory  emphj^sema  which  modifies  the  dulness.  The 
association  of  heightened  pitch  and  diminished  volume  with  diminished  pul- 
monary resonance  must  always  be  borne  in  mind.  In  many  instances  the 
well-trained  ear  will  recognize  a  change  in  the  pitch  of  the  percussion  sign 
before  alteration  in  its  quality.  The  sensation  of  increased  resistance — 
loss  of  elasticity — which  is  experienced  by  the  pleximeter  finger  in  fluid 
exudates  and  dense  consolidations  is  also  to  be  remembered. 

Impaired  resonance  is  a  sign  of  beginning  or  disseminated  tubercle, 
bronchopneumonia,  early  croupous  pneumonia,  small  effusions,  thickened 
pleura,  gangrene  of  limited  extent,  and  small  abscesses  or  tumors.  Dulness  is 
present  when  the  lesions  of  the  above  conditions  are  close  set  or  extended. 

Flatness  when  no  Air  is  Present. — The  percussion  sound  is  dull  over 
the  complete  consolidation  of  croupous  pneumonia  involving  a  lobe  or  an 
entire  lung  because  some  air  yet  remains  in  the  large  and  middle-sized 
bronchial  tubes;  it  is  flat  over  a  large  effusion  because  the  lung  with  its 
compressed  vesicles  and  w-ith  it  the  air-containing  bronchi  are  pushed 
wholly  away!  The  presence  of  circumscribed  consolidations,  especiallj' 
when  not  directly  beneath  the  chest  wall,  cannot  be  recognized  by  percus- 
sion. Their  only  sign  may  be  a  slight  elevation  of  the  pitch.  Hence  central 
pneumonias  and  deep-seated  aneurisms  are  frequently  overlooked.  An 
effusion  into  the  pleura  of  serum,  pus,  or  blood  which  does  not  reach  500 
to  750  cubic  centimetres  in  volume  does  not  often  yield  definite  physical 
signs  upon  percussion,  and  a  pericardial  effusion  of  half  this  amount  may 
escape  detection.  In  pneumothorax  when  the  bronchopulmonary  fistula 
has  closed  and  the  air  is  present  under  a  high  degree  of  tension,  the  per- 
cussion note  over  the  greater  part  of  the  affected  side  may  be  dull. 

Impaired  resonance  over  the  apex  or  upper  lobe  of  one  lung  with 
normal  resonance  elsewhere  is  commonly  significant  of  tuberculosis.    It 


PHYSICAL  DIAGNOSIS:     PERCUSSION. 


137 


may,  however,  be  caused  by  an  apex  pneumonia  or  gangrene.  Dense 
pleural  thickening  is  also  a  cause  of  dulness  in  this  region.  Slight  impair- 
ment of  resonance  in  this  region  which  passes  away  upon  repeated  deep 
inspiration  or  prolonged  percussion  may  simply  indicate  habitual  deficient 
respiratory  expansion  of  the  lungs. 

Dulness  at  the  base  of  the  chest,  always  more  pronounced  and  signifi 
cant  posteriorly,  may  be  the  sign  of  pneumonia,  oedema,  hypostatic  con- 
gestion, atelectasis,  or  pleural  effusion  or  thickening.     Less  commonly  it 
stands  for  infarct,  abscess,  gangrene,  tuberculosis,  or  tumor. 


Fig.  73. — Pleural  effusion,  left  side,  showing  degree  of  displacement  of  heart  and   of  obliteration  of 

Traube's  semilunar  space. 


Fig.  74. — Pneumohydrothorax — erect  posture. 


Fig.  75. — Pneumohydrothorax — dorsal  decubitus. 


Flattening  of  the  convexity  of  Traube's  semilunar  space  is  a  sign 
of  moderate  pleural  effusion  ;  marked  depression,  with  a  concave  upper 
line,   occurs   in    massive   effusion. 

Vesiculotympanitic  resonance  of  woodeny  quality  is  significant  of 
extensive  fibroid  changes  in  the  lung. 

Dulness  at  one  or  the  other  base,  the  upper  line  shifting  quickly  upon 
change  in  posture,  is  characteristic  of  pneumohydrothorax.  The  upper 
line  of  small  pleural  effusions  shifts  much  more  slowly  and  that  of  large 
effusions  scarcely  at  all  save  in  prolonged  and  decided  change  of  posture. 
It  is  to  be  remembered  that  a  pleural  effusion  which  develops  insidiously 
while  the  patient  is  up  and  about  occupies  the  lower  part  of  the  chest  and 
causes  dulness  at  the  base  anteriorly,  while  one  that  accumulates  in  a  bed- 


138  MEDICAL  DIAGNOSIS. 

ridden  patient  may  cause  extensive  dulness  posteriorly  and  reveal  itself 
anteriorly  merely  by  skodaic  resonance.  The  significance  of  dulness  in  the 
interscapular  region  is  often  obscure.  It  may  be  a  sign  of  pulmonary 
collapse  or  great  enlargement  of  the  bronchial  glands.  In  the  latter  case 
there  is  also  dulness  instead  of  osteal  tympany  over  the  lower  cervical 
vertebrae.  Dulness  or  flatness  in  the  left  suprascapular  or  particularly 
in  the  left  interscapular  space  may  be  caused  by  the  presence  of  an  aneurism 
of  the  descending  aorta. 

Increased  Resonance — Hyperresonance — Vesiculotympanitic  Reso= 
nance — Tympany. — Solidification  of  lung  tissue  changes  its  percussion 
note  to  dulness.  An  increase  in  the  amount  of  air  causes  an  increase  of 
resonance,  but  does  not  necessarily  change  the  quality  of  the  note,  which 
retains  its  clearness  alike  in  shallow-chested  and  in  deep-chested  individ- 
uals and  in  forced  expiration  and  in  full  held  inspiration.  In  truth 
the  change  from  the  clear  to  the  tympanitic  percussion  note  very  fre- 
quently accompanies  a  reduction  in  the  amount  of  air  contained  in  the 
portion  of  the  lung  under  examination.  The  resonance  has  a  tympanitic 
quality  in  extreme  dilatation  of  the  air-cells,  as  emphj^sema,  in  deep  con- 
gestion, oedema,  the  pressure  atelectasis  overlying  an  effusion  or  adjacent 
to  a  tumor,  and  that  part  of  the  lung  which  is  the  seat  of  collateral  fluxion 
in  pneumonia;  it  may  be  exquisitely  tympanitic  in  any  of  these  conditions. 

Clearness  is  replaced  by  tympany  over  portions  of  the  lung  which  have 
broken  down  with  the  formation  of  cavities,  provided  that  the  cavities 
contain  air;  when  they  are  filled  with  fluid  the  percussion  sound  is  dull. 

The  note  is  tympanitic  in  pneumothorax  and  in  the  rare  instances  of 
pneumopericardium  that  occur.  But  when  the  cavity  in  pneumothorax 
is  closed  and  the  air  is  present  under  high  tension  the  note  becomes  dull. 

The  tympanitic  percussion  sound  may  be  due  to  extrapulmonary 
conditions.  We  have  seen  that  percussion  of  the  parts  immediately  over 
the  trachea  and  main  bronchi  yields  resonance  having  this  quality.  In  the 
same  manner  inexpert  percussion  over  a  consolidated  lung  may  yield  a 
tympanitic  sound  due  to  the  air  in  the  trachea  and  large  bronchi  on  the 
one  hand  or  to  the  air  in  the  stomach  and  intestines  on  the  other. 

Finally,  the  bases  of  the  chest  posteriorly  in  crying  infants  in  health 
often  yield  a  tympanitic  sound,  and  that  sound,  as  has  been  pointed  out, 
sometimes  has  the  cracked-pot  quahty. 

When  we  come  to  review  the  physical  conditions  present  under  the 
foregoing  circumstances,  we  are  impressed  with  the  fact  that,  whether 
directly  or  by  conduction,  the  vibrations  produced  by  percussion  act  upon 
air-containing  structures  which  do  not  fulfil  the  requirements  of  the  clear 
percussion  sound,  namely,  air  contained  in  elastic  vesicles  under  physio- 
logical tension  within  the  chest.  On  the  contrary,  they  present,  completely 
or  in  a  modified  manner,  the  very  conditions  necessary  to  the  tympanitic 
percussion  sound,  namely,  air  in  spaces,  the  walls  of  which  are  not  under 
any  great  degree  of  tension. 

In  emphysema  we  recognize  as  an  essential  lesion  that  nutritive  change 
in  the  alveolar  walls  which  interferes  with  expiratory  contraction;  even 
in  local  or  compensatory  emphysema  there  is  some  degree  of  impairment 
of  contractility  from  vesicular  overdistention.     In  congestion  and  oedema 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  139 

the  volume  of  air  in  the  chest  is  decreased  as  the  quantity  of  blood  is 
increased  or  serum  is  present  and  the  normal  tension  diminished  to  a  corre- 
sponding degree.  In  compression  of  the  lung  the  air  is  squeezed  out  of  the 
atelectic  portion  as  the  water  out  of  a  sponge  and  the  vesicular  tension 
is  done  away  with  altogether.  In  collateral  fluxion  the  condition  is  the 
same  as  in  congestion  from  other  causes.  In  the  foregoing  conditions  the 
percussion  sound  varies  from  vesiculotympanitic  resonance — mere  hyper- 
resonance — to  an  exquisite  tympany.  In  air-containing  cavities  within 
the  lungs  or  in  the  pleural  space  and  in  the  case  of  the  tracheobronchial 
or  gastro-intestinal  tympanitic  sound  we  have  to  do  with  the  conditions 
essential  to  this  phenomenon  and  the  quality  is  unmixed  and  constant. 

The  pitch  of  the  tympanitic  sound  varies  with  the  degree  of  tension 
of  the  air  within  the  cavity,  becoming  higher — dull  tympany — as  the 
tension  increases,  and  with  the  relative  width  of  the  opening  with  which 
the  cavity  communicates  with  the  air,  the  wider  the  opening  the  higher 
the  pitch.  The  student  may  demonstrate  these  facts  by  percussing  his 
distended  cheeks  under  progressive  degrees  of  tension  with  his  mouth 
closed  and  with  his  mouth  opened  progressively  to  the  full  extent. 

1.  Vesiculotympanitic  resonance  on  both  sides  of  the  chest  is  signifi- 
'cant  of  emphysema,  which  may  be  acute  as  in  asthma  or  pertussis,  or  chronic 
as  in  pseudohypertrophic  emphysema.  The  degree  of  tympany  varies  with 
the  grade  of  the  disease.  In  extreme  cases  the  percussion  sound  becomes 
high  in  pitch,  small  in  volume,  and  short  in  duration — dull  tympany. 

2.  The  percussion  note  is  hyperresonant  and  has  the  tympanitic 
quality  over  the  sound  side  in  the  vicarious  respiration  such  as  occurs  in 
extensive  disease  of  the  lung,  massive  pleural  effusion,  or  large  tumor  of 
the  opposite  side. 

3.  An  exquisite  tympanitic  sound,  often  partaking  of  the  amphoric 
quality,  is  present  over  the  affected  side  in  pneumothorax.  With  extreme 
intrapleural  tension  the  sound  becomes  less  resonant — dull  tympany  or 
flat  tympany — or  may  become  quite  dull. 

4.  Local  tympanitic  percussion  resonance  is  a  constant  sign  of  pressure 
atelectasis.  It  is  present  at  the  level  of  pleural  effusions,  above  towards 
the  axilla  and  at  the  base  posteriorly  on  the  left  side  in  massive  pericardial 
effusions,  and  surrounds  the  dulness  caused  by  pleural  and  pulmonary 
tumors.  In  old  cases,  as  the  atelectasis  becomes  complete,  the  tympanitic 
resonance  is  replaced  by  dulness. 

5.  Tympanitic  resonance  in  one  or  both  infraclavicular  spaces  asso- 
ciated with  dulness  at  the  base  of  the  chest  may  be  a  sign  of  pleural  effusion, 
pneumonia  of  the  lower  lobe,  infarct,  abscess,  gangrene,  or,  if  bilateral, 
of  oedema. 

6.  Tympanitic  resonance  at  the  sternoclavicular  articulation  and 
below  it  with  dulness  at  the  apex  is  usually  conducted  tracheobronchial 
resonance.    It  is  encountered  in  tuberculosis  and  apex-pneumonia. 

7.  Circumscribed  tympanitic  percussion  resonance  is  the  sign  of  a 
cavity  which  may  be  tuberculous,  bronchiectatic,  or  the  result  of  abscess 
or  gangrene.  The  nearer  the  cavity  lies  to  the  surface  the  better  defined 
the  tympany.  Consolidation  of  the  intervening  lung  tissue  acts  in  the  same 
way.     In  tuberculosis  a  cluster  of  small  communicating  cavities  is  often 


140  MEDICAL  DIAGNOSIS. 

present  at  the  apex.  Single  small  cavities  even  when  they  are  superficial, 
and  deeply  seated  cavities  even  when  of  moderate  size,  do  not  yield  a 
tympanitic  percussion  sound. 

8.  Subdiaphragmatic  tympanitic  resonance  when  the  distention  is 
extreme  may  be  elicited  by  percussion  in  the  anterior  axillary  line  on  the 
left  side  as  high  as  the  third  interspace. 

Amphoric  Resonance. — This  is  the  sign  of  a  cavity  of  large  size  or, 
when  very  extensive,  of  pneumothorax.  The  cracked-pot  sound  is  usually 
the  sign  of  a  cavity  of  some  size  with  compressible  walls  and  communicat- 
ing freely  with  a  bronchus.  The  essential  physical  requirement  is  that  the 
walls  should  be  freely  compressible  so  that  there  may  be  a  free  outrush  of 
air  at  the  moment  of  the  percussion  stroke. 

The  following  percussion  phenomena  described  in  the  text-books  are 
of  greater  clinical  interest  than  practical  value.  They  are  very  rarely 
brought  out  in  a  manner  that  amounts  to  a  demonstration. 

1.  Wintrich's  Sign. — The  tympanitic  percussion  sound  is  higher 
in  pitch  upon  opening  the  mouth  and  lower  when  it  is  closed.  The  patient 
should  open  his  mouth,  protrude  his  tongue,  and  breathe  quietly.  This 
phenomenon  is  occasionally,  but  by  no  means  in  the  majority  of  instances, 
observed  in  large  cavities  of  the  lung  or  pneumothorax  with  wide  com- 
munication with  a  bronchus. 

2.  Interrupted  Wintrich's  Sign. — If  the  foregoing  sign  is  exclu- 
sively present  in  the  sitting  posture,  it  is  evidence  of  a  cavity  containing 
fluid  which  in  one  posture  occludes  and  in  the  other  leaves  open  the  com- 
munication with  the  bronchus.  Under  these  circumstances  gurgling  or 
the  rale  of  cavities  is  usually  present. 

3.  Gerhardt's  Sign.  —  The  pitch  changes  with  change  of  posture, 
usually  becoming  higher  in  the  erect  posture  but  scarcely  ever  becoming 
higher  in  the  recumbent  position.  The  alterations  in  pitch  are  attributed 
to  the  changes  in  the  shape  of  the  cavity  caused  by  the  gravitation  of  the 
fluid  to  its  lowest  part. 

4.  Friedreich's  Sign.  —  The  tympanitic  resonance  over  a  cavity 
communicating  with  a  bronchus  is  higher  in  pitch  upon  inspiration  than 
upon  expiration.  The  change  in  pitch  is  always  slight  and  often  too  slight 
to  be  of  value  in  diagnosis.  The  inspiratory  rise  is  attributed  to  the  widely 
open  glottis  and  the  increased  tension  of  the  air  in  the  cavity. 

5.  Biermer's  Sign.  —  In  pneumohydrothorax  the  tympanitic  per- 
cussion note  is  lower  in  the  recumbent  than  the  erect  posture,  the  change 
being  due  to  alterations  in  the  shape  and  relative  diameters  of  the  air 
space  caused  by  the  gravitation  of  the  fluid.  The  underlying  principle  in 
Gerhardt's  sign  and  Biermer's  sign  is  the  same. 

Coin  Percussion— Coin  Test— Anvil  Test. — Auscultation  is  performed  upon 
the  chest  while  an  assistant  percusses  at  a  point  diametrically  opposite 
upon  the  front  or  back  as  the  case  may  be,  using  a  coin  laid  flat  upon 
the  surface  as  a  pleximeter  and  another  as  the  plexor,  striking  with  its 
edge.  The  coins  should  be  of  some  weight,  as  fifty-cent  pieces  or  silver 
dollars.  If  pneumothorax  be  present  the  peculiar  auscultatory  sign  consists 
of  a  clear  metallic,  ringing,  bell-like  note.  Control  observations  may  be 
made  upon  the  opposite  side  and  over  the  compressed  lung.  This  sign 
does  not  occur  over  very  large  cavities — voiyiicce. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  141 

PERCUSSION    IN    DISEASE   OF   THE    HEART. 

The  normal  superficial  and  deep  cardiac  dulness  and  the  method  of 
determining  them  have  been  discussed  in  a  foregoing  section.  By  this 
method  of  physical  diagnosis  we  ascertain  approximateh^  the  size,  shape, 
and  position  of  the  heart,  the  relation  of  the  anterior  borders  of  the  lungs, 
especially  upon  the  left  side,  to  it,  and  the  presence  of  pericardial  effusion 
when  it  is  of  sufficient  amount.  The  area  of  superficial  cardiac  dulness  is 
ascertained  by  light  percussion  in  the  parasternal  line  from  above  down- 
wards until  dulness  with  a  distinct  sense  of  resistance  is  reached,  usually 
about  the  level  of  the  fourth  rib  or  its  lower  border.  This  point  is  in  a 
transverse  or  oblique  line  extending  downward  and  outward  from  mid- 
sternum.  Next  percuss  over  the  lung  upon  the  right  side  about  the  level 
of  the  fifth  rib  and  in  a  transverse  line  across  the  sternum  to  the  left.  About 
or  just  beyond  the  ixiiddle  line  the  sound  again  becomes  dull  and  the  resist- 
ance increased.  This  marks  the  limit  of  the  anterior  border  of  the  right 
lung.  Continuing  to  percuss  in  the  same  line  and  lightly  as  before,  we  reach 
a  point  at  which  the  sound  again  becomes  clear  and  which  corresponds  to 
the  anterior  border  of  the  left  lung  at  the  level  named.  This  determines 
the  transverse  diameter  of  the  superficial  area  of  cardiac  dulness.  The 
left  lower  angle  corresponds  to  the  apex  and  can  be  determined  by  palpa- 
tion. The  lower  border  is  bounded  by  a  line  prolonged  from  the  upper 
border  of  liver  dulness  to  the  apex  of  the  heart. 

The  area  of  deep  cardiac  dulness  may  be  roughly  estimated  by  per- 
cussion in  corresponding  parallel  lines  from  the  parasternal  line  on  the  right 
side  across  the  chest  to  the  left  and  from  above  downward  upon  the  left 
side  along  the  sternal  border,  the  parasternal  line  and  the  mamillary  line. 
The  base  line  is  the  same  in  both  areas.  The  first  modification  of  clear 
pulmonary  resonance  as  we  approach  the  heart  may  be  accepted  as  a  sign 
indicating  the  outline  of  that  organ. 

SIGNIFICANCE   OF   VARIATIONS    IN   THE    CARDIAC    DULNESS. 

Alterations  in  the  size  of  the  superficial  area,  as  has  been  heretofore 
stated,  are  usually  signs  of  pulmonary  rather  than  of  cardiac  disease.  They 
correspond  to  increase  as  in  emphysema,  or  decrease  as  in  phthisis  in  the 
volume  of  the  lung.  This  area  together  with  the  deep  area  undergoes 
changes,  however,  with  changes  in  the  volume  of  the  heart. 

Increase  of  Cardiac  Dulness. — When  the  enlargement,  as  determined 
by  percussion  and  other  methods,  extends  chiefiy  to  the  left  and  downward, 
the  longest  diameter  being  oblique  from  above  downward  and  to  the  left, 
it  is  the  sign  of  hypertrophy  and  dilatation  of  the  left  ventricle.  When 
the  enlargement  is  to  the  right,  with  an  extension  of  the  dulness  in  the  third 
and  fourth  intercostal  spaces  at  the  right  border  of  the  sternum  and  a 
rounded  blunt  apex,  the  longest  diameter  being  transverse,  it  is  a  sign  of 
hypertrophy  and  dilatation  of  the  right  ventricle  and  auricle.  Enlarge- 
ment both  to  left  and  right  indicates  hypertrophy  and  dilatation  of  both 
ventricles,  the  dilatation  under  these  circumstances  being  almost  always 
in  excess  of  the  hypertrophy. 


142  MEDICAL  DIAGNOSIS. 

Enlargement  of  the  boundaries  of  precordial  dulness  to  the  lett.  right, 
and  upwards  may  indicate  the  presence  of  a  pericardial  effusion.  The 
dulness  is  marked  and  its  outline  is  pyramidal  or  pear-shaped,  the  smaller 
end  being  directed  upward.  The  increase  in  dulness  ma}'  be  first  observed 
in  the  angle  formed  by  the  right  border  of  the  cardiac  and  the  upper  border 
of  the  liver  dulness,  which  becomes  at  first  rounded  and  then  obliterated. 
The  dulness  may  extend  to  the  second  interspace  or  higher  and  is  sharply 
defined  at  its  borders.  In  pericardial  effusions  of  considerable  size  the 
compressed  left  lung  yields  a  vesiculotympanitic  or  tympanitic  resonance 
— dull  tAmipany;  skodaic  resonance.  The  apex-beat  may  be  felt  or  located 
by  the  intensity  of  the  first  sound  within  the  borders  of  dulness.  Percus- 
sion alone  will  not  always  enable  us  to  make  a  differential  diagnosis  between 
a  moderate  pericardial  effusion  and  extreme  dilatation  of  the  heart. 

Under  normal  conditions  the  impairment  of  resonance  due  to  the 
presence  of  the  aorta  and  pulmonary  artery  does  not  extend  beyond  the 
manubrium  on  either  side.  When  it  can  be  made  out  upon  the  right  side 
in  the  first  and  second  interspaces,  or  in  the  notch  of  the  sternum,  it  is 
usually  a  sign  of  dilatation  of  the  aorta  or  of  aneurism  of  the  ascending  or 
transverse  portion  of  the  arch.  Sometimes  it  indicates  the  presence  of  a 
mediastinal  tumor. 

Decrease  in  the  area  of  cardiac  dulness  is  mosth'  caused  by  pul- 
monar}'  emphysema,  by  which  the  heart  is  covered  more  completely  by 
the  lung  and  displaced  towards  the  middle  of  the  thorax.  The  heart  like 
other  muscle  masses  undergoes  atrophic  changes  in  acute  and  chronic 
wasting  diseases,  as  enteric  fever  and  consumption,  with  a  corresponding 
diminution  in  the  area  of  cardiac  dulness.  This  area  is  diminished  in  extent, 
altered  in  outline,  and  in  extreme  cases  rendered  wholly  unrecognizable 
by  percussion  in  left  pneumothorax,  pneumopericardium,  and  emphysema 
of  the  mediastinum,  such  as  follows  trauma  and  occasionally  occurs  in  fatal 
cases  of  pertussis  or  after  tracheotomy.  Extreme  meteorism  and  great 
distention  of  the  stomach  by  gas  may  cause  like  effects.  Under  these 
conditions  the  modified  pulmonary  resonance  of  the  deep  area  and  the 
dulness  of  the  superficial  area  are  replaced  by  a  tympanitic  note. 

Dislocation  of  the  Cardiac  Dulness. — The  heart  is  a  very  movable 
organ.  The  shifting  which  the  apex  undergoes  upon  changes  of  the  posture 
of  the  body  has  already  been  described.  The  heart  is  displaced  upwards 
by  great  meteorism.  ascites,  a  massive  abdominal  tumor,  or  pregnancy; 
to  the  left  by  pleural  effusion,  pneumothorax,  or  tumor  on  the  right  side; 
to  the  right  by  similar  conditions  upon  the  left  side.  Great  enlargement 
of  the  right  lobe  of  the  liver  likewise  displaces  the  heart  to  the  left.  Con- 
traction of  the  lung  with  adherent  pleurisy  displaces  the  heart  by  traction 
toward  the  affected  side,  as  in  old  pleural  effusions  that  have  undergone 
resorption  or  been  relieved  by  operation,  and  in  cirrhosis  of  the  lung. 
Aneurismal  or  cancerous  tumors  and  diaphragmatic  hernia  are  among  the 
rarer  causes  of  displacement  of  the  heart.  Practically  speaking,  displace- 
ments of  the  heart  are  the  result  of  diseases  of  the  pleura  or  lungs. 
The  greater  part  of  the  heart  and  its  apex  may  lie  to  the  right  of  the  median 
line  with  or  without  general  transposition  of  the  viscera.  Under  all  these 
conditions  except  the  last,  there  are  such  modifications  of  the  percussion 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  143 

signs  relating  to  the  heart  as  to  render  that  method  of  physical  diagnosis 
still  more  unsatisfactory  and  frequently  wholly  useless  in  determining  the 
boundaries  of  the  cardiac  dulness,  valuable  as  it  remains  in  the  diagnosis 
of  the  primary  disease.  The  position  of  the  apex  as  located  by  palpation 
and  auscultation  constitutes  the  most  reliable  evidence  of  the  region  occu- 
pied by  the  displaced  heart.  The  diagnosis  of  congenital  displacement  of 
the  heart  should  in  no  instance  be  made  until  all  other  causes  capable  of 
producing  such  displacement  have  been  shown  to  be  absent. 

Percussion  in  the  Examination  of  the  Abdomen. 

This  method  is  far  less  valuable  than  palpation  in  the  diagnosis  of 
abdominal  diseases.  It  has,  however,  much  usefulness  for  direct  examina- 
tion and  is  particularly  important  in  controlling  the  results  obtained  by 
the  other  methods  of  physical  examination. 

The  Technic. — The  general  directions  are  the  same  as  in  the  technic 
of  palpation.  Direct  percussion  except  flicking  percussion  cannot  be 
employed,  owing  to  the  sensitiveness  of  the  surface  and  the  elasticity  of 
the  walls  of  the  abdomen.  As  in  palpation  the  patient  must  be  examined 
in  various  postures,  and  it  is  frequently  necessary  to  distend  the  stomach 
or  colon  with  air  or  water.  Auscultatory  percussion  is  of  service  in  deter- 
mining the  boundary  lines  between  contiguous  viscera,  whether  they  be 
solid  or  air  containing. 

PERCUSSION   OF  THE   ABDOMEN    IN    HEALTH. 

The  upper  limits  of  hepatic  and  splenic  dulness  are  determined  by 
vesicular  resonance.  With  this  exception  the  signs  relate  to  dulness  and 
tympanitic  resonance  and  their  modifications. 

The  normal  dull  areas  in  the  abdomen  are: 

(a)  Hepatic- -The  upper  border  of  dulness  begins  about  the  level  of 
the  sixth  rib  in  the  midclavicular  line.  Its  lower  border  nearly  corre- 
sponds with  the  arch  of  the  ribs.  This  area  of  dulness  shifts  with  the 
respiratory  movements  about  two  fingers'  breadth  on  quiet  and  slightly 
more  upon  deep  breathing.  The  dulness  extends  upon  corresponding 
lines  in  the  epigastric  zone  and  its  respiratory  excursus  is  less  at  the 
back  than  in  front.  The  dulness  of  the  left  lobe  extends  to  the  left  of 
the  median  line  and  is  continuous  vertically  with  that  of  the  heart. 

(b)  Splenic. — The  dull  area  of  the  spleen  occupies  the  space  between 
the  ninth  and  eleventh  ribs,  its  anterior  border  being  slightly  in  advance 
of  the  midaxillary  line.  Its  respiratory  excursus  is  slightly  less  than  that 
of  the  liver.    The  observation  must  in  all  cases  be  confirmed  by  palpation. 

The  above  are  constant  in  health. 

Dull  areas  that  are  not  constant  also  occur  under  physiological 
conditions.     These  are: 

(c)  The  Distended  Bladder.— The  dull  area  is  situated  in  the  supra- 
pubic region  in  the  median  line.  It  may  extend  half-way  to  the  umbilicus. 
It  is  oval  and  symmetrical  in  outline  and  disappears  upon  micturition  or 
catheterization. 


144  MEDICAL  DIAGNOSIS. 

(d)  A  Distended  Stomach. — A  hearty  meal  or  the  large  ingestion  of 
fluid  will  cause  an  area  of  dulness  in  the  epigastrium  which  disappears 
in  the  course  of  digestion.  The  sharp  contrast  between  the  lower  border 
of  the  dulness  and  the  tympanitic  resonance  of  the  transverse  colon 
indicates  the  position  of  the  greater  curvature  of  the  stomach. 

(e)  Fecal  Masses  in  the  Colon. — In  persons  of  sedentary  habits  it 
is  not  uncommon  to  find  areas  of  dulness  corresponding  to  the  course  of 
the  colon,  and  especially  to  the  left  end  of  its  transverse  portion,  which 
disappear  upon  brisk  and  repeated  purgation. 

(f)  Pregnancy.  —  The  oval  area  of  dulness  gradually  developing 
upward  from  the  pelvis,  always  central,  at  first  symmetrical,  later  deflected 
somewhat  laterally,  is  suggestive.  The  diagnosis  of  this  physiological 
condition  under  ambiguous  circumstances  or  in  a  doubtful  case  must  be 
a  guarded  one. 

With  the  above  exceptions  the  percussion  resonance  of  the  abdomen 
is  tympanitic.  Its  pitch  varies  with  the  dimensions  of  the  particular  space 
and  the  tension  of  the  contained  air,  being  relatively  high  as  the  space  is 
small  and  the  tension  great.  The  stomach  and  colon  yield  therefore  a 
percussion  note  of  lower  pitch  than  the  small  intestines.  The  structure 
and  functions  of  these  organs  are,  however,  such  as  to  cause  great  varia- 
tions in  the  size,  tension,  and  relation  of  their  various  parts,  and  lessen  the 
value  of  the  signs  obtained  by  this  method  of  examination.  The  percussion 
signs  are  furthermore  greatly  modified  by  the  thickness  of  the  abdominal 
walls  and  their  general  state  as  to  tension  and  relaxation. 

PERCUSSION  IN  DISEASE  OF  THE  ABDOMINAL  ORGANS. 

Under  ordinary  circumstances  except  as  above  stated  the  abdomen 
in  health  is  everywhere  tympanitic  beyond  the  borders  of  the  liver  and 
spleen.  Persistent  dulness  is  significant  of  morbid  conditions.  It  may  be 
general  or  local,  continuous  with  the  dulness  of  the  liver  or  spleen  or 
separated  from  them,  fixed  or  shifting. 

General  Dulness  of  the  Abdomen. — The  retracted  abdomen  seen 
in  the  wasting  diseases  and  in  resophageal  and  pyloric  carcinoma,  cholera, 
and  the  pernicious  vomiting  of  pregnancy  is  usually  dull  upon  percussion. 
The  areas  of  tympanitic  resonance  are  limited  in  extent  and  of  irregular 
distribution.  This  is  especially  true  of  the  scaphoid  abdomen  so  often 
observed  in  meningitis,  tumor  of  the  brain,  and  lead  colic.  The  bowels 
are  empty  of  air  and  collapsed. 

The  general  distention  due  to  fat  in  the  walls  and  intra-abdominal 
fat,  fluid  within  the  peritoneal  cavity,  or  abdominal  tumor  yields  dulness 
upon  percussion.  The  bowels  contain  air  but  under  conditions  which 
modify  the  results  of  percussion.  In  the  case  of  an  excess  of  fat  in  the 
walls  the  force  of  the  blow  is  not  transmitted  to  the  underlying  gut;  in 
excessive  omental  fat  the  same  is  true.  Fluid  accumulates  in  the  depend- 
ent parts,  displacing  the  coils  of  intestine,  which  float  upon  the  surface, 
and  yields  dulness  upon  percussion  at  the  lower  levels  with  tympany  above 
shifting  with  change  of  posture,  the  line  between  them  tending  to  maintain 
its  correspondence  with  the  plane  of  the  horizon.    Thus,  in  the  recumbent 


PHYSICAL  DIAGNOSIS  :     PERCUSSION. 


145 


posture  there  is  general  dulness  save  in  a  limited  oval  region  around  the 
umbilicus,  over  which  there  is  tympanitic  resonance;  in  the  erect  posture 
the  resonance  of  this  region  is  replaced  by  dulness  while  there  may  be 
demonstrated  a  broad  line  of  tympanitic  resonance  in  the  epigastric  zone, 
previously  dull ;  in  the  lateral  postures  the  area  of  resonance  seeks  the  upper 
spaces  and  shifts  alternately  as  the  patient  turns  from  side  to  side.  The 
fluid  commonly  gravitates  slowly  from  region  to  region  and  a  few  moments 
must  be  permitted  to  elapse  before  the  change  of  note  can  be  demonstrated. 
Large  monocystS;  as  of  the  pancreas  or  ovary,  also  yield  fluctuation  and 
general  dulness,  but  the  intestines  do  not  float  at  the  highest  level,  being, 


Fig.  76.- 


-Free   fluid   in   abdominal    cavity — dorsal    decubitus — flatness   in   flanks    and   tympany  over 
supernatant  coils  of  intestines. 


Fig.  77. — Free  fluid  in  peritoneal  cavity — lat- 
eral decubitus — flatness  in  dependent  side  and 
tympany  above. 


Fig.  78. — Abdominal  tumor — increase  in  antero- 
posterior diameter — flatness  centrally  and  tympany 
in  flanks. 


on  the  contrary,  pushed  aside,  and  causing  resonance  in  the  flanks,  which 
does  not  change  to  any  great  extent  with  change  of  position  and  does  not 
present  the  oval  area  of  tympanitic  resonance  in  the  umbilical  region  which 
is  characteristic  of  ascites.  The  presence  of  peritoneal  adhesions  and  a  great 
quantity  of  fluid  sometimes  renders  fluctuation  obscure  and  the  results  of 
percussion  uncertain  by  interfering  with  the  free  movement  of  the  superna- 
tant intestines.  Tumors  of  sufficient  size  to  give  rise  to  marked  distention 
and  general  dulness  or  flatness  usually  increase  the  anteroposterior  diameter 
of  the  abdomen  to  a  greater  extent  than  the  bilateral  as  compared  with 
ascites  and  meteorism.  The  enlargement  caused  by  tumor  is  not  usually 
symmetrical.  The  intestines  are  pushed  aside  and  tympanitic  resonance  is 
10 


146 


MEDICAL  DIAGNOSIS. 


elicited  upon  percussion  in  the  flanks  and  especially  upon  the  opposite 
part  of  the  abdomen  to  that  from  which  the  growth  has  developed — on 
the  left  side  in  case  of  tumor  of  the  liver,  on  the  right  in  case  of  tumor  of 
the  spleen,  above  in  tumors  springing  from  the  pelvic  organs,  below  in 
those  springing  from  organs  in  the  epigastric  zone,  and  so  forth,  while  over 
the  tumor  there  is  dulness.  The  list  of  tumors  which  attain  dimensions 
sufficiently  great  to  cause  general  distention  of  the  abdomen  comprises 
cancer,  syphilitic  and  amyloid  disease,  and  hydatid  cysts  of  the  liver; 
malignant  disease  and  multiple  cysts  of  the  kidney;  cancer  of  the  intestines 
and  peritoneum;   ovarian  cysts  and  uterine  fibromata  and  retroperitoneal 

sarcoma.  Very  marked  distention 
may  be  present  in  pancreatic  cyst, 
hydronephrosis  and  tuberculosis  of 
the  mesenteric  glands,  and  Hodgkin's 
disease.  All  these  conditions  yield 
dulness  upon  percussion.  An  impor- 
tant sign  in  the  diagnosis  of  large  neo- 
plasms of  the  retroperitoneal  glands 
arises  from  the  fact  that,  while  the 
intestines  are  in  general  pushed  aside 
by  the  tumor,  the  ascending  or 
descending  colon,  according  to  the 
side  upon  which  the  growth  develops, 
passes  obliquely  across  it  and  yields 
tympanitic  resonance,  at  both  borders 
of  which  dulness  begins. 

Gaseous  distention  of  the  abdo- 
men—  meteorism,  tympany — yields 
tympanitic  resonance  at  all  points 
and  increases  the  vertical  diameter 
of  the  abdomen  by  pushing  the  dia- 
phragm upwards  and  interfering  with 
its  descent.  In  extreme  distention  the  note  becomes  higher  in  pitch, 
shorter  in  duration,  and  diminished  in  intensity  until  it  finally  may  be  dull. 
This  condition  is  commonly  due  to  paresis  of  the  intestinal  wall  and 
occurs  in  peritonitis,  the  advanced  stages  of  the  infectious  fevers,  and 
hysteria.  To  a  less  degree  it  is  present  in  cretinism,  rickets,  and  pseudo- 
hypertrophic paralysis.  Great  dilatation  of  the  stomach  and  congenital 
dilatation  of  the  colon  are  attended  with  general  abdominal  enlargement 
over  which  the  note  is  tympanitic. 

Free  gas  in  the  peritoneal  cavity  may  be  the  outcome  of  a  perforating 
ulcer  of  the  stomach  or  duodenum — peptic  ulcer — or  of  the  ileum  in  enteric 
fever  or  of  the  appendix.  The  accident  which  leads  to  the  escape  of  gas 
is  usually  attended  with  severe  abdominal  pain,  collapse,  and  meteorism. 
Rapid  obliteration  of  liver  dulness  in  an  abdomen  not  previously  much 
distended  is  an  important  sign.  Mere  disappearance  of  the  anterior  liver 
dulness  at  the  margin  of  the  ribs  or  in  the  nipple  line  may  be  a  sign  of  ordi- 
nary meteorism.  If,  however,  liver  dulness  is  present  in  the  infra-axillary 
line  while  the  patient  is  in  the  dorsal  decubitus  and  is  replaced  by  tym- 


FlG.  79. — Tumor  of  left  side  of  abdomen — 
dulness  with  strip  of  tympany  corresponding 
to  colon. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  147 

panitic  resonance  when  he  is  turned  upon  the  left  side,  it  may  be  inferred 
that  there  is  free  air  in  the  peritoneal  cavity. 

Local  Areas  of  Dulness. — Spasmodic  local  contractions  of  the  abdom- 
inal muscles  and  phantom  tumors  may  yield  dulness  upon  percussion. 
In  obscure  cases  a  somewhat  deeply  seated  tumor  may  be  examined  by 
percussion,  if  the  walls  are  relaxed,  by  pressing  with  the  pleximeter  hand 
gently  but  firmly  for  a  time  until  the  bowel  is  pushed  aside,  and  the  mass 
may  be  recognized  by  palpation  and  its  percussion  signs  ascertained. 
Any  local  tumor  or  new  growth  gives  rise  to  percussion  dulness  in  that 
area  of  the  abdominal  wall  which  overlies  it.  The  variety  of  such  morbid 
conditions  is  very  great.  The  nature  and  point  of  origin  of  the  most 
important  of  them  have  been  indicated  under  the  heading  Palpation 
in  Diseases  of  the  Abdominal  Organs. 

AUSCULTATION. 

Auscultation  as  a  method  of  physical  diagnosis  is  the  art  by  which 
we  recognize  and  interpret  the  sounds  produced  within  the  body  in  health 
and  disease. 

This  is  the  most  important  of  the  methods  of  physical  diagnosis.  It 
is  essential  to  the  diagnosis  of  diseases  of  the  organs  of  respiration  and 
circulation  and  of  limited  service  in  the  diagnosis  of  diseases  of  the  diges- 
tive organs. 

The  Methods. — Auscultation  is  of  two  kinds, — immediate  or  direct,  in 
which  the  ear  is  applied  directly  to  the  surface  to  be  examined,  and  mediate 
or  indirect,  in  which  a  stethoscope  is  employed.  The  latter  was  practised  by 
Laennec,  the  discoverer  of  auscultation;  the  former  has  since  come  into  use. 

Each  of  these  methods  has  its  peculiar  advantages  in  diagnosis.  Direct 
auscultation  is  useful  for  a  general  survey  of  the  chest,  including  both  its 
respiratory  and  circulatory  phenomena,  the  study  of  broad  areas  and  the 
determination  of  the  presence  or  absence  of  abnormal  signs.  It  also  enables 
us  to  detect  the  signs  of  deep-seated  lesions,  as  central  consolidation  o'f  the 
lung,  which  are  not  audible  by  the  stethoscope.  Indirect  auscultation,  on 
the  other  hand,  is  preferable  for  the  nice  study  of  the  signs  heard  in  limited 
areas,  the  point  of  maximum  intensity  of  a  murmur  or  the  limits  of  a  fric- 
tion sound.  Just  as  in  palpation  we  use  the  palm  of  the  hand  to  find  and 
estimate  the  extent  of  the  impulse  of  the  heart  and  then  study  its  force  and 
characters  with  the  smaller  and  more  sensitive  finger-tips,  so  the  experi- 
enced diagnostician  uses  the  two  methods  of  auscultation.  Like  the  other 
methods  of  physical  diagnosis  they  are  not  independent  and  sufficient  of 
themselves,  but  interdependent  and  complementary.  There  is  no  question 
as  to  which  should  be  employed,  since  both  are  necessary:  the  one  for  one 
kind  of  observation,  the  other  for  a  different  kind;  the  one  for  clinical 
research,  the  other  to  control  its  results. 

Many  experienced  auscultators  use  the  direct  method  in  the  exam- 
ination of  the  back  of  the  chest  and  the  stethoscope  for  the  examination 
of  the  anterior  surface,  the  reason  for  this  being  found  in  the  difficulty 
in  reaching  the  supraclavicular  and  axillary  regions  by  the  direct  method, 
the  closer  study  necessary  in  the  examination  of  cardiac  and  pericardial 


148 


MEDICAL  DIAGNOSIS. 


conditions,  and  certain  personal  considerations  which  appeal  to  the  user  of 
the  stethoscope. 

Stethoscopes. — These  instruments  are  made  of  various  materials  and 
shapes.  The  young  auscultator  of  a  mechanical  turn  of  mind  is  very  apt 
to  turn  his  attention  to  the  stethoscope  and  there  are  many  inventions. 
Few  only  deserve  serious  consideration.  The  underlying  principle  is  the 
conduction  of  the  sound.  There  are  two  kinds  of  stethoscopes,  the  single 
and  the  double  or  binaural. 

The  single  stethoscope  was  used  by  Laennec.  The  best  form  is  the 
gun-metal  instrument  with  detachable  hard-rubber  ear-piece  devised  by 
Hawksley  of  London. 

The  double  stethoscope  of  Cammann  of  New  York  consisted  of  a  chest- 
piece  connected  with  two  tubes  fitted  with  ear-pieces.  Many  modifications 
of  this  instrument  have  since  been  made  and  the  double  stethoscope  has 
come  into  general  use.  The  chest-pieces  as  now  made 
consist  of  interchangeable  bell-like  expansions  of  hard  or 
soft  rubber,  or  a  shallow  metal  cup  with  a  hard-rubber 
diaphragm  held  in  place  by  a  metal  ring,  seven-eighths 
of  an  inch  in  diameter  so  as  to  be  applied  to  the  costal 
interspaces,  or  larger;  the  tubes  are  long  and  flexible 
to.  enable  the  examiner  to  move  the  chest-pieces  freely 
without  changing  his  position,  while  the  ear-pieces  are 
in  some  instances  attached  to  metal  arms  held  together 
by  a  spring  or  hinged  and  held  in  position  by  a  rubber 
band.  In  other  forms  the  soft-rubber  tubes  are  con- 
nected directly  with  the  chest-piece  and  ear-piece,  the 
latter  retaining  its  place  in  the  meatus  by  its  appropri- 
ate shape  and  size. 

In  selecting  a  stethoscope  attention  should  be  given 
to  the  kind.  It  should  be  an  excellent  conductor  of 
sound  as  tested  by  comparing  several  different  instru- 
ments under  similar  conditions,  and  simple  in  construc- 
tion, durable,  and  convenient  to  carry.  Attention  must  also  be  given  to 
the  particular  instrument  to  see  that  the  ear-pieces  fit  comfortably,  that 
the  pressure  is  right,  and  that  extraneous  sounds  are  excluded. 

With  a  good  instrument,  even  with  the  unaided  ear,  and  a  fair  amount 
of  training  the  sounds  which  constitute  auscultatory  signs  may  be  heard. 
The  problem  in  diagnosis  is  their  proper  interpretation. 

The  phonendoscope  of  Bianchi  consists  of  a  shallow  metallic  circular 
chest -piece  with  vibrating  hard-rubber  disks  and  soft-rubber  tubing  con- 
ductors to  the  ear-pieces.  It  is  readily  applied,  and,  while  it  intensifies  the 
sounds,  does  not  produce  exaggerated  sounds.  It  is  especially  useful  in 
auscultatory  percussion. 

In  the  Bowles  stethoscope  the  chest-piece  is  constructed  wdth  a 
vibrating  hard-rubber  diaphragm  with  the  attachment  for  the  conducting 
tubes  at  a  right  angle  to  its  central  axis.  Multiple  attachments  are  made 
for  class  demonstration.  The  sounds  are  intensified  and  the  claim  has 
been  made  that  cardiac  murmurs  otherwise  inaudible  may  be  distinctly 
heard.     The  flat    chest-piece  is  especially  serviceable  in  the  examination 


Fig.  80.  —  Hawksley's 
single  stethoscope. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION. 


149 


of  the  back  of  the  chest  in  persons  too  ill  to  be  moved,  since  it  may,  by  push- 
ing the  bedclothes  down,  be  slipped  under  the  patient's  back  at  different 
points  without  changing  his  position.  Combinationformsin  which  the  Bowles 
attachment  is  fitted  into  the  chest-piece  of  an  ordinary  stethoscope  are  sold. 

The  differential  stethoscope  of  Alison  has  two  chest- 
pieces  with  separate  conducting  tubes.  This  instrument 
enables  the  examiner  to  compare  the  sounds  heard  at 
different  parts  of  the  chest  and  to  study  differences  in 
their  acoustic  properties  as  well  as  in  the  time  of  their 
occurrence.  Notwithstanding  its  value  it  has  not  come 
into  general  use. 

The  Technic  of  Auscultation.  —  The  following  gen- 
eral rules  are  to  be  observed: 

1.  The  patient's  attitude  should  in  so  far  as  possible 
be  comfortable  and  unconstrained. 

2.  Let  the  chest  be  bared  or  covered  only  with  a 
towel  or  single  layer  of  undergarment.  When  the  steth- 
oscope is  used  it  is  better  to  have  the  chest  bare. 
When  direct  auscultation  is  practiced  it  is  convenient 
and  fitting,  though  not  essential,  to  have  a  layer  of  thin 
stuff  between  the  ear  of  the  examiner  and  the  skin  of 
the  patient.  Auscultation  cannot  be  properly  performed 
through  the  patient's  ordinary  clothing.  The  superim- 
posed layers  of  several'  garments,  silk  fabrics,  and  the 
suspenders  or  corsets  not  only  mask  the  sounds  within 
the  chest  but  also  give  forth  sounds  of  their  own  upon 
respiratory  movements. 

3.  In  indirect  auscultation  apply  the  chest-piece 
of  the  stethoscope  closely  to  the  surface,  steadying  it 
by  grasping  it  between  the  thumb  and  index  finger. 

4.  If  the  single  stethoscope  is  used,  it  must  be 
applied  perpendicularly  to  the  surface.  If  it  is  tilted, 
external  sounds  are  not  excluded.    ' 

5.  The  stethoscope  must  be  applied  very  lightly  in 
auscultation  of  blood-vessels.  The  rim  of  the  instru- 
ment may  cause  a  murmur  in  the  vessels  at  the  root  of 
the  neck  or  in  the  abdominal  aorta  by  causing  the 
physical  condition  to  which  such  murmurs  are  due, 
namely,  sudden  narrowing  of  the  lumen — stenosis. 

6.  Examine  the  chest  in  a  routine  manner  first  at 
one  apex,  then  at  the  other,  and  at  corresponding  points 
upon  the  two  sides  from  above  downwards,  in  front, 
behind,  and  at  the  sides.  Comparison  and  contrast  are  essential  to  auscul- 
tation. Equally  important  are  the  differences  in  the  sounds  upon  ordinary 
quiet  breathing,  full  respiration,  and  coughing.  The  respiratory  signs  are 
to  be  considered  also  in  connection  with  the  signs  upon  auscultation  of 
the  voice.  In  very  serious  cases,  where  the  patient  cannot  be  disturbed 
or  where  the  condition  can  be  at  once  recognized,  a  complete  systematic 
examination  may  be  omitted. 


Fig 


81. — Bowles  bin- 
aural stethoscope. 


150  MEDICAL  DIAGNOSIS. 

7.  Examine  the  heart  in  the  same  systematic  manner,  placing  the 
stethoscope  over  the  puncta  maxima  in  turn  and  noting  the  direction  in 
which  sounds  or  murmurs  are  propagated  together  with  the  presence  or 
absence  of  friction  sounds,  etc. 

8.  Consider  the  patient.  Do  not  fatigue  him  unnecessarily"  either  in 
mind  or  body.  Do  not  cause  distress  by  undue  pressure  of  the  stethoscope 
or  by  insisting  upon  the  rejDetition  of  deep  breathing  or  cough  when  they 
give  rise  to  pain.  Conduct  the  examination  with  method,  dispatch,  and 
regard  for  his  feelings  and  do  not  repeat  it  with  unnecessary  frequency. 

9.  Consider  yourself.  Assume  a  position  which  enables  you  to  place 
your  ear  or  the  stethoscope  in  accurate  relation  to  the  surface  to  be  ex- 
amined. Use  such  patience  with  skill  as  will  render  the  examination 
satisfactory  to  you.  If,  despite  your  efforts,  the  results  do  not  justify 
a  diagnosis,  defer  expressing  an  opinion  until  you  have  an  opportunity 
of  repeating  the  examination  under  more  favorable  circumstances.  In 
dispensary  and  hospital  practice  be  on  your  guard  against  vermin. 

In  children  auscultation  is  even  more  valuable  in  the  diagnosis  of 
diseases  of  the  chest  than  in  adults.  Owing  to  the  great  elasticity  of  the 
walls  of  the  chest  and  the  corresponding  increase  of  resonance,  percussion 
is  of  much  less  general  applicability.  Dulness.  even  when  the  physical 
conditions  which  cause  it  are  present,  is  not  usually  so  marked  nor  its 
limits  so  easily  recognized,  nor  do  we  derive  the  same  advantage  from 
comparing  and  contrasting  the  two  sides,  since  the  acute  pulmonary 
affections  of  early  life  are  much  more  frequently  double  than  those  after 
the  second  dentition. 

In  children  the  back  of  the  lungs  should  be  first  listened  to.  The 
diagnosis  may  often  be  made  at  once  upon  a  careful  and  systematic  exami- 
nation of  the  back  alone,  after  taking  the  history  of  the  illness  and  noting 
the  symptoms.  This  is  especially  true  in  acute  and  chronic  bronchitis, 
croupous  and  bronchopneumonia,  and  pleural  effusion.  Crying  is  of  great 
assistance.  The  deep  inspirations  develop  the  signs  characteristic  of  the 
lesions  which  are  present,  and  we  also  obtain  the  signs  which  arise  from  the 
character  and  modifications  of  the  vocal  resonance. 

The  position  in  which  the  child  is  examined  by  auscultation  should 
vary  with  its  age.  Very  young  infants  may  be  examined  in  either  a  lying 
or  sitting  posture  on  the  lap  of  the  nurse  or  upon  a  pillow;  or  they  may 
be  held  in  the  arms  of  an  attendant  who  presents  one  part  of  the  chest 
after  another  to  the  ear  of  the  physician.  The  physician  himself  may 
hold  the  baby  seated  upon  his  left  hand  and  supported  by  his  right  hand 
applied  to  the  front  of  its  chest  and  listen  to  its  back  with  his  right  ear. 
Older  children  may  be  held  seated  upon  the  forearm  of  the  mother  or 
nurse  with  the  head  resting  upon  her  shoulder  while  the  physician  listens 
to  the  back. 

The  difficulty  with  beginners  in  auscultation  is  that  they  hear  too 
much.  They  cannot  at  first  discriminate  between  sounds  that  are  signifi- 
cant and  those  which  are  irrelevant.  The  power  to  do  this  comes,  however, 
with  practice. 

The  most  important  of  the  sounds  which,  by  a  process  of  selective 
attention,  the  young  auscultator  must  learn  to  disregard  are  the  following: 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  151 

1.  Outside  Noises. — A  quiet  room  and  silence  are  desirable  but  cannot 
always  be  secured.  We  must  train  ourselves  not  to  hear  extraneous  sounds 
while  engaged  in  listening  to  those  which  are  the  object  of  our  immediate 
attention.  Properly  fitting  ear-pieces  and  accurate  adjustment  of  the  chest- 
piece  of  the  stethoscope  are  of  help  in  excluding  the  sounds  which  we  do 
not  want  to  hear. 

2.  Accidental  noises  produced  by  the  stethoscope.  These  comprise 
friction  rubs  of  the  instrument  upon  the  skin,  especially  when  it  is  dry  and 
harsh  or  covered  with  coarse  hair;  friction  rubs  of  the  auscultator's  fingers, 
or  his  sleeves,  or  the  like,  upon  the  stethoscope;  friction  or  fine  snapping 
sounds  caused  by  the  movement  of  one  part  upon  another  of  an  adjustable 
stethoscope  of  several  pieces;  sounds  made  by  the  breath  of  the  examiner 
upon  the  rubber  cross-piece  or  steel  spring  of  the  stethoscope,  and  finally 
the  humming  or  buzzing  sound — tinnitus — made  by  the  ear-pieces.  Most  of 
these  sounds  are  easily  recognized  and  avoided.  The  last  is  to  be  dimin- 
ished by  very  careful  adjustment  of  the  ear-pieces  and  overcome  by  usage. 

3.  Adventitious  sounds  conducted  by  the  stethoscope  but  not  properly 
constituting  auscultatory  signs.  The  sounds  made  by  the  friction  of  the 
clothing  and  coarse  hairs  are  very  confusing.  The  first  are  easily  obviated; 
the  second  by  practice,  by  applying  the  chest-piece  beyond  the  borders 
of  the  hairy  patch,  or  by  the  use  of  oil.  Sounds  produced  by  the  contraction 
of  muscular  masses  may  often  be  heard,  especially  upon  deep  breathing, 
in  various  parts  of  the  chest  and  in  particular  over  the  pectorals  and  tra- 
pezii.  These  sounds  are  faint  and  variable  in  kind  but  often  quite  distinct. 
They  can  be  produced  upon  the  forcible  contraction  of  any  muscle.  The 
thenar  mass,  for  example,  when  contracted  with  the  stethoscope  applied 
over  it,  affords  a  good  illustration  of  such  sounds.  Cabot  has  suggested 
that  auscultatory  sounds  described  as  ''crumpling,"  "obscure,"  "distant," 
and  "indeterminate"  rales  are  in  reality  due  to  muscular  contractions. 
The  fact  that  such  sounds  are  very  often  associated  with  distinct  or  easily 
recognized  rales  and  other  evidences  of  pulmonary  disease  and  occur  in 
individuals  with  atrophic  chest  muscles,  should  put  us  on  our  guard  against 
hasty  conclusions. 

Auscultation  as  Applied  to  the  Diagnosis  of  Diseases 
of  the  Organs  of  Respiration. 

It  is  of  practical  importance  that  the  movement  of  the  tidal  air  on 
quiet  breathing  is  in  many  persons  not  sufficient  to  cause  auscultatory 
phenomena  of  significance.  It  becomes  necessary  then  to  listen  to  the 
chest  during  deep  or  forced  respiration.  If  the  patient  is  stupid  or  awk- 
ward, difficulties  arise.  He  holds  his  breath,  or  pants,  or  makes  strange 
noises,  or  does  not  appear  able  to  take  a  deep  breath.  You  show  him  how 
to  breathe  for  the  examination  or  you  ask  him  to  cough,  listening  to  the 
respiratory  signs  during  the  deep  inspiration  which  follows  or  precedes, 
or  you  ask  him  to  count  as  long  as  he  can  with  a  single  breath.  The  full 
breath  which  follows  enables  us  to  ascertain  the  presence  or  absence  of 
abnormal  signs.  These  difficulties  are  usually  encountered  in  subacute 
and  doubtful  cases.  In  acute  cases  and  in  chronic  cases  with  advanced 
lesions  the  signs  are  commonly  distinctive  upon  ordinary  breathing. 


152  MEDICAL  DIAGNOSIS. 


THE  SIGNS  IN  HEALTH. 


Auscultation  of  the  normal  chest  discovers  two  respiratory  sounds 
which  are  tj^pical: 

1.  Tracheal,  bronchial,  or  tubular  breathing, 

2.  Vesicular  breathing,  and  combinations  of  these  types  in  varying 
degree,  namely, 

3.  Bronchovesicular  breathing. 

1.  Tracheal,  bronchial,  or  tubular  breathing  is  heard  when  the 
stethoscope  is  placed  over  the  thyroid  cartilage,  over  the  trachea  in  the 
episternal  notch,  and  in  the  upper  part  of  the  interscapular  space  upon  the 
right  side — normal  bronchial  respiration.  Sometimes  nearly  pure  bronchial 
breathing  can  be  heard  in  health  over  the  manubrium  sterni  or  the  three 
lower  cervical  vertebrae. 

It  has  its  origin  in  the  larynx,  and  is  sometimes  for  that  reason  spoken 
of  as  laryngeal,  and,  from  the  situations  at  which  it  is  heard  in  health, 
tracheal  or  bronchial.  Since  it  is  conducted  along  the  column  of  air  in  the 
bronchial  system  and  probably  also  along  its  elastic  walls  and  resembles 
the  sound  produced  by  breathing  through  a  tube,  it  is  called  tubular. 

This  type  of  breath  sound  is  heard  with  inspiration  and  expiration, 
these  two  elements  of  the  sound  being  separated  by  a  brief  interval  of  silence 
at  the  end  of  inspiration.  Its  quality  is  bronchial,  tubular,  or  blowing; 
its  pitch  relatively  high  as  compared  with  vesicular  breathing.  The  expira- 
tory element  is  slightly  more  intense,  usually  of  higher  pitch,  and  slightly 
more  prolonged  than  the  inspiratory  part.  It  may  be  imitated  by  slowly 
breathing  through  the  hollow  of  the  hand,  closed  by  flexing  the  fingers 
till  their  tips  touch  thenar  and  hypothenar  eminences,  or  through  the 
lips  and  teeth  held  in  the  position  to  sound  the  German  ch. 

It  is  produced  at  the  chink  of  the  glottis  where  the  air  upon  inspira- 
tion and  expiration  is  thrown  into  eddies  or  swirls — fluid  veins.  For  the 
reason  that  a  similar  mechanism  is  involved  in  the  production  of  vesicular 
breathing  and  cardiac  and  vascular  murmurs,  it  may  properly  be  considered 
at  this  point. 

The  Theory  of  Fluid  Veins.  —  Chauveau  pointed  out  the  fact  that 
when  a  fluid  is  forced  under  pressure  from  a  narrow  into  a  wider  tube  or 
channel,  or  through  a  narrow  opening  into  a  large  cavity  or  space,  it  is 
thrown  into  swirls  or  eddies,  the  vibrations  of  which,  transmitted  to  the 
enclosing  substance  and  to  the  surrounding  air,  are  recognized  as  auditory 
phenomena.  These  swirls  have  been  called  fluid  veins.  They  are  currents 
within  currents,  and  their  vibrations  are  not  only  transmitted  laterally 
but  also  longitudinally  in  the  stream  in  which  they  exist,  so  that  the  sounds 
are  heard  over  the  point  at  which  they  are  produced  and  at  a  distance  in 
the  direction  of  the  flow.  The  extent  and  force  of  these  swirls  and  the 
consequent  loudness  of  the  sound  by  which  they  are  represented  depend 
to  some  extent  upon  the  composition  and  density  of  the  fluid  but  mainly 
upon  the  force  of  the  current.  The  student  will  realize  the  nature  of  fluid 
veins  and  the  part  they  play  in  the  production  of  the  bronchial  respiration 
and  the  vesicular  murmur, — for  the  air  acts  in  the  same  way  as  other 
fluids, — and  especially  their  part  in  the  production  of  endocardial  and  vas- 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  153 

cular  murmurs,  if  he  considers  the  course  of  a  rivulet  which  flows  at  one 
time  down  a  steep  and  rapid  course,  and  at  another  along  a  nearly  level 
bed  with  even  sides  and  a  smooth  bottom,  and  now  as  a  gentle  stream  and 
again  with  considerable  force.  The  quiet  current  flowing  in  even  banks 
is  smooth  and  noiseless,  while  the  little  torrent  in  its  rocky  bed  has  its 
surface  thrown  into  countless  screw-like  swirls,  and  murmurs  or  roars, 
according  to  the  force  and  volume  of  the  water.  The  stream  is  an  open 
channel;  the  respiratory  and  vascular  spaces  are  closed  tubes;  but  the 
mechanism  by  which  the  sounds  are  produced  is  the  same  in  each.  It  is 
evident  that  the  intensity  of  the  bronchial  respiration  will  vary  with  the 
quantity  of  the  tidal  air,  the  force  with  which  it  passes  through  the 
glottis,  the  distance  at  which  it  is  heard,  and  the  conducting  properties 
of  the  media  through  which  it  is  transmitted.  Variations  in  pitch  depend 
upon  the  size  and  shape  of  the  spaces — pharynx,  buccal  cavity,  trachea, 
etc. — which  constitute  resonating  chambers  in  relation  with  the  larynx. 
We  are  thus  prepared  to  find  wide  differences  in  intensity  and  pitch  in  the 
breath  sounds  which  have  the  characteristic  tubular  or  bronchial  quality. 

2.  Vesicular  Breathing. — Respiration  of  this  type  is  heard  when  the 
stethoscope  is  placed  elsewhere  over  the  chest  where  the  lungs  are  in 
contact  with  the  chest  wall,  namely,  in  the  front  of  the  thorax  with  the 
exception  of  the  area  of  superficial  cardiac  and  hepatic  dulness,  in  the 
infrascapular  regions  and  in  the  axillary  and  the  upper  part  of  the  infra- 
axillary  regions.  In  the  right  interscapular  region  the  breathing  in  health 
is  usually  broncho  vesicular,  the  vesicular  element  predominating. 

This  sound  has  its  origin  in  the  parenchyma  of  the  lung,  and  is  due  to 
the  transmission  of  the  vibrations,  caused  by  fluid  veins  or  swirls  in  the 
air  passing  into  and  out  of  the  infundibula  and  alveoli,  to  the  surface  of 
the  chest.  The  hypothesis  that  the  vesicular  respiration  is  merely  a  modi- 
fication of  the  bronchial  appears  to  me  to  rest  upon  insufficient  facts.  This 
type  of  breathing  is  heard  throughout  the  whole  act  of  inspiration,  and  is 
immediately  followed,  without  an  interval  of  silence,  by  a  short  but  incon- 
stant expiratory  sound.  The  inspiratory  portion  is  low  in  pitch  as  com- 
pared with  bronchial  respiration,  of  variable  intensity,  and  has  the  char- 
acteristic quality  described  as  vesicular,  which  is  to  be  learned  only  by 
experience.  It  is  sometimes  called  the  vesicular  murmur,  and  it  may  be 
of  service  to  the  student  to  note  that  it  possesses  the  distinguishing  pecuUar- 
ity  of  murmurs,  namely,  that  they  are  sounds  made  up  of  a  multitude  of 
small  sounds,  all  having  about  the  same  acoustic  properties,  as  we  speak 
of  the  murmur  of  a  crowd,  of  the  leaves  of  the  forest,  of  the  sea,  and  so  on. 
The  expiratory  part  is  still  lower  in  pitch  than  the  inspiratory,  much  less 
intense,  frequently  absent  altogether,  and  does  not  exceed  one-third  the 
length  of  the  latter. 

The  vesicular  murmur  is  not  equally  intense  in  all  parts  of  the  chest. 
It  is  loudest  in  the  infraclavicular,  axillary,  and  infrascapular  regions,  and 
fainter  at  the  bases  in  front  and  behind.  That  is  to  say,  it  is  loudest  over 
large  masses  of  lung  tissue  and  faintest  over  the  thin  wedge-shaped  borders. 
But  it  is  also  less  distinctly  heard  in  the  mammary  and  scapular  regions. 
We  conclude  therefore  that  it  is  not  well  conducted  through  thick  layers 
of  muscle,  bone,  and  fat.    Wherever  heard,  whether  loud  or  faint,  it  retains 


154  MEDICAL  DIAGNOSIS. 

its  characteristic  breezy  quality  and  low  pitch,  and  the  relative  duration, 
intensity,  and  pitch  of  the  inspiratory  and  expiratory  elements  are  preserved. 

The  vesicular  murmur  is  feeble  and  distant  on  shallow  breathing  and 
intense  upon  deep  breathing,  especially  after  prolonged  deep  breathing  as 
after  exertion.  It  is  intense  over  the  unaffected  lung  in  cases  in  which  the 
opposite  lung  has  been  thrown  out  of  service  by  disease,  and  in  healthy  chil- 
dren, hence  it  is  spoken  of,  when  thus  intensified,  as  "puerile"  or  "exagger- 
ated' '  respiration.  Intense  vesicular  respiration  somewhat  modified  is  spoken 
of  as  "rough";  just  as  broncho  vesicular  respiration  is  often  called  "harsh." 

3.  Bronchovesicular  Breathing.  —  This  form  of  respiration,  as  the 
name  indicates,  has  the  characteristics  of  both  bronchial  and  vesicular 
breathing  and  consists  in  fact  of  a  breath  sound  in  which  both  are  present. 
It  is  heard  in  the  normal  chest  very  often,  but  not  invariably  directly  below 
the  right  clavicle,  and  quite  constantly  at  the  sternal  borders  opposite  the 
lower  part  of  the  manubrium  and  in  the  upper  portions  of  the  interscapular 
spaces,  namely,  in  situations  in  which  both  sounds  are  within  range  of 
hearing.  Many  of  the  difficulties  regarding  bronchovesicular  respiration 
are  solved  when  we  recognize  the  fact  that  it  is  made  up  of  the  two  forms 
in  varying  degrees  of  combination,  so  that  it  sometimes  presents  the  traits 
of  bronchial  breathing  slightly  modified  by  the  admixture  of  faint  vesicular 
breathing  and  sometimes  those  of  vesicular  breathing  slightly  modified 
by  bronchial,  and  between  these  two  we  encounter  every  grade  of  admixture. 
This  gradation  by  which  the  breath  sound  passes  from  bronchial  to  the 
vesicular  respiration  may  be  heard  in  the  normal  chest  by  moving  the 
stethoscope  from  point  to  point,  starting  at  that  part  of  the  manubrium 
over  which  bronchial  breathing  is  heard  and  advancing  towards  the  nipple 
where  the  vesicular  murmur  alone  can  be  recognized.  The  inspiration 
becomes,  as  we  proceed,  lower  in  pitch,  less  intense,  and  longer  in  duration, 
and  the  expiration  also  lower  in  pitch  and  less  intense,  but  shorter  in 
duration.  The  interval  of  silence  which  is  characteristic  of  bronchial 
respiration  is  filled  by  the  vesicular  element  in  bronchovesicular  respiration. 
This  interval  of  silence  is  present  in  bronchial  breathing  because  the  swirls 
— fluid  veins — by  which  the  vibrations  causing  the  sound  are  produced, 
arise  at  a  single  point,  the  glottis,  and  there  is  at  that  point  an  interval  of 
equilibrium  between  the  flood  tide  of  inspiratory  and  the  ebb  tide  of  expira- 
tory air.  The  vesicular  murmur,  on  the  other  hand,  is  produced  at  a 
multitude  of  different  points,  and  the  moment  of  silence  is  as  variable  as  the 
individual  httle  sounds  which  cover  the  whole  time  of  the  inspiratory 
act,  since  vesicles  at  the  distant  periphery  of  the  lung  are  still  expanding 
when  those  nearer  the  inlet  have  ceased  to  dilate. 

The  conditions  which  modify  the  bronchial  respiration  as  a  physical 
sign  and  those  which  modify  the  vesicular  murmur  also  modify  the  broncho- 
vesicular breathing.  It  therefore  presents  differences  in  intensity,  dura- 
tion, and  pitch,  corresponding  to  variations  in  the  quantity  and  force  of 
movement  of  the  tidal  air,  to  the  size  and  shape  of  the  resonating  chambers 
formed  by  the  upper  air  spaces  and  the  tracheobronchial  system  and  the 
physical  condition  of  the  intervening  tissues  through  which  the  sounds  are 
conducted  to  the  ear.  The  qualities  of  the  two  component  types  of  breath- 
ing, though  they  vary  in  proportion,  are  not  changed. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  155 

It  is  essential  for  the  student  to  become  familiar  with  these  three 
forms  of  normal  breath  sounds  and  the  localities  in  which  they  may  be 
heard  in  the  normal  chest.  Familiarity  with  normal  physical  signs  is  the 
first  step  towards  the  recognition  of  those  w^hich  are  abnormal. 

Bronchial  breathing  is  heard  in  the  front  of  the  neck  and  over  the 
upper  part  of  the  manubrium,  vesicular  breathing  over  the  greater 
part  of  the  chest,  as  above,  because  the  mechanism  by  which  they  are 
respectively  produced  is  situated  in  the  regions  indicated.  Broncho- 
vesicular  respiration  is  heard  normally  over  the  lower  part  of  the  manu- 
brium and  laterally  to  it  and  in  the  interscapular  spaces  because  both  its 
factors  are  within  the  range  of  hearing.  Bronchial  respiration  is  heard  in 
the  right  interscapular  space  and  bronchovesicular  respiration  is  more 
prominent  (bronchial)  over  the  upper  part  of  the  right  lung  by  reason  of 
the  larger  size  and  higher  origin  of  the  large  bronchus  on  the  sight  side. 

Bronchial  or  tubular  breathing  is  conducted  in  the  column  of  air  in 
the  bronchial  tree  to  its  remote  twigs.  It  is  not  conducted  to  the  surface 
of  the  chest  because  the  vibrations  are  on  the  one  hand  lost  in  the  mass 
of  cushiony,  elastic  vesicular  tissue  which  constitutes  the  lung  parenchyma, 
and  on  the  other  hand  the  bronchial  sound  is  drowned  in  the  vesicular 
murmur.  When  this  tissue  becomes  soUdified  by  compression — atelectasis 
— or  by  an  exudate — pneumonia,  tuberculosis — the  vesicular  murmur  is 
done  away  with  and  the  vibrations  conducted  by  the  bronchial  tubes  are 
freely  transmitted  to  the  surface. 

THE  SIGNS  IN  DISEASE. 

The  auscultatory  phenomena  which  constitute  abnormal  or  morbid 
physical  signs  are  (a)  variations  in  the  intensity  and  rhythm  of  the  breath 
sounds,  (b)  normal  physical  signs  heard  in  abnormal  situations,  and  (c) 
purely  adventitious  sounds. 

(a)  Variations  in  Intensity  and  Rhythm. — Bronchial  Respiration. — 
It  has  been  explained  that  bronchial  respiration  heard  beyond  the  limits 
of  certain  regions  of  the  chest  in  which  it  is  normally  present  is  usually 
due  to  the  consolidation  of  lung  tissue — atelectasis;  presence  of  an  exudate, 
as  in  pneumonia,  tuberculosis,  etc.  It  may,  however,  arise  in  connection 
with  cavities  in  the  lungs  or  pneumothorax.  Under  these  circumstances 
there  are  layers  and  masses  of  compressed  or  consolidated  lung  tissue 
present  and  the  peculiar  modification  of  the  bronchial  respiration  is  prob- 
ably due  to  the  fact  that  the  cavity  acts  as  a  resonating  space.  Bronchial 
respiration  varies  greatly  in  pitch.  This  variation  is  the  outcome  of  com- 
plex conditions  not  fully  understood,  but  has  been  attributed  to  the  rela- 
tive size  of  the  tubes  or  cavities  from  which  the  sound  is  directly  conducted 
through  consolidated  tissue  to  the  ear.  The  pitch  is  usually  high  and  the 
sounds  whiffing  or  snoring  in  pneumonia  of  the  lower  lobes,  especially  in 
children,  and  low  and  the  sound  soft  and  sighing  or  metallic  over  cavities. 

The  following  varieties  of  bronchial  respiration  are  to  be  especially 
considered: 

1.  Feeble  and  distant  bronchial  respiration  is  often  heard  in  central 
pneumonia  and  pulmonary  infarct  and  over  a  pleural    effusion      In  the 


156  MEDICAL  DIAGNOSIS. 

former  case  the  bronchial  breathing  may  be  only  heard  upon  deep  inspira- 
tion and  is  therefore  inconstant;  in  the  latter  it  is  frequently  so  faint  as 
to  be  overlooked.  The  sound  is  conducted  by  the  chest  wall  or  by  tense 
adhesions,  the  result  of  former  attacks  of  pleurisy. 

2.  Intense  bronchial  breathmg  usually  conveys  the  sensation  of  being 
close  to  the  ear,  that  is,  well  conducted.  It  accompanies  dense  consolida- 
tion of  the  lung  in  which  vicarious  or  supplemental  respiration  is  well 
established. 

3.  Absence  of  bronchial  respiration  or  its  sudden  disappearance  under 
conditions  in  which  the  mechanism  for  its  conduction  exists  may  be  due 
to  the  plugging  of  a  large  bronchus  with  a  mass  of  tenacious  exudate. 
The  disappearance  of  cavernous  or  amphoric  respiration  often  results  from 
the  accumulation  of  fluid  within  the  walls  of  the  cavity.  Under  these  cir- 
cumstances the  bronchial  respiration  returns  after  cough  and  expectoration. 

4.  Cavernous  respiratioti  is  a  variety  of  bronchial  breathing  sometimes 
heard  over  a  cavity.  It  is  low  in  pitch,  soft  in  quality,  and  the  expiratory 
element  is  prolonged. 

5.  Amphoric  respiration  is  a  variety  which  has  the  peculiar  quality 
heard  when  one  produces  a  sound  by  blowing  across  the  mouth  of  an  empty 
jar  or  bottle.  The  pitch  is  variable,  usually  low,  and  the  sound  is  hollow, 
metallic,  and  musical.  Amphoric  respiration  is  never  heard  over  the  normal 
chest,  and  indicates  a  superficial  cavity  vdih.  rigid  walls — or  pneumothorax 
— having  free  communication  with  a  large  bronchus.  The  sound  may  be 
imitated  by  whispering  "who"  with  some  force  and  the  lips  held  rigid. 

Vesicular  Respiration  —  The  normal  vesicular  murmur  undergoes 
modifications  in  intensity  and  rhythm  which  are  of  diagnostic  significance. 

1.  Feeble  vesicular  respiration  primarily  indicates  diminution  in  the 
quantity  and  energy  of  the  movement  of  the  tidal  air.  Hence  it  is  present 
in  varying  degrees  in  quiet  breathing  in  aged  and  bed-ridden  persons, 
in  paretic  conditions  of  the  respirator}^  muscles,  including  the  diaphragm, 
when  the  movement  of  the  diaphragm  is  impeded  by  meteorism,  ascites, 
abdominal  tumor,  or  pregnancy.  The  vesicular  murmur  is  often  feebly 
heard  because  it  is  poorly  conducted,  as  in  very  thick  chest  walls.  In 
pleural  adhesions  the  expansion  of  the  periphery  of  the  lung  may  be  em- 
barrassed, and  with  thickening  conduction  is  also  impaired.  A  thin  layer 
of  effusion  or  a  tumor  acts  in  the  same  waj'.  In  pneumothorax  the  lung 
is  compressed  and  removed  from  contact  with  the  chest  wall,  and  the 
vesicular  murmur,  if  heard  at  all,  is  faint  and  distant.  In  acute  bronchitis 
the  swelling  of  the  mucosa  and  the  presence  of  the  exudate  interfere  with 
the  access  of  air  to  the  vesicles  and  proportionately  enfeeble  the  vesicular 
murmur,  especially  over  the  lower  lobes.  In  chronic  bronchitis  enfeeble- 
ment  is  brought  about  by  the  accompanying  emphysema  and  restricted 
movements  of  the  chest. 

In  congestion  and  oedema  of  the  lungs  the  murmur  is  enfeebled. 

Emphysema  by  impairing  the  elasticity  of  the  lungs  and  restricting 
the  respiratory  excursus  increases  the  residual  and  diminishes  the  tidal  air, 
thus  rendering  the  vesicular  murmur  faint  and  in  rare  cases  almost 
wholly  abolishing  it.  Pain,  as  in  pleurisy,  restricts  the  respiratory 
movement  and  renders  the  vesicular  sound  faint. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  157 

Occlusion  of  the  upper  air-passages,  as  by  spasm,  oedema  of  the  glottis, 
the  presence  of  an  exudate,  as  in  diphtheria,  quinsy,  or  retropharyngeal 
abscess,  renders  the  murmur  feeble  in  proportion  to  the  extent  of  the 
obstruction.  Pressure  upon  the  trachea  or  a  primary  bronchus  by  aneurism, 
tumor,  or  enlarged  lymph-gland  acts  in  the  same  way.  A  foreign  body 
or  a  plug  of  tenacious  mucus  in  a  bronchus  enfeebles  the  respiratory  murmur 
in  the  corresponding  region  to  a  degree  proportionate  to  the  stenosis.  In 
such  conditions  the  occurrence  of  rales  obscures  the  enfeeblement  of  the 
respiratory  sounds  and  the  latter  will  be  overlooked  unless  made  the 
subject  of  especial  attention. 

2.  Absence  of  the  vesicular  murmur  may  be  noted  over  an  area  of  the 
chest  more  or  less  extensive  when  the  obstruction  to  a  bronchus  in  any  of 
the  foregoing  conditions  is  complete.  Marked  obstruction  of  the  upper  air- 
passages  is  at  once  followed  by  the  signs  of  asphyxia.  The  murmur  is 
absent  over  the  greater  part  of  the  chest  in  rare  cases  of  advanced  emphy- 
sema, and  no  respiratory  sound  is  heard  over  a  pneumothorax  not  com- 
municating with  a  bronchus,  a  large  pleural  effusion  and  locally  over  limited 
areas  in  some  cases  of  cirrhosis  of  the  lung  and  at  the  apex  in  rare  instances 
in  beginning  tuberculosis. 

3.  Intensified  or  exaggerated  vesicular  breathing — puerile,  vicarious,  or 
compensatory  respiration — is  normal  in  childhood  and  gradually  decreases 
until  some  time  before  puberty  the  intensity  of  the  sound  becomes  that 
of  adult  life.  It  occurs  in  health  after  exertion  and  in  dyspnoea  from 
almost  any  cause  in  which  there  is  no  obstruction  to  the  entrance  of  air. 
It  occurs  over  one  lung  when  the  other  is  put  out  of  service,  as  in  pneu- 
monia, large  effusion,  tumor,  etc.,  and  in  some  instances  over  a  portion 
of  one  lung  under  similar  conditions,  hence  the  adjectives  vicarious  and 
compensatory. 

4.  Derangements  of  rhythm  occur  in  emphysema,  in  which  the  loss  of 
elasticity  relatively  prolongs  the  expiratory  act  and  the  expiratory  sound; 
in  asthma,  in  which  the  dyspnoea  is  expiratory,  in  the  ordinary  dyspnoea 
or  panting  of  great  exertion,  in  which  the  inspiratory  and  the  expiratory 
breath  sounds  are  nearly  equal,  and  in  various  forms  of  inspiratory  dyspnoea 
which  are  attended  by  diminution  of  the  intensity  and  prolongation  of 
the  inspiratory  element  of  the  vesicular  murmur. 

5.  Interrupted  or  cogwheel  inspiration  is  characterized  by  a  series  of  two, 
three,  or  four  inspiratory  sounds  instead  of  the  normal  continuous  murmur. 
It  indicates  in  some  instances  a  fault  in  the  muscular  function  and  occurs 
during  periods  of  excitement  or  during  a  chill;  more  commonly  it  is  a  sign 
of  early  pulmonary  tuberculosis,  the  air  entering  adjacent  lobules  in  turn 
as  the  force  of  inspiration  increases.  It  is  usuall}^  heard  in  limited  areas. 
When  restricted  to  the  precordial  space  it  is  significant  of  pressure  of  the 
heart  upon  the  borders  of  the  lung — cardiopulmonary  murmur.  In  some 
instances  the  respiratory  sound  is  not  actually  broken,  but  wavy  or  jerky, 
and  is  then  described  under  these  terms.  It  is  not  rarely  present  in  tuber- 
culosis before  the  disease  has  shown  itself  by  other  signs,  and  individuals 
who  present  it  should  be  carefully  watched.  In  other  cases  it  is  wholly 
without  diagnostic  significance,  which  it  acquires  only  in  conjunction  with 
other  physical  signs  or  the  symptoms  of  pulmonary  disease. 


158  MEDICAL  DIAGNOSIS. 

(b)  Normal  Physical  Signs  in  Abnormal  Situations. — Normal  Sounds 
Heard  in  Abnormal  Situations. — Note  the  relative  duration  of  the  inspir- 
atory and  expiratory  sounds  and  determine  the  presence  or  absence  of  an 
interval  of  silence  between  them  and  the  quality  of  the  sound,  whether  soft 
and  breezy — vesicular  murmur;  blowing  and  tubular — bronchial  breathing; 
or  whether  these  qualities  are  both  present — bronchovesicular.  The  most 
important  facts  for  the  beginner  in  the  recognition  of  bronchovesicular  respi- 
ration are  the  prolongation  and  relatively  high  pitch  of  the  expiratorj^  sound. 

Perfectly  normal  vesicular  respiration  is  rarely  heard  in  other  than  its 
extensive  normal  domain  in  the  chest.  The  rare  cases  of  dextrocardia  are 
attended  with  dislocation  of  the  precordial  space,  and  fibroid  contraction 
of  one  lung  frequently  displaces  the  border  of  the  opposite  lung  towards 
the  affected  side  so  that  it  occupies  the  area  of  superficial  cardiac  dulness 
in  whole  or  in  part.  The  modified  respiration  of  emphysema,  faint  and 
prolonged,  is  sometimes  heard  in  the  precordia  and  over  the  upper  normal 
area  of  the  liver  dulness. 

Bronchovesicular  and  bronchial  respiration  are  on  the  contrary  com- 
mon and  significant  signs  of  disease  in  the  chest.  The  lesions  are  commonly 
progressive,  and  bronchovesicular  usually,  both  in  acute  and  chronic  affec- 
tions, precedes  and  progressively  develops  into  bronchial  respiration. 
Pulmonary  consolidation  either  from  compression  or  infiltration  is  the 
underlying  physical  condition  and  reaches  its  extreme  development  whether 
rapidly  or  slowly  by  progressive  advance. 

These  signs  are  heard  over  the  compressed  lung  in  the  following 
conditions:  pleural  effusion,  the  area  in  which  they  are  present  becom- 
ing more  limited  and  the  respiration  more  characteristically  bronchial 
as  the  effusion  augments;  pericardial  effusion;  pneumothorax,  in  which 
more  or  less  complete  compression  of  the  lung,  unless  prevented  by  old 
partial  adhesions,,  takes  place  rapidly;  tumor  of  the  lung  or  pleura;  massive 
enlargement  of  the  heart,  and  large  aortic  aneurism.  They  are  heard  over 
the  lung  undergoing  solidification  or  already  solidified  from  infiltration  in 
tuberculosis,  bronchopneumonia,  croupous  pneumonia,  pulmonary  infarct. 
As  already  pointed  out,  distant  bronchial  breathing  may  frequently  be  heard 
over  an  effusion.  It  remains  to  point  out  the  more  important  fact  that 
loud,  distinct,  and  well-conducted  bronchial  respiration  is  by  no  means 
uncommon  over  pleural  effusions  of  large  amount  in  thin-walled  individuals 
and  especially  in  children.  This  sign  is  conducted  from  the  compressed 
lung  by  way  of  the  wall  of  the  chest  and  probably  in  some  cases  also  along 
bands  of  old  adhesions  tightly  stretched  between  the  compressed  lung  and 
the  chest  wall  by  the  force  of  the  accumulating  fluid.  In  pneumothorax 
the  variety  of  bronchial  breathing  known  as  amphoric  is  heard  when  there 
is  free  communication  between  the  pleural  cavity  and  a  bronchus. 

Cavernous  or  amphoric  respiration  may  be  heard  over  cavities, 
whether  due  to  the  breaking  down  of  lung  tissue  (tuberculosis,  abscess, 
gangrene)  or  to  dilatation  of  bronchi  (bronchiectasis).  Deep-seated  cavi- 
ties due  to  any  of  these  causes  may  be  attended  with  distinct  bronchial 
respiration  yet  be  difficult  to  locate  with  precision. 

Bronchovesicular  respiration  must  be  distinguished  on  the  one  hand 
from  puerile  or  exaggerated  vesicular  respiration  and  on  the  other  from 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  159 

bronchial  respiration.  The  breezj^  quality,  low  pitch,  short  expiratory 
element,  and  absence  of  a  period  of  silence  between  inspiration  and  expira- 
tion are  characteristic  of  the  former,  however  intense.  The  tubular  quality, 
relatively  high  pitch,  longer  expiratory  sound,  and  an  interval  of  silence 
are  distinctive  of  the  latter,  and  between  the  two  are  all  degrees  of  transi- 
tional sounds.  Normal  in  the  right  infraclavicular  region,  at  the  upper 
sternal  borders,  and  in  the  neighborhood  of  the  upper  dorsal  vertebrae, 
bronchovesicular  respiration  elsewhere  in  the  chest  becomes  a  sign  of 
disease,  and  denotes  partial  consolidation  of  the  lung,  patches  of  collapse 
or  infiltrated  lung  or  consolidation  with  intervening  normal  vesicular 
tissue.  This  sign  is  present  in  early  pulmonary  tuberculosis,  at  the  borders 
of  the  exudate  in  croupous  pneumonia,  in  bronchopneumonia,  and  in 
incomplete  atelectasis  from  any  cause. 

(c)  Adventitious  Sounds. — Purely  adventitious  respiratory  signs 
are  of  two  kinds:  (1)  Rales,  which  are  produced  by  abnormal  conditions 
within  the  lungs,  and  (2)  friction  sounds  which  originate  in  the  pleura. 

1.  Rales. — Literally  a  rale  is  a  "rattle"  and  may  be  defined  as  an 
abnormal  respiratory  sound  heard  on  auscultation.  Rales  are  grouped  as 
dry  or  moist  according  to  the  impression  conveyed  to  the  mind  as  to  the 
presence  or  absence  of  fluid  in  the  mechanism  by  which  they  are  produced. 
They  are  laryngeal,  tracheal,  bronchial,  vesicular,  and  cavernous,  according 
to  the  situations  in  which  they  occur. 

In  general  rales  or  rhonchi  are  generated  in  the  air-passages  by  the 
ebb  and  flow  of  the  air  when  their  lumen  is  contracted  or  when  they  con- 
tain fluid — dry  and  moist  bronchial  rales.  Certain  rales  originate  in  the 
bronchioles  and  vesicular  structure  of  the  lung  (vesicular  rales),  others 
in  cavities  (gurgling),  and  finally  the  succussion  sound  and  the  sign  known 
as  gutta  cadens  or  metallic  tinkling  have  their  origin  in  hydropneumothorax. 
Rales  may  be  heard  upon  inspiration  or  expiration  or  during  both  acts. 
They  may  obscure  the  normal  breath  sounds  or  entirely  replace  them. 

Dry  rales  are  produced  by  stenosis  of  the  bronchial  tubes.  This 
narrowing  may  be  present  at  one  point  only  as  in  laryngeal  diphtheria  or 
oedema  of  the  glottis,  or  a  tumor  pressing  upon  the  trachea,  but  is  usually 
present  at  the  same  time  at  many  points  and  in  many  bronchial  tubes  of 
varying  diameter.  It  is  brought  about  by  a  variety  of  pathological  con- 
ditions, as  a  mass  of  tenacious  mucus  adherent  to  the  surface  of  the  tube, 
swelling  of  the  mucosa  or  submucosa,  spasmodic  contraction  of  the  bronchial 
musculature,  and  the  external  pressure  of  enlarged  glands  or  a  tumor. 
When  this  narrowing  involves  the  smaller  bronchial  tubes  the  rales  which 
result  are  high  pitched — sibilant;  when  it  affects  the  larger  tubes  the 
rales  are  low  pitched — sonorous.  They  resemble  the  cooing  of  doves,  the 
hissing  of  geese,  and  have  very  often  a  musical  quality.  Sometimes  they 
are  groaning  or  squeaking.  In  asthma  they  are  often  heard  in  great  variety 
of  size,  pitch,  intensity,  and  quality,  both  upon  inspiration  and  expiration, 
and  appear  and  disappear  with  the  most  remarkable  modifications  and 
great  rapidity. 

Moist  rales  are  caused  by  the  passage  of  air  through  the  bronchi 
when  they  contain  fluid — mucus,  pus,  blood.  The  mechanism  consists  in 
the  presence  of  bubbles  or  diaphragms  before  the  incoming  and  outgoing  air 


160  MEDICAL  DIAGNOSIS. 

which  continuously  burst  and  reform.  When  this  process  takes  place  in 
the  larger  tubes,  the  bubbles  are  large  and  the  rales  coarse  or  large  bubbling; 
when  in  the  smaller  tubes,  they  are  finer,  small  bubbling  or  subcrepitant 
rales.  Large  moist  rales  are  usually  low  in  pitch;  small  moist  rales  higher, 
and  in  this  respect  moist  and  dry  rales  correspond.  The  tracheal  rale  or 
death-rattle  is  an  example  of  a  very  coarse  rale;  the  small  moist  or  sub- 
crepitant rale  heard  in  bronchopneumonia  in  both  respiratory  acts  is  an 
example  of  a  fine  moist  rale. 

Both  dry  and  moist  rales  vary  in  intensity  and  locality.  The  extent 
of  the  area  over  which  they  are  heard  depends  upon  that  of  the  process 
by  which  they  are  caused;  their  acoustic  characters  upon  the  physical 
changes  produced  by  that  process.  In  bronchitis  rales  are  very  often  best 
heard  at  the  bases  of  the  lungs  posteriorly;  in  tuberculous  disease  of  an 
apex,  in  the  subclavicular  region.  Rales  are  very  often  influenced  by  the 
act  of  coughing  and  expectoration.  Dry  rales  produced  by  pressure  steno- 
sis, tenacious  exudate  which  cannot  be  dislodged,  or  bronchial  spasm,  do 
not  disappear  upon  coughing. 

Vesicular  or  crepitant  rales  originate  in  the  finest  bronchioles  and 
air-cells.  Notwithstanding  the  differences  of  view  in  regard  to  the  mechan- 
ism by  which  they  are  produced,  the  weight  of  evidence  is  still  in  favor  of 
the  theory  that  it  is  by  the  inspiratory  separation  of  the  walls  of  terminal 
structures — bronchioles,  alevoli — previously  collapsed  or  held  together  by 
a  thin  layer  of  sticky  exudate  or  serum.  In  support  of  this  theory  the 
following  facts  may  be  adduced:  This  rale,  at  one  time  held  to  be  pathog- 
nomonic of  croupous  pneumonia,  is  now  known  to  occur  also  in  other 
pathological  conditions  in  which  an  exudate  or  blood  is  present  in  the 
lung  parenchyma,  as  pulmonary  cedema,  hemorrhagic  infarct,  and  acute 
pneumonic  phthisis.  It  is  common  in  partial  atelectasis — atelectatic 
crepitation  of  Abrams.  Crepitant  rales  sometimes  associated  with  sub- 
crepitant rales  are  frequently  heard  during  deep  inspiration  at  the  bases 
of  the  chest  posteriorly  and  laterally  in  persons  whose  respiration  is  habitu- 
ally shallow.  This  is  not  only  the  case  in  bed-ridden  individuals  but  also 
in  many  healthy  persons,  especially  after  middle  age.  The  crepitant  rale 
is  heard  only  upon  inspiration.  The  subcrepitant  rale  with  which  it  is 
often  associated  is  usually  coarser  and  slightly  moist. 

The  crepitant  rale  is  usually  heard  towards  the  end  of  inspiration; 
the  individual  rales  are  of  the  same  size  and  intensity  and  they  often 
occur  in  "showers,"  a  large  number  of  single  sounds  having  the  same 
acoustic  properties  following  each  other  in  rapid  and  irregular  succession. 

The  crepitant  rale  occurs  in  croupous  pneumonia  at  the  beginning  of 
the  process,— crepitus  indux, —  disappears  when  the  exudate  undergoes 
coagulation,  and  reappears  together  with  subcrepitant  rales  when  the 
exudate  undergoes  liquefaction  and  resorption,— cre/^iY us  redux.  This 
auscultatory  sign  may  be  imitated  by  placing  a  little  mucilage  between 
the  finger  and  thumb  and  making  repeated  contact  and  separation.  With 
contact  there  is  no  sound,  but  upon  separating  the  thumb  and  finger  a 
string  of  tenacious  mucilage  is  drawn  out  which  finally  snaps  with  a  sharp 
sound  not  unlike  the  rale.  It  may  also  be  imitated  by  the  crackling  of 
fine  salt  thrown  upon  the  fire,  the  creaking  of  a  silk  garment,  or  lightly 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  161 

rubbing  a  few  strands  of  hair  between  the  thumb  and  finger.  If  the  stetho- 
scope is  applied  over  the  thick  growth  of  coarse  hair  found  upon  the  chest 
of  many  men,  a  sound  closely  resembling  crepitation  will  be  heard.  Crack- 
ling is  the  term  used  technically  to  designate  a  rale  coarser  than  crepitus 
but  having  in  other  respects  similar  acoustic  properties.  This  rale  consists 
of  a  limited  number  of  well-defined  sharp  crackling  sounds  often  heard  in 
beginning  pulmonary  tuberculosis  or  at  the  borders  of  an  advancing  tuber- 
culous lesion  and  for  this  reason  is  of  considerable  diagnostic  importance. 
The  distinction  between  crepitus  and  crackling  is  not  always  unattended 
with  difficulty.  Crepitus  consists  of  a  number  of  fine  sounds,  heard  only 
upon  inspiration  and  often  over  a  considerable  area  at  the  base  of  the 
lung;  crackling  of  a  few  sharp,  well-defined,  rather  coarser  sounds  heard  also 
in  inspiration  but  over  a  limited  area  and  commonly  at  the  apex.  It  is 
probable  that  the  mechanism  is  the  same  in  both,  but  that  crackling  occurs 
in  limited  lesions,  hence  only  a  few  individual  sounds  are  heard;  in  wider 
spaces,  terminal  bronchi,  hence  the  sounds  are  coarser;  and  at  a  point 
surrounded  by  densely  consolidated  tissue,  hence  they  are  better  conducted 
to  the  ear.  Moist  crackling  and  clicking  are  varieties  of  crackling  which 
are  regarded  as  indicative  of  softening  tubercle.  In  certain  cases  of  dry 
or  plastic  pleurisy  fine,  dry  friction  sounds  are  to  be  heard  which  can 
scarcely  be  distinguished  from  subcrepitant  rales.  If  they  occur  only  upon 
inspiration  they  may  be  mistaken  for  crepitus. 

Gurgling  or  the  rale  of  cavities  is  caused  by  the  entrance  and  exit 
of  air  in  a  cavity  containing  fluid.  Coarse  churning  sounds  are  heard  resem- 
bling those  produced  by  pouring  fluid  rapidly  from  a  bottle.  These  very 
coarse,  well-defined  rales  are  known  also  as  cavernous,  and  sometimes 
have  the  metallic  or  amphoric  quality. 

Metallic  Tinkling — Gutta  Cadens. — All  rales  heard  in  pneumothorax 
acquire  the  amphoric  or  metallic  quality.  In  some  instances  single  rales 
having  an  exquisite  metallic  or  bell-like  musical  quality  may  follow  deep 
inspiration  or  the  act  of  coughing.  This  sound,  which  resembles  that  made 
by  single  fine  shot  dropped  into  a  metal  bowl  or  basin,  was  at  one  time 
thought  to  be  caused  by  a  drop  of  exudate  or  pus  collecting  at  the  vault 
of  the  cavity  and  falling  upon  the  surface  of  the  fluid  collected  at  its  base. 
It  is  now  known  that  it  may  occur  in  the  absence  of  any  such  collection 
of  fluid  and  that  it  may  be  due  to  the  bursting  of  a  bubble  formed  at  the 
pleural  orifice  of  a  bronchopulmonary  fistula. 

Hippocratic  Succussion. — This  phenomenon,  although  it  is  not  a  rale 
in  the  narrow  sense,  may  be^best  described  at  this  point.  It  is  character- 
istic of  hydro-  (pyo-haemo-)  pneumothorax  and  consists  of  a  distinct  loud 
splashing  which  may  be  heard  and  felt  when  the  thorax  is  suddenly  shaken. 
It  is  due  to  the  swash  of  the  free  fluid  against  the  wall  of  the  chest,  just  as  a 
similar  sound  is  produced  by  the  sudden  movement  of  a  partially  filled  cask. 

The  Bronchopulmonary  Fistula  Rale. — In  hydro-  or  pyopneumo- 
thorax, when  the  accumulating  fluid  rises  above  the  pleural  opening  of  the 
fistula  there  may  be  sometimes  heard  in  connection  with  paroxysmal 
cough  bubbling  sounds  due  to  inspired  air  being  forced  from  the  lung  and 
up  through  the  fluid.  Under  such  circumstances  violent  spells  of  cough 
are  apt  to  be  followed  by  copious  expectoration. 
11 


162  MEDICAL  DIAGNOSIS. 

Rales  may  be  conveniently  grouped  as  follows: 

f  Low  pitched — ^Sonorous. 
Bronchial  Rales  I  ^''^'  °^  Vibrating   J  High  pitched— Sibilant. 
1  Moist  or  Bubbling  I  Large  bubbling — Mucous. 

[  Small  bubbling — Subcrepitant. 

Vesicular  Rales  j  S^'^PJ^r^-    .<^,.  ,.     , 
(.Crackling  (Clicking). 

The  Rale  of  Cavities  |  i^'^''^'  hoarse  Bubbling-Gurgling. 
i.  Cavernous  and  Amphoric  Rales. 

(  Metallic  Tinkling — Gutta  Cadens. 
Rales  in  Pneumothorax  and  similar  conditions.  <  The  Bronchopulmonarj^  Fistula  Rale. 
(Hydro-pyo-heemo-pneumothorax)  (,  The  Hippocratic  Succussion. 

2.  Friction  Sounds. — The  surfaces  of  the  normal  pleura,  being  moist 
and  smooth,  glide  noiselessly  over  one  another  with  the  movements  of  respi- 
ration. When,  however,  the  serous  membrane  is  roughened  by  the  presence 
of  a  fibrinous  exudate,  as  in  pleurisj^,  the  movement  of  the  opposed  surfaces 
gives  rise  to  sounds  known  as  "pleural  friction  sounds"  or  "friction  rubs. " 
As  the  lesions  of  pleurisy  vary  from  a  mere  dryness  of  the  surface  in  the 
beginning  to  every  grade  of  exudate  in  amount,  texture,  and  arrangement, 
including  the  fibrinoserous  forms,  so  the  friction  sounds  present  great 
diversity  in  their  acoustic  properties,  not  only  in  different  cases  but  also 
in  the  same  case  during  its  course. 

The  general  and  almost  constant  character  of  pleural  friction  is,  how- 
ever, that  of  the  sounds  produced  by  the  rubbing  together  of  dry  or  slightly 
moistened  surfaces,  and  is  properly  characterized  as  grazing,  rubbing, 
creaking,  leathery,  grating,  rasping,  and  the  like.  Friction  sounds  are 
usually  jerky  and  irregularly  interrupted,  and  change  in  character  not 
only  in  the  course  of  time  but  even  in  the  course  of  a  single  respiratory 
act.  They  are  superficial  and  give  the  impression  of  being  produced  very 
near  the  ear.  They  vary  in  intensity  from  a  mere  graze,  scarcely  audible^ 
to  a  coarse,  loud,  and  prolonged  creaking  like  that  of  new  leather  and 
audible  to  the  patient  himself  or  the  bystanders.  They  are  described  as 
fine,  medium,  or  coarse.  They  are  as  a  rule  best  heard  and  often  only  heard 
in  the  infra-axillary  or  inframammarj^  region  where  the  respiratory  excursus 
is  widest  and  the  pleura  investing  the  thin  wedge  of  lung  is  in  contact 
upon  one  side  with  the  costal  and  upon  the  other  with  the  diaphragmatic 
pleura.  Not  being  well  conducted,  they  are  heard  where  they  are  produced, 
so  that  in  cases  of  diaphragmatic  pleurisy  the  friction  sounds  may  be  heard 
below  the  level  of  the  lung,  in  croupous  pneumonia  opposite  the  seat  of 
the  exudate,  and  in  the  earliest  days  of  phthisis  at  the  apex.  They  may 
sometimes  be  heard  over  the  entire  lung  from  the  apex  to  the  base.  In 
children  and  spare  persons  the  intensity  of  these  sounds  may  be  increased 
by  firm  pressure  upon  the  chest,  and  they  are  often  attended  by  a  palpable 
sign — friction  fremitus.  They  occur  most  commonly  during  inspiration  and 
especially  toward  the  end  of  the  act,  and  are  frequently  heard  also  during 
expiration.     Less  often  they  are  present  during  expiration  alone. 

Friction  sounds  are  sometimes  inconstant,  ceasing  after  several  deep 
inspiratory  acts  and  being  again  heard  after  a  period  of  quiet  breathing. 
They  are  not  modified,  however,  to  the  same  extent  as  rales,  nor  do  they 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  163 

disappear  upon  coughing  and  the  expectoration  of  mucus.  Various  pos- 
tural methods  of  bringing  out  friction  sounds  in  suspected  cases  have  been 
described,  as  raising  the  arm  upon  the  affected  side  or  having  the  patient 
quickly  rise  from  the  recumbent  to  the  sitting  posture  during  held  expira- 
tion and  then  take  a  ver}'  deep  inspiration. 

Deep  breathing,  coughing,  pressure  upon  the  affected  side,  not  only 
increase  the  intensity  of  the  sounds,  but  are  also  attended  with  pain.  In 
exceptional  cases  friction  sounds  are  unattended  by  pain  during  these  acts. 
When  a  plastic  pleurisy  is  followed  by  a  serofibrinous  exudate  the  friction 
sounds  disappear,  but  recur  upon  the  resorption  or  removal  of  the  fluid. 
They  are  usually  present  upon  one  side  of  the  chest  only,  but  may  some- 
times, especially  in  disseminated  tuberculosis,  be  heard  in  circumscribed 
areas  on  both  sides. 

Crumpling  friction  sounds  are  the  signs  of  acute  inflammation  of  the 
pleura.  When  the  process  subsides  the  surfaces  become  fused,  the  fibri- 
nous exudate  organized.  The  condition  is  that  of  adherent  pleura  and, 
unless  dense  and  extensive,  does  not  give  rise  to  physical  signs.  In  old 
pleurisy  at  the'  apex  and  especially  when  cavities  exist,  curious,  low- 
pitched,  soft,  creaking  sounds  are  sometimes  heard.  This  sound  resembles 
that  produced  by  squeezing  soft  thick  paper  together  in  the  hand  in 
irregular  folds  and  is  described  as  crumpling.  It  is  present  upon  inspira- 
tion and  expiration  and  is  not  affected  by  cough,  nor  has  it  the  characters 
by  which  we  recognize  rales. 

In  some  cases  of  pleural  effusion  a  considerable  period  elapses  between 
the  resorption  of  the  fluid  and  the  formation  of  adhesions.  During  this 
time  friction  sounds  may  be  heard  and  the  patient  may  experience  annoying 
grating  or  rubbing  sensations,  especially  upon  deep  breathing  or  coughing. 

Sounds  closely  simulating  friction  sounds  may  be  produced  by  rubbing 
the  thumb  and  finger  together  near  the  ear  or  by  holding  the  hollow  of  the 
hand  over  the  ear  and  rubbing  or  stroking  the  back  of  it  with  the  fingers 
of  the  other  hand.  There  is  a  fine  friction  sound  which  cannot  be  dis- 
tinguished from  crepitus.  Both  occur  in  showers  at  the  end  of  inspiration, 
both  are  close  to  the  ear  and  have  the  same  acoustic  qualities,  both  are 
accompanied  by  an  expiratory  element  which  may  be  in  one  case  a  fric- 
tion sound  and  in  the  other  a  subcrepitant  rale.  By  the  sound  itself  the 
differentiation  is  impossible,  but  when  concomitant  phenomena  are  taken 
into  account  we  find  the  friction  sound  is  usually  more  limited  in  extent, 
attended  more  commonly  by  expiratory  sounds,  is  less  uniform  in  charac- 
ter, and  disappears  when  the  movement  of  the  chest  wall  is  restricted  by 
compression,  while  crepitus  persists.  The  distinction  between  fine  friction 
of  this  form  and  the  crepitant  rale  or  crackling  is  rather  of  theoretical  than 
practical  importance  when  we  reflect  that  in  pneumonia,  when,  as  is  com- 
monly the  case,  the  exudate  extends  to  the  periphery  of  the  lung,  the 
pleura  overlying  it  is  the  seat  of  an  inflammatory  exuclate,  and  in  tuber- 
culosis of  the  apex  the  early  lesions  which  give  rise  to  creaking  are  accom- 
panied by  a  circumscribed  pleurisy.  In  point  of  fact  when  we  hear  one  of 
these  signs  the  other  usually  is  also  present. 

The  friction  sound  which  closely  resembles  crepitus  or  crackling  is 
very  rarely,  if  ever,  heard  in  simple,  uncomplicated  pleurisy. 


164  MEDICAL  DIAGNOSIS. 

Friction  sounds  heard  over  the  chest  are  significant  of  pleurisy.  Those 
over  the  precordial  space,  having  the  cardiac  rhythm,  are  usually  but  not 
invariably  signs  of  pericarditis.  The  subject  of  pericardial  and  pleuro- 
pericardial  friction  will  engage  our  attention  in  a  subsequent  section. 
Friction  sounds  heard  in  the  epigastric  zone  constitute  in  rare  instances 
the  signs  of  a  peritonitis.  The  effusion  in  hydrothorax  is  not  preceded 
by  a  friction  sound.  Pleurisy  is  frequently  primary;  often  secondary  to 
intrapulmonary  disease,  pneumonia,  tuberculosis,  cirrhosis  of  the  lung, 
abscess,  gangrene,  or  cancer;  and  sometimes,  especially  upon  the  right 
side,  secondary  to  subdiaphragmatic  disease,  as  abscess,  cancer  or  hyda- 
tids of  the  liver,  or  subphrenic  abscess.  Friction  sounds  may  therefore  be 
significant  of  any  of  these  affections. 

Riesman  has  described  under  the  term  subpleural  friction  a  fine  soft 
rubbing  or  crepitation  which  occurs  in  the  absence  of  pain  or  the  signs  of 
consolidation  in  miliary  tuberculosis.  The  difficulty  in  distinguishing  fine 
pleural  friction  from  crepitus  has  already  been  discussed. 

AUSCULTATION    DURING   PHONATION. 

Auscultation  of  the  Voice  in  Health  and  Disease. — The  sounds  heard 
upon  auscultation  of  the  chest  of  a  person  who  is  speaking  when  the  face 
of  the  patient  is  turned  away  or  the  opposite  ear  of  the  examiner  closed, 
or  when  the  binaural  stethoscope  is  employed,  constitute  the  set  of  physi- 
cal signs  comprised  under  the  general  term  vocal  resonance,  and  have 
diagnostic  value.  The  ordinary  spoken  and  the  whispered  voice  are  studied. 
Obstacles  to  the  employment  of  this  method  of  physical  diagnosis  consist 
in  want  of  cooperation,  as  in  children  and  extremely  ill  persons,  in  inability 
to  use  the  voice,  as  in  mutes,  those  suffering  from  aphonia  from  any  cause, 
and  in  extremely  feeble  patients  and  great  obesity. 

TheTechnic. — The  patient  is  instructed  to  turn  his  face  away  and 
count  "one,  two,  three";  or  repeat  "twenty-one"  or  "ninety-nine"  in 
the  loud  voice  or  in  a  stage  whisper.  The  sound  is  conducted  through 
the  bronchi  and  along  their  walls  in  the  same  manner  as  in  a  speaking 
tube  and  greatly  dispersed  and  damped  in  the  cushiony  vesicular  tissue. 
Changes  in  the  physical  condition  of  the  lung  parenchyma  favor  or  still 
further  impede  the  transmission  of  the  voice  in  such  a  manner  that  increase, 
diminution,  or  absence  of  vocal  resonance  correspond  to  these  changes  and 
thus  become  signs  of  disease.  The  modifications  of  vocal  resonance  corre- 
spond in  general  to  those  of  vocal  fremitus  and  have  the  same  significance. 

Normal  Vocal  Resonance. — The  voice  is  heard  as  a  confused  inarticu- 
late hum,  most  distinct  in  adults  possessed  of  deep  voices  and  tremulous 
in  aged  persons.  This  sound  is  more  intense  upon  the  right  than  upon  the 
left  side  and  at  the  apices  than  at  the  base.  As  the  stethoscope  is  carried 
to  a  position  nearer  the  main  bronchi  the  resonance  becomes  louder  and 
more  distinct  until  finally,  when  it  is  placed  over  the  bronchi  or  trachea 
in  the  position  in  which  normal  bronchial  breathing  is  heard,  the  audible 
words  may  be  recognized — bronchophony. 

Increased  Vocal  Resonance. — This  sign  when  heard  over  the  lung — 
with  rare  exceptions,  presently  to  be  mentioned — denotes  an  increase  in 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  165 

the  power  of  the  lung  to  conduct  sound-producing  vibrations, — namely, 
consolidation.  It  has,  therefore,  the  same  significance  as  bronchial  respi- 
ration. Fully  developed  it  constitutes  bronchophony,  and  indicates  con- 
solidation of  lung  tissue  in  the  neighborhood  of  large  or  medium-sized 
bronchial  tubes.  In  addition  to  this  simple  form  of  bronchophony  there 
are  the  following  varieties: 

Pectoriloquy. — Laennec  used  this  term  to  indicate  the  complete  trans- 
mission of  articulate  words.  The  voice  appears  to  be  directly  spoken  into 
the  observer's  ear.  This  sign  occurs  in  dense  consolidation  extending  from 
a  large  bronchus  to  the  wall  of  the  chest,  over  a  cavity  communicating 
freely  with  a  bronchus  of  some  size,  in  a  pneumothorax  communicating 
with  a  bronchus,  and  in  some  instances  over  the  atelectatic  lung  over- 
lying a  large  pleural  effusion.  When  pectoriloquy  is  very  distinct  and 
circumscribed  it  constitutes  the  distinct  physical  sign  of  a  cavity,  and, 
as  Da  Costa  well  said,  deserves  the  name  of  cavernous  voice. 

Amphoric  Vocal  Resonance.  —  Over  large  cavities  and  in  pneumo- 
thorax communicating  with  a  bronchus  the  voice  is  peculiarly  ringing  and 
metallic.  The  amphoric  character  is  due  to  the  same  physical  conditions 
which  we  find  to  underlie  the  amphoric  quality  in  the  breath  sounds  and  rales. 

Whispering  Pectoriloquy. — As  a  rule  the  whispered  voice  is  heard  as  a 
faint,  distant,  expiratory  whiff  or  puff  over  the  trachea  and  primary  bronchi 
in  front  and  behind  while  elsewhere  it  is  almost  or  quite  inaudible.  When, 
however,  the  physical  conditions  which  cause  bronchophony  are  present, 
the  whispered  voice  is  heard  with  curious  nearness  and  distinctness.  Whis- 
pering pectoriloquy  is  a  very  important  physical  sign,  indicating,  when 
distinct  and  circumscribed,  a  cavity,  and  in  varying  degrees  of  intensity 
consolidation  of  lung  tissue.  It  is  therefore  of  practical  value  in  the  diag- 
nosis of  limited  areas  of  consolidation  and  in  determining  the  boundaries 
of  large  ones.  The  more  dense  the  consolidation  the  more  distinct  the 
whispered  voice.  Whispering  pectoriloquy  may  be  present  over  the 
atelectatic  lung  in  pleural  effusion  and  occasionally  over  the  effusion  itself. 

Diminished  Vocal  Resonance.  —  This  sign  indicates  impaired  con- 
duction in  the  lung  and  is  present  in  emphysema  and  the  occlusion  of  a 
bronchus.  It  also  denotes  the  interposition  of  substances  between  the 
lung  and  the  chest  wall,  which  leads  to  the  diffusion  and  weakening  of 
vibrations  passing  from  one  medium  to  another,  and  occurs  in  pleural 
effusion,  pleural  thickening,  and  tumors.  The  more  massive  the  effusion, 
the  greater  the  thickening,  or  the  larger  the  tumor,  the  more  marked  the 
diminution  in  the  transmitted  voice  resonance.  It  may  be  completely 
absent  in  closed  pneumothorax.  Absent  vocal  resonance  is  most  common 
in  large  pleural  effusion. 

/Egophony. — Literally,  the  bleating  of  a  goat.  A  peculiar  quavering 
quality  of  the  voice  with  a  distinctly  nasal  tone  is  heard  when  the  patient' 
speaks  in  a  natural  voice.  This  sign  is  best  brought  out  by  using  repeated 
rather  than  single  syllables,  as  "twenty-one  "  or  "  ninety-nine.  "  It  may  be 
heard  at  or  just  below  the  upper  limit  of  moderate-sized  pleural  effusions 
in  the  region  of  the  angle  of  the  scapula;  less  frequently  in  the  front  of  the 
chest.  It  is  in  rare  instances  heard  over  consolidated  lung  tissue.  It  is 
not  an  important  physical  sign. 


166  MEDICAL  DIAGNOSIS. 

Bacelli's  Sign. — Upon  direct  auscultation  in  the  anterolateral  region 
of  the  affected  side  the  whispered  voice  is  said  to  be  distinctly  transmitted 
through  a  serous  but  not  through  a  purulent  effusion,  the  difference  being 
attributed  to  variations  in  the  density  of  serofibrinous  and  purulent  effu- 
sions. This  sign  is  not  constant,  since  in  large  effusions  there  is  commonly 
absence  of  vocal  resonance  in  both  kinds  of  fluid. 

Auscultation   as  Applied  to  the   Diagnosis  of  Diseases 
of  the  Circulatory  Organs. 

The  Technic. — This  method  is  of  cardinal  importance  in  the  examina- 
tion of  the  heart.  Upon  it  in  most  instances  the  diagnosis  depends. 
Inspection,  palpation,  and  percussion  may  be  used  to  amplify  and  control 
the  signs  obtained  by  auscultation,  but  in  a  considerable  proportion  of 
the  cases  they  contribute  no  essential  facts.  Before  we  apply  the  stetho- 
scope, we  inquire  into  the  history  of  the  case  and  place  the  patient  as  far 
as  possible  at  his  ease.  The  examination  is  best  conducted  when  the  patient 
is  in  a  comfortable  position,  leaning  back  in  a  chair  or  propped  up  with 
pillows  in  bed.  We  note  the  facial  expression,  the  appearance  of  the 
eyes,  the  state  of  the  capillary  circulation,  the  presence  or  absence  of 
dropsical  swellings,  whether  or  not  there  is  cough,  the  character  of  the 
respiration  and  any  abnormal  impulse  or  movement  that  may  be  present 
at  the  root  of  the  neck  or  in  the  chest.  The  signs  elicited  upon  inspec- 
tion, palpation,  and  percussion  are  then  ascertained.  Finally  we  employ 
auscultation. 

In  women  the  breast  is  drawn  aside  and  held  by  the  patient  herself 
or  her  nurse.  In  young  children  inspection  and  palpation  should  precede 
auscultation.  Percussion  is  useless.  Very  often  the  auscultatory  signs 
must  be  caught  in  the  intervals  of  crjdng  and  struggling.  Many  difficulties 
may  be  overcome  by  tact  and  gentleness. 

The  increase  in  the  frequency  of  the  heart's  action  and  the  accom- 
panying change  in  the  character  of  the  first  sound  that  occur  in  nervous 
persons  under  examination  {le  coeur  medicale)  must  be  borne  in  mind.  A 
few  minutes'  chat  upon  indifferent  subjects  will  usually  cause  the  excited 
action  to  subside.  If  on  the  other  hand  the  action  of  the  heart  is  weak 
and  the  sounds  too  faint  to  be  well  studied,  or  there  is  a  doubt  as  to  the 
presence  of  a  murmur,  the  patient  should  be  asked,  unless  his  general  con- 
dition forbids,  to  take  a  series  of  very  deep  breaths,  or  quickly  stoop  and 
rise  several  times,  or  take  a  few  brisk  turns  up  and  down  the  room.  The 
increase  in  the  force  of  the  heart's  action  will  often  render  the  sounds 
distinct  and  dispel  any  doubt  as  to  the  presence  of  a  murmur.  In  cases 
of  acute  disease  or  profound  general  or  cardiac  asthenia  such  diagnostic 
measures  are  strictly  contraindicated. 

Faint  and  distant  sounds  and  obscure  murmurs  may  become  more 
audible  if  the  patient  leans  slightly  forward  and  to  his  left,  thus 
bringing  the  heart  under  the  influence  of  gravity  into  closer  relation 
with  the  wall  of  the  chest.  It  is  important  also  to  request  the  patient 
to  stop  breathing  for  a  moment  now  and  again  during  the  course  of  the 
examination,  since  the  breath  sounds  may  mask  the  normal  and  abnormal 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION. 


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168  MEDICAL  DIAGNOSIS. 

sounds  of  a  feeble  heart.     The  heart  sounds  should  also  be  studied  with 
full  held  inspiration  and  forced  expiration. 

Auscultation  has  for  its  object  the  determination  of  the  character, 
intensity,  and  rhythm  of  the  normal  heart  sounds,  and  their  modifications 
within  the  range  of  health,  the  recognition  of  modifications  which  tran- 
scend those  limits,  and  the  detection  of  abnormal  or  adventitious  sounds. 

THE  SIGNS  IN  HEALTH. 

The  Normal  Heart  Sounds. — When  the  stethoscojDe  is  placed  over 
the  heart  two  sounds  are  heard.  Of  these  one  is  found  to  correspond 
in  time  with  the  cardiac  impulse,  and  the  other  to  follow  it  after  a  short 
interval  of  silence.  After  a  longer,  but  still  short  interval,  these  sounds 
are  repeated  in  the  same  order.  For  this  reason  they  are  spoken  of  re- 
spectively as  the  first  and  second  sound  of  the  heart. 

The  Characters  of  the  Sounds. — The  first  sound  is  not  only  compara- 
tively long,  but  it  is  also  low  in  pitch  and  muffled.  The  second  sound, 
on  the  contrary,  is  comparatively  short  and  is  high  pitched  and  clear.  The 
two  sounds  are  therefore  in  sharp  contrast  in  regard  to  their  duration, 
pitch,  and  quality.  The  respective  characters  of  the  two  sounds  may  be 
roughly  imitated  by  the  repetition  of  the  syllables  "  ubb  dup. " 

Causes  of  the  First  Sound.  —  The  first  sound  is  due  to  vibrations 
caused  by  the  simultaneous  tension  of  the  mitral  and  tricuspid  valves 
in  closure,  the  muscular  contraction  of  the  ventricles  and  the  vibration 
of  the  blood  contained  within  the  ventricles  at  the  moment  of  systole. 

The  Cause  of  the  Second  Sound. — The  second  sound  is  due  to  the  vibra- 
tions caused  by  the  simultaneous  closure  of  the  semilunar  valves  of  the 
pulmonary  artery  and  the  aorta  at  the  beginning  of  the  ventricular  diastole. 

A  Third  Sound  of  the  Heart. — Gibson  has  recently  described  a  wave 
in  the  jugular  pulse  in  healthy  young  adults  occurring  after  the  clos- 
ure of  the  semilunar  valves  and  before  the  auricular  contraction,  and 
accompanied  by  a  low-pitched,  clear  sound  at  the  apex,  more  distinctly 
audible  in  the  cardiac  revolutions  which  occur  in  the  intervals  between 
expiration  and  inspiration  than  at  any  other  stages  of  respiration.  This 
sound  is  not  easily  appi^eciated  and  is  only  audible  in  a  certain  propor- 
tion of  the  diastolic  periods.  It  corresponds  in  time  to  the  first  element 
of  the  reduplicated  second  sound  heard  only  at  the  apex,  long  familiar 
to  clinicians.  The  explanations  of  this  sound  are  at  present  purely 
hypothetical. 

The  Cardiac  Cycle  or  Revolution. — Each  revolution  of  the  heart 
consists  of  an  auricular  systole,  the  instantly  succeeding  ventricular  systole, 
and  a  period  of  repose  of  the  whole  heart.  The  relative  time  occupied 
with  these  events  varies  with  the  frequency  of  the  action  of  the  heart. 
With  a  pulse-rate  of  74,  that  is,  a  cardiac  revolution  of  about  0.8  second, 
the  cardiac  revolution  comprises  an  auricular  systole  of  0.1  second,  a 
ventricular  systole  of  0.3  second,  and  a  period  of  repose  of  the  whole  heart 
of  0.4  second.  With  increased  pulse-frequency  the  diastole  of  the  ven- 
tricles is  shortened  much  more  than  the  systole;  it  is  also,  with  slowing 
of  the  pulse-rate,  lengthened  to  a  greater  extent.     The  statements  which 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  169 

assign  regular  proportions  to  the  duration  of  the  sounds  and  silences  of 
the  heart  are  misleading,  since  these  vary  in  length,  not  relatively  with 
varying  heart  frequency,  but  absolutely,  the  second  silence  being  very 
fluctuating,  since  it  corresponds  to  the  fluctuating  ventricular  diastole, 
while  the  first  sound  and  the  short  first  silence  together,  which  nearly 
correspond  to  the  ventricular  systole,  are  much  more  constant. 

The  Valve  Areas  or  Puncta  Maxima. — With  the  stethoscope  applied 
over  the  apex  of  the  heart  the  first  sound  is  heard  much  more  distinctly 
than  the  second  sound  and  has  a  booming  character  which  is  in  sharp 
contrast  with  the  short  and  "valvular"  quality  of  the  latter.  The  temp- 
tation to  rely  upon  the  rhythm  of  the  sounds  for  the  recognition  of  the 
systolic  sound  or  the  first  and  second  sounds  is  to  be  avoided.  The  aus- 
cultatory sign  must  be  verified  by  inspection  or  palpation.  This  is  espe- 
cially important  in  the  rapidly  acting  heart  and  in  all  morbid  conditions. 
The  systolic  or  first  sound  corresponds  to  the  impulse  as  determined  by 
sight  or  touch,  or  in  default  of  these  by  the  pulsation  of  the  carotid.  The 
radial  pulse  cannot  be  depended  upon  as  a  guide.  The  recognition  of 
the  first  and  second  sounds  is  of  especial  importance  in  the  diagnosis  of 
valvular  diseases. 

When  the  stethoscope  is  carried  to  the  base  of  the  heart,  either  to  the 
right  or  the  left  border  of  the  sternum,  the  first  sound  becomes  less  distinct 
than  at  the  apex  while  retaining  its  acoustic  properties,  and  the  second  sound 
more  distinct  and  prominent  with  an  intensification  of  its  snapping  or 
valvular  quality. 

The  sounds  may  be  further  analyzed  by  placing  the  stethoscope  at 
the  following  principal  points  or  areas: 

1.  The  Mitral  Area. — At  or  above  the  apex  in  the  fifth  intercostal 
space  and  upon  the  parasternal  line.  At  this  point  that  factor  of  the  first 
sound  made  up  by  the  closure  of  the  mitral  valve  and  the  contraction  of 
the  left  ventricle  is  best  heard. 

2.  The  Tricuspid  Area. — At  the  juncture  of  the  ensiform  cartilage  with 
the  sternum  and  at  the  right  border  of  the  base  of  the  sternum.  In  this 
region  that  factor  of  the  first  sound  caused  by  the  closure  of  the  tricuspid 
valve  and  the  contraction  of  the  right  ventricle  is  most  distinctly  heard. 

3.  The  Aortic  Area. — In  the  second  right  intercostal  space  near  the 
sternum  or  directly  over  the  second  right  costal  cartilage  at  its  sternal 
articulation — the  aortic  cartilage.  At  this  point  the  aortic  element  of 
the  second  sound  is  best  heard. 

4.  The  Pulmonary  Area.^ — In  the  second  left  intercostal  space  near 
the  sternal  border.  At  this  point  the  pulmonary  element  of  the  second 
sound  is  best  appreciated. 

These  areas  do  not  correspond  to  the  position  of  the  respective  valve 
systems,  but  they  do  correspond  to  the  anatomical  relationship  to  the 
wall  of  the  chest  of  the  structure  in  which  the  mechanism  producing 
the  sound  exists,  or  in  which  the  sound  is  conducted.  That  is  to  say,  the 
anatomical  apex  of  the  heart  formed  by  the  left  ventricle  comes  nearest 
to  the  chest  at  the  apex;  the  tricuspid  valve  system  at  the  right  border 
and  base  of  the  sternum;  the  aorta  just  above  its  origin  at  the  second 
right  interspace,  and  the  pulmonary  artery  above  its  valves  at  the  second 
left  interspace. 


170  MEDICAL  DIAGNOSIS. 

At  the  apex  the  first  sound  and  its  modifications  in  health  and  disease 
are  best  studied;  at  the  base  the  second  sound.  In  the  former  position 
this  first  sound  is  louder  and  more  distinct;  in  the  latter  the  rhythm  is 
changed  and  the  stress  falls  upon  the  second  sound.  The  rhythm  is  the 
same  in  the  mitral  and  the  tricuspid  areas  and  the  quality  of  the  first 
sound  is  similar,  though  in  health  the  first  sound  is  usually  less  intense 
in  the  tricuspid  area.  The  rhythm  is  likewise  the  same  in  the  aortic  and 
the  pulmonary  areas,  and  the  quality  of  the  second  sound  is  similar  upon  the 
right  and  left  sides. 

Modifications  in  the  Normal  Heart  Sounds. — Variations  in  character, 
intensity,  and  rhythm  are  to  be  considered.  There  are  marked  differences 
in  the  sounds  in  different  individuals  and  in  the  same  individual  at  differ- 
ent periods  of  life  and  under  varying  conditions  of  activity  and  emotion. 

Character. — The  heart  in  children  is  less  covered  by  the  lungs  than  in 
later  life  and  the  chest  wall  is  far  thinner  and  more  elastic.  It  follows 
that  the  sounds  though  feeble  are  more  distinctly  heard.  As  the  muscle 
is  smaller  and  thinner  the  valvular  element  of  the  first  sound  is  more  in 
e^'idence,  and  as  the  frequency  is  greater  the  long  pause  is  shortened  so 
that  the  rhythm,  which  at  birth  has  the  characteristic  tic-tac  of  the  fetal 
heart,  like  the  ticking  of  a  watch,  only  gradually  changes  to  that  above 
described  as  occurring  in  later  life. 

Embryocardia  is  a  common  condition  in  which  the  rhythm  suggests 
that  of  the  fetal  heart,  the  long  pause  being  shortened  and  the  first  and 
second  sound  presenting  nearly  the  same  acoustic  properties.  This  modifi- 
cation of  the  cardiac  rhythm  occurs  in  tachycardia,  the  cardiac  asthenia 
of  the  later   periods  of  exhausting   diseases   and   in   extreme   dilatation. 

The  first  sound  at  the  apex  is  not  only  somewhat  louder  in  powerful 
persons  wdth  well-developed  muscles  but  it  is  also  more  prolonged  than  in 
feeble  persons  who  lead  sedentary  lives — a  difference  due  to  an  increase 
of  the  muscular  factor  entering  into  the  production  of  the  sound. 

A  similar  increase  in  the  duration  and  intensity  of  the  first  sound 
occurs  under  conditions  of  bodily  exercise  and  mental  excitement.  Under 
these  circumstances  the  sound  is  occasionally  attended  by  curious  metallic 
reverberations,  the  cliquetis  vietallique  of  the  French. 

Intensity. — In  young  persons  with  thin,  elastic  chest  walls  the  sounds 
of  the  heart  are  louder  and  more  distinct  than  in  older  persons,  in  w^hom  the 
walls  are  thicker  and  the  costal  cartilages  more  rigid.  Thick  layers  of  sub- 
cutaneous fat  may  render  the  sounds  faint  and  distant.  The  interposition 
of  the  thick  edge  of  a  voluminous  lung  may  have  the  same  effect.  There 
are  marked  differences  in  the  intensity  of  the  sounds  in  repose  and  activity. 

The  First  Sound  at  the  Apex. — The  first  sound  is  louder  and  more 
distinct  in  the  mitral  area  than  in  the  tricuspid,  but  in  young  persons 
under  conditions  of  excitement  or  after  great  muscular  effort  it  may  be 
heard  with  equal  clearness  and  intensity  over  the  whole  front  of  the  chest. 

The  Second  Sound  at  the  Base. — The  peculiarity  of  the  second 
sound  is  its  valvular  quality.  Its  intensity  varies  in  health  with  the  energy 
of  the  heart's  action.  It  has  been  assumed  that  the  intensity  of  the  aortic 
sound  under  normal  conditions  is  greater  than  that  of  the  pulmonary 
second  sound.    Vierordt,  however,  in  1885  first  called  attention  to  the  fact 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  171 

that  the  relative  intensity  of  these  two  components  of  the  second  sound 
varies  at  different  periods  of  life,  an  observation  that  has  been  confirmed 
by  other  recent  clinicians  and  especially  by  the  investigations  of  Creigh- 
ton  in  1899.  This  observer  found  that  in  90  per  cent,  of  healthy  children 
under  ten  years  of  age  the  pulmonic  second  sound  is  more  intense  than  the 
aortic;  in  66  per  cent,  between  the  tenth  and  twentieth  years  the  pul- 
monic sound  is  more  distinct;  in  about  half  in  the  following  decade,  and 
after  the  thirtieth  year  the  proportion  gradually  declines  until  after  sixty, 
when  the  aortic  second  sound  is  more  intense — accentuated — in  almost 
every  case.  It  thus  appears  that  the  relative  intensity  of  the  two  elements 
of  the  second  sound  depends  upon  the  age  of  the  individual,  the  sound  in 
the  pulmonary  area  being  more  intense  in  early,  and  that  in  the  aortic 
area  more  intense  in  later  life,  while  in  middle  life  their  intensity  is  much 
the  same.  Cabot  suggests  that  "it  is  therefore  far  from  true  to  suppose 
that  we  can  obtain  evidence  of  a  pathological  increase  in  the  intensity  of 
either  of  the  sounds  at  the  base  of  the  heart  simply  by  comparing  it  with 
the  other."  The  difficulty  lies  in  the  failure  on  the  part  of  the  auscultator 
to  recognize  the  difference  between  mere  loudness  or  intensity  which  may 
be  normal,  and  accentuation,  which  is  a  morbid  physical  sign. 

In  elderly  persons  the  second  sounds  are  frequently  heard  more 
distinctly  in  the  third  or  fourth  interspace  than  in  the  second. 

Rhythm. — The  derangements  of  rhythm  which  may  occur  in  health  are: 

1.  Gallop  Rhythm  in  which  the  Diastolic  Pause  is  Shortened  with  the 
Addition  of  an  Extra  Sound  of  the  Heart. — The  rhythm  suggests  the 
cadence  of  the  footfall  of  a  cantering  horse.  It  is  expressed  by  the 
repetition  of  the  syllables  "rat-ta-ta."  The  mechanism  of  its  produc- 
tion is  not  clear. 

G.  Canby  Robinson  has  summarized  the  results  of  recent  studies  of 
gallop  rhythm  as  follows:  "  Gallop  rhythm  of  the  heart  is  a  fairly  frequent 
clinical  phenomenon,  and  consists  in  the  presence  of  a  group  of  three 
cardiac  tones,  none  of  which  are  murmurs.  It  occurs  under  variable 
clinical  conditions.  That  form  of  gallop  rhythm  which  is  best  heard  at 
the  apex  or  over  the  central  part  of  the  precordium  may  be  divided 
into  the  presystolic,  protodiastolic,  and  mesodiastolic  types,  depending 
on  whether  the  extra  tone  falls  at  the  end,  at  the  beginning,  or  in  the 
middle  of  diastole.  Each  form  is  associated  with  a  characteristic 
cardiogram.  There  are  a  number  of  factors  which  probably  combine 
in  various  ways  to  produce  the  various  forms  of  gallop  rhythm. 

"Presystolic  gallop  rhythm  is  heard  in  two  classes  of  cases.  It  is 
heard  in  strongly  acting  hearts  in  which  a  muscle  sound  produced  by  a 
strongly  acting,  hypertrophied  auricle  is  probably  the  cause  of  the  extra 
tone;  and  it  is  also  heard  in  weak,  rapidly  acting  hearts  at  the  height  of 
acute  febrile  diseases,  at  which  time  there  is  possibly  a  delay  in  the  con- 
duction of  the  heart-beat  from  the  auricles  to  the  ventricles.  Under  these 
circumstances  the  sound  produced  during  the  contraction  of  the  auricles 
becomes  distinguishable  from  that  produced  during  the  contraction  of  the 
ventricles.  In  both  classes  of  cases,  the  extra  tone  seems  to  be  produced 
in  the  auricle  rather  than  in  the  ventricle.  Protodiastolic  and  mesodiastolic 
gallop  rhythm  are  caused  by  the  production  of  an  extra  tone  in  the  ven- 


172  MEDICAL  DIAGNOSIS. 

tricles.  The  factors  that  probably  combine  to  produce  this  extra  tone  are 
an  increase  in  the  amount  and  velocity  of  the  flow  of  blood  from  the  auricles 
into  the  empty  ventricles  and  a  loss  of  tone  of  the  heart  muscle  of  the 
ventricles.  The  longer  silent  period  in  cases  of  gallop  rhythm  does  not 
as  a  rule  occur  during  diastole,  but  is  usually  a  systolic  silence." 

This  derangement  of  the  cardiac  rhythm  may  sometimes  be  observed 
in  the  normal  heart  when  rapidly  acting  under  conditions  of  great  exertion 
or  excitement. 

2.  Reduplication  of  the  Second  Sound  at  the  Base  of  the  Heart. — Splitting 
of  the  second  sound  may  be  heard  at  the  base  of  the  heart  at  the  end  of 
full  inspiration,  especially  if  the  breath  be  held  or  after  active  muscular 
exertion.  Its  mechanism  probably  consists  in  the  asynchronous  closure 
of  the  aortic  and  pulmonary  valve  systems  as  the  result  of  heightened 
pressure  in  the  pulmonary  circuit. 

3.  Reduplication  of  the  First  Sound  at  the  Apex. — An  impure  first 
sound  may  occasionally  be  heard  at  the  apex,  especially  at  the  end  of 
expiration  under  normal  circumstances.  This  modification  varies  from  a 
mere  blur  or  prolongation  of  the  sound  to  a  distinct  repetition,  consti- 
tuting a  form  of  the  gallop  rhythm.  It  may  be  represented  by  the  syllables 
"trupp"  or  "turrupp."  In  health  it  is  not  constant  in  the  same  indi- 
vidual. It  has  been  attributed  to  conditions  temporarily  giving  rise  to  an 
increase  in  the  vis-a-fronte  of  one  or  the  other  ventricle. 

MODIFICATIONS  OF  THE  HEART  SOUNDS  IN  DISEASE. 

Variations  in  the  character,  intensity,  and  rhythm  which  transcend 
the  borders  of  health,  together  with  wholly  abnormal  or  adventitious 
sounds,  are  to  be  considered. 

Character. — The  acoustic  properties  of  the  heart  sounds  are  modi- 
fied not  only  by  changes  in  the  heart  itself  and  in  the  arteries  but  also  by 
pathological  conditions  in  the  adjacent  parts  and  the  state  of  the  chest 
walls  as  regards  elasticity  and  thickness.  Finally  the  character  of  the  heart 
sounds  is  modified  by  constitutional  conditions.  Changes  in  character  are 
commonly  associated  with  changes  in  intensity,  but  it  is  well  for  the 
student  to  train  himself  to  appreciate  modifications  of  character  and  of 
intensity  as  constituting  distinct  groups  of  physical  signs. 

1.  The  Heart.— The  first  sound  is  prolonged  and  dull  in  hypertrophy; 
when  the  associated  dilatation  is  marked  it  is  sometimes  very  clear  and 
sharp.  A  metallic  clinking— tintement  metallique—is  occasionally  heard 
to  the  right  of  the  apex-beat.  The  second  sound  is  loud  and  distinct,  often 
ringing  in  character  and  doubled.  When  valvular  lesions  are  present  the 
sounds  are  greatly  modified  and  replaced  or  accompanied  by  murmurs. 

In  hypertrophy  of  the  right  ventricle  the  first  sound  at  the  lower  part 
of  the  sternum  is  louder  and  fuller  than  normal;  but  with  much  associated 
dilatation  it  is  clearer  and  sharper.  Accentuation  of  the  pulmonary 
second  sound  is  frequently  present. 

In  dilatation  the  first  sound  is  shorter  and  sharper,  in  other  words, 
more  valvular  in  character  than  normal.  The  muscular  element  is  dimin- 
ished.    With  progressive  thinning  of  the  walls  these  changes  become  more 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  173 

marked.  The  second  sound  when  heard  in  aortic  insufficiency  ma}^  be 
distinct,  or  faint  and  obscure;  wlien  tliere  is  dilatation  of  tlie  aortic  arch  it 
may  be  ringing  and  prolonged. 

The  second  sound  is  rarely  heard  in  the  aortic  area  in  aortic  stenosis  for 
the  reason  that  the  deformity  of  the  cusps  is  such  as  to  prevent  their  free  play. 

Accentuation  of  the  pulmonary  second  sound  is  an  important  sign  in 
mitral  insufficiency. 

The  first  sound  is  unusually  sharp  and  clear  in  mitral  stenosis,  while 
the  second  sound  in  the  second  left  interspace  is  strongly  accentuated  and 
sometimes  reduplicated. 

2.  The  Arteries.  —  Accentuation  of  the  aortic  second  sound  occurs 
in  arteriosclerosis,  —  especially  that  form  which  accompanies  chronic 
nephritis, — in  atheroma  and  dilatation  of  the  aortic  arch,  and  in  aortic 
aneurism.  It  is  the  sign  of  increased  arterial  tension  and  is  associated 
with  hypertrophy  of  the  left  ventricle. 

3.  Diseases  of  Neighboring  Organs. — In  pericardial  effusion  the  heart 
sounds  are  not  only  indistinct  but  they  also  have  a  peculiar  muffled  and 
distant  quality,  due  to  diffusion.  Accentuation  of  the  pulmonary  second 
sound  is  frequently  an  early  and  persistent  sign. 

In  some  cases  of  pneumothorax  the  heart  sounds  acquire  a  metallic 
quality;   in  pneumopericardium  they  are  feeble,  distant,  and  muffled. 

They  are  distant  and  muffled  in  pulmonary  emphysema,  well  trans- 
mitted in  consolidation  of  the  lung  and  in  chronic  interstitial  pneumonia 
and  pulmonary  phthisis,  and  sharp  and  ringing  during  cardiac  overaction, 
especially  in  young  persons  and  in  the  periods  of  excitement  and  palpita- 
tion which  occur  in  exophthalmic  goitre,  chlorosis,  and  anaemic  states. 

4.  Different  Conditions  of  the  Walls  of  the  Chest. — As  in  health  so  in 
disease,  remarkable  differences  in  the  heart  sounds  occur  as  the  result 
of  differences  in  the  chest  wall.  Through  the  thin  and  elastic  tissues  of 
the  young  the  sounds  are  conducted  with  great  distinctness;  they  are 
faint  and  diffuse  when  the  chest  walls  are  thick  and  fat,  and  when  the  car- 
tilages are  calcified,  the  sternum  thickened,  or  when  deformities  of  the  chest 
derange  the  normal  relation  of  the  heart  to  the  wall,  or  finally  when  a  new 
growth  is  interposed. 

5.  Constitutional  Conditions.  —  The  first  sound  is  shortened  as  well 
as  faint  in  conditions  of  general  asthenia  such  as  result  from  actual  star- 
vation and  wasting  diseases.  In  enteric  fever  the  first  sound  becomes 
progressively  shorter,  more  indistinct  and  valvular  in  quality — a  change 
due  to  the  progressive  wasting  of  the  myocardium. 

Intensity. — The  significance  of  increase  or  decrease  in  the  intensity 
of  the  heart  sounds  as  morbid  physical  signs  has  already  to  some  extent 
been  indicated.  It  is  important  to  note  that  as  a  rule  increase  in  the 
intensity  of  the  first  sound  is  associated  with  its  prolongation,  while  de- 
crease in  intensity  is  attended  with  decrease  in  duration.  The  loud  first 
sound  is  in  strong  contrast  with  the  short  second  sound;  the  faint  first 
sound  resembles  it.  As  the  feeble  heart  is  commonly  also  a  rapid  heart, 
in  which  the  long  pause  is  shortened,  it  may  become  difficult  to  tell  which 
is  the  first  and  which  the  second  sound.  The  first  sound  corresponds  to 
the  impulse  at  the  apex  or  to  the  carotid  pulse. 


174  MEDICAL  DIAGNOSIS. 

Accentuation.  —  It  is  important  at  this  point  to  emphasize  the  dis- 
tinction between  "loudness"  and  "accentuation" — a  matter  not  always 
made  clear  in  the  books.  Loudness  or  sound  intensity  has  to  do  with  the 
volume  of  a  given  sound;  accentuation  is  that  acoustic  property  which 
indicates  suddenness  in  the  application  of  the  energy  by  which  the  sound 
is  produced.  The  first  sound  of  the  heart  is  often  loud,  even  booming, 
but  never,  according  to  my  belief,  accentuated.  It  may  have  a  slapping 
equality  as  in  mitral  stenosis,  but  that  is  something  altogether  different 
from  accentuation.  The  second  sound  of  the  heart  at  the  base  may  be  loud 
and  distinct  without  being  accentuated.  It  may  become  accentuated  with- 
out becoming  louder.  Accentuation  is  then  something  quite  different  from. 
loudness.  The  word  conveys  the  idea  of  suddenness,  sharpness,  a  certain 
vibrating  quality  due  to  quick  and  sharp  tension.  Loudness  is  a  matter 
of  degree;  accentuation  a  matter  of  quality.  From  this  point  of  view 
accentuation  becomes  a  physical  sign  of  great  importance. 

The  first  sound  is  increased  in  intensity  in  conditions  which  cause 
the  heart  to  act  with  unusual  energy.  In  intense  emotional  states  the  first 
sound  is  greatly  increased  and  may  sometimes  be  heard  all  over  the  chest. 
Such  overaction  may  be  pathological,  as  in  mania  and  acute  febrile  states. 
The  first  sound  is  louder  than  normal  in  hypertrophy  of  the  left  ventricle, 
but  less  constantly  so  than  has  been  assumed;  even  with  a  considerable 
degree  of  associated  dilatation  the  sound  may  still  be  quite  intense. 

The  first  sound  is  enfeebled  in  conditions  of  general  asthenia  such  as 
result  from  starvation,  long-continued  fevers,  wasting  diseases,  hemorrhage, 
shock,  and  profound  exhaustion  from  over-exertion;  in  dilatation  of  the 
ventricles,  myocarditis,  fatty  heart,  and  rupture  of  the  compensation  in 
chronic  valvular  disease;  in  chlorosis  and  ansemia  and  in  all  conditions 
that  interfere  with  its  transmission  to  the  ear  of  the  auscultator,  such  as  fat 
in  the  chest  walls,  emphysema,  pleural  and  pericardial  effusions,  and  certain 
mediastinal  tumors.  In  conditions  in  which  direct  pressure  is  exerted  upon 
the  wall  of  the  heart  by  effusion  or  tumor,  its  action  is  impeded  and  its 
sound  enfeebled. 

The  second  sound  is  increased  in  intensity  in  nervous  overaction  of 
the  heart  and  in  all  conditions  in  which  the  lungs  are  retracted  so  as  to 
bring  the  aortic  arch  and  the  conus  arteriosus  into  more  extended  relation 
with  the  wall  of  the  thorax.  An  apparent  increase  in  the  loudness  of  one 
or  the  other  elements  of  the  second  sound  is  produced  by  the  retraction  of 
the  anterior  border  of  the  lung  upon  the  corresponding  side.  The  second 
sound  is  diminished  in  intensity  by  those  conditions,  both  general  and 
cardiac,  which  weaken  the  action  of  the  heart  and  diminish  the  intensity 
of  the  first  sound. 

The  significance  of  changes  in  the  intensity  of  the  aortic  and  pul- 
monary elements  in  the  second  sound  demands  consideration. 

It  has  already  been  pointed  out  that  in  normal  individuals  after  middle 
life  the  aortic  second  sound  is  more  intense  than  the  pulmonary.  A  mere 
increase  in  the  volume  of  the  sound  may  be  the  result  of  increased  cardiac 
action.  An  increase  associated  with  that  change  of  quality  designated  by 
the  term  accentuation  constitutes  a  morbid  physical  sign  and  becomes 
more  significant  in  proportion  as  the  accentuation  becomes  more  marked. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  175 

Accentuation  of  the  aortic  second  sound  occurs  in  all  conditions  in 
which  the  arterial  blood-pressure  —  vis-a-fronte  —  is  increased,  nameh', 
arteriosclerosis,  chronic  nephritis,,  and  in  aortic  aneurism  and  dilatation 
of  the  aortic  arch.  In  conditions  characterized  by  habitual  increase  in 
arterial  tension  there  is  usually  cardiac  hypertrophy. 

Diminution  in  the  intensity  of  the  aortic  second  sound  occurs  in 
conditions  in  which  the  blood  thrown  into  the  aorta  by  the  ventricular 
systole  is  reduced  in  amount  as  in  aortic  and  mitral  stenosis  and  to  some 
degree  also  in  mitral  insufficiency.  Under  these  circumstances  the  aortic 
second  sound  may  be  so  diminished  as  to  be  no  longer  heard  at  the  apex. 
Weakening  of  the  wall  of  the  heart,  as  in  fibrous  and  interstitial  myocarditis, 
fatty  degeneration,  and  extreme  dilatation,  likewise  gives  rise  to  enfeeble- 
ment  of  the  aortic  second  sound.  Relaxation  of  the  peripheral  arteries 
produces  the  same  effect.  The  aortic  second  sound  is  extremely  faint  in 
collapse  from  any  cause. 

The  pulmonic  second  sound  is  louder  than  the  aortic  in  children  and  in 
young  adults.  A  pathological  increase  in  the  loudness  of  this  sound  has  the 
same  significance  in  regard  to  the  pulmonary  circulation  that  an  increase 
in  the  aortic  second  sound  has  in  regard  to  the  general  circulation,  namely, 
an  augmentation  in  the  resistance  to  the  flow  of  the  blood.  This  occurs 
in  chronic  valvular  disease  of  the  heart,  especiall}'  in  mitral  stenosis  and 
insufficiency,  and  in  various  pulmonary  diseases,  particularly  emphysema, 
chronic  bronchitis,  phthisis,  interstitial  pneumonia,  and  compression 
atelectasis.  These  conditions  are  associated  with  hypertrophy  of  the 
right  ventricle,  compensatory  in  nature;  when  the  compensation  fails, 
the  pulmonary  second  sound  becomes  faint  and  indistinct.  Under  all 
these  conditions  the  more  intense  pulmonary  second  sound  is  also 
accentuated. 

Weakening  of  the  pulmonary  second  sound  is  the  sign  of  a  weakened 
right  ventricle  or  tricuspid  insufficiency.  This  sign  is  of  great  value  in 
pneumonia  as  indicating  failure  of  the  right  ventricle.  The  pulmonic  second 
sound  should  therefore  be  systematically  studied,  since  it  affords  at  once 
indications  for  treatment  and  data  for  prognosis. 

Rhythm. — The  derangements  of  the  rhythm  of  the  heart  which  may 
be  heard  under  certain  circumstances  in  health,  namely,  the  gallop  rhythm, 
reduplication  of  the  second  sound  at  the  base  of  the  heart  and  reduplica- 
tion of  the  first  sound  at  the  apex,  have  alread}^  been  described.  The  forms 
of  arrhythmia  which  occur  in  health  are  transitory,  like  the  conditions 
which  cause  them.  When  the  causes  are  persistent  they  likewise  persist 
and  constitute  morbid  physical  signs. 

Allorrhythmia  is  the  general  term  used  to  designate  deviations  from 
the  normal  rhythm  of  the  heart. 

Intermission  occurs  when  one  or  more  beats  of  the  heart  are  dropped. 
The  dropping  of  the  beat  sometimes  occurs  at  regular  intervals;  more 
frequently  without  any  definite  sequence.  This  fault  of  rhythm  is  encoun- 
tered in  neurotic  persons  and  sometimes  in  the  aged,  and  is  usually  the 
sign  of  defective  innervation  rather  than  of  organic  disease.  When  the 
patient  is  conscious  of  it,  as  is  frequently  the  case,  it  constitutes  a  source 
of  great  annoyance  and  distress. 


176  MEDICAL  DIAGNOSIS. 

Irregularity  is  the  condition  in  which  the  beats  are  unequal  in  volume 
and  force  or  follow  one  another  at  unequal  intervals. 
The  following  forms  of  arrhythmia  are  recognized : 

1.  Intermission. — There  is  an  occasional  intermission  or  dropping 
of  a  beat  of  a  heart  otherwise  acting  regularly.  The  absence  of  the  heart 
sounds  proves  that  the  systole  does  not  occur.  The  systole  may  be  too 
weak  to  cause  a  pulse  wave  yet  a  faint  first  sound  may  be  heard.  Inter- 
mittent pulse  may  occur  without  complete  cardiac  intermission. 

2.  Reduplication. — (a)  Reduplication  or  doubling  of  the  second  sound 
at  the  base.  Any  pathological  condition  which  increases  the  tension  in  the 
general  arterial  system  on  the  one  hand,  or  in  the  pulmonary  circulation  on 
the  other,  and  thus  deranges  the  synchronism  of  the  aortic  and  pulmonary 
elements  of  the  second  sound,  may  cause  this  form  of  arrhythmia. 

(b)  Reduplication  or  doubling  of  the  first  sound  at  the  apex  occurs  in 
many  pathological  conditions  causing  an  increase  in  the  work  of  one  or  the 
other  side  of  the  heart.    It  occurs  also  in  myocarditis. 

3.  Cardiac  Alternation. — Strong  and  feeble  systolic  contractions  occur 
in  regular  alternation,  with  a  corresponding  alternate  pulse  rhythm. 

4.  Series  of  Cardiac  Revolutions  in  Rapid  Succession,  each  group  being 
separated  from  the  following  one  by  a  longer  interval.  This  form  of  arrhyth- 
mia corresponds  to  the  pulsus  bigeminus  or  pulsus  trigeminus.  The  first 
beat  of  the  series  is  commonly  stronger  than  the  succeeding  pulsations, 
and  in  some  cases  the  last  may  be  so  feeble  that  the  pulse  wave  is  not 
transmitted  to  the  wrist;  in  the  bigeminal  variety  only  one  radial  pulse 
is  felt  for  two  contractions  of  the  heart.  This  form  of  arrhythmia  is  not 
usually  continuous  but  occurs  at  intervals  in  a  heart  otherwise  regular. 

5.  Delirium  Cordis. — The  loss  of  rhythm  is  complete.  The  heart's 
action  is  wholly  irregular  in  time  and  force  and  characterized  by  weakness 
and  rapidity. 

6.  The  Pendulum  Rhythm. — The  pause  between  the  systolic  and  dias- 
tolic sounds  is  prolonged  and  tends  to  become  equal  with  the  long  pause. 
This  variety  of  arrhythmia  has  been  observed  in  conditions  of  high 
arterial  tension,  as  chronic  nephritis,  and  is  due  to  a  prolongation  of  the 
ventricular  systole. 

7.  Embryocardia. — The  rhythm  of  the  fetal  heart.      (See  p.  170.) 

8.  The  Gallop  Rhythm.  —  This  variety  has  already  been  described. 
When  permanent  it  is  usually  a  sign  of  great  weakness  of  the  heart  muscle. 

The  significance  of  arrhythmia  is  not  always  apparent.  It  may  be 
due  to  emotional  or  other  psychical  causes,  to  central  or  cerebral  conditions, 
as  hemorrhage  or  concussion,  to  reflex  influences,  especially  those  of 
gastric  origin,  or  to  toxic  agencies.  Among  the  last,  excesses  in  tea, 
coffee,  and  tobacco  are  prominent,  and  certain  narcotic  drugs,  as  digitalis, 
belladonna,  and  aconite,  are  to  be  named. 

Changes  in  the  heart  itself  are  potent  factors  in  the  causation  of 
derangements  of  rhythm.  These  may  involve  the  ganglia,  which  may  be 
fatty,  pigmented,  or  sclerotic,  or  the  walls  of  the  heart,  which  may  show 
simple  dilatation,  fatty  degeneration,  or  sclerosis,  or  the  coronary  arteries 
and  their  branches,  which  are  frequently  sclerotic.  Yet  there  are  cases 
in  which  these  conditions  are  present  without  arrhythmia,  and  again  cases 


PHYSICAL  DIAGNOSIS:    AUSCULTATION.  177 

of  marked  and  persistent  arrhythmia  in  which  the  health  appears  to  be 
in  no  other  respect  impaired.  Nor  do  valvular  lesions  necessarily  give 
rise  to  faults  of  rhythm  so  long  as  compensation  is  maintained.  With 
failure  of  compensation  arrhythmia  is  often  present,  especially  in  mitral 
disease,  and  it  is  interesting  to  note  that  while  the  other  symptoms  of 
this  condition  disappear  under  rest  and  treatment  some  degree  of  irregu- 
larity of  the  heart  usually  persists.  The  bigeminal  and  trigeminal  rhythm 
occur  most  commonly  in  mitral  disease;  delirium  cordis  in  rupture  of 
compensation,  particularly  toward  the  end;  the  pendulum  rhythm  in 
conditions  of  high  arterial  tension;  embryocardia  in  dilated  heart. 

ABNORMAL  OR  ADVENTITIOUS  SOUNDS. 

Upon  auscultation  over  the  heart  and  great  vessels  and  in  some  cases 
over  wide  areas  of  the  surface  of  the  chest  both  anteriorly  and  posteriorly, 
sounds  are  heard  in  pathological  conditions  which  differ  from  the  normal 
heart  sounds  and  constitute  abnormal  or  morbid  physical  signs.  These 
sounds  bear  a  definite  relation  to  the  cardiac  cycle  and  are  dependent 
upon  the  action  of  the  heart.  They  may  be  arranged  in  two  groups 
according  as  they  have  been  found,  upon  comparison  of  clinical  with 
post-mortem  findings,  to  originate  from  (A)  abnormal  conditions  within 
the  heart,  or  (B)  outside  of  it. 

Those  which  have  their  origin  within  the  heart  are  spoken  of  as 
endocardial;  those  which  arise  outside  of  the  heart  as  exocardial. 

A.  Endocardial  adventitious  sounds  are  called  murmurs.    They  are: 

Organic ; 

Functional,  Accidental  or  Hsemic. 

B.  Exocardial    adventitious    sounds,    sometimes    called    paracardial 

murmurs,  include: 

Pericardial  Friction; 

Pleuropericardial  Friction; 

Cardiopulmonary  Murmurs; 

The  Precordial  Rales  of  Emphysema; 

Pericardial  Splashing; 

The  Murmurs  of  Aneurism. 

A.  Endocardial  Murmurs.  —  Much  confusion  has  arisen  from  the 
attempts  of  writers  and  teachers  to  explain  auscultatory  phenomena  in 
muscial  terms.  Neither  the  sounds  of  the  heart — sometimes  erroneously 
called  "tones" — nor  cardiac  murmurs,  with  exceptions  presently  to  be 
mentioned,  are  musical  phenomena.  They  both  arise  from  irregular 
sound-producing  vibrations  which  lack,  as  a  rule,  the  rapidity  necessary 
to  the  production  of  musical  tones,  though  exceptionally  murmurs  acquire 
a  distinct  musical  quality.  A  "sound"  of  the  heart  is  produced  by  a 
single  sudden  derangement  of  the  equipoise  of  sound-producing  structures, 
which  are  thrown  into  vibration;  a  murmur  by  the  continuous  action  of 
forces  which  maintain  such  vibrations.  The  sound  presently  ceases;  the 
murmur  continues  so  long  as  the  force  which  causes  the  vibrations  con- 

12 


178  MEDICAL  DIAGNOSIS. 

tinues  to  act.  The  sound  corresponds  in  a  way  to  a  single  blow  upon  a  drum; 
the  murmur  to  the  continuous,  rapidly  repeated,  but  less  intense  sounds 
known  as  the  roll  of  the  drum;  or  the  sound  to  the  picking  of  the  violin 
string,  the  murmur  to  the  continuous  note  made  by  the  drawing  of  the 
bow.  But  both  these  comparisons  have  the  fault  of  Ukening  musical  phe- 
nomena to  those  which  usually  lack  the  musical  quality.  Furthermore  the 
mechanism  by  which  sounds  and  murmurs  are  produced  is  different. 

The  Mechanism  of  Endocardial  Murmurs. — The  heart  sounds  arise  from 
the  contraction  of  the  heart  muscle,  the  vibration  of  the  blood  mass,  and 
the  sudden  tension  of  the  auriculoventricular  and  semilunar  valve  sys- 
tems. When  murmurs  arise  a  new  set  of  physical  conditions  comes  into 
play,  namely,  fluid  veins  (see  p.  152).  These  swirls,  or  currents  within 
currents  of  the  blood,  are  attended  with  vibrations,  which,  first  com- 
municated to  the  wall  of  the  heart  or  vessels  and  thence  by  way  of  the 
intervening  tissues  to  the  surface  of  the  chest,  are  recognized  by  the 
auscultator  as  auditory  phenomena^murmurs. 

The  Mechanism  of  Organic  Murmurs — Lesions. — In  by  far  the  greater 
number  of  instances  the  fluid  veins  are  due  to  actual  lesions  of  the  heart, 
and  for  this  reason  the  murmurs  are  known  as  organic.  The  lesions  mostly 
involve  the  valves,  a  fact  which  is  indicated  by  the  descriptive  adjective 
valvular.  They  are  on  the  one  hand  inflammatory  and  proliferative  or 
adhesive,  on  the  other  sclerotic.  Those  that  occur  in  early  life  are  usu- 
ally inflammatory;  those  which  develop  later  are  mostly  sclerotic;  but 
the  inflammatory  lesions  of  the  valves  undergo  sclerotic  changes,  and  old 
sclerotic  valves  are  frequently  the  seat  of  recurrent  inflammatory  proc- 
esses— recurrent  endocarditis.  As  the  result  of  each  of  these  processes 
involving  the  valves,  deformities  arise.  Inflammation  causes  vegetations, 
thickening,  adhesions,  and  in  extreme  cases  necrosis;  sclerosis  gives  rise 
to  thickening,  retraction,  crumpling;  both  result  in  loss  of  elasticity  and 
freedom  of  movement.  In  cases  of  long  standing  hme  salts  are  deposited 
and  the  rigidity  and  deformity  are  correspondingly  increased. 

Stenosis  and  Insufficiency. — The  impairment  of  function  is  two- 
fold. That  function  of  the  valves  by  which  they  yield  before  the  blood 
stream  and  permit  it  to  pass  unhindered  from  auricle  to  ventricle  or 
from  ventricle  to  artery  may  be  deranged.  The  condition  is  known  as 
stenosis  or  narrowing,  and  the  fluid  veins  are  developed  in  the  normal 
direction  of  the  blood  stream.  Or  that  function  by  virtue  of  which  the 
valves  close  their  respective  orifices  is  at  fault,  and  there  is  valvular 
insufficiency  or  incompetency,  the  fluid  veins  developing  in  the  reverse 
direction.  Very  often  both  these  functions  are  impaired,  and  the  condi- 
tion is  that  of  combined  stenosis  and  insufficiency,  with  double  murmurs. 

Relative  Insufficiency.  —  Again,  the  orifice  guarded  by  a  valve 
system  may  be  enlarged  in  consequence  of  the  dilatation  of  the  heart,  so 
that  the  edges  of  the  valves  may  be  unable  to  meet  and  close  it.  This  con- 
dition is  known  as  relative  insufficiency  or  incompetence,  and  is  dependent 
not  upon  lesions  of  the  valves,  but  upon  nutritive  or  degenerative  lesions 
of  the  heart  muscle.  Acute  relative  insufficiency  such  as  sometimes  accom- 
panies the  heart  failure  of  violent  exertion  is  due  to  relaxation  of  the  wall 
of  the  heart  and  papillary  muscles. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  179 

Roughening  of  the  surfaces  of  the  valves  or  of  the  parts  immediately 
adjacent  to  them  and  sudden  dilatation  of  the  artery  just  beyond  the  valve 
system  may  lead  to  the  production  of  a  murmur. 

The  deformity  which  gives  rise  to  an  endocardial  murmur  may  be  of  all 
degrees,  from  such  as  only  slightly  impair  the  function  of  the  valve  system 
to  a  stenosis  which  leaves  a  tiny  orifice  or  mere  chink  for  the  passage  of 
the  blood  or  an  incompetence  that  is  almost  complete  and  transfers  the 
pressure  of  the  blood  column  to  the  wall  of  the  chamber  of  the  heart  which 
is  immediately  behind  the  defective  valve,  namely,  the  left  ventricle  in 
aortic  insufficiency  and  the  left  auricle  in  mitral  insufficiency.  A  projecting 
firm  vegetation  or  rigid  spicule  or  the  inelastic  edge  of  a  sclerotic  valve 
may  be  the  cause  of  a  systolic  murmur,  where  there  is  practically  no 
actual  narrowing  of  the  orifice.  One  of  the  first  lessons  for  the  student 
of  heart  murmurs  to  learn  is  that  by  no  means  every  systolic  murmur 
having  its  point  of  maximum  intensity  in  the  aortic  area  is  the  sign  of 
aortic  stenosis. 

Stenosis  or  Narrowing  of  an  Orifice  Guarded  by  a  Valve 
System. — There  is  impairment  of  the  function  by  which  the  valves  open 
at  the  physiological  moment.  The  flow  of  the  blood  is  obstructed  and 
under  ordinary  circumstances  a  murmur  is  produced,  which  is  spoken  of 
as  an  obstructive  murmur.  If  the  heart  be  very  feeble,  marked  obstruc- 
tion may  exist  without  producing  a  murmur  that  can  be  recognized.  If  the 
left  auriculoventricular  orifice  is  involved,  the  condition  is  known  as  mitral 
stenosis  or  obstruction;   if  the  aortic,  as  aortic  stenosis  or  obstruction. 

Incompetence  or  Insufficiency. — The  function  of  the  valves  by 
which  they  close  the  orifice  is  impaired  and  a  portion  of  the  blood  which 
has  just  passed  through  the  orifice  escapes  from  the  main  stream  and  flows 
back  into  the  chamber  of  the  heart  whence  it  came.  This  pathological 
event  is  known  as  regurgitation,  and  the  murmur  which  attends  it  is  called 
a  regurgitant  murmur.  We  then  have  mitral  and  aortic  incompetence, 
insufficiency  or  regurgitation  as  one  or  the  other  of  these  valve  systems  is 
affected. 

Valvular  lesions  of  the  right  side  of  the  heart  are  of  infrequent  occur- 
rence. They  are  sometimes  the  result  of  developmental  defects  or  prenatal 
endocarditis.  However  produced  they  cause  similar  impairment  of  the 
valve  functions,  manifest  by  murmurs — tricuspid  and  pulmo^iary  stenosis 
and  incompetence.  Stenosis  is  always  due  to  deformity  of  the  segments 
of  a  valve  system.  Incompetence  is  mostly  due  to  the  same  cause,  but 
not  always.  The  deformity  which  prevents  a  valve  from  fully  opening 
also  generally  prevents  it  from  fully  closing. 

Combined  stenosis  and  incompetence  arises  under  the  conditions 
just  indicated.  The  lesion  is  a  "double"  one  and  manifests  itself  by  a 
"double"  or  "to-and-fro"  murmur. 

Incompetence  may,  however,  arise  in  the  absence  of  stenosis  as  the 
result  of  (a)  a  lesion  by  which  a  valve  segment  has  been  destroyed  by 
ulcerative  endocarditis  or  has  contracted  adhesions  to  the  wall  of  the 
heart,  or  (b)  of  relaxation  of  the  cardiac  muscle,  as  in  relative  insufficiency. 

Stenosis  without  incompetence  is  comparatively  infrequent;  incom- 
petence without  stenosis  is  not  very  uncommon. 


180  MEDICAL  DIAGNOSIS. 

Valvular  lesions  exert  their  effect  (a)  upon  the  blood  stream  within 
the  heart,  (b)  upon  the  walls  of  the  heart,  (c)  upon  the  viscera,  and  finally 
(d)  upon  the  peripheral  circulation. 

(a)  The  Effect  of  the  Valvular  Lesions  which  Produce  Endo- 
cardial Murmurs  upon  the  Blood  Stream  within  the  Heart. — The 
beginning  of  evil  in  stenosis  and  incompetence  is  the  same.  It  consists 
in  a  reduction  of  the  quantity  of  blood  which  eventually  passes  the 
diseased  valve  system  with  each  revolution  of  the  heart.  In  stenosis  a 
portion  of  the  stream  corresponding  to  the  extent  of  the  pathological 
barrier  is  held  back;  in  incompetence  a  portion  corresponding  to  the 
degree  of  the  pathological  defect  returns  into  the  chamber  whence  it 
came — regurgitates.  The  result  is  a  tendency  to  retardation  of  the  flow, 
diminution  in  the  volume  of  blood  entering  the  arteries,  and  increase  in 
the  volume  retained  in  the  veins,  with  progressive  transference  of  blood- 
pressure  from  the  arterial  to  the  venous  side  of  the  circulation.  Were  this 
tendency  unchecked  every  case  of  valvular  disease  would  in  a  short  time 
terminate  in  death,  the  venous  pressure  rising  and  the  arterial  falling  until 
the  circulation  becomes  no  longer  possible.  This  result,  which  is  the  usual 
cause  of  death  in  valvular  disease,  is  postponed  for  an  indefinite  period  by 
compensatory  changes  in  the  muscle  of  the  heart  itself.  It  is  true  these 
changes  are  consecutive  to  the  lesion,  but  as  the  latter  is  progressive,  the 
former  are  correspondingly  progressive.  When  the  one  advances  at  the 
same  rate  as  the  other  a  physiological  balance  is  again  established,  the 
stability  of  which  depends  upon  the  tardiness  of  the  valvular  disease  on  the 
one  hand,  and  the  ability  of  the  hypertrophied  heart  muscle  to  maintain 
its  nutrition  on  the  other.  When  extensive  valvular  defects  develop  sud- 
denly or  are  rapidly  progressive,  compensation  is  not  established  and 
death  occurs  in  a  short  time. 

(b)  The  Effects  upon  the  Walls  of  the  Heart. — The  immediate 
effects  of  the  separation  of  the  blood  stream  into  a  major  part  circulating 
under  physiological  conditions  and  a  minor  part  held  back  under  patho- 
logical influences  are  exerted  upon  the  walls  of  the  chamber  behind  the 
affected  valve  system.  They  are  first  dilatation,  then  hypertrophy.  These 
changes  may  affect  the  whole  organ,  the  heart  acting  as  a  single  muscle 
and  undergoing  a  general  enlargement  in  response  to  the  increased  work 
required  of  it;  more  commonly  they  affect  one  or  more  of  the  chambers 
and  in  particular  that  chamber  immediately  subjected  by  the  valvular 
lesion  to  increase  in  its  blood  contents  in  diastole  and  to  a  necessary 
increase  in  its  energy  in  systole  in  order  to  overcome  the  obstacle  in  stenosis 
or  propel  an  augmented  volume  of  blood  in  incompetence.  In  mitral 
stenosis  the  left  auricle  cannot  empty  itself  and  receives  blood  from  the 
pulmonary  circuit;  in  mitral  incompetence  it  receives  blood  at  the  same 
moment  from  the  pulmonary  circuit  and  the  left  ventricle;  in  combined 
mitral  lesions  some  blood  is  retained  and  some  regurgitates,  while  the 
physiological  supply  enters  by  the  pulmonary  veins.  Consequently  the 
left  auricle  is  first  dilated  and  then  hypertrophied.  In  aortic  stenosis  the 
left  ventricle  cannot  empty  itself  and  in  diastole  the  blood  received  from 
the  left  auricle  is  augmented  by  that  retained  at  the  time  of  the  previous 
systole;   in  aortic  incompetence  blood  enters  the  left  ventricle  in  diastole 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  181 

at  the  same  moment  from  two  sources,  the  left  auricle  and  the  aorta; 
in  combined  aortic  disease  the  blood  coming  from  the  left  auricle  is 
augmented  by  that  retained  at  the  previous  systole  and  that  returning 
from  the  aorta.  Under  these  circumstances  the  left  ventricle  is  first  dilated 
and  then  hypertrophied.  It  is  important  to  bear  in  mind  the  cardinal 
fact  that  all  these  changes,  like  the  lesion  itself,  are  slight  at  first  and 
gradually  progress,  and  that  in  the  early  stages  neither  the  dilatation 
nor  the  hypertrophy  can  be  recognized  by  the  ordinary  methods  of  physical 
diagnosis.  Even  at  this  period  the  murmurs  indicative  of  the  respective 
lesions  are  commonly  quite  audible,  often  loud  or  harsh,  and  months 
may  elapse  before  the  signs  of  enlargement  of  the  heart  or  venous  stasis 
can  be  determined.  The  diagnosis  rests  upon  the  presence  and  characters 
of  the  murmur.  Nevertheless  it  is  an  error  to  speak  of  this  stage  as  pre- 
ceding compensation.  There  are,  however,  cases  of  rapidly  developing 
lesions  in  which  complete  compensation  is  only  gradually  attained;  some 
in  which  it  is  never  reached.  If  the  quantity  of  blood  held  back  in  stenosis 
or  regurgitated  in  incompetence  be  represented  by  x,  it  is  evident  that 
there  must  be  an  increased  capacity  of  the  affected  chamber,  represented 
by  the  same  symbol,  and  that  the  chamber  must  be  dilated  to  that 
extent.  While  if  the  resulting  hypertrophy  of  the  wall  of  the  chamber  be 
such  as  to  enable  it  to  propel  the  normal  quantity  of  blood  plus  x,  it  is 
evident  that  a  condition  is  established  in  respect  to  the  volume  of  blood 
maintained  in  circulation,  which  is  practically  normal  despite  the  valvular 
lesion,  and  this  condition  is  known  as  compensation.  This  condition  exists, 
however,  by  virtue  of  an  abnormal  increase  in  the  nutrition  and  work  of 
the  heart  muscle  and  at  the  expense  of  the  normal  reserve  power  of  the 
heart,  and  is  therefore  unstable.  It  consists  in  a  degree  of  dilatation  and 
hypertrophy  combined  and  in  ratio  to  the  valvular  defect,  but  demands 
for  its  maintenance  a  hypertrophy  slightly  in  excess  of  the  dilatation.  The 
nutrition  of  the  overgrown  and  overworked  muscle  ultimately  fails  and 
dilatation  develops  in  excess  of  hypertrophy.  The  compensation  under 
these  circumstances  is  said  to  be  at  first  "deranged"  or  "failing,"  later 
"broken "  or  "ruptured."  It  is  a  question  of  degree.  In  a  small  proportion 
of  the  cases  failure  of  compensation  occurs  in  the  absence  of  marked 
increase  in  the  size  of  the  affected  chamber  or  chambers  of  the  heart 
and  has  been  ascribed  to  derangement  of  the  innervation  of  the  heart. 

(c)  Effects  upon  the  Viscera. — Compensation,  while  adequate  to 
the  maintenance  of  a  fair  degree  of  health  for  an  indefinite  period,  is  never 
complete.  There  is  always  increased  resistance  to  the  onward  flew  of  the 
arterial  blood  and  a  corresponding  increase  in  the  blood-pressure  upon  the 
venous  side  of  the  circulation.  This  results  in  increased  fulness  of  the 
pulmonary  circuit,  manifest  by  accentuation  of  the  pulmonary  second 
sound,  hypertrophy  of  the  right  ventricle  and  a  tendency  to  passive  hyper- 
semia  of  the  viscera  in  general;  hence,  accentuation  of  the  aortic  second 
sound,  dyspnoea  upon  exertion,  a  peculiar  liability  to  bronchial  catarrh 
and  the  occasional  occurrence  of  blood-streaked  sputum  or  slight  haemop- 
tysis— phenomena  which  are  common  in  mitral  disease  even  while  the 
compensation  remains  fairly  good.  Upon  failure  of  compensation  there  is 
marked  venous  engorgement  of  the  viscera,  with  grave  derangement  of 


182  MEDICAL  DIAGNOSIS. 

function,  shown  on  the  part  of  the  lungs  by  marked  dyspnoea  or  orthop- 
nea, cyanosis,  cough,  and  the  occasional  expectoration  of  frothy  blood; 
of  the  liver  and  gastro-intestinal  organs  by  loss  of  appetite,  deficient  diges- 
tion, nausea,  slight  jaundice  and  constipation;  on  the  part  of  the  kidneys 
by  scanty  urine  and  albuminuria.  Dulness,  stupor,  somnolence  with  ina- 
bility to  sleep  are  symptoms  of  the  derangement  of  the  cerebral  circulation. 

(d)  Effects  upon  the  Peripheral  Circulation. — While  compen- 
sation is  maintained,  dropsy,  as  the  result  of  valvular  lesions,  does  not 
occur.  There  is  sometimes  to  be  found  slight  pretibial  cedema,  especially 
after  fatiguing  exertion  or  long  standing.  When  compensation  fails,  how- 
ever, the  diminished  arterial  pressure  and  the  increased  venous  pressure 
interfere  with  the  circulation  of  the  blood  in  the  capillary  zone  and  give 
rise  to  oedema.  Under  these  circumstances,  there  is  an  accumulation  of 
extravascular  serum  about  the  capillaries  and  a  retardation  of  the  lymph- 
flow.  Hence  the  visceral  derangements  are  not  only  hypersemic,  they  are 
also  oedematous.  The  action  of  gravity  renders  this  accumulation  of  extra- 
vascular  fluid  early  manifest  in  the  dependent  parts,  namely,  the  legs  and 
feet.  As  it  increases,  the  thighs,  genitalia,  and  loins  become  involved,  and 
finally  there  is  general  oedema  with  effusion  into  the  serous  sacs.  The 
dropsy  of  heart  disease  is  often  irregularly  distributed,  but  its  presence 
in  particular  localities  may  usually  be  explained  by  the  relatively  loose 
arrangement  of  the  subcutaneous  or  other  tissues  involved,  postural 
influences,  and  the  action  of  gravity. 

Compensation  in  mitral  disease  commonly  fails  by  degrees,  with 
periods  of  improvement  following  rest  and  treatment,  and  the  ultimate 
catastrophe  usually  occurs  after  impaired  health  of  prolonged  duration. 

Compensation  in  aortic  disease  is  chiefly  maintained  by  the  left  ven- 
tricle, which  often  becomes  enormously  hypertrophied,  —  cor  bovinum. 
There  is  some  increase  in  the  venous  pressure,  since  the  ventricle  receives 
its  blood  in  diastole  not  only  from  the  auricle  but  also  from  the  aorta, 
but  so  long  as  the  mitral  valve  remains  competent,  the  visceral  engorge- 
ment and  general  oedema  which  characterize  the  dyscrasia  of  the  stadium 
ultimum  of  mitral  disease  do  not  occur.  Precordial  pain,  angina  pectoris, 
and  momentary  faintness  upon  rising  or  at  stool  are  common,  and  in  many 
cases  the  rupture  of  compensation  is  immediate  and  instantly  fatal,  death 
occurring  with  the  heart  in  asystole. 

The  Mechanism  of  Functional,  Accidental,  or  Hsemic  Murmurs.  —  The 
murmurs  designated  by  these  terms  are  not  signs  of  disease  of  the  valves 
or  orifices  of  the  heart.  The  frequency  of  their  occurrence  enables  us 
to  determine  with  precision  that  they  do  not  correspond  to  anatomical 
changes  in  the  organ  found  upon  examination  after  death.  The  mechanism 
by  which  they  are  produced  has  been  the  subject  of  much  controversy, 
but  none  of  the  explanations  advanced  has  been  generally  accepted. 
Functional  murmurs  are  almost  exclusively  systolic  and  are  heard  over  a 
limited  space  in  the  pulmonary  area.  They  have  been  ascribed  to  dila- 
tation of  the  conus  arteriosus,  to  the  fact  that  in  ansemia  and  similar 
conditions  there  is  lowered  tonicity  of  the  arterial  walls  which  undergo  an 
abnormal  dilatation  at  the  time  of  the  systole,  and  to  the  lowered  blood- 
pressure  of  ansemia  in  the  aorta  and  pulmonary  artery,  which,  in  connec- 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  183 

tion  with  the  relatively  high  intraventricular  pressure  at  the  beginning  of 
systole,  prevents  the  closure  of  the  semilunar  valves  and  the  systolic 
tension  of  the  vessels,  with  the  result  that  a  systolic  murmur  arises 
upon  the  passage  of  the  blood  into  the  large  vessels  at  the  moment  of 
physiological  stenosis — contraction  of  the  cardiac  sphincters. 

Diastolic  functional  murmurs,  which  are  so  rare  that  they  scarcely 
demand  consideration  for  diagnostic  purposes,  are  probably  venous  mur- 
murs transmitted  to  the  innominata  or  vena  cava  and  heard  at  the  base 
of  the  heart. 

The  Significance  of  Endocardial  Murmurs. — In  order  to  determine  the 
diagnostic  meaning  of  a  murmur  heard  upon  auscultation  of  the  precordial 
area,  we  must  first  answer  the  following  questions:  Is  it  endocardial 
or  exocardial?  (See  page  177.)  If  endocardial,  is  it  organic  or  functional? 
(See  page  188.)  Having  found  it  to  be  an  endocardial  murmur  of  organic 
origin  we  must  then  ascertain  (1)  its  time  in  the  cardiac  cycle;  (2)  its 
point  of  maximum  intensity;  (3)  the  direction  in  which  it  is  propagated 
and  the  area  over  which  it  can  be  heard;  (4)  its  relation  to  the  normal 
sounds  of  the  heart;  (5)  its  acoustic  properties,  and  (6)  the  effects  of 
exercise,  respiration,  and  posture  upon  it. 

(1)  The  Time  of  Murmurs  in  the  Cardiac  Cycle. — The  determina- 
tion of  this  point  is  of  primary  importance.  For  diagnostic  purposes  the 
systole  may  be  regarded  as  lasting  from  the  beginning  of  the  first  sound  of 
the  heart  until  the  second  sound;  the  diastole  from  the  beginning  of  the 
second  sound  until  the  beginning  of  the  first  sound  in  the  next  revolution  of 
the  heart.  A  murmur  heard  at  the  time  of  the  first  sound  or  replacing  the 
first  sound  or  extending  into  or  developing  in  the  period  between  the  first 
and  the  second  sounds  is  systolic.  Murmurs  which  develop  in  the  latter 
period  are  designated  late  systolic. 

A  murmur  which  occurs  at  the  time  of  the  second  sound  or  replaces  it 
is  diastolic.  Murmurs  which  occur  during  the  last  portion  of  the  diastole 
and  run  up  to  the  first  sound  are  known  as  presystolic. 

When  the  heart  is  acting  moderately  there  is  no  difficulty  in  recognizing 
the  first  and  second  sounds  by  their  respective  characters,  and  the  long  and 
short  silences  by  their  relative  duration.  But  when  the  heart  is  rapid  the 
different  acoustic  characters  of  the  two  sounds  cannot  always  be  made  out 
and  the  rhythm  is  so  deranged  that  the  difference  between  the  long  and 
the  short  silence  is  less  marked.  Under  these  circumstances  the  systole 
may  be  determined  by  palpation  with  the  finger  over  the  apex  or  the 
carotid  artery  during  auscultation,  or  by  inspection  if  the  double  stetho- 
scope is  used.  The  interval  between  the  time  of  the  cardiac  impulse  and 
the  radial  pulse  renders  the  latter  a  misleading  guide  for  this  purpose. 

(2)  The  Point  of  Maximum  Intensity  of  Murmurs. — The  area  in 
which  a  murmur  is  best  heard  is  likewise  of  cardinal  importance  in  diag- 
nosis. The  murmur  is  loudest  at  the  point  of  its  production  and  is  best 
transmitted  in  the  direction  of  the  blood  stream  in  which  the  fluid  veins 
which  produce  it  are  developed.  It  is  in  accordance  with  these  laws  that  a 
murmur  having  its  point  of  greatest  intensity  in  the  mitral  area  has  its 
origin  at  the  mitral  valve.  It  is  necessary  in  this  connection  to  bear  in 
mind  the  fact  that  the  mitral  area  is  not  constant  in  the  normal  position 


184  MEDICAL  DIAGNOSIS. 

but  that  it  shifts  with  displacement  of  the  heart.  In  a  limited  proportion 
of  cases  of  mitral  disease  this  murmur  is  best  heard  to  the  right  of  the 
normal  position  of  the  impulse,  and  in  rare  instances  at  the  left  border  of 
the  sternum  higher  up,  even  as  high  as  the  punctum  maximum  of  the 
pulmonary  second  sound. 

It  is  also  in  accordance  with  the  above  laws  that  murmurs  heard  in 
the  pulmonary  area,  namely,  the  second  left  intercostal  space,  have  their 
origin  in  the  conus  arteriosus  or  at  the  pulmonary  orifice;  that  murmurs 
having  their  maximum  intensity  at  the  right  lower  border  of  the  sternum, 
at  the  level  of  the  fourth  and  fifth  intercostal  spaces,  or  at  the  base  of  the 
ensiform  cartilage  are  produced  at  the  tricuspid  orifice,  and  that  murmurs 
whose  maximum  intensity  is  in  or  near  the  aortic  area  have  their  origin 
at  the  aortic  orifice.  Murmurs  arising  at  this  point  very  often,  however, 
are  best  heard  over  the  upper  part  of  the  body  of  the  sternum  near  its 
left  border  or,  less  frequently,  at  the  apex  or  over  the  lower  part  of  the 
sternum — aortic  insufficiency. 

(3)  The  Propagation  of  Murmurs  and  the  Extent  of  the  Area 
IN  WHICH  THEY  CAN  BE  Heard. — Murmurs  are  very  often  heard  over 
limited  areas  and  transmitted  in  definite  directions.  This  is  especially  but 
not  exclusively  true  of  the  murmurs  produced  by  lesions  of  single  valve 
systems.  Thus  the  murmur  of  mitral  stenosis — the  presystolic  murmur — 
is  heard  over  a  circumscribed  area  just  above  the  apex  and  is  not  propa- 
gated, while  the  systolic  murmur  of  mitral  incompetence  is  heard  over  a 
considerable  area  to  the  right  of  the  apex  and  upward  and  is  transmitted 
distinctly  in  the  direction  of  the  left  axilla  and  to  the  back.  On  the  other 
hand  the  systolic  murmur  of  aortic  stenosis  is  usually  prolonged  and  loud, 
heard  over  an  extended  area  and  transmitted  into  the  carotid  and  sub- 
clavian artery;  it  is  in  some  instances  heard  at  a  distance  from  the  chest. 
The  diastolic  murmur  of  aortic  incompetence  may  also  be  heard  over  an 
extensive  area  of  the  chest  both  in  front  and  behind.  A  murmur  distinctly 
heard  over  two  or  more  valve  areas  may  be  due  to  one  or  to  several  valve 
lesions.  If  it  is  systolic  in  time,  it  may  be  the  sign  of  mitral  insufficiency 
or  of  aortic  stenosis,  or  the  murmur  may  be  a  compound  of  two  murmurs, 
each  representing  one  of  these  lesions.  The  difficulties  are  greatly  increased 
when  there  are  to-and-fro  murmurs  representing  double  lesions — stenosis 
and  incompetence — of  the  respective  valves.  A  correct  diagnosis  rests 
upon  the  application,  in  the  study  of  individual  cases,  of  the  knowledge, 
obtained  by  clinical  experience  and  post-mortem  examination,  that  the 
murmur  produced  by  each  valvular  lesion  has  its  characteristic  point  of 
maximum  intensity  and  definite  line  of  propagation  along  which  its  inten- 
sity gradually  diminishes  as  the  stethoscope  is  moved  away  from  that 
point.  A  murmur  which  fulfils  these  requirements  in  regard  to  a  particular 
valve  area  and  line  of  propagation  and  is  unaccompanied  by  any  other 
murmur  may  be  regarded  as  the  sign  of  a  lesion  of  that  valve.  When, 
however,  two  or  more  murmurs  are  heard  which  differ  in  their  acoustic 
characters,  as  pitch,  quality,  and  duration,  and  present  each  its  point  of 
maximum  intensity,  and  are  propagated  respectively  in  different  direc- 
tions, a  correct  diagnosis  can  only  be  reached  by  the  separate  study  of 
each  as  though  it  alone  were  present,  the  others  being  for  the  time  being 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  185 

disregarded.  In  this  analytical  study  too  much  importance  cannot  be 
placed  upon  the  differences  in  pitch  and  quality  and  the  evidences  of  the 
influence  of  the  lesions  which  cause  the  murmurs,  upon  the  size  of  the  heart, 
the  viscera  and  the  pulmonary  and  peripheral  circulation.  In  compli- 
cated cases  of  cardiac  disease  the  diagnosis  cannot  be  made  by  an  analysis 
of  the  murmurs  alone.  A  systematic  study  of  the  associated  physical  signs 
is  essential  to  success. 

When  several  murmurs  are  present,  it  is  best  not  to  attempt  an  over- 
refined  diagnosis  in  regard  to  the  lesions  which  underlie  all  of  them.  We 
may  be  content  when  we  have  determined  with  accuracy  the  two  which 
are  most  important,  and  we  may  be  reconciled  to  our  inability  to  satis- 
factorily do  more  than  this  by  the  knowledge  that  greater  nicet}^  of  diag- 
nosis, though  it  might  gratify  our  technical  ambition,  is  not  demanded 
by  the  requirements  of  therapeutics  and  prognosis,  and  has  been  dis- 
credited by  the  experience  of  the  post-mortem  room. 

In  this  connection  it  is  important  to  call  the  attention  of  the  student 
to  the  fact  that  the  intensity  of  a  murmur  does  not  necessarily  gradually 
and  progressively  diminish  in  its  line  of  propagation,  but  may  be  modified 
by  the  presence  of  a  viscus  or  the  interposition  of  a  new  growth.  Thus  an 
aortic  murmur  may  be  distinctly  heard  in  the  aortic  area  and  near  the  apex 
and  only  faintly  in  the  intervening  space.  This  phenomenon  has  been 
attributed  to  the  interposition  of  the  right  ventricle,  while  the  transmission 
of  a  mitral  regurgitant  in  the  direction  of  the  left  axilla  may  be  abruptly 
interrupted  by  a  pleural  effusion  or  neoplasm. 

(4)  The  Relation  of  Murmurs  to  the  Sounds  of  the  Heart. — A 
murmur  may  accompany  the  sounds  of  the  heart  or  may  replace  them. 
The  systolic  apex  murmur  of  mitral  incompetence  wholly  or  in  part 
replaces  the  first  sound.  The  systolic  basic  murmur  of  aortic  stenosis 
accompanies  the  first  sound,  but  when  compensation  fails  the  first  sound 
is  greatly  weakened,  and  with  enfeeblement  and  dilatation  of  the  ventricle 
or  upon  the  supervention  of  relative  mitral  incompetence  it  may  no  longer 
be  heard.  In  aortic  stenosis  the  second  sound  is  not  often  heard  at  the 
aortic  cartilage,  because  the  deformity  of  the  valve  usually  prevents  its 
closure.  In  aortic  incompetence,  the  second  sound  may  be  well  heard  or  it 
may  be  replaced  by  the  murmur.  In  some  cases  it  may  be  absent  in  the 
aortic  area  but  heard  over  the  carotid  artery. 

A  murmur  which  accompanies  a  sound  also  follows  it,  since  the  time 
of  the  murmur  is  longer  than  that  of  the  sound.  A  murmur  may  run  up 
to  a  sound,  as  the  presystolic  murmur  of  mitral  stenosis.  In  rare  cases 
murmurs  occur  between  the  sounds.  The  persistence  of  the  sound  along 
with  the  murmur  may  be  of  favorable  prognostic  significance,  as,  for 
example,  in  aortic  incompetence,  where  it  indicates  partial  closure  of  the 
damaged  valve  cusps  with  corresponding  preservation  of  function. 

(5)  The  Acoustic  Properties  of  Murmurs. — Under  this  caption  the 
(a)  intensity,  (b)  quality,  (c)  pitch,  and  (d)  duration  of  murmurs  are  to  be 
considered. 

(a)  Intensity. — The  intensity  of  cardiac  murmurs  is  extremely  variable. 
A  murmur  may  be  so  loud  that  it  may  be  heard  at  a  distance  of  some 
feet,  or  so  low  as  to  be  scarcely  audible  when  the  patient  holds  his  breath. 


186  MEDICAL  DIAGNOSIS. 

Not  infrequently  a  loud  murmur  is  heard  by  the  patient  himself.  Such  very 
loud  murmurs  are  rare.  The  intensity  of  a  murmur  is  by  no  means  pro- 
portionate to  the  gravity  of  the  lesion  by  which  it  is  produced.  On  the 
contrary,  since  its  intensity  depends  upon  the  energy  with  which  the  blood 
is  propelled  through  the  affected  orifice,  that  is,  upon  the  compensation,  a 
loud  murmur  is,  other  things  being  equal,  more  favorable  than  a  faint  one. 
As  compensation  fails,  the  murmur  becomes  fainter  and  it  not  infrequently 
happens  that  in  patients  coming  under  observation  with  greatly  impaired 
compensation  no  murmur  can  be  recognized  upon  careful  auscultation, 
but  after  rest  and  suitable  treatment  have  brought  about  inprovement  in 
the  general  condition  and  in  compensation  a  murmur  appears  which 
becomes  more  intense  as  the  patient  grows  better.  This  is  especially 
the  case  in  mitral  disease.  There  are,  however,  cases  of  acute  rheumatic 
endocarditis,  especially  in  children,  and  of  malignant  endocarditis  in 
which  the  changes  in  the  valvular  lesions  develop  rapidly  while  the  power 
of  the  myocardium  is  still  maintained,  in  which  increasing  loudness  of  the 
murmur  constitutes  a  most  unfavorable  sign.  The  intensity  of  an  organic, 
endocardial  murmur  is  important  less  from  its  degree  at  any  one  time  than 
from  its  decrease  or  increase  during  the  progress  of  the  case. 

A  murmur  is  not  usually  of  the  same  intensity  during  its  brief  course. 
In  general  it  is  louder  at  the  beginning  than  at  the  end.  Presystolic  mur- 
murs are,  however,  usually  louder  at  the  close.  The  cause  of  the  increase 
in  intensity  is  here  due  to  the  fact  that  the  blood  flows  gently  through  the 
auriculoventricular  orifice  at  the  beginning  of  the  ventricular  diastole, 
but  with  increased  force  under  the  stress  of  the  auricular  contraction  later. 

(b)  Quality. — Endocardial  murmurs  vary  in  quality  from  a  soft  blow- 
ing sound  —  bellows  murmur  souffle — of  little  intensity,  to  a  coarse, 
harsh,  rasping  sound  of  considerable  loudness.  In  rare  instances  they 
are  musical.  The  musical  quality  is  usually  manifest  during  a  part  of 
the  murmur  only,  the  remainder  having  the  ordinary  blowing  or  rasping 
character.  The  musical  quality  indicates  an  organic  lesion,  but  does  not 
enable  us  to  define  its  nature  and  is  without  significance  in  prognosis 
•except  that  it  indicates  a  certain  degree  of  power  in  the  heart  muscle.  The 
presystolic  murmurs  which  are  produced  by  mitral  and  tricuspid  stenosis 
and  the  "Flint  murmur"  of  aortic  insufficiency  have  a  peculiar  "rum- 
bling" or  "blubbering"  quality  not  heard  under  other  conditions.  These 
murmurs  have  been  compared  to  a  short  roll  of  the  drum,  but  they  are 
much  less  regular. 

(c)  Pitch.— This  attribute  of  murmurs  is  also  variable.  Blowing 
murmurs  of  soft  quality  are  commonly  low  pitched,  while  the  coarser 
murmurs  are  often  high  in  pitch:  to  this  general  statement  the  excep- 
tion that  the  very  coarse,  blubbering  presystolic  murmurs  are  usually 
of  low  pitch.  It  is  the  high-pitched  murmur  that  tends  to  assume  the 
musical  quality. 

(d)  Duration. — A  murmur  may  occupy  the  whole  period  of  the  systole 
or  the  diastole  or  any  part  of  either  of  these  periods.  The  systolic  murmur 
of  mitral  incompetence  is  sometimes  prolonged,  the  diastolic  murmur  of 
aortic  incompetence  almost  always  so.  Presystolic  murmurs  are  of  shorter 
duration.    The  length  of  murmurs  is  not  of  itself  of  prognostic  significance. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  187 

(e)  Variation  in  Murmurs. — Rapid  changes  in  the  acoustic  properties  of 
murmurs,  even  their  disappearance  and  reappearance,  may  occur  in  acute 
endocarditis  when  vegetations  are  forming  upon  the  valve  segments,  and 
especially  in  the  malignant  form,  in  which  the  vegetations  grow  with  rapidity 
upon  the  valves  and  adjacent  walls  and  ulcerative  lesions  occur.  Similar 
changes  may  occur  in 'the  course  of  acute  endocarditis  as  the  result  of 
rupture  of  chordae  tendinese  or  the  formation  of  adhesions  between  valve 
segments  or  between  a  segment  and  the  wall  of  the  heart. 

(6)  Effects  of  Exercise,  Respiration,  and  Posture  upon  Endo- 
cardial Murmurs. — Faint  murmurs  usually  become  more  distinct  upon 
moderate  exercise,  as  walking  rapidly  two  or  three  times  across  a  room,  or 
stooping  and  rising  several  times  in  succession,  and  these  movements  are 
sometimes  necessary  in  the  examination  of  doubtful  cases.  When,  how- 
ever, a  murmur  has  grown  indistinct  or  disappeared  as  the  result  of  rupture 
of  compensation,  movement  simply  increases  the  cardiac  dyscrasia. 

Organic  murmurs  are  usually  more  distinctly  audible  upon  quiet 
breathing,  or  while  respiration  is  momentarily  suspended,  and  at  the  close  of 
expiration,  when  a  larger  area  of  the  heart  is  uncovered.  In  this  respect 
they  differ  from  functional  murmurs,  which  are  frequently  best  heard  upon 
inspiration. 

Posture  exerts  an  important  influence  upon  the  intensity  of  certain 
murmurs.  Systolic  murmurs  not  heard  in  the  upright  position  may  be 
distinctly  audible  in  recumbency;  on  the  other  hand,  murmurs  not  heard 
in  the  recumbent  posture  may  be  recognized  when,  by  the  patient 
leaning  forward,  the  heart  is  brought  into  closer  relation  with  the  wall 
of  the  thorax.  Presystolic  murmurs  are  sometimes  much  better  heard  in 
the  erect  than  in  the  recumbent  posture. 

The  Significance  of  Functional,  Accidental,  or  Hsemic  Murmurs. — A  large 
proportion  of  endocardial  murmurs,  much  larger  than  was  formerly 
supposed,  are  not  associated  with  anatomical  cardiac  lesions.  Certainly 
murmurs  are  not  rarely  heard  intra  vitam  in  cases  in  which  no  corresponding 
valvular  lesions  are  found  post  mortem.  Systolic  murmurs  arising  in  condi- 
tions of  cardiac  asthenia  from  relaxation  of  the  cardiac  sphincter — rela- 
tive incompetence — and  having  all  the  characters  of  incompetence  from 
actual  lesions  at  the  mitral  orifice,  though  often  transient  are  not  usually 
described  as  "functional."  Short,  whiffing,  systolic  murmurs,  sometimes 
heard  in  the  mitral  area  directly  after  violent  or  prolonged  physical  effort, 
are  probably  due  to  relative  insufficiency  resulting  from  acute  dilatation. 
They  disappear  in  the  course  of  a  little  time. 

Functional  murmurs  are  almost  always  systolic  in  time.  By  far  the 
greater  number  of  them  have  their  point  of  maximum  intensity  in  the 
pulmonic  area;  occasionally  only  are  they  most  distinctly  heard  in  the 
aortic  or  mitral  areas.  They  are  commonly  well  heard  to  a  little  distance 
from  the  point  of  maximum  intensity  in  all  directions  rapidly  diminishing 
in  loudness,  and  are  not  distinctly  transmitted  in  a  definite  line,  as  is  usual 
with  organic  murmurs.  They  are  as  a  rule  soft  and  blowing  in  character. 
A  loud  coarse  murmur,  whatever  its  other  points  of  resemblance  to  func- 
tional murmurs,  is  likely  to  prove  to  be  organic,  especially  when  persistent. 
Functional  murmurs  are  usually  most  distinct  at  the  close  of  inspiration. 


188  MEDICAL  DIAGNOSIS. 

They  are  commonly  transient  and  disappear  when  the  condition  with 
which  they  are  associated  improves.  They  are  not  associated  with  the 
signs  of  enlargement  of  the  heart  or  with  accentuation  of  the  pulmonary 
second  sound. 

Functional  murmurs  are  significant  of  the  various  forms  of  anaemia. 
For  this  reason  they  are  spoken  of  as  ''hsemic  murmurs."  They  occur  in 
secondary  anaemias,  chlorosis,  pernicious  anaemia,  leukeemia  and  Hodgkin's 
disease.  A  distinct,  prolonged  systolic  murmur  in  the  pulmonary  area  is 
common  in  chlorosis,  and,  in  consequence  of  the  retraction  of  the  bor- 
ders of  the  lungs,  is  frequently  associated  with  a  loud  pulmonary  second 
sound.  In  the  stadium  ultimum  of  pernicious  anaemia  the  haemic 
murmurs  often  disappear. 

The  differential  diagnosis  between  organic  and  functional  endocardial 
murmurs  rests  upon  the  following  facts: 

Organic  murmurs  occur  at  any  period  in  the  revolution  of  the  heart; 
functional  murmurs  are  practically  always  systolic.  It  becomes  necessary, 
therefore,  to  contrast  the  characters  of  organic  systolic  murmurs  with  those 
of  functional  murmurs. 

Systolic  organic  murmurs  are  usually  well  propagated  in  the  case  of 
mitral  insufficiency  toward  the  left  axilla  and  to  the  back;  in  aortic 
stenosis,  to  the  carotids  and  the  subclavians,  especially  upon  the  right  side. 
They  are  often  soft  and  blowing,  not  rarely  coarse  and  loud,  sometimes 
musical.  The  point  of  maximum  intensity  corresponds  to  the  respective 
mitral  and  aortic  areas  as  above  described  (see  page  169),  and  only  in  excep- 
tional cases  is  to  be  located  in  the  neighborhood  of  the  pulmonary  area. 
Organic  murmurs,  except  in  the  case  of  relative  insufficiency,  are  persist- 
ent, diminishing  in  intensity  and  ultimately  disappearing  only  when  the 
compensation  fails  and  is  finally  ruptured.  They  are  sooner  or  later  asso- 
ciated with  the  signs  of  enlargement  of  the  heart  and  increase  of  the  blood- 
pressure  in  the  veins,  as  accentuation  of  the  pulmonic  second  sound,  visceral 
engorgement  and  anasarca.  The  anamnesis  commonly  points  to  an  acute 
infection,  rheumatic  fever,  hard  work  and  worry  as  causal  factors. 

Functional  murmurs,  on  the  other  hand,  are  not  propagated  in  definite 
directions;  practically  always  soft  and  blowing,  very  exceptionally  loud  or 
coarse;  never  musical.  Their  point  of  maximum  intensity  is  almost  invari- 
ably in  the  pulmonic  area.  They  are  transient  and  not  associated  with 
the  signs  produced  by  the  effects  of  valvular  lesions,  as  manifest  in  retard- 
ation of  a  part  of  the  blood  stream;  accentuation  of  the  pulmonic  second 
sound,  enlargement  or  distention  of  the  walls  of  the  heart;  visceral  derange- 
ments— venous  engorgement;  or  disorders  of  the  peripheral  circulation 
— dropsy.     Anaemia  is  almost  always  present. 

The  rare  diastolic  functional  murmur,  so  rare  as  to  be  unimportant 
in  diagnosis,  has  been  observed  only  in  anaemia  of  very  high  grade  and  in 
association  with  a  venous  hum. 

B.  Exocardial  Adventitious  Sounds. — Morbid  physical  signs  not  hav- 
ing their  origin  within  the  heart  are  frequently  heard  upon  auscultation 
in  the  precordial  region.  Important  in  themselves,  the}''  acquire  addi- 
tional diagnostic  importance  by  reason  of  their  occasional  close  resemblance 
to  endocardial  murmurs.     Of  these  the  following  are  the  more  important. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  189 

(a)  Pericardial  Friction.  —  The  friction  rub  of  dry  or  fibrinous  peri- 
carditis is  heard  upon  auscultation  as  a  grazing,  creaking,  or  rasping  sound 
occupying  some  part  of  the  time  of  the  cardiac  revolution.  It  is  sometimes 
systolic,  sometimes  diastoHc,  often  to-and-fro,  but  rarely  corresponds  to 
the  systole  or  diastole  as  endocardial  murmurs  do.  It  occurs  irregularly 
and  with  momentary  interruptions,  commonly  changes  in  character  and 
time  from  one  examination  to  another,  and  may  appear,  disappear,  and 
appear  again  in  the  course  of  a  few  hours.  Pericardial  friction  is  usually 
best  heard  in  the  area  of  superficial  cardiac  dulness,  but  may  be  heard  at 
any  part  of  the  precordial  region  and  sometimes  over  the  greater  part 
of  it.  In  some  instances  it  is  confined  to  the  base  of  the  heart.  It  is  always, 
however,  distinctly  circumscribed  and  never  propagated  in  any  direction 
beyond  the  borders  of  the  heart.  It  conveys  the  impression  of  being  pro- 
duced close  to  the  ear  and  is  intensified  by  the  pressure  of  the  stethoscope, 
which  also  increases  the  pain  which  is  present.  It  is  apt  also  to  be  increased 
when  the  patient  inclines  his  body  forward.  It  is  little  influenced  by  the 
respiratory  movements,  except  that  in  some  instances  its  area  is  slightly 
extended  in  expiration.  Pericardial  friction  is  frequently  associated  with 
endocardial  murmurs,  the  signs  occurring  as  the  manifestations  of  an 
endopericarditis  or  the  pericarditis  developing  in  an  individual  already 
the  subject  of  chronic  valvular  disease.  Under  these  circumstances  the 
friction  sound  is  usually  more  conspicuous  than  the  endocardial  murmur 
and  at  times  may  mask  it  altogether. 

The  differential  diagnosis  between  an  endocardial  murmur  and  a 
pericardial  friction  rests  upon  a  critical  analysis  of  the  signs  in  the  light 
of  the  history  of  the  case. 

(b)  Pleuropericardial  Friction. — Cases  occasionally  occur  in  which  fibri- 
noid exudate  upon  that  part  of  the  pleura  which  is  in  relation  with  the 
pericardium  gives  rise  to  a  friction  sound  having  the  cardiac  rhythm,  the 
roughened  pleural  surfaces  being  moved  in  apposition  to  each  other  by  the 
movement  of  the  heart.  The  differential  diagnosis  between  pericardial 
and  pleuropericardial  friction  rests  upon  the  following  facts: 

The  pleuropericardial  friction  is  commonly  heard  in  connection  with 
a  friction  sound  having  also  the  respiratory  rhythm — pleural  friction. 
It  is  apt  to  be  increased  by  forced  respiratory  movements  and  to  be  more 
distinct  upon  inspiration,  whereas  pericardial  friction  is  best  heard  at  the 
close  of  expiration.     A  positive  diagnosis  cannot  always  be  made. 

(c)  Cardiopulmonary  Murmurs. — Murmurs,  hitherto  known  as  cardio- 
respiratory, having  the  cardiac  rhythm,  are  occasionally  produced  in 
the  borders  of  the  lung  in  relation  with  the  heart  by  the  traction  or 
pulsion  of  the  heart  upon  the  lung  tissue  in  systole  or  diastole.  The  mur- 
murs are  pulmonary  but  not  respiratory,  and  are  due  to  the  sudden  dis- 
placement of  a  certain  volume  of  air  from  a  mass  of  lung  tissue  confined 
by  adhesions.  They  are  most  commonly  heard  near  the  apex  of  the  heart 
and  over  the  projection  of  the  left  lung  which  overlaps  it,  known  as  the 
lingula;  less  often  under  the  left  clavicle  or  about  the  angle  of  the  left 
scapula.  These  murmurs  are  mostly  systolic— traction  murmurs;  very 
rarely  diastolic — pulsion  murmurs — and  are  heard  over  circumscribed 
areas.     They  are  much  influenced  by  active  respiration  and  cough.     They 


190  MEDICAL  DIAGNOSIS. 

occur  during  inspiration  and  are  scarcely,  if  at  all,  audible  during  expira- 
tion, a  fact  which  is  of  importance  in  distinguishing  them  from  endocardial 
murmurs,  which  are  usually  better  heard  when  the  breath  is  held  in  expira- 
tion and  a  larger  cardiac  surface  left  uncovered  by  the  retracted  lung. 
Cardiopulmonary  murmurs  have  the  soft,  breezy  quality  of  the  vesicular 
murmur  and  suggest  an  inspiratory  act  broken  by  successive  movements 
of  the  heart,  which  in  point  of  fact  they  are.  In  rare  instances  these  mur- 
murs are  accompanied  by  crepitant  or  subcrepitant  rales.  Their  importance 
from  the  standpoint  of  the  diagnostician  consists  in  their  superficial  resem- 
blance to  endocardial  murmurs,  from  which  they  may  be  differentiated 
without  difficulty. 

(d)  The  Precordial  Rales  of  Emphysema. — In  rare  cases  of  emphysema, 
in  consequence  of  the  rupture  of  the  walls  of  vesicles,  air  finds  its  way 
along  the  interstitial  tissue  to  the  root  of  the  lung  and  thence  to  the 
connective  tissue  of  the  anterior  mediastinum.  The  superficial  cardiac 
dulness,  if  not  previously  obliterated  by  the  borders  of  the  emphysematous 
lung,  disappears  with  weakening  of  the  heart  sounds  and  the  occurrence  of 
high-pitched  metallic  or  crepitant  rales  which  have  the  rhythm  of  the 
heart.  These  signs  are  to  be  differentiated  by  their  acoustic  properties 
from  the  tricuspid  regurgitant  murmurs,  due  to  the  dilatation  of  the  right 
ventricle,  so  frequently  heard  in  emphysema.  They  are  also  to  be  differ- 
entiated from  the  rales  having  the  cardiac  rhythm,  which  are  heard  in  rare 
cases  of  infiltration  of  the  lungs  or  cavity  formation  in  the  neighborhood  of 
the  heart,  by  the  persistence  in  the  latter  of  superficial  cardiac  dulness  and 
the  heart  sounds,  the  character  of  the  associated  respiratory  sounds,  and  by 
the  fact  of  their  occurrence  in  pulmonary  emphysema. 

(e)  Pericardial  Splashing. — In  pneumohydro-  or  pneumopyo-pericar- 
dium  there  may  be  heard  peculiar  splashing  sounds  of  metallic  character 
similar  to  the  succussion  sounds  of  pneumohydrothorax,  but  having  the 
cardiac  rhythm.  The  heart  sounds  under  these  circumstances  are  usually 
feeble  and  distant.  The  cardiac  dulness  is  in  the  recumbent  posture 
replaced  by  an  area  of  tympany,  the  borders  of  which  shift  with  changes  in 
the  posture  of  the  patient.  These  splashing  sounds  can  under  no  circum- 
stances be  mistaken  for  murmurs,  but  they  may  closely  resemble  the  splash- 
ing of  the  gastric  contents  sometimes  produced  by  the  movements  of  the 
heart,  or  that  of  pneumothorax  or  of  a  large  vomica,  from  which  they  may, 
however,  be  distinguished  by  the  gravity  of  the  symptoms,  the  concomi- 
tant signs  of  pericardial  perforation  or  inflammation,  the  examination  of 
the  patient  when  the  stomach  is  empty,  or  a  systematic  routine  examina- 
tion of  the  lungs. 

(f)  The  Murmurs  of  Aneurisms. — Aneurism  of  the  thoracic  aorta  more 
commonly  involves  the  ascending  portion  of  the  arch.  On  auscultation 
at  the  base  of  the  heart  or  sometimes  in  a  wide  area  there  may  be  heard  a 
systolic  murmur,  transmitted  like  the  murmur  of  aortic  stenosis  in  the 
direction  of  the  aorta  itself  and  the  vessels  of  the  neck.  A  diastolic  mur- 
mur is  sometimes  also  present.  The  latter  is  due  to  the  reflux  of  blood  into 
the  sac,  and  may  easily  be  mistaken  for  the  murmur  of  aortic  insufficiency 
with  which  it  is  not  infrequently  associated,  as  the  manifestation  of  relative 
incompetence  in  consequence  of  the  dilatation  of  the  aorta  or  of  valvular 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  191 

deformities  resulting  from  sclerotic  changes.  The  differential  diagnosis 
rests  upon  the  presence  or  absence  of  the  signs  of  aneurism,  as  deter- 
mined by  systematic  inspection,  palpation,  percussion,  and  the  anamnesis. 

SOUNDS  HEARD  OVER  THE  PERIPHERAL  VESSELS. 

Auscultation  of  the  Arteries.  Normal  Conditions. — When  the  steth- 
oscope is  lightly  placed  over  the  larger  arteries  where  they  run  superficially, 
sounds  may  be  heard  which  correspond  to  the  sounds  of  the  heart.  These 
sounds  are  produced  (a)  in  the  heart  and  (b)  in  the  arteries  themselves. 

The  carotid  may  be  studied  at  the  angle  of  the  jaw  or  at  the  inner 
border  of  the  sternocleidomastoid  muscle;  the  subclavian  directly  above 
the  clavicle  and  external  to  the  sternocleido  muscle  or  directly  below  it, 
in  the  arm  between  the  pectoralis  major  and  the  deltoid;  the  brachial 
at  the  inner  border  of  the  biceps  or  at  the  bend  of  the  elbow,  the  arm  being 
slightly  flexed;  the  radial  just  above  the  wrist,  and  the  femoral  immediately 
below  Poupart's  ligament. 

(a)  The  normal  heart  sounds  are  transmitted  to  some  distance  along 
the  course  of  the  main  arteries  at  the  root  of  the  neck  and  may  be  heard 
in  adults  over  the  carotids  and  subclavians,  more  distinctly  upon  the  right 
than  upon  the  left  side.  In  infancy  and  childhood  only  the  second  sound 
is  thus  transmitted,  the  first  being  very  indistinct  or  wholly  inaudible. 

(b)  A  systolic  sound,  due  to  the  sudden  tension  of  the  arterial  walls, 
may  in  some  cases  be  heard  over  the  abdominal  aorta  and  the  femorals. 
In  the  majority  of  cases  no  sound  is  heard  over  these  vessels  nor  over  the 
smaller  superficial  arteries  so  long  as  the  stethoscope  is  applied  without 
pressure.  When,  however,  some  degree  of  pressure  is  exerted  upon  the 
wall  of  the  artery  by  the  rim  of  the  stethoscope,  a  systolic  murmur  is  pro- 
duced, often  intense  and  high-pitched,  the  so-called  compression  murmur. 
This  murmur  is  due  to  sudden  narrowing  of  the  lumen  of  the  vessel  at  the 
point  of  pressure  with  the  production  of  fluid  veins.  If  the  pressure  is 
increased  to  such  a  degree  as  to  obliterate  the  lumen  of  the  artery  a  sys- 
tolic sound  is  produced  by  the  increased  force  of  the  tension  of  the  arterial 
wall — pressure  sound.  These  phenomena  are  physiological  and  without 
other  clinical  significance  than  that  which  attends  the  risk  of  attaching 
erroneous  importance  to  them. 

(c)  Intracranial  Murmurs. — In  children  up  to  the  sixth  year  there 
is  sometimes  to  be  heard  upon  auscultation  over  the  cranium,  and  especially 
over  the  anterior  fontanelle  and  in  the  parietal  regions,  a  distinct  systolic 
murmur,  which  apparently  originates  in  the  internal  carotids  from  some 
unknown  cause  and  is  without  diagnostic  significance. 

(d)  The  Uterine  Souffle. — A  soft  blowing  systolic  murmur  is  heard 
over  the  pregnant  uterus.  It  is  first  heard  about  the  end  of  the  sixteenth 
week  and  increases  in  frequency  until  the  eighth  month,  after  which  it 
remains  stationary.  This  murmur  is  subject  to  great  variation  as  regards 
quality,  intensity,  rhythm,  and  point  of  maximum  intensity.  It  is  usually 
most  distinct  low  down  and  upon  one  or  the  other  side  of  the  uterus,  some- 
times at  the  fundus,  but  very  rarely  over  the  entire  uterine  body.  It  is 
attributed  to  the  circulation  of  the  blood  in  the  arteries  of  the  uterine 


192  MEDICAL  DIAGNOSIS. 

wall.  The  diagnostic  importance  of  this  sign  is  impaired  by  the  fact  that 
a  similar  murmur  is  occasionally  heard  in  chronic  metritis,  uterine  myomata, 
and  ovarian  cysts. 

Single  or  double  murmurs  corresponding  in  time  to  the  fetal  heart- 
beats are  sometimes  recognized  in  auscultation  in  pregnancy.  They  have 
in  some  instances  been  found  to  be  associated  with  defects  of  development 
or  endocardial  lesions  of  the  fetal  heart — cardiac  souffle.  In  other  cases 
murmurs   have  originated  in  the  umbilical   cord — funic  murmurs. 

Auscultation  of  the  Arteries.  Pathological  Conditions. — (a)  It  is 
obvious  that  abnormal  sounds — murmurs — heard  in  the  aorta  will  be 
transmitted  into  the  carotids  and  subclavians.  The  systolic  and  less 
intensely  the  diastolic  murmurs  of  lesions  of  the  aortic  valve  system 
are  transmitted  along  the  course  of  these  vessels. 

(b)  In  any  condition  in  which  the  pulse  is  quick — pulsus  celer — the 
arteries  may  yield  upon  auscultation  a  systolic  sound.  This  sign  is  some- 
times present  in  fever  and  is  common  in  aortic  insufficiency,  and  may  be 
heard  over  the  radials  as  well  as  over  arteries  of  larger  calibre.  In  aortic 
insufficiency  of  high  grade  a  double  sound  is  sometimes  heard  over  the 
femorals,  the  systolic  dilatation  and  the  diastolic  contraction  of  the  artery 
being  alike  attended  with  an  audible  sound.  Systolic  and  diastolic  sounds 
in  the  femoral  artery  have  also  been  observed  in  pregnancy  and  in  chronic 
lead  poisoning, 

(c)  Double  Murmurs  in  the  Arteries.  Diiroziez's  Murmurs.— In  well- 
marked  cases  of  expansile  pulse  in  which  the  blood  wave  rises  rapidly 
and  rapidly  recedes  there  may  frequently  be  detected  over  the  femoral 
or  brachial  artery  at  a  certain  point  in  the  gradually  increased  pressure  of 
the  stethoscope  a  double — namely,  systolic  and  diastolic — murmur.  Some 
care  is  necessary  to  exert  the  degree  of  pressure  under  which  this  sign  is 
best  heard.  It  may  be  observed  in  aortic  insufficiency,  chlorosis,  and 
other  conditions  in  which  there  is  well-marked  pulsus  celer. 

(d)  Subclavian  Murmurs. — Systolic  murmurs  occurring  independently 
of  pressure  by  the  stethoscope  are  common.  Heard  upon  one  side  only 
when  the  attitude  of  the  patient  is  unconstrained  and  the  arms  hanging 
at  the  sides,  such  a  murmur  is  very  suggestive  of  apex  disease  of  the  lung 
with  pleural  adhesions  implicating  the  artery  in  its  course.  They  are 
commonly  louder  upon  inspiration,  exceptionally  upon  expiration.  Such 
murmurs  are  occasionally  to  be  heard  upon  one  or  both  sides  in  normal 
individuals,  and  there  are  those  who  are  able  to  produce  them  at  will 
by  assuming  certain  attitudes,  with  fixation  of  the  arms  and  the  muscles 
of  the  upper  part  of  the  chest. 

(e)  Thyroid  Murmurs. — Systolic  murmurs  are  very  common  over  the 
enlarged  and  tortuous  arteries  in  goitre  and  especially  in  Graves's  disease. 

(f)  Murmurs  in  Local  Arteriosclerosis  in  Superficial  Arteries. — Sys- 
tolic murmurs  due  to  this  cause  are  occasionally  observed.  They  are 
audible  in  some  cases  without  pressure  by  the  stethoscope;  in  others  upon 
a  minimum  pressure.     They  are  most  common  in  the  carotids. 

Auscultation  of  the  Veins.  Normal  Conditions. — In  healthy  individ- 
uals the  blood  flows  in  the  veins  without  sound  or  murmur.  In  rare  instances 
the  occurrence  of  a  venous  hum  constitutes  an  exception  to  this  rule. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  193 

Auscultation  of  the  Veins.  Pathological  Conditions. — (a)  The  venous 
pulse  in  tricuspid  insufficiency  may  by  sudden  tension  of  the  valves  and 
walls  of  the  jugular,  and  in  particular  the  valves  of  the  bulb,  give  rise  to 
a  systolic  sound  which  is  scarcely  to  be  distinguished  from  the  almost 
synchronous  systolic  carotid  sound,  except  by  the  fact  that  it  slightly 
precedes  it. 

(b)  Venous  Hum — Nun's  Murmur. — This  is  the  single  venous  murmur 
of  practical  diagnostic  importance.  Since  the  return  flow  of  the  venous 
blood   is   to   all   intents  uninterrupted,   venous  murmurs  are  continuous. 

The  patient  should  assume  the  upright  posture  with  the  head  straight. 
The  stethoscope  should  be  placed  over  the  space  between  the  sternal  and 
clavicular  portions  of  the  sternocleidomastoid  muscle  without  pressure. 
The  murmur  in  question  when  present  is  heard  as  a  pecuUar,  sometimes 
blowing,  sometimes  coarse  and  humming  or  again  musical  continuous 
sound,  with  rhythmical  systolic,  diastolic,  and  inspiratory  intensifications. 
It  is  best  heard  upon  the  right  side  and  diminishes  in  loudness  or  entirely 
disappears  when  the  patient  assumes  the  recumbent  posture.  Rotation 
of  the  face  toward  the  opposite  side  increases  the  intensity  of  the  sound. 
Pressure  with  the  stethoscope  at  first  increases  then  enfeebles  the  murmur 
until  it  wholly  ceases  and  the  systolic  sound  of  the  carotid  is  heard.  In 
some  cases  a  feeble  murmur  loses  its  continuous  character  and  is  perceived 
only  at  the  moment  of  systole,  diastole,  or  during  inspiration.  Under 
these  circumstances  the  murmur  becomes  continuous  upon  light  pressure 
with  the  stethoscope  or  if  the  head  is  rotated  toward  the  opposite  side — 
manoeuvres  which  enable  the  diagnostician  to  distinguish  the  murmur 
from  arterial  and  inspiratory  murmurs.  In  other  cases  the  diastolic  por- 
tion of  the  murmur  may  be  transmitted  to  the  base  of  the  heart  and  heard 
there  as  a  diastolic  murmur  apparently  of  endocardial  origin.  The  differ- 
ential diagnosis  may  be  attended  with  difficulty  unless  auscultation  is 
practised  from  point  to  point  from  the  heart  along  the  course  of  the  jugular, 
when  it  will  become  clearly  apparent  that  the  diastolic  murmur  heard  over 
the  base  of  the  heart  is  in  point  of  fact  the  transmitted  venous  hum.  The 
venous  hum  occurs  in  anaemic  and  chlorotic  persons  and  occasionally  in 
healthy  individuals  with  normal  blood.  In  the  last  it  has  been  assumed 
that  the  phenomenon  is  due  to  some  anatomical  peculiarity,  as,  for  instance, 
sudden  and  unusual  widening  of  the  jugular  at  the  bulb. 

In  general  terms  the  causes  of  the  venous  hum  are  the  more  rapid 
flow  of  the  blood  current  by  reason  of  its  lowered  specific  gravity  and  defi- 
cient haemoglobin,  and  the  sudden  widening  of  the  jugular  at  the  bulb. 
The  fact  that  this  murmur  is  louder  in  the  erect  posture  is  rightly  ascribed 
to  the  influence  of  gravity  in  hastening  the  flow;  the  increased  intensity 
upon  inspiration  to  the  aspiration  exerted  by  the  chest  movement  at  that 
time,  and  the  greater  loudness  upon  the  right  side  to  the  more  direct  and 
unrestrained  flow  of  the  blood  arising  from  differences  in  the  anatomical 
arrangement  of  the  veins  of  the  two  sides. 


13 


194  MEDICAL  DIAGNOSIS. 


III. 

THE  EXAMINATION  OF  THE  STOMACH  AND  INTESTINES. 

General  Considerations. — Diseases  of  these  organs  are  (a)  primary  or 
organic  and  (b)  secondary  or  symptomatic,  and  in  each  of  these  groups 
there  are  cases  in  which  recognizable  anatomical  lesions  are  present  and 
cases  in  which  there  is  merely  derangement  of  function.  Thus,  carcinoma 
and  ulcer  are  examples  of  organic  disease  with  characteristic  lesions,  and 
hyperchlorhydria  and  pyloric  spasm  are  functional  affections;  while  loss 
of  appetite,  eructations,  and  vomiting  occur  as  symptoms  of  phthisis, 
often  without  actual  lesions  of  the  stomach,  and  erosion  and  ulcer  are 
not  infrequent  in  chlorosis.  It  is  of  cardinal  importance  that  the  differ- 
ential diagnosis  between  organic  and  functional  disease  of  the  stomach 
and  intestines  should  in  all  cases  be  made,  particular^  as  the  former 
only  require  direct  local  treatment  and  the  latter  are  frequentlj^  made 
worse  by  such  treatment. 

The  Anamnesis. — It  is  very  common  for  patients  to  attribute  to 
''stomach  trouble"  or  "bowel  trouble"  symptoms  due  to  diseases  of  other 
organs  or  to  constitutional  disease.  A  careful  and  systematic  anamnesis 
is  therefore  necessary  in  all  cases. 

Status  Praesens. — The  actual  condition  is  ascertained  by,  (a)  physical 
examination,  with  special  modifications,  as  inflation,  transillumination, 
the  Rontgen  rays;  (b)  chemical  and  (c)  microscopic  examination  of  the 
gastric  contents  and  alvine  discharges.  Differences  in  the  methods,  the 
substances  to  be  examined,  and  the  results  render  it  convenient  to 
consider  the  stomach  and  intestines  separatel5^ 

EXAMINATION   OF   THE   STOMACH. 

(a)  Physical  Examination. — Inspection. — The  recumbent  posture 
and  exposure  of  the  w^hole  abdomen  as  well  as  the  thorax  and  neck  are 
necessary.  In  the  neck  may  sometimes  be  seen  the  enlarged  left  supra- 
clavicular lymph-node  in  cases  of  carcinoma  of  the  subdiaphragmatic 
viscera;  the  general  conformation  of  the  thorax  and  abdomen  may  be 
studied  and  in  some  cases  the  flaring  of  the  left  costal  arch  from  the  pres- 
sure of  a  distended  high-placed  stomach.  When  the  abdominal  wall  is 
thin  and  relaxed  the  outline  of  the  distended  stomach,  the  slow,  large 
movements  of  gastric  peristalsis  from  left  or  right,  far  more  rarely  reverse 
peristalsis,  the  presence  of  tumor  masses  in  the  gastric  wall  or  at  the 
pylorus,  or  of  metastatic  growths  about  the  umbilicus,  in  the  Hver,  or 
elsewhere,  may  be  observed. 

Palpation. — This  method  is  useful  in  determining  localized  or  general 
tenderness,  the  presence  of  a  tumor,  enlargement  and  displacement  of  the 
stomach,  and  "splashing.  "  The  stomach  should  be  palpated  systematically 
with  both  hands  and  for  several  minutes.  By  this  means  peristalsis  may 
be   aroused   and   a   tumor  which  is   not  otherwise  recognizable   brought 


THE  STOMACH  AND  INTESTINES. 


195 


within  reach.  In  stenosis  of  the  pylorus  and  gastroptosis  the  wall  of  the 
stomach  may  sometimes  be  felt  to  become  tense,  with  the  sensation  of  the 
passage  of  fluid  in  the  region  of  the  pylorus,  and  in  persons  with  thin- 
walled  abdomens  the  tip  of  a  bougie  may  be  recognized  as  it  is  cautiously 
moved  along  the  greater  curvature.  Succussion  or  ''splashing"  may  be 
recognized  both  by  the  palpating  hand  and  by  the  ear.  It  occurs  in  motor 
insufficiency  and  is  of  diagnoctic  value  when  elicited  after  a  fasting  period 
of  seven  hours.  The  patient  should  be  in  the  dorsal  posture  with  the 
head  and  shoulders  slightly  elevated  and  at  the  moment  the  examination 
is  made  the  stomach  should  be  depressed  by  deep-held  inspiration.  The 
examiner  exerts  pressure  upon  the  epigastrium  at  the  level  of  the  xyphoid 
appendix  and  with  the  finger-tips  of  the  other  hand  makes  quick  pressing 
movements  immediately  followed  by  relaxation.  This  method  may  be 
used  in  the  determination  of  the  lower  border  of  the  stomach  after  the 


Fig.  82. — Palpating  the  abdomen. — Cohnheim. 

administration  of  half  a  litre  of  water.  The  outspread  fingers  of  the 
palpating  hand  are  used  with  the  short  pushing  stroke  of  palpatory  per- 
cussion, beginning  below  the  level  of  the  umbilicus  and  proceeding  upward 
until  the  splash  is  felt. 

Percussion. — This  method  is  of  little  value  by  itself.  The  stomach 
and  adjacent  coils  of  intestines  yield  tympanitic  resonance  or,  when  they 
contain  fluid  or  solid  matter,  dulness,  and  their  boundary  lines  cannot 
be  defined  by  ordinary  percussion.  Auscultatory  percussion,  especially 
when  the  stomach  is  inflated,  is  of  use.  The  percussion  should  be  per- 
formed in  lines  radiating  from  a  centre  over  the  stomach  and  the  points  of 
change  in  the  auscultatory  phenomena  marked  upon  each  line  in  turn. 
Those  points  are  then  connected.  Control  observations  may  be  made  by 
changing  the  centre  and  repeating  the  observation. 

Auscultation  has  only  a  limited  application  in  the  examination  of  the 
stomach.  It  is  employed  in  the  study  of  deglutition  phenomena,  "splash- 
ing, "  the  Spritzgerausch  of  pyloric  stenosis  and  hour-glass  contraction 
of  the  stomach.     In  the  last,  if  the  narrowing  be  of  high  degree,  there 


196  MEDICAL  DIAGNOSIS. 

may  be  an  audible  sound  produced  by  the  passage  of  water  from  the 
cardiac  to  the  pyloric  loculus,  especially  if  pressure  be  used. 

The  Swallowing  Test. — This  test  is  used  to  determine  the  patency 
of  the  cardiac  orifice  and  is  performed  in  the  following  manner:  The  ear 
or  the  bell  of  a  stethoscope  is  placed  at  the  left  of  the  tip  of  the  ensiform 
cartilage  or,  better,  at  the  left  of  the  seventh  thoracic  vertebra  of  the 
patient,  standing,  who  is  directed  to  take  a  mouthful  of  water  and  swallow. 
There  is  at  once  heard  the  rumble  of  the  contracting  oesophageal  and 
cervical  muscles  brought  into  play  and  in  about  seven  seconds  the  trickling 
of  the  fluid  entering  the  stomach  through  the  cardiac  orifice.  Delay  or 
absence  of  the  latter  sound  suggests  more  or  less  complete  stenosis  in  the 
course  of  the  cesophagus  or  at  the  cardia. 

Inflation. — The  stomach  may  be  distended  by  means  of  a  stomach- 
tube  and  an  ordinary  rubber  bulb  syringe  or  by  carbon  dioxide  evolved 
within  the  organ  itself.  To  this  end  3  to  5  grammes  of  tartaric  acid  dis- 
solved in  half  a  glass  of  water  are  swallowed  and  this  is  followed  bj^  an 
equal  amount  of  sodium  bicarbonate  dissolved  in  the  same  quantity  of 
water.  The  stomach  first  distends  at  its  least  resisting  part  and  in  the 
case  of  moderate  enlargement  and  thin  abdominal  walls  its  greater  curva- 
ture and  inferior  border  may  be  made  out  by  inspection  or  auscultatory 
percussion.  The  gas  may  be  expelled  as  it  is  formed  either  at  the  cardia 
or  at  the  pylorus,  and  in  large  stomachs  the  introduction  of  a  sufficient 
quantity  of  air  may  cause  much  discomfort  or  even  pain,  or  the  gas  evolved 
may  be  insufficient.  The  chief  value  of  this  method  Ues  in  the  determina- 
tion of  the  size,  outline,  and  position  of  the  stomach.  It  is  of  importance 
in  the  differentiation  between  tumors  of  the  anterior  wall  and  those  sit- 
uated in  the  posterior  wall  or  behind  the  stomach.  It  is  evident  that 
upon  inflation  the  former  will  become  more  prominent,  the  latter  less 
obvious.  Inflation  is  of  some  value  also  in  bringing  into  prominence 
obscure  tumors  of  the  pylorus. 

Position  of  Fluids  Ingested  under  Observation. — The  position 
of  the  lower  border  of  the  stomach  is  ascertained  as  closely  as  possible, 
the  patient  standing.  He  is  then  directed  to  swallow  a  glass  of  water  and 
the  resulting  dulness  is  determined  by  percussion.  This  manoeuvre  being 
repeated  two  or  three  times  at  short  intervals,  changes  in  the  level  of  the 
dulness  may  occur,  which  are  indicative  of  the  position  of  the  lower  border 
of  the  stomach.  In  normal  stomachs  of  good  musculature  the  increased 
amount  of  fluid  enlarges  the  area  of  dulness  in  an  upward  direction;  in 
relaxed  and  dilated  stomachs  the  dulness  sinks  with  the  increasing  weight. 
The  method  is  of  no  great  value  except  in  dilated  stomachs  and 
gastroptosis  in  individuals  with  thinned  abdominal  walls. 

Transillumination. — The  gastrodiaphane  of  Einhorn  consists  of  a 
flexible  tube  carrying  at  its  tip  a  small  electric  light.  The  patient  drinks 
two  or  more  glasses  of  water;  the  tube  is  introduced  and  the  circuit  com- 
pleted. The  light  shows  through  the  abdominal  wall  in  the  normal  stomach 
as  a  triangular  area  having  its  apex  and  focus  of  intensity  somewhat  to 
the  left  of  the  median  line  and  above  the  umbilicus;  in  gastroptosis  or 
dilatation  the  point  of  illumination  is  lower  and  the  light  more  diffused. 
Changes  follow  movements  of  the  bulb.     This  procedure  shows  the  lowest 


THE  STOMACH  AND  INTESTINES.  197 

limit  of  the  stomach  at  one  point.  There  is  no  certainty  that  the  lamp 
does  not  push  the  greater  curvature  into  positions  it  would  not  otherwise 
occupy,  or  that  the  position  of  the  illuminated  area  affords  positive  data 
in  regard  to  the  size  and  shape  of  the  organ. 

Direct  Gastroscopy. — Direct  inspection  of  the  mucous  membrane 
of  the  stomach  through  a  rigid  metal  tube  requires  the  patient  recum- 
bent, with  his  head  extended  in  such  a  manner  that  the  trachea  and 
oesophagus  approach  nearly  a  direct  course.  General  anaesthesia  is  recom- 
mended for  the  best  results.  The  tube  used  is  fitted  with  a  small  electric 
light,  mirror,  and  obturators,  and  in  general  resembles  those  employed  in 
the  diagnosis  of  rectal  and  sigmoid  disor.ders,  being,  however,  longer  and 
slightly  thinner.  Many  conditions  of  the  stomach  are  readily  recognized 
by  direct  inspection.  An  empty  or  even  well  washed  stomach  is  preferable 
at  the  time  of  examination.  Ulcerations  and  local  thickenings  can  be 
readily  located.  Inflammation,  catarrh,  or  atrophy  of  the  mucous  mem- 
brane can  be  determined.  Some  care  is  necessary  to  ensure  inspection  of 
the  whole  interior,  particularly  if  the  stomach  is  enlarged.  The  cardia 
is  first  inspected.  Inflation  aids  in  bringing  other  parts  into  view. 
By  some  manipulation  of  the  upper  end  of  the  gastroscope  and  simul- 
taneous palpation  and  manipulation  on  the  part  of  an  assistant  the  whole 
stomach  can  be  gone  over  and  outlined.  The  readiness  with  which  the 
end  of  the  tube  can  be  felt  through  the  abdominal  wall  is  of  some 
service.  The  use  of  the  oesophagoscope  and  gastroscope  demands  consider- 
able technical  skill. 

The  Rontgen  Rays. — Thickenings,  the  puckerings  caused  by  dense 
cicatricial  masses  and  tumors  at  the  pylorus  or  elsewhere  cast  shadows 
which  often  afford  confirmatory  evidence  of  great  importance  in  diag- 
nosis. By  the  aid  of  the  bismuth  meal — two  ounces  of  bismuth  subnitrate 
mixed  in  six  ounces  of  rice  pudding  or  suspended  in  eight  ounces  of  kefir — 
the  outline  of  the  greater  curvature,  hour-glass  contraction,  the  position 
of  the  pylorus,  and  the  motor  power  of  the  stomach  can  be  determined. 
The  tracing  of  such  a  meal  through  the  alimentary  canal  by  serial  obser- 
vations during  the  course  of  several  hours  frequently  jdelds  diagnostic 
data  of  great  value  in  diseases  of  the  small  and  large  intestines,  while 
important  facts  are  sometimes  to  be  acquired  in  disorders  of  the  lower 
bowel  by  X-ray  studies  made  after  the  injection  of  bismuth  suspension 
per  rectum.  Recent  improvements  in  apparatus  and  technic,  which 
render  possible  instantaneous  radiograms,  have  led  to  more  accurate 
knowledge  in  regard  to  gastric  and  intestinal  peristalsis  under  normal 
and  pathological  conditions,  much  of  which  may  become  available  for 
diagnostic  purposes. 

The  Stomach-tube. — Various  styles  are  in  use.  The  simplest  is  the 
best.  They  are  made  of  soft  red  rubber  with  a  lumen  of  about  .50  to  .75 
cm.,  walls  not  too  thick,  and  about  70  to  90  cm.  in  length;  near  the  gastric 
end  one  or  two  large  lateral  openings.  Whether  there  should  be  an  open- 
ing at  the  end  is  a  matter  of  opinion.  The  upper  end  is  fitted  to  a  glass 
funnel  of  a  capacity  of  500  c.c.  At  the  middle  there  may  be  a  bulb  which 
serves  for  inflation  or  suction  and  permits  free  siphonage.  As  the  distance 
from  the  incisor  teeth  to  the  cardia  is  on  the  average  40  cm.,  or  slightly 


198  MEDICAL  DIAGNOSIS. 

less  than  16  inches,  there  should  be  an  encircling  mark  at  this  point.  It 
is  important  to  note  that  many  of  the  tubes  supplied  at  the  shops  are 
marked  at  a  point  51-60  cm.  from  the  tip,  about  the  distance  to  the  lowest 
point  of  the  greater  curvature.  For  infants  a  soft  catheter  may  be  used. 
Introducing  the  Tube. — The  sitting  position  is  easiest.  It  is  best  not  to 
elevate  the  chin,  since  stretching  the  neck  seems  to  occlude  the  upper 
oesophagus.  Plates  and  false  teeth  should  be  removed.  Soaking  the 
last  several  inches  of  the  tube  in  hot  water  makes  the  first  contact  of  the 
tube  with  the  pharynx  less  irritating.  Holding  the  tube  in  the  hand,  as 
one  would  a  pen,  with  five  or  six  inches  projecting,  the  examiner  instructs 
the  patient  to  open  his  mouth  moderately  wide,  with  the  tongue  touch- 
ing and  against  the  teeth.  The  tube  is  then  passed  straight  back  to  the 
middle  of  the  posterior  pharyngeal  wall  and  directed  downward.  If  the 
patient  can  swallow  at  this  moment  the  tube  is  usually  engaged    at  once 


Fig.  83. — Stomach-tube. — Cohnheim. 

in  the  upper  oesophagus  and  can  be  rapidly  pushed  in,  reaching  the  stomach 
in  several  seconds,  and  is  securely  in  place  before  the  first  expulsive 
coughing  efforts  begin.  By  ordering  the  patient  to  breathe  deeply  several 
times  one  usually  succeeds  in  quieting  most  of  the  discomfort  and  can 
proceed  with  the  examination.  To  avoid  the  doubling  up  of  the  tube  or 
the  unpleasantness  of  the  coughing  or  vomiting  which  often  ensues,  many 
prefer  to  introduce  the  forefinger  of  one  hand  along  the  side  of  the  mouth 
as  a  guide  and  to  pass  the  tube  along  this  guiding  finger.  Many  attempts 
are  often  necessary  to  overcome  the  spasmodic  expulsive  efforts  of  the 
pharynx.  At  times  the  distress  is  such  that  it  is  necessary  to  forego  the 
attempt.  Cocainization  of  the  pharynx  has  been  recommended;  it  does 
not,  however,  seem  to  have  been  very  successful  in  difficult  cases. 

The  great  value  of  the  stomach-tube  in  gastric  diagnosis  lies  in  the 
ease  with  which  the  stomach  may  be  inflated  and  its  contents  removed. 
Much  time  will  be  saved  by  having  the  patient  take  one  or  other  of  the 
various  test-meals  whenever  the  tube  is  to  be  passed.  After  removal  of  the 
meal  the  patient's  clothes  are  loosened  and  he  is  directed  to  lie  down  with 
the  tube  still  in  position.    Inflation  can  now  be  performed  and  in  conjunction 


THE  STOMACH  AND  INTESTINES. 


199 


with  some  of  the  various  methods  already  mentioned  will  be  found  to  be  the 
most  satisfactory  way  of  estimating  the  size  and  position  of  the  stomach. 

The  stomach  is  inflated  until  the  patient  indicates  the  beginning  of 
discomfort.  The  examiner  then  clamps  the  tube  or  can  ask  the  patient  to 
hold  it  firmly  in  his  teeth,  thus  giving  the  examiner  the  free  use  of  both 
hands.  During  the  inflation  the  examiner  should  carefully  watch  for  the 
area  where  the  stomach  first  manifests  its  presence.  In  a  normal  stomach 
this  will  be  just  below  the  left  costal  margin  and  in  the  epigastrium 
between  the  ensiform  and  navel.  The  stomach  will  stretch  easily  and  its 
greater  curvature  can  be  followed  to  the  umbilicus  before  overdistention 
is  complained  of.  The  lesser 
■curvature  must  be  outlined  as 
well,  either  by  inspection,  per- 
cussion, or  auscultatory  percus- 
sion, and  marked  in  pencil.  Its 
position  should  be  under  the  cos- 
tal arch  as  high  as  the  sixth  and 
seventh  ribs,  and  just  below  the 
ensiform  cartilage  in  the  mid- 
line. The  fundus  may  distend 
high  up  toward  the  axilla.  A 
distinct  stomach-shaped  outline 
can  usually  be  obtained.  It  is 
only  by  outlining  both  lesser  and 
greater  curvatures  that  the  differ- 
ence between  displaced  and  di- 
lated  stomachs    is    determined. 

The  great  advantage  of  the 
use  of  the  stomach-tube  in 
inflating  is  that  the  process  can 
be  repeated  as  often  as  may  be 
desired  without  undue  discom- 
fort or  delay,  since  after  the  first 
few  minutes  the  patient  experi- 
ences   little    or    no    uneasiness. 

In  addition  to  the  estimation  of  the  size,  shape,  and  position  of  the 
stomach,  the  stomach-tube  is  used  to  determine  conditions  of  hyper- 
secretion and  retention.  To  test  for  hypersecretion  the  stomach-tube  is 
passed  in  the  morning  before  any  fluid  or  food  has  been  ingested,  or  the 
stomach  may  be  washed  out  and  the  tube  again  passed  after  several  hours' 
fasting.  The  recovery  of  more  than  10  to  20  c.c.  suggests  disturbance  of 
the  gastric  functions.  In  testing  for  retention  the  examiner  washes  the 
stomach  clean,  administers  certain  solid  articles  of  diet,  and  passes  the 
tube  to  obtain  samples  of  the  stomach  contents,  seven  or  eight  hours 
later,  or,  according  as  marked  conditions  are  suspected,  twelve,  twenty- 
four,  or  even  forty-eight  hours  after  the  taking  of  the  meal. 

Contraindications  for  the  Use  of  the  Stomach-tube.  —  Those  who  for 
repeated  diagnostic  or  therapeutic  purposes  have  become  accustomed  to 
the  tube  take  it  without  difficulty  and  many  learn  to  introduce  it  them- 


FiG.  84.- 


-Method  of  introducing  the  stomach-tube. - 
Cohnheim. 


200  MEDICAL  DIAGNOSIS. 

selves.  Its  first  introduction  is  often  attended  witli  great  gagging,  strain- 
ing, and  congestion,  and  is  not  wholly  without  danger  in  elderly  persons 
with  arteriosclerosis,  myocarditis,  and  emphysema  of  high  degree.  It  is 
also  hazardous  and  unjustifiable  in  hemorrhagic  cases,  especially  haemop- 
tysis, hsematemesis,  or  cases  of  marked  anaemia  with  tarry  stools,  and  in 
aneurism  of  the  aorta,  in  great  debility  from  acute  or  chronic  illness,  and 
in  pregnancy.  Even  in  the  absence  of  any  of  the  foregoing  conditions  the 
retching,  gagging,  and  distress  of  the  patient  may  be  so  great  that  the 
attempt  to  pass  the  tube  must  be  temporarily  abandoned. 

(b)  The  Chemical  Examination. — The  further  examination  of  the 
stomach  consists  in  the  administration  of  certain  test-meals  or  substances, 
their  removal  by  means  of  the  stomach-tube  after  a  given  period  of  time, 
and  the  application  of  various  chemical  tests  for  the  digestive  agents  of 
the  gastric  juice. 

Previous  to  the  giving  of  a  test-meal  the  stomach  should  be  perfectly 
free  from  food  remains;  hence  in  cases  of  suspected  dilatation  or  retention 
lavage  must  first  be  employed.  Whatever  the  form  of  test-meal  some 
difficulty  may  be  met  with  in  removing  it.  Frequently  the  tube  is  not  in 
the  stomach,  either  not  reaching  beyond  the  cardia,  or  doubled  up  in  the 
oesophagus  or  pharynx.  In  other  cases  the  tube  may  have  reached  the 
greater  curvature  and  turned  upward  upon  itself  until  the  openings  are 
above  the  level  of  the  stomach  contents.  Not  infrequently  plugs  of  mucus 
will  close  the  eyes  of  the  tube.  In  marked  displacement  and  dilatation 
the  end  of  the  tube  may  not  reach  the  ingested  test-meal  unless  introduced 
many  inches  beyond  the  average  distance.  Forcing  in  a  little  air,  partly 
withdrawing  and  advancing  the  tube,  will  usually  clear  the  opening  and 
enable  one  to  find  the  proper  distance  and  the  point  at  which  the  material 
best  flows  out  or  comes  out  by  suction.  Some  little  information  is  gained 
by  the  way  in  which  the  material  comes  away.  In  atonic  conditions  of 
the  gastric  muscles  suction  must  often  be  used,  even  w^hen  large  amounts 
of  fluid  material  are  present.  With  a  musculature  of  fair  or  active  tone  the 
gushing  forth  of  the  stomach  contents  is  not  uncommon. 

Test=MeaIs. — Several  standard  test-meals  are  in  use. 

The  Ewald  Test-breakfast. — This  consists  of  35  grammes  of  stale 
bread  or  toast  without  butter  and  200-400  c.c.  of  weak  tea  or  water.  Two 
small  sUces  of  toast  without  butter  and  one  cup  of  weak  tea  without 
cream  or  sugar  represent  these  amounts  fairly  well.  This  meal  is  to  be 
removed  at  the  end  of  one  hour,  or  not  later  than  an  hour  and  a  quarter, 
since  in  the  normal  stomach  the  height  of  acidity  is  reached  by  this  time 
and  the  stomach  has  already  begun  to  empty  itself.  Not  infrequently  the 
stomach  is  found  empty  at  this  time  and  one  must  repeat  the  meal  and 
remove  it  earlier.  Attention  to  the  details  of  managing  the  tube  will 
usually  enable  one  to  obtain  some  part  of  the  gastric  contents.  With  this 
meal  after  one  hour's  time  40  to  60  c.c.  of  stomach  contents  should  be 
obtained,  brown  or  white  according  as  toast  or  bread  has  been  used,  of 
the  consistency  of  thin  porridge,  or  if  the  absorption  of  fluid  has  been  rapid 
much  thicker,  the  bread  or  toast  finely  minced  by  the  stomach's  activity 
and  without  an  odor.  The  glairy  saliva  produced  in  excess  by  the  tube's 
presence  in  the  mouth  and  the  whiter  plugs  of  mucus  from  the  posterior 


THE  STOMACH  AXD  INTESTINES.  201 

nares,  are  often  mixed  with  the  contents  and  can  be  readily  distinguished 
and  at  once  removed.  As  the  contents  settle  mucus  from  the  stomach 
will  gather  together  and  remain  upon  the  top.  Little  or  none  should  be 
present,  nor  should  there  be  a  layer  of  froth.  On  standing,  if  in  sufficient 
amount,  the  removed  test-meal  and  gastric  juice  show  two  layers:  the 
upper  fluid,  gray,  milky,  or  light  green  in  color;  the  lower  brown  or  white, 
composed  of  the  remains  of  the  bread  or  toast.  The  tea  or  water  is 
usually  quickly  absorbed,  and  the  overlying  fluid  consists  largely  of 
gastric  juice. 

Objections  to  the  Ewald  test-meal  are,  first,  that  even  stomachs 
whose  motive  power  is  failing  can  get  rid  of  most  of  the  fluid  of  the  meal 
within  the  stated  time,  and  hence  relaxed  conditions  in  their  early  stages 
may  be  overlooked;  secondly,  that  the  mild  character  of  the  meal  does  not 
bring  out  certain  conditions  of  hyperactivity  of  the  gastric  mucosa  as  a 
more  stimulating  one  would  tend  to  do. 

Riegel's  test-meal — 200  c.c.  mutton  broth,  150-200  grammes  beef- 
steak, potato  puree  50  grammes,  one  roll  35-50  grammes — has  been  pro- 
posed in  order  to  overcome  these  difficulties.  The  gastric  contents  are 
removed  at  the  end  of  four  hours  for  the  various  tests  of  gastric  secretion, 
or  at  the  end  of  seven  hours  to  test  for  gastric  motility  or  retention,  it 
being  usual  for  the  normal  stomach  to  have  emptied  itself  by  that  time. 
The  general  readings  of  the  chemical  tests  in  Riegel's  meals  after  four 
hours  are  found  to  correspond  more  or  less  with  those  of  the  Ewald  meal 
after  one  hour.  As  a  matter  of  experience  it  might  be  said  that  careful 
physical  examination  will  overcome  the  first  objection,  and  that  only 
occasionally,  when  the  symptoms  do  not  correspond  with  results  of  the 
Ewald  test-meal,  will  the  Riegel  meal  be  necessary. 

Many  other  test-meals  have  been  proposed,  but  thej^  do  not  seem  to 
yield  any  better  results  than  the  two  mentioned.^ 

After  consideration  of  such  points  as  the  amount  removed,  the  manner 
of  its  expulsion  or  withdrawal,  and  preferably  after  a  preliminar}^  setthng, 
the  upper  liquid  layer  or  the  whole  contents  are  filtered  and  the  filtrate 
submitted  to  chemical  examination. 

Starch.  —  The  effect  of  the  salivary  enzjmies  can  be  first  and  most 
simply  ascertained.  The  conversion  of  starch  to  achroodextrin  and  mal- 
tose goes  on  in  the  stomach  until  the  free  acids  of  gastric  secretion  reach 
a  certain  point.  The  well-known  iodine  reaction,  coloring  starch  violet, 
coloring  erythrodextrin,  the  first  product,  mahogany  brown,  and  having 
no  characteristic  color  effect  in  the  final  stages,  achroodextrin  and  maltose, 
allows  us  to  estimate  quickly  and  qualitatively  the  extent  of  salivary 
digestion.  Both  the  filtrate  and  residue  contain  reacting  substances, 
soluble  and  insoluble  starch.  Excess  of  unaltered  starch  gives  at  once 
with  iodine  solutions  (Lugol's  solution  .1  Gm.  'iodine,  .2  Gm.  potass,  iodide, 
200  c.c.  water)  a  deep  violet  color;  achroodextrin  and  maltose  show  no 
color  reaction,  though  the  latter  is  readily  detected  by  Fehling's  solution. 
Iodine,  however,  must  be  added  in  excess,  since  achroodextrin  has  a 
greater  affinity  for  it  than  has  starch,  and  the  violet  starch  reaction  may 

iFor  a  full  discussion  of  this  subject  consult  Clinical  Diagnosis:  Emerson;  second  edition. 
J.  B.  Lippincott  Co.,  1908. 


202  MEDICAL  DIAGNOSIS. 

only  appear  after  all  the  achrooclextrin  has  been  satisfied.  The  same 
color  effects  can  be  readily  seen  under  the  low  power  of  the  microscope. 

The  main  relationship  which  starch  tests,  i.e.,  saUvarj^  digestion, 
bear  to  stomach  digestion  is  that  hyperacid  conditions  of  the  stomach 
interfere  with  its  progress,  and  that  hj^po-acid  conditions  may  favor  it. 

The  more  important  tests  in  ordinary  clinical  work  are  those  for  (1) 
acidity;  (2)  presence  of  free  acids;  (3)  presence  of  free  HCl,  lactic,  and 
butyric  acids;  (4)  presence  of  HCl  in  combination  (combined  HCl).  Tests 
for  proteid  digestion,  pepsin  and  peptone  reaction,  are  usually  considered 
to  be  unnecessary  when  normal  or  increased  free  HCl  is  found.  Milk- 
curdling  ferment  is  rarely  tested  for.  A  fat-splitting  ferment  in  small 
amounts  has  been  occasionally  demonstrated,  but  is  not  regarded  as  of 
great  practical  importance.  The  qualitative  tests  in  common  use  can  be 
first  considered. 

Qualitative  Tests. — 1.  Test  for  Acidity. — The  products  and  agents 
of  gastric  digestion  are  normally  acid,  this  reaction  being  due  to  free  acids 
— HCl,  lactic  acid,  butyric  acid,  and  their  combinations.  Blue  litmus 
paper  is  reddened  by  their  presence. 

2.  Tests  for  the  Presence  of  Free  Acids. — Congo  red  paper  or 
solution  is  turned  deep  blue  by  free  HCl.  A  less  intense  reaction  is  given 
by  the  organic  acids. 

3.  Tests  for  the  Presence  of  Free  HCl,  Lactic  Acid,  etc. — HCl. 
— (a)  Methyl  Violet  Reaction. — To  a  pale  violet  solution  of  methyl  violet 
(one  drop  concentrated  aqueous  or  alcoholic  solution  in  a  test-tube  of 
water)  add  a  few  drops  of  the  filtrate.  A  distinct  blue  change  takes  place 
if  free  HCl  is  present.    A  control  tube  should  be  on  hand  for  comparison. 

(b)  TrojDCEolin  00  Reaction.  —  Two  or  more  drops  of  fresh  concen- 
trated alcoholic  solution  of  tropseolin  (a  deep  orange-colored  solution) 
are  spread  on  a  porcelain  plate  or  dish.  The  same  amount  of  filtrate  is 
added  to  this  surface  and  the  porcelain  gently  heated.  A  distinct  violet 
reaction  turning  to  blue  takes  place. 

(c)  Phloroglucin-vanillin  {Gilnzburg's)  Reaction. — Two  or  three  drops 
of  the  solution  (phloroglucin  2  Gm.,  vanillin  1  Gm..  alcohol  30  c.c.)  are 
used  with  the  same  amount  or  more  of  the  filtrate  as  in  the  tropjeolin 
test  and  dried  by  gentle  heat.  The  brown  color  of  the  phloroglucin-vanilhn 
is  changed  to  a  distinct  carmine  red  if  free  HCl  is  present. 

(d)  Dimethylamidoazohenzol  Reaction.  —  A  drop  of  a  .5  per  cent, 
alcoholic  solution  of  this  substance  (a  light  red-brown  solution)  added  to 
the  filtrate  or  to  the  residue,  quickly  gives  a  bright  red  color  if  free  HCl 
is  present.  In  cases  where  but  a  few  drops  of  gastric  contents  have  been 
secured  this  test  can  be  readily  applied  without  waiting  to  filter. 

The  last  two  tests  are  by  far  the  most  reliable  and  are  generally  con- 
sidered as  absolute  tests  for  the  presence  of  free  HCl.  Lactic  acid  in  excess 
may  give  suggestive  results  in  the  methyl  violet  and  tropseolin  reactions. 

Lactic  Acid. —  Uff'elman's  Test. — One  drop  of  a  10  per  cent,  solution 
of  ferric  chloride  is  added  to  20  c.c.  of  a  1  per  cent,  solution  of  carbolic 
acid.  The  resulting  deep  blue  mixture  is  diluted  until  it  appears  as  a  light 
amethyst.  On  the  addition  of  a  gastric  filtrate  containing  lactic  acid  the 
amethyst  changes  to  distinct  yellow.    Excess  of  free  HCl,  sugars,  or  peptones 


THE  STOMACH  AND  INTESTINES. 


203 


may  decolorize  the  amethyst,  and  the  yellow  tint  of  many  filtrates  if  added 
in  excess  gives  suggestive  but  uncertain  results.  A  comparison  with  a 
test  solution  of  lactic  acid  is  always  useful  for  a  beginner.  Far  better 
results  are  obtained  by  shaking  a  portion  of  the  filtrate  with  ether,  which 
extracts  the  lactic  acid,  and  applying  the  test  to  the  evaporated  residue, 
which  may  be  preferably  diluted  with  2  or  3  c.c.  of  water.  Strauss'  modi- 
fication of  this  test  is  also  serviceable.  One  may  dispense  with  the  sep- 
arator if  it  is  not  obtainable.  Five  c.c.  of  gastric  juice  are  placed  in  a  test- 
tube;  20  c.c.  of  ether  are  then  added,  the  tube  corked,  thoroughly  shaken 
for  a  few  minutes,  and  allowed  to  settle.  The  overlying  ether  and  extract 
can  now  be  carefully  removed  with  a  pipette  and  mixed  with  5  c.c.  of 
distilled  water.  To  this  mixture  two  drops  of  a  1  in  9 
watery  solution  of  ferric  chloride  are  added  and  the  mixture 
is  again  shaken.  The  watery  layer,  as  it  settles  below,  is  of 
an  intense  greenish-yellow  color  if  lactic  acid  be  present. 

Butyric  Acid. — This  acid  is  usually  only  tested  for  by 
its  odor.  This  and  others  of  the  volatile  fatty  acids,  acetic 
and  valerianic,  are  only  looked  for  in  marked  conditions 
of  stagnation  of  the  gastric  contents.  Very  minute  quanti- 
ties   of    them    all,    however,    occur    in    various    food-stuffs. 

Combined  HCl. — A  qualitative  test  for  the  proteid  com- 
binations of  HCl  is  not  in  general  use.  The  quantitative 
tests  will  be  considered  below. 

.  Proteid  Digestive  Power. — For  the  qualitative  tests 
of  the  power  of  the  gastric  juice  to  digest  proteid,  one  or 
two  simple  devices  have  been  used.  Fibrin  and  coagulated 
albumin  (egg  albumin)  are  the  common  proteids  used:  the 
fibrin,  well  washed,  hardened  in  alcohol  and  stained  by 
neutral  carmine,  will  digest  in  gastric  juice  containing 
free  HCl  and  pepsin,  imparting  a  red  color  to  the  liquid 
mixture    as    the    carmine    is    set    free    by   the    digestion. 

Small  pieces,  or  disks  2  mm.  in  diameter,  1  mm.  in 
thickness,  of  not  too  firmly  coagulated  egg  albumin  are 
placed  in  a  few  c.c.  of  gastric  contents.  According  to  the 
amount  of  pepsin  and  free  HCl  present  digestion  begins 
more  or  less  rapidly,  and  softening  of  the  edges  of  the 
seen  in  one  to  two  hours.  Many  hours  are  required  for  the  complete  gran- 
ulation of  either  fibrin  or  albumin.  Gastric  juices  deficient  in  free  HCl 
have  less  and  less  effect  upon  the  proteids  employed.  Some  slight  diges- 
tion goes  on  even  with  complete  absence  of  free  HCl. 

Neither  of  the  proteid  digestive  tests  is  very  instructive,  and  one 
must  remember  that  the  pepsin  present  in  the  gastric  filtrate  has  been 
already  partly  used  in  the  proteid  digestion  of  the  test-meal.  Sahli's  des- 
moid-proteid  digestive  test  will  be  considered  under  the  absorption  tests. 

Tests  for  Rennin  and  Rennin  Zymogen. — To  10  or  15  c.c.  of  neutral 
milk  add  5  c.c.  of  gastric  filtrate,  and  place  the  mixture  in  a  thermostat  or 
in  any  warm  place.  In  10  to  15  minutes  coagulation  begins.  This  is 
merely  the  familiar  ''junket  making."  Free  HCl  is  not  necessary  for  its 
performance. 


Fig.  85.— Sepa- 
rating apparatus 
suitable  for  test- 
ing for  lactic  acid. 
— Strauss. 


disks 


can 


be 


204  MEDICAL  DIAGNOSIS. 

Quantitative  Tests.  —  For  the  differentiation  of  many  of  the  dis- 
orders of  gastric  secretion  an  estimation  of  the  amount  of  acids  and  acid 
combinations  is  often  necessary.  Free  HCl  is  the  only  free  acid  regularly 
estimated.  The  estimation  of  the  total  acidity  of  the  gastric  contents, 
which  is  made  up  of  free  HCl,  traces  perhaps  of  other  acids  (lactic  acid), 
and  combinations  of  HCl  and  lactic  acid  (if  present)  with  the  proteids  of 
the  administered  meal,  is  the  next  important  step.  Estirr.ations  of  these 
combined  products  are  also  made. 

Quantitative  Estimation  of  the  Amount  of  Free  HCl.  —  The 
amount  not  used  in  the  process  of  digestion  at  the  time  of  the  test-meal's 
removal.  The  general  principle  of  all  the  tests  for  total  acidity  and  free 
acids  is  the  same,  namely,  to  add  to  the  filtrate  a  standard  alkaline  solu- 
tion until  the  acid  contents  are  neutralized.  To  aid  in  determining  neutral- 
ization various  coloring  agents,  some  of  which  have  been  alreadj^  described 
in  the  qualitative  tests,  are  added  to  the  gastric  filtrate.  These  coloring 
agents  all  have  the  peculiarity  of  losing  or  even  changing  their  color  when 
the  filtrate  becomes  neutral  or  faintly  alkaline  in  reaction  from  the  added 
alkaH.  The  solution  in  general  use  is  the  ''one-tenth  normal"  sodium 
hydrate.  This  one-tenth  normal  solution,  written  f-^  NaOH,  is  preferred  on 
account  of  its  dilution,  which,  when  dealing  with  such  small  amounts  and 
percentages  as  are  found  in  the  stomach  contents,  is  very  necessary.  One 
c.c.  of  this  ^  NaOH  corresponds  to  or  exactly  neutrahzes  .00365  gramme 
of  free  HCl. 

In  making  the  quantitative  estimation,  10  c.c.  of  the  gastric  filtrate 
are  taken  in  a  beaker.  By  means  of  a  graduated  burette  the  ^  NaOH  is 
allowed  to  drop  into  the  beaker  until  the  so-called  indicators  or  coloring 
agents  show  their  characteristic  changes,  indicating  complete  neutraliza- 
tion. The  number  of  c.c.  of  ^  NaOH  used,  multiplied  by  the  free  HCl 
equivalent  of  1  c.c.  -^  NaOH  (.00365  gramme),  gives  the  amount  of  HCl 
in  the  10  c.c.  of  gastric  filtrate,  and  one  readily  calculates  the  percentage 
amount  therefrom,  normally  about  .1825  gramme  per  100  c.c. 

At  present  it  is  more  common  to  express  the  results  in  direct  figures 
or  per  cent.,  indicating  merely  how  many  c.c.  of  ^  NaOH  are  necessary 
to  neutralize  100  c.c.  of  the  gastric  filtrate  {i.e.,  its  contained  free  HCl),  as, 
for  instance,  if  10  c.c.  of  gastric  filtrate  (containing  free  HCl)  are  neutral- 
ized by  5  c.c.  of  ^  NaOH,  the  percentage  of  free  HCl  is  said  to  be  50. 

The  most  convenient  indicator  for  free  HCl  is  dimethylamidoazo- 
benzol.  In  contact  with  free  HCl  in  the  filtrate  a  bright  red  color  is  shown. 
Neutralization  by  ^  NaOH  turns  the  red  color  to  a  turbid  yellow.  The 
beaker  containing  the  filtrate  and  indicator  should  be  well  stirred  or  shaken 
while  adding  the  alkaline  solution  from  the  burette. 

Equally  satisfactory  for  quantitative  estimation  is  the  phloroglucin- 
vanillin  test.  Ten  c.c.  of  the  filtrate  are  placed  in  a  beaker,  the  ^  NaOH 
is  added  slowly,  and  after  every  10  to  15  drops  one  takes  a  drop  of  the 
filtrate  and  tests  it  for  free  HCl  on  a  porcelain  plate  with  the  phloroglucin- 
vanillin.  The  non-appearance  finally  of  any  trace  of  the  carmine-red 
color  indicates  the  complete  neutralization  of  the  free  HCl  in  the  filtrate. 

Estimation  of  Total  Acidity. — The  same  methods  are  used  with 
merely  different  indicators:    either  phenolphthalein  or  rosolic  acid.     Two 


THE  STOMACH  AND  INTESTINES.  205 

or  three  drops  of  a  1  per  cent,  alcoholic  solution  of  the  former  give  to  the 
gastric  filtrate  a  turbid  appearance.  Upon  the  gradual  addition  of  the 
^  NaOH  there  appears  a  red-purple  color  where  the  drop  strikes,  quickly- 
disappearing  at  first  but  becoming  more  and  more  persistent  until  shaking 
the  filtrate  no  longer  causes  the  color  to  disappear.  A  good  rule  to  follow 
in  this  test  is  to  consider  the  reaction  complete  when  the  color  will  remain 
for  40  or  60  seconds. 

Upon  the  addition  of  2  or  3  drops  of  a  concentrated  solution  of  rosolic 
acid  to  10  c.c.  of  the  filtrate  the  color  is  changed  to  light  brown.  Neu- 
tralization is  shown  by  the  appearance  of  a  rosy  red  color. 

Since  the  estimation  of  the  total  acidity  requires  the  greater  amount 
of  alkaline  solution,  it  is  possible  to  make  both  tests  in  one  beaker  con- 
taining 10  c.c.  of  filtrate.  Using  dimethylamidoazobenzol  as  an  indicator 
one  can  find  first  the  amount  of  -^  NaOH  necessary  to  neutralize  the  free 
HCl  present.  By  adding  phenolphthalein  or  rosolic  acid  to  the  now  light 
yellow  mixture  the  determination  of  the  total  acidity  can  be  made;  the 
amount  of  ^  NaOH  dropped  in  after  using  the  last  indicator  being  merely 
added  to  the  amount  recorded  in  the  estimation  of  the  free  HCl. 

Frequently  it  is  of  interest  to  estimate  how  much  of  the  secreted  HCl 
has  combined  with  the  proteid  of  the  meal  forming  the  so-called  combined 
HCl.  Many  cases  showing  no  free  HCl  on  tests  will  show  that  there  has 
been  free  HCl  secreted  in  the  stomach  as  evidenced  by  the  existence  of 
its  combined  products. 

The  simplest  tests  require  the  finding  of  the  total  acidity  in  the 
beginning. 

The  total  acidity  represents  free  acid,  acid  combined  with  proteids, 
and  acid  salts  (acid  phosphate). 

Alizarin  as  an  indicator  reacts  acid  to  free  acid  and  acid  salts,  but 
not  to  combinations  of  acids  and  proteids;  hence  the  difference  between 
two  tests,  the  amount  of  -^  NaOH  used  in  one  with  phenolphthalein  as 
an  indicator,  the  other  with  alizarin,  must  represent  the  acids  in  combina- 
tion. The  reaction  is  complete  when  the  yellow  of  the  indicator  turns  to 
a  distinct  violet. 

To  summarize  these  tests  with  an  example,  the  following  normal 
figures  may  be  used. 

1.  10  c.c.  of  gastric  filtrate  with  phenolphthalein  as  an  indicator  for 
neutralization  require  4  c.c.  -^  NaOH:  100  c.c.  would  require  40  c.c. 
Free  acids,  acids  in  combination,  acid  salts  =  total  acidity  40. 

2.  10  c.c.  of  gastric  filtrate  with  alizarin  as  indicator  (free  acids,  acid 
salts)  requires  3  c.c.  -^NaOH:  for  neutrahzation  100  c.c.  would  require 
30  c.c.     Total  acidity  40-30  =  10.     Combined  acids  10. 

3.  10  c.c.  of  gastric  juice  with  dimethylamidoazobenzol  as  indicator 
(free  hydrochloric  acid  only)  require  2.5  c.c.  fjy  NaOH  for  neutralization. 
Free  HCl  therefore  =  25,  in  terms  of  100. 

A  much  more  reliable  method  of  estimating  combined  HCl  is  that  of 
Cohnheim  and  Krieger.  Calcium  phosphotungstate  separates  HCl  from 
its  combination  with  albumin  and  albumoses,  the  calcium  uniting  with  the 
HCl  forming  neutral  calcium  chloride.  In  the  process  a  reduction  of  the 
total  acidity  takes  place,  corresponding  to  the  amount  of  combined  HCl, 


206  MEDICAL  DIAGNOSIS. 

which  has  been  changed  to  the  neutral  calcium  chloride.  The  difference 
between  titrations  before  and  after  the  calcium  phosphotungstate  reaction 
must  represent  the  amount  of  acid  in  proteid  combination.  The  detail  is 
more  troublesome  than  the  simple  alizarin  process,  but  gives  far  more 
accurate  results  than  can  be  expected  where  two  separate  color  changes  are 
required. 

Four  per  cent,  phosphotungstic  acid  is  neutralized  by  gently  boihng 
with  calcium  carbonate.  Calcium  phosphotungstate  is  formed;  the  solu- 
tion is  filtered,  tested  for  neutrality,  and  can  be  kept  for  any  length  of 
time.  30  c.c.  of  this  calcium  phosphotungstate  is  added  to  10  c.c.  of  gastric 
juice.  A  heavy  precipitate  of  proteid  phosphotungstate  results  while  the 
newly  formed  neutral  calcium  chloride  remains  in  solution.  This  mixture 
is  now  filtered,  the  precipitate  remaining  on  the  filter  paper  being  well 
washed  by  pouring  on  it  distilled  water  (two  or  three  separate  additions  of 
5  or  10  c.c.)  and  adding  the  wash  water  to  the  original  filtrate. 

Using  rosolic  acid  as  an  indicator  the  total  acidity  of  10  c.c.  of  gastric 
juice  is  first  estimated,  then  the  same  test  is  repeated  with  the  material 
obtained  after  the  phosphotungstate  reaction,  usually  about  50  c.c.  of 
clear  fluid.     As  an  illustration: 

1.  Total  acidity  of  10  c.c.  gastric  juice,  rosolic  acid  as  indicator  =  50. 

2.  Total  acidity  of  mixture  (10  c.c.  gastric  juice +  30  c.c.  calcium 
phosphotungstate  +  wash  water),  rosolic  acid  as  indicator  =  35.  50—35  =  15, 
difference  due  to  conversion  of  HCl  combined  with  proteids  into  neutral 
calcium  chloride.     Combined  HCl  therefore  =  15. 

Gastric  juices  in  which  the  free  HCl  is  absent  are  often  examined 
for  free  HCl  deficiency.  This  is  necessary  if  the  calcium  phosphotung- 
state method  of  estimating  combined  acids  is  used.  The  process  is  simple 
and  similar  to  the  above  tests.  To  10  c.c.  of  filtrate,  dimethylamidoazo- 
benzol  is  added.  With  absence  of  HCl  there  is  of  course  no  reaction. 
^  HCl  is  now  added  until  a  reaction  for  free  HCl  takes  place.  If  for 
instance  1  c.c.  y^  HCl  must  be  added,  the  equation  is  10  c.c.  gastric  filtrate, 
with  dimethylamidoazobenzol  as  indicator,  required  1  c.c.  -^  HCl  to  pro- 
duce a  reaction  of  HCL    In  terms  of  100,  HCl  deficit=10. 

Quantitative  tests  for  lactic  acid  are  not  necessary.  The  chlorides 
as  a  general  rule  are  not  tested.  Since,  however,  their  increase  in  gastric 
carcinoma  has  been  claimed,  a  quantitative  estimation  is  at  times  called 
for.  The  procedure  is  lengthy,  and  for  its  methods  the  reader  is  referred 
to  works  on  chemistry. 

Test  of  Gastric  Absorption.  —  The  absorptive  power  of  the  stomach 
may  be  estimated  by  the  administration,  when  the  organ  is  empty,  of  a 
gelatin  capsule  containing  0.2  Gm.  of  potassium  iodide.  The  saliva  and 
urine  are  tested  at  intervals  of  several  minutes  by  the  addition  of  a  small 
quantity  of  starch  meal  or  a  bit  of  starch  paper  and  HCl.  A  positive  re- 
action is  shown  by  the  familiar  blue  color  which  normally  should  appear 
in  the  saliva  in  six  to  fifteen  minutes  and  in  the  urine  in  about  fifteen 
minutes.    This  test  is  of  no  great  value. 

Sahli's  Desmoid  Test. — More  as  a  test  of  peptic  activity  than  of 
gastric  absorption,  this  deserves  mention  and  description.  Recognizing 
that  peptic  digestion  as  shown  in  the  test-tube  represents  by  no  means  the 


THE  STOMACH  AND  INTESTINES.  207 

conditions  inside  the  stomach,  many  investigators  have  endeavored  to 
invent  some  capsule  which  would  open  and  give  out  its  absorbable  con- 
tents as  a  result  of  gastric  digestion  alone.  Great  trouble  was  experienced 
for  two  reasons.  First,  osmosis  between  the  contents  of  the  capsule  and 
gastric  juice  took  place  through  the  animal  membranes  (proteid  sub- 
stances), and,  secondly,  many  of  the  substances  used  were  disintegrated 
by  the  muscular  action  of  the  stomach.  Sahli's  invention  consisted  in 
enclosing  absorbable  substances  (iodoform  and  methylene  blue)  in  a  small 
piece  of  rubber  dam,  tying  them  in  with  a  strand  of  raw  catgut.  Osmosis 
cannot  take  place  through  the  rubber;  raw  catgut  can  only  be  dissolved 
by  the  gastric  contents  resisting  absolutely  the  pancreatic  ferments.  The 
appearance  of  iodine  in  the  saliva  and  methjdene  blue  in  the  urine  is  held 
to  indicate  that  the  raw  catgut  has  been  digested  by  the  gastric  juice  and 
set  the  contents  of  the  ''pill"  free;  hence  the  main  value  of  the  test  is  the 
proof  of  the  digestion  of  proteid  and  peptic  activity.  The  details  of  the 
desmoid  test  are  as  follows: 

Iodoform  .1  gramme  and  methylene  blue  .05  gramme  are  enclosed  in 
a  square  of  rubber  dam  2X2  cm.  The  rubber  is  stretched  tightly  to  make 
a  small  pill  and  its  loose  ends  tied  with  catgut  which  has  been  previously 
softened  in  water.  All  free  hanging  edges  of  rubber  are  trimmed  off. 
The  pill  properly  formed  should  sink  in  water  and  should  show  no  diffu- 
sion of  methylene  blue  when  placed  therein.  Well  made  and  tested  in 
this  way  a  pill  given  during  a  full  general  meal,  preferably  at  mid-day, 
should  sink  to  the  bottom  of  the  stomach  and  will  not  be  carried  off  until 
the  end  of  digestion.  In  from  5  to  7  hours  the  first  blue  tingeing  of  the 
urine  from  methylene  blue  takes  place.  Iodine  can  be  determined  in  the 
saliva  or  urine  by  shaking  a  small  quantity  of  the  respective  fluid  with  a 
few  c.c.  of  chloroform  and  adding  pure  colorless  nitric  acid,  a  reddening 
of  the  chloroform  being  the  indicator  of  the  presence  of  iodine. 

Tests  of  the  Motor  Power  of  the  Stomach.  —  Lavage.  —  The  most 
satisfactory  test  for  gastric  motility  consists  in  the  administration  of  a 
Riegel  test-meal  and  the  washing  out  of  the  stomach  at  the  end  of  seven 
hours,  when  under  normal  conditions  the  organ  will  be  found  to  have 
emptied  itself.  After  an  Ewald  test-meal  traces  of  food  should  have  dis- 
appeared at  the  end  of  two  hours.  No  remnants  of  an  ordinary  supper 
should  be  found  upon  washing  out  the  stomach  the  following  morning 
after  rising  at  the  usual  hour.  In  atonic  conditions  and  dilatation 
remnants  of  partially  digested  food  may  be  washed  out  not  only  at  the  end 
of  these  periods  but  in  extreme  cases  even  at  the  end  of  two  or  three  days. 

The  Salol  Test. — Less  reliable  is  the  administration  of  one  gramme 
of  salol  in  gelatin  capsules  directly  after  an  ordinary  meal.  The  urine  is 
voided  at  subsequent  intervals  of  half  an  hour,  one,  two,  three,  and  twenty- 
seven  hours,  and  the  respective  discharges  preserved  for  examination  in 
separate  vials.  Each  portion  is  then  separately  tested  for  the  presence 
of  salicyluric  acid  by  the  addition  of  a  small  quantity  of  a  solution  of  ferric 
chloride,  which  develops  in  the  presence  of  the  acid  a  violet  color.  The 
presence  of  salicyluric  acid  in  the  urine  is  the  sign  of  the  decomposition 
of  the  salol  into  phenol  and  salicylic  acid,  and,  as  this  takes  place  onh"-  in 
an  alkaline  medium,  it  is  the  indication  that  the  salol  has  passed  from  the 


208 


MEDICAL  DIAGNOSIS. 


stomach  into  the  intestine,  which  with  normal  gastric  motility  takes  place 
in  about  one  hour.  A  retarded  reaction  indicates  impairment  of  motility, 
a  delay  of  twenty-four  hours  is  suggestive  of  pyloric  obstruction.  This  test 
is  not  accurate,  as  it  is  impossible  to  determine  in  different  individuals  the 
relative  time  consumed  by  the  chemical  changes  in  the  intestine  and  the 
elimination  by  the  kidneys.  Moreover,  the  salol  may  go  out  of  the  stomach 
not  with  the  first  portion  of  the  food  but  with  the  last.  Normally  all  of 
the  salicyluric  acid  should  have  been  eliminated  within  twenty-seven  hours, 
(c)  Microscopical  Examination  of  Gastric  Contents.  —  With  the 
ordinary  Ewald  test-meal  little  is  to  be  learned  by  microscopical  exami- 
nation. Starch  granules,  a  few  epithelial  cells,  and  bacteria  are  usually 
seen.  If  there  has  been  much  trouble  in  passing  the  tube  a  few  blood-cells 
may  be  found.    With  a  mixed  meal  or  in  vomited  material  starch,  potato 


Fig.  86. — K,  free  nuclei;  Sp,  spirals;  Sch, 
mucus;  H,  yeast-cells;  E,  epithelium;  AE,  alveolar 
epi  thelium . — Cohnheim . 


Fig.  87.  —  E,  epithelium;  L,  leucocytes; 
RB,  red  blood-cells;  F,  fat-cells. — Cohnheim. 


starch,  fat  droplets,  and  meat  fibres  are  readily  recognized.  Many  and  larger 
bacteria  are  seen,  a  few  leucocytes  are  commonly  met  with,  and  in  sedi- 
ments deposited  after  standing,  many  large  granular  mononuclear  cells. 
In  cases  of  acute  gastritis  considerable  blood  and  pus  may  be  found  among 
the  stringy,  transparent  strands  of  mucus.  In  gastric  ulcer,  blood  in  the 
test-meal  or  vomitus  is  common.  It  may  be  recognizable  if  the  hemorrhage 
has  been  recent.  The  hyperacid  condition  of  the  gastric  juice  in  these 
cases,  however,  destroys  the  blood-cells  rapidly  and  chemical  tests  for  the 
blood  are  necessary.  Tissue  cells  from  the  ulcerating  area  are  often  found. 
In  gastric  cancer  with  lessened  acidity  blood-cells  are  less  quickly  destroyed, 
but  as  a  general  rule  the  digestive  juices  rapidly  alter  the  separate  cells. 
Small  clots  which  have  partially  resisted  the  gastric  juice  form  the  sediment 
in  the  characteristic  "coffee-ground"  vomitus  of  cancer  of  the  stomach. 
Occasionally  small  masses  showing  distinct  adenocarcinomatous  arrange- 
ment may  be  found  and  are  conclusive  proof  of  the  existence  of  cancer. 
Small  masses  of  tumor  visible  macroscopically  are  occasionally  seen  in 
the  vomit  or  washings  from  a  caicinomatous  stomach. 


THE  STOMACH  AND  INTESTINES. 


209 


Of  the  bacilli  present  a  majority  are  small,  more  or  less  motile,  prob- 
ably introduced  with  food.  A  few  extra  large  organisms  of  the  hay  bacillus 
group  are  always  to  be  found.  One  should  be  careful  not  to  consider  these 
large  regular  organisms  as  the  form  described  by  Oppler  and  Boas.  The 
latter  are  large,  irregular  club-shaped  and  vacuolated  bacilli,  possibly  the 
degenerate  forms  of  the  so-called  gas  bacillus,  or  of  a  special  lactic  acid 
forming  bacillus.  They  are  most  commonly  found  when  lactic  acid  is  pres- 
ent, and  under  this  condition  have  been  considered  as  suggestive  of  cancer. 

Einhorn's  Bead-test  of  Digestive  Activity.  —  Six  small  glass 
beads  are  connected  with  a  silk  thread;  to  each  bead  is  tied  some  par- 
ticular sort  of  food.  Raw  catgut  and  a  soft  long-bone  of  a  pickled  herring 
are  the  two  substances  used  to  test  gastric  digestion;  raw  meat,  raw 
thymus  gland,  mutton  fat,  and  a  cube  of  cooked  potato  test  the  intestinal 
digestive  power.     The  beads  and  thread  can  be  placed  together  in  a  gela- 


FiG.  88.  —  .S'^  starch-cells  ;  H,  yeast- 
cells;  Sa,  sarcinae;  M,  muscle-fibres;  F,  fat- 
balls  and  droplets;  K,  potato-starch  cells. — 
Cohnheim. 


Fig.  89.  —  H,  yeast-cells  ;  M,  muscle-fibres; 
L,  leucocytes  with  shrunken  nuclei;  B,  Oppler-Boa.s 
bacilli;  St,  starch-cells;  F,  fat;  E,  epithelium;  A', 
potato-starch  cells  with  yeast-cells. — Cohnheim. 


tin  capsule  and  swallowed.  Normally  the  beads  should  appear  in  the  stool 
in  one  or  two  days;  their  elimination  earlier  than  this  indicates  accelerated 
motility  of  the  intestine;  their  appearance  in  the  stool  later  than  two 
days  after  administration  is  held  to  indicate  retardation  of  the  fecal  excre- 
tion. All  the  beads  should  be  empty,  though  traces  of  fat,  thymus,  and 
fish-bone  may  be  left  undigested.  Excretion  of  the  catgut  and  fish-bone 
undigested  would  indicate  impaired  gastric  digestion.  Excretion  of  undi- 
gested meat,  thymus,  or  fat  indicates  deficient  intestinal  digestion.  The 
silk  thread  is  of  course  merely  to  facilitate  the  finding  of  the  beads. 


EXAMINATION   OF   THE   INTESTINES    AND    F/ECES. 

Only  the  lower  bowel  is  accessible  for  direct  examination  of  its  inte- 
rior. Inspection  with  the  aid  of  proctoscopes,  digital  examination  of  the 
rectum,  and  inflation  of  the  colonic  area  enable  us  to  investigate  at  least  a 
part  of  the  large  bowel  directly.  The  remainder  as  well  as  the  small  intes- 
tine can  only  be  reckoned  with  through  the  abdominal  wall  by  inspection, 
14 


210 


MEDICAL  DIAGNOSIS. 


palpation,  percussion,  auscultation,  and  radioscopy.  On  the  other  hand,  a 
careful  examination  of  the  faeces  will  tell  us  much  as  to  function  of  the 
intestines  and  as  to  the  presence  of  abnormal  conditions. 

Inspection  as  apphed  to  the  examination  of  the  intestines  ma}^  be,^ 
as  we  have  said,  direct  when  we  are  dealing  with  the  large  bowel;  the 
proctoscope  and  the  rectal  tubes  ahowing  inspection  of  the  mucous  mem- 
brane practically  to  the  splenic  flexure  of  the  colon.  The  tubes  or  specula 
come  in  varying  sizes,  usually  four  in  a  set,  ranging  from  -i  to  14  inches 
(14  to  35  cm.)  in  length  and  from  1  inch  diameter  in  the  short  speculum 
to  i  inch  diameter  in  the  longer.  They  are  provided  with  obturators. 
Their  use  is  associated  with  considerable  pain,  though  with  persistence 
and  gentleness  most  patients  can  go  through  the  performance  without 
an  ansesthetic.  Warming  and  oiling  the  instruments  thoroughly  will 
overcome  some  of  the  cUfficulties.  After  the  sphincter  muscle  of  the  anus- 
has  been  stretched  and  dilated  the  discomfort  lessens.  Either  the  knee- 
chest  or  the  recumbent  posture  with  the  knees  elevated  may  be  used. 
Too  much  elevation  of  the  lower  part  of  the  body  will  naturally  by  gravity 

send  the  bowel  away 
from  the  examiner.  The 
electric  headlight  with 
reflector  facilitates  ex- 
amination. Very  little 
trouble  is  experienced  in. 
straightening  out  the 
sigmoid  flexure,  nor  dO' 
the  valves  of  the  rectum 
interfere  with  the  prog- 
ress of  the  speculum. 
It  is  common  to  find  that  the  bowel  dilates  perceptibly  with  air  when 
the  speculum  is  in  place,  thus  materially  aiding  the  examination. 

In  the  more  modern  rectoscopes  and  sigmoidoscopes  the  distal  end  is 
so  arranged  that  air  can  be  forced  into  the  bowel  in  front  of  the  advancing 
tube.  A  glass  shield  near  the  distal  end  allows  the  observer  to  look  into 
the  bowel  and  at  the  same  time  keeps  in  the  injected  air  which  balloons 
the  bowel  for  several  inches.  A  small  electric  hght  arranged  in  front  of  the 
tube  gives  a  clear  view  of  the  mucous  membrane. 

Inspection  with  the  proctoscope  or  rectoscope  may  show  us  first 
the  presence  of  scybala,  beyond  reach  of  the  palpating  finger,  revealing 
themselves  often  as  hard,  adherent,  though  detachable,  masses  of  vary- 
ing size,  dark  in  color,  or  gray  if  covered  by  mucus,  and  usually  easily 
indented  or  broken  away  with  a  probe,  and  readily  differentiated  from 
polypoid  and  other  growths;  second,  ulcerating  and  bleeding  points, 
dilated  venules,  fistulous  communications,  thickening  and  reddening  of 
the  mucous  membrane  of  the  bowel;  general  reddening  of  the  whole  sur- 
face in  colitis,  showing  mucus,  glairy  or  dense  and  white  if  the  condition 
of  mucous  colitis  is  present,  and  often  in  large  amounts;  third,  polypoid 
growths,  malignant  growths  in  the  form  of  local  thickening,  strictures, 
foreign  bodies,  ulcerating  tumor  masses;  fourth,  obstructions  outside  the 
bowel,  tumors  of  uterus,  ovary,  etc.,  preventing  insertion  of  the  examining 


Fig.  90. — Rectoscope. 


THE  STOMACH  AND  INTESTINES.  211 

tubes.  It  is  usually  considered  permissible  and  advisable  to  remove 
small  particles  of  suspicious  growths  for  microscopical  examination. 

Examination  of  the  bowel  by  means  of  bougies  may  at  times  help  in 
diagnosing  a  stricture,  particularly  if  the  feeling  of  distinct  resistance  and 
the  sensation  of  passing  an  obstruction  can  be  appreciated  repeatedly  at 
the  same  point  both  during  the  introduction  and  withdrawal  of  the  sound. 

Palpation  as  a  means  of  examination  in  regard  to  the  intestine  has 
but  limited  direct  application,  namely,  the  examination  of  the  rectum 
by  the  finger,  or  if  the  sphincter  can  be  dilated  by  two  fingers  or  the  whole 
hand.  Examination  is  always  facilitated  by  a  previous  good  clearing  out 
of  the  lower  bowel.  The  forefinger  of  either  hand  may  be  used  and  various 
positions  employed.  The  examiner,  however,  reaches  a  higher  point  in 
the  bowel  if  the  patient  lies  on  his  side  with  his  knees  drawn  up  to  a  mod- 
erate extent.  In  this  posture  more  freedom  is  given  the  introduced  finger, 
and  the  rotation  of  the  hand  and  finger  in  examining  the  sides  and  front 
of  the  rectum  much  aided.    The  knee-chest  position  is  also  convenient. 

To  avoid  the  unpleasant  fecal  odor  it  is  advised  to  fill  the  space  be- 
tween one's  nail  and  finger  with  a  little  moist  soap  and  to  follow  this  by  a 
free  greasing  of  the  finger  with  oil  or  vaseline.    A  finger  cot  can  be  used. 

After  inspecting  the  anus  and  neighborhood  for  fissures,  fistulas, 
hemorrhoids,  exuding  blood  or  pus,  etc.,  the  finger  is  gently  inserted, 
overcoming  gradually  the  spasm  of  the  sphincter  which  always  occurs 
and  which  must  not  be  taken  for  a  stricture.  The  tight  grip  of  the  muscle 
on  the  finger  relaxes  during  the  examination  and  gives  considerably  more 
freedom  of  movement.  Examining  as  a  routine  the  prostate  and  bladder, 
or  the  uterus,  one  may  at  once  exclude  or  determine  conditions  affecting 
those  organs;  then,  sweeping  around  to  either  side  one  feels  for  points  of 
tenderness,  irregularities  on  the  smooth  wall  of  the  bowel,  dilated  veins, 
fistulous  communications,  polypi,  etc.  The  finger  is  then  turned  toward 
the  back  of  the  rectum.  The  position  and  condition  of  the  coccyx  should 
always  be  determined  during  any  rectal  examination.  Various  obstetrical, 
genito-urinary,  and  gynaecological  examinations  may  be  made  by  w^ay  of 
the  rectum.  The  fact  that  impacted  ureteral  calculi  can  at  times  be  per- 
ceived by  the  examining  finger  if  caught  in  the  bladder  wall  or  in  the 
neighborhood  of  the  pelvic  brim  must  be  mentioned.  Too  little  considera- 
tion is  given  to  a  rectal  examination  in  appendicitis  and  appendicular 
complications.  An  appendix  abscess  extending  downward,  though  often 
painless,  is  frequently  associated  with  an  extreme  tenderness  when  touched 
by  the  examining  finger.  This  tenderness  is  usually  too  localized  to  be 
confused  with  any  general  abdominal  distress,  and  its  high  position  to  the 
right  is  of  diagnostic  significance. 

The  examining  finger  has  first  l-L^'  inches  of  contracted  sphincter 
area  to  overcome.  A  slow  inserting  movement  dilates  the  muscles  with- 
out pain,  and  allows  the  examiner  and  patient  to  appreciate  localized 
tender  areas,  such  as  are  occasioned  by  fistulae,  or  ulcerations  of  hemor- 
rhoidal veins.  A  forcible  dilatation  would  readily,  by  the  pain  occasioned, 
prevent  the  disclosure  of  many  of  these  minor  conditions.  Beyond  the 
sphincters  the  finger  has  free  play  and  at  times  one  fails  to  touch  any 
part  of  the  bowel,  the  rectum  being  ballooned  by  flatus;   by  crooking  the 


212  MEDICAL  DIAGNOSIS. 

finger  one  touches  readily  the  rectal  wall.  It  is  at  times  possible  to  dis- 
tinguish emptied  fallen  coils  of  small  intestines  in  the  pelvis  by  rectal 
examination;  such  a  condition  may  take  place  when  a  complete  stricture 
has  occurred  high  up  in  the  small  intestine,  the  empty  tract  below  col- 
lapsing and  descending. 

Indirectly  both  the  small  and  large  bowel  can  be  examined  through 
the  abdominal  wall  by  inspection  and  palpation.  Auscultation  has  but  a 
doubtful  bearing  on  abdominal  conditions;  even  marked  intestinal  dis- 
orders may  yield  nothing  to  the  most  experienced.  On  the  other  hand, 
correct  interpretations  of  simple  existing  phenomena  may  give  most 
important  results.  Inspection  is  always  preferably  performed  with  the 
patient  lying  on  his  back,  with  his  knees  either  flexed  or  extended.  (See 
Methods  of  Physical  Diagnosis.) 

Examination  of  the  large  intestine  and  the  csecal  region  is  helped  by 
the  easily  applied  method  of  inflation.  Before  this  procedure  a  thorough 
purging  is  always  advisable.  The  soft  rubber  rectal  tubes,  i  to  i  inch  in 
diameter,  with  two  or  more  lateral  openings,  and  connected  with  a  David- 
son syringe  or  a  double  or  single  atomizer  bulb,  can  be  inserted  to  any 
distance  desired.  A  slow  twisting  insertion  will  quickly  put  the  openings 
above  the  anus  and  sphincters.  Since  the  sigmoid  flexure  is  the  most 
commonly  dilated  part  of  the  bowel,  inflation  should  begin  while  the  tube 
is  entering  the  flexure,  and  the  first  examination  directed  to  this  part. 
Unless  previously  distended  by  gas  or  continued  fecal  accumulations  the 
sigmoid  flexure  should  not  rise  easily  out  of  the  pelvis  during  inflation. 
Usually  when  a  point  half  way  between  the  groin  and  the  umbilicus  is 
reached  distinct  discomfort  is  felt  unless  relieved  by  passage  of  the  air 
upward.  In  many  instances  it  will  be  found  that  the  inflating  air  passes 
readily  beyond  the  sigmoid  and  shows  its  presence  in  the  descending  and 
transverse  colon.  It  is  now  generally  conceded  that  the  ileocsecal  valve 
allows  air  to  pass  during  the  process  of  inflation  and  its  passage  can  at 
times  be  heard  with  the  stethoscope  applied  in  the  right  iliac  fossa. 

To  further  inflate  the  colon  the  rectal  tube  may  be  passed  upward 
its  whole  length;  we  cannot  be  sure,  however,  that  it  will  pass  beyond 
the  splenic  flexure  nor  could  further  passage  be  expected.  Inflation  of 
the  transverse  and  ascending  colon  and  of  the  caecum  take  place  quite 
readily  with  the  tube  in  this  locahty.  The  pain  of  extreme  distention  will 
always  warn  the  operator  when  to  temporarily  moderate  the  air-pressure, 
which,  however,  is  usually  reheved  at  this  stage  by  the  passage  of  air 
upward  through  the  ileocsecal  valve.  Detaching  the  rectal  tube  from  the 
inflating  apparatus  aflows  the  bowel  to  return  to  its  normal  state,  by 
expelling  the  contained  air. 

Carefully  applied  inflation  in  connection  with  inspection  and  palpa- 
tion may  give  important  results.  Idiopathic  dilatation  of  the  sigm.oid 
flexure  can  be  readily  differentiated  from  abdominal  distention  due  to 
other  causes,  the  sigmoid  clearly  outlining  itself  as  it  rises  from  and  descends 
again  into  the  left  iliac  fossa,  often  overlying  the  rest  of  the  abdominal 
contents  in  its  sweep  upward  and  to  the  right.  Tumors,  malignant  or 
other  strictures  of  the  bowel,  fecal  accumulations  may  be  brought  up  from 
the  pelvis  into  sight  and  touch.    The  position  of  the  colon  and  caecum  can 


THE  STOMACH  AND  INTESTINES.  213 

be  readily  outlined,  visibly  in  thin  subjects,  by  percussion  and  palpation 
in  those  stouter  and  more  muscular,  although  the  examiner  can  always  see 
that  inflation  is  going  on  by  the  puffing  up  of  the  various  regions.  One 
must  know  that  at  both  the  splenic  and  hepatic  flexure  the  bowel  will  be 
less  prominent  than  elsewhere.  The  same  pathological  conditions  men- 
tioned in  connection  with  the  sigmoid  flexure  may  be  shown  in  the  colon. 
One  would  naturally  expect  that  complete  strictures  from  any  cause 
would  prevent  passage  of  air  upward  or  downward.  In  such  cases  the 
distention  and  condition  (muscular  hypertrophy,  visible  peristalsis)  above 
the  stricture  may  tell  us  as  much  or  more  than  inflation  from  below;  and 
further,  in  such  conditions  the  diagnosis  is  rarely  in  doubt.  Incomplete 
or  partial  strictures,  whose  symptoms  may  be  very  obscure,  are  at  times 
clearly  brought  out  by  the  rapid  inflation  from  below,  as  a  sudden  nar- 
rowing above  the  dilated  lower  part. 

Easily  recognized  is  the  displacement  of  the  colon,  particularly  the 
transverse  colon  in  enteroptosis.  The  transverse  colon  may  lie  below 
the  umbilicus,  or  even  in  the  pelvis,  the  common  appearance  on  inflation 
being  a  shallow  V-shaped  protuberance,  the  arms  of  the  V  running  up  to 
the  liver  and  spleen.  The  relation  of  the  bowel  to  retroperitoneal  and 
other  tumors  is  more  easily  determined  by  inflation  than  by  any  other 
means.  Inflation  of  the  bowel  above  the  ileocsecal  valve  doubtless  may  be 
of  value.  Its  application  has  given  but  uncertain  results.  Inflation  of 
the  bowel  as  a  test  for  perforation  is  now  universally  condemned.  Many 
cases  of  flatulence  supposedly  due  to  gastric  distention  can  be  found  to  be 
due  to  distention  of  the  colon.  Inflation  is  a  valuable  aid  in  the  differ- 
ential diagnosis  of  these  conditions. 

RoNTGEN-RAY  EXAMINATION  OF  THE  INTESTINES. — Large  and  Small 
solid  tumors,  thickening  and  muscular  hypertrophy  can  at  times  be 
made  out  by  the  fluoroscope  or  in  skiagrams.  The  data  obtained  by  this 
method  are,  however,  usually  confirmative  of  facts  elicited  by  the  anam- 
nesis and  the  above  described  methods.  Scybalous  masses  present  no 
different  shadow  from  that  of  organic  disease.  Lining  the  intestine  by 
continuous  doses  of  bismuth  allows  the  coils  to  be  readily  photographed, 
and  under  this  condition  peristalsis  can  be  readily  observed  by  the  fluoro- 
scope and  the  rate  of  progress  of  fecal  matter  observed.  More  feasible 
and  of  distinct  value  in  recognizing  displacements  of  the  colon  is  the 
injection  of  suspensions  of  bismuth  in  large  quantities.  Very  serviceable 
photographs  can  be  secured  by  this  method.  Localization  of  small  metallic 
or  other  solid  foreign  bodies  in  the  intestines  is  remarkably  facilitated  by 
the  X-rays. 

So-called  "test  lavage"  is  used  at  times  to  bring  away  secretion  or 
material  from  the  large  bowel:  mucus,  blood,  ulcerating  fragments  of  new 
growths.  The  examination  of  the  sediment  of  such  washings  at  times 
gives  distinct  help.  It  can  only  be  satisfactorily  performed  when  the  large 
bowel  has  been  previously  completely  emptied. 

It  has  been  suggested  that  dilatation  of  the  duodenum,  with  stricture 
beyond,  can  be  diagnosed  by  filling  the  stomach  and  duodenum  with  water 
through  a  stomach-tube.  Dulness  and  distention  toward  or  in  the  right 
hypochondrium  and  the  fact  that  the  fluid  may  return  as  does  the  fluid 


214  MEDICAL  DIAGNOSIS. 

from  an  hour-glass  stoniacli,  part  at  once  and  the  rest  a  few  minutes  later, 
is .  considered  suggestive.  An  inflation  that  outlines  the  stbmach  and 
produces  an  extra  prominenc'e  in  the  right  hypochondrium  would  be 
equally  suggestive. 

Fffices. — The  accurate  determination  of  many  points  with  regard  to  the,-* 
faeces  is  difficult,  owipg  to  xhe  wide  A'ariations  in  their  composition  and  to 
the  fact  that  the  establishment  of  a  normal  or  standard  bowel  movement 
requires  the  continued  administration  of  certain  standard  diets  for  several 
successive  days.^ 

I^arious  standard  diets  are  recommended,  the  simplest  being  milk, 
since  it  contains  fat,  proteids,  and  carbohydrates. 

1.  Milk,  '8  oz.  every  two  hours  from  8  a.m.  to  10  p.m.,  amounting  to 
4  pints  in  the  twenty-four  hours. 

2.  That  of  Schmidt  is  more  complicated,  but  approaches  more  nearly 
a  general  diet: 

7.30  A.M.     Milk,  17 J  oz.,  and  6  biscuits. 

9.00  A.M.     Gruel,  l|  oz.  oatmeal,  1  egg,  2  biscuits,  |  oz.  butter,  7  oz.  milk,  10^  oz. 

water. 
1.00  P.M.     ]Minced  beef,  4J  oz.  raw  weight,  lightly  fried  in  J  oz.  butter,  leaving  the 
,  interior  raw,  and  potato  puree — 7  oz.  mashed  potatoes,  7  oz.  milk, 
J  oz.  butter. 
4.30  P.M.     Milk,  17^  oz. 
7.30  P.M.     Same  as  at  9  a.m. 

3.  A  "mixed  diet"  is  more  liberal  and  better  borne,  but  the  neces- 
sary cooking  makes  the  eventual  microscopical  examination  much  less 
satisfactory  than  either  of  the  preceding: 

8.00  A.M.     10  oz.  hot  water. 

9.00  a.m.     3  oz.  fresh  fish,  4  biscuits,  J  oz.  butter,  10  oz.  tea,  2  oz.  milk. 
12.00  M.        10  oz.  hot  water. 

1.00  P.M.     3  oz.  mutton,  3  oz.  cabbage,  4  biscuits,  J  oz.  butter,  rice  pudding  (h  oz. 
rice  in  10  oz.  milk). 

4.30  P.M.     10  oz.  tea,  2  oz.  milk,  2  biscuits. 

6.00  P.M.     10  oz.  hot  water. 

7.00  P.M.     3  oz.  fresh  fish,  3  oz.  chicken,  3  oz.  spinach,  rice  pudding  (as  before),  2 

biscuits,  ^  oz.  butter. 
10.00  P.M.     10  oz.  milk. 

4.  A  meat  diet:  I  lb.  finely  minced  beef  every  three  hours  and  10  ounces 
hot  water  one  hour  before  meal-time.    It  contains  no  carbohydrates. 

The  first  dejecta  usuahy  appear  in  from  twenty-four  to  forty  hours 
after  the  standard  meal  has  been  given.  Radioscopic  examination  of  the 
intestine  and  the  passage  of  its  contents  shows  that  in  about  seven  hours 
the  ileocsecal  valve  has  been  reached  by  part  of  the  residue,  which  may 
now  remain  four  hours  in  the  colon,  three  hours  in  the  sigmoid  flexure  and 
rectum  before  being  expelled. 

Attempts  to  describe  bowel  movements  resulting  from  standard  diets 
have  been  made. 

1.  F^CES  Resulting  from  Milk  Diet. 

Amount. — 

Quantity  of  milk  in  24  hrs.  Faces  excreted,  average  weight  in  Gm. 

4  pints  135.2  Gm. 

5  pints  151      Gm. 

6  pints  198     Gm. 


THE  STOMACH  AND  INTESTINES.  215 

Color. — Yellow-white,  or  white  tinged  with  orange. 

Consistency. — Not  well  formed,  tending  to  Be  lumpy;  rolls  of  fecal 
matter  not  homogeneous  but  composed  of  lumps  welded  together,  or  firm 
sausage-shaped  masses  plus  soft  paste.  *  .  . 

Odor. — Not  offensive;   more  hke  stale  cheese  than  faeces. 

If  constipation  exists,  a  tendency  to  isolated  scybala  of  pale  color  is 
seen,  often  firm,  hard,  and  dry  enough  to  rattle  in  tlie  vessel,  and  to  break 
up  like  dry  clay,  with  an  earthy  odor. 

With  diarrhoea  a  milk  diet  gives  faeces  resembling  Devonshire  cream — 
sticky,  but  capable  of  being  poured  from  one  vessel  to  another.  Gas  bubbles 
and  froth  are  seen  on  shaking,  and  the  odor  is  that  of  decomposed  cheese 
or  putrid  proteid. 

Caseous  fiocculi,  the  evidences  of  disturbed  digestion,  are  readily 
recognized  as  bright  white,  small,  fibrillary-looking,  friable  masses. 

2.  F^CES  Resulting  prom  the  Schmidt  Diet. 

Amount. — Smaller  "than  that  from  the  milk  diet.     Average  90  Gm. 

Color.— Light  brownish-yellow,  darker  on  the  outside  than  inside. 

Consistency. — Well  formed  rolls  or  sausage-shaped  masses,  as  a  rule. 
These  readily  break  up  on  drying. 

Odor. — Distinctly  fecal. 

In  constipation  on  a  Schmidt  diet  lumps  of  fecal  matter  are  massed 
together,  or  isolated  scybala  are  seen. 

In  diarrhoea  on  this  diet  the  fgeces  resemble  closely  those  of  a  patient 
on  a  milk  diet. 

3.  F^CES  Resulting  from  a  Mixed  Diet. 
Amount. — Average  102  Gm. 

Color.  —  Nut-brown,  olive-green  (chlorophyll  of  vegetables),  varies 
much  from  day  to  day. 

Consistency  and  Form. — Usually  large,  firm,  roll  or  sausage-like  motions. 
On  drying  break  up  easily. 

Odor. — Fecal. 

In  constipation  the  feeces  of  a  mixed  diet  are  usually  dark  brown  or 
black  scybala  with  pressure  facets  and  mucus  in  the  crevices.  They  may 
be  of  stony  hardness  and  not  offensive. 

In  diarrhoea  the  motions  are  dark  brown  or  nearly  black,  of  thick 
sticky  or  pasty  consistence  with  small  scybala.  Soft  movements  in  general 
from  a  mixed  diet  have  most  offensive  odors.  An  increase  of  the  quantity 
of  milk  in  mixed  diets  makes  the  stools  paler  and  less  firm. 

4.  Meat  Diet. 
Amount. — Average  54  Gm. 
Color. — Dark  brown  to  black. 

Consistency  and  Form. — Firm  rolls,  2  to  3  inches  in  length. 

Odor. — Fecal  but  very  offensive. 

Variations  in  consistency  and  form,  in  odor,  and  in  color  naturally 
depend  on  local  conditions  and  the  time  the  fecal  material  is  retained  in 
the  large  bowel.  The  amount  is  important,  but  several  days  are  required 
to  get  the  proper  average.  The  formation  of  scybala,  according  to  these 
results,  may  take  place  in  a  very  few  days. 


216  MEDICAL  DIAGNOSIS. 

The  faeces  are  composed  of: 

1.  Food  remains. 

(a)  Indigestible  remnants. 

(b)  Digestible  but  not  absorbed  remains. 

2.  The  remains  of  the  digestive  secretion. 

3.  Products  resulting  from  the  digestion  of  food  in  the  intestinal  canal. 

4.  Formed  and  unformed  products  of  the  intestinal  mucosa. 

5.  Bacteria. 

6.  Various  substances  introduced  accidentally  from  without;  various 
concrements,  gall-stones,  intestinal  stones,  parasites,  cotton,  wool,  or  linen 
fibres. 

The  faeces  are  collected  in  a  bed-pan  or  any  large  clean  vessel. 

In  the  study  of  any  question  of  absorption  or  excretion  the  rule  is 
to  place  the  patient  on  one  of  the  standard  diets  for  at  least  four  days 
before  beginning  any  estimation.  The  administration  of  some  coloring 
matter  such  as  charcoal  or  carmine  with  the  first  meals  of  the  standard 
diet  will  render  easy  the  recognition  of  their  first  dejecta. 

The  faeces  are  to  be  examined  macroscopically,  microscopically,  and 
chemically. 

Fermentation. — Normal  firm  bowel  movements  will  usually  dry  with- 
out appreciable  gas  formation,  and  even  semisolid  or  pultaceous  stools  ordi- 
narily produce  only  a  small  amount.  A  stool  which  on  standing  shows 
evidence  of  fermentation  by  the  production  of  gas  bubbles  or  a  distinct 
frothy  layer,  or  gas  bubbles  in  such  abundance  as  to  give  a  pale  appearance 
to  a  more  or  less  soKd  stool,  should  be  considered  pathological  and  examined 
for  fermentable  products — carbohydrates. 

Excess  of  neutral  fat  in  the  stools  can  be  readily  noted.  The  normal 
bowel  movement  leaves  no  greasy  mark  upon  a  vessel  containing  it.  Neu- 
tral fat  will  show  itself  in  the  gross  examination  either  as  a  very  pale,  white, 
distinctly  greasy  bowel  movement,  or  if  the  stool  be  Hquid  the  fat  may 
rise  to  the  top,  forming  the  characteristic  appearance  of  melted  fat,  and  on 
cooling  may  partially  or  completely  solidify.  The  soaps  in  ordinarj^  amounts 
and  the  fatty  acids  are  not  macroscopically  recognizable. 

Excess  of  proteids  in  the  faeces,  when  in  the  form  of  meat,  can  often 
be  recognized  by  the  appearance  of  numerous  reddish  points  throughout 
the  bowel  movement.  One  must  be  certain  that  other  coloring  or  colored 
matters  have  not  been  ingested.  Casein  shows  itself  as  the  familiar  white 
floccuh,  easily  disintegrated,  much  denser  white  than  mucus.  Undissolved 
connective  tissue  has  the  appearance  of  fine  cotton-wool  fibres  and  can  be 
removed  for  further  examination.  Other  substances  to  be  considered  in 
the  gross  examination  are  mucus,  blood,  pus,  foreign  bodies,  and  parasites. 
Small  amounts  of  mucus  are  always  present,  but  require  search  to  demon- 
strate their  presence.  A  constipated  stool  often  shows  flakes  of  dense 
white  mucus  in  the  interstices  of  the  firm  masses,  or  mucus  may  follow  the 
movement. 

Brownish,  gelatinous-look-ing  mucus,  colored  by  the  bile  pigments, 
usually  comes  from  the  small  intestine;  colorless  mucus  and  that  appear- 
ing as  denser,  whiter  masses  and  flakes,  from  the  colon.  Tubular  masses 
from  the  large  intestine,  sometimes  many  centimetres  in  length,  are  seen 


THE  STOMACH  AND  INTESTINES.  217 

in  membranous  colitis.  Floating  or  softening  these  masses  or  strands 
in  water  will  usually  determine  their  character.  Unformed  mucus,  par- 
ticularly in  liquid  stools,  sometimes  on  standing  accumulates  in  masses 
as  large  as  a  hen's  egg. 

Fresh  blood  can  be  easily  recognized.  Unless  quickly  voided,  blood 
in  the  intestines  becomes  black  and  small  amounts  do  not  show  in  the 
stools.  Large  amounts  appear  as  'Harry  stools" — large  black  masses, 
clots  too  large  to  be  broken  up  or  absorbed. 

Pus  is  usually  quickly  disintegrated.  Fresh  pus  which  retains  its 
appearance  is  practically  always  from  the  sigmoid  or  rectum. 

Parasites  are  described  in  another  section.  Many  food  remains  are 
detected  at  a  glance:  fruit  stones  and  seeds,  skin  of  fruit,  vegetables,  food 
pulp  of  oranges,  grape  fruit,  lemons,  large  masses  of  connective  tissue,, 
bones,  etc. 

For  the  more  careful  examination  various  simple  plans  are  recom- 
mended. In  examining  the  whole  quantity  of  faeces  an  ordinary  fine  sieve 
on  which  running  water  can  play  enables  one  to  collect  the  larger  foreign 
bodies  and  soHd  material;  or  the  faeces  are  placed  in  a  large  vessel  with 
water  and  thoroughly  broken  up.  Mucus,  woody  fibres,  smaller  seeds,  and 
bacteria  float  and  can  be  removed  by  pouring  off  after  settling.  By  repeat- 
ing the  process  several  times  a  residue  of  solid  matter,  deodorized  and 
decolorized,  is  obtained.  Gall-stones,  pancreatic  calculi,  muscle  fibres, 
connective  tissue,  casein,  parasites,  are  easily  looked  for  in  this  way. 

Spreading  the  faeces  on  a  glass  plate  with  a  dark  background  facilitates 
the  examination.  Pieces  of  connective  tissue,  muscle  fibres,  casein,  foreign 
bodies,  or  anything  differing  from  the  homogeneous  fecal  matter  may  be 
readily  found  in  this  way. 

Microscopical  Examination. — Mixed  Diet. — A  small  piece  of  fecal 
matter  can  be  taken  from  the  stool  after  it  has  been  mixed  in  a  mortar  or 
a  vessel,  or  several  loopsful  of  a  liquid  stool  can  be  smeared  on  a  slide. 
A  cover-glass  is  preferable  if  high  power  is  used.  For  a  low-power  exami- 
nation a  glass  3  or  4  inches  square  on  which  a  comparatively  large  amount 
of  fasces  has  been  thinly  spread,  can  be  placed  on  the  stage  of  the  microscope. 
A  large  area  can  be  quickly  gone  over  in  this  way. 

Masses  of  mucus,  blood,  or  pus,  meat  fibres,  etc.,  should  be  picked  off 
for  separate  examination  before  mixing  the  fecal  material.  Schmidt 
recommends  taking  three  separate  specimens  of  softened  faeces.  No.  1  is 
examined  direct.  In  it  we  can  note  much  fibre,  colorless  soaps,  neutral 
fat  if  present,  small  and  large  yellow  salts  of  calcium.  No.  2  is  stirred 
with  a  small  drop  of  30  per  cent,  acetic  acid  heated  for  a  moment  until 
it  begins  to  boil,  then  covered  with  a  cover-glass.  After  cooling,  small 
flakes  of  fatty  acids  appear.  The  soap  flakes  and  calcium  salts  will  have 
disappeared.  No.  3  is  rubbed  up  with  a  drop  of  Lugol's  solution.  Under 
the  microscope  unaltered  starch  will  assume  a  violet  color. 

Since  85  per  cent,  or  more  of  the  food  is  digested  and  absorbed,  and 
since  of  the  remainder  a  portion  is  in  the  shape  of  products — albumoses, 
fatty  acid,  soaps,  dextrin,  etc.,  little  unaltered  food  is  present  in  the  speci- 
men. Easily  recognized  are  the  bacteria  which  make  up  practically  one- 
third  of  the  dry  substance  of  the  stool.     Acid-fast  bacilli  may  be  tubercle 


218  MEDICAL  DIAGNOSIS. 

or  smegma  bacilli.  Leptothrix  threads  are  easily  recognized.  Epithelial 
cells  in  considerable  numbers  are  always  present.  They  are  usually  of  the 
smaller  round  type,  and  show  evidences  of  digestion  or  disintegration. 
No  deduction  can  be  drawn  from  their  number  or  form  as  to  conditions  in 
the  bowel.  Squamous  epithelia  from  the  mouth  or  from  the  food  are 
occasionally  seen.  Structureless  or  faintly  striated  mucus  in  small  amounts, 
bile-stained  if  from  parts  high  up,  pale  if  from  lower  down,  may,  by  the 
number  of  leucocytes  or  epithelial  cells  entangled  in  it,  give  evidence  of 
catarrhal  conditions  of  the  bowels.  Mucus  is  less  dense,  less  sharp  in  outline 
than  connective  tissue;  acetic  acid  causes  it  to  show  faint  striations.  A 
few  leucocytes  are  always  present. 

Food  Remains.  —  Undigestible  remnants  of  any  kind  may  appear. 
Many  of  them  are  recognizable  macroscopically.  The  framework  of  vege- 
tables gives  most  varied  pictures.  Many  of  the  structures  suggest  parasites 
and  have  frequently  been  mistaken  for  them.  Remnants  of  undigested 
starch  may  be  suspected  by  their  pallid  color  and  their  cellular  envelope. 
It  is  well  to  stain  suspicious  specimens  with  iodine  and  look  for  the  blue 
stained  masses;  to  judge  whether  starch  is  being  excreted  in  excess  is  not 
easy  with  the  microscope;  the  fermentation  test  is  the  more  accurate 
method. 

Two  or  three  small  meat  fibres  in  a  field,  showing  very  dim  or  no  stria- 
tion,  and  with  no  remnants  of  nuclei,  may  be  considered  normal  in  patients 
on  a  mixed  diet.  Retention  of  the  striation,  persistence  of  the  nuclei  in 
good  condition,  and  presence  of  meat  fibres  in  numbers  suggest  disturbance 
of  intestinal  digestion,  particularly  that  part  related  to  the  pancreas.  It 
is  not  likely  that  anacidity  of  the  gastric  juice  will  show  the  same  condition. 
Specimens  from  fsBces  of  patients  with  pancreatic  derangements  may  show 
meat  fibres  in  such  numbers  that  counting  them  in  one  field  may  be  difficult 
or  impossible.  Some  cases  show  excess  of  meat  fibres  in  the  stools  if  over 
60  grammes  of  meat  are  taken  per  day. 

Schmidt's  Nucleus  Test  for  Pancreatic  Disease  or  Impairment  of  Pan- 
creatic Function. — The  disintegration  or  non-disintegration  of  the  meat 
fibre  nuclei  in  the  centre  of  small  balls  of  meat  of  standard  size — |  to  *  inch 
in  diameter — kept  together  by  non-digestible  netting  and  given  in  the  food, 
cannot  be  said  to  be  positive  enough  for  any  certain  deductions  to  be  made. 
We  can  only  say  that  if  all  the  nuclei,  even  those  on  the  outside  of  the  balls, 
are  found  unaffected  by  digestion,  pancreatic  insufficiency  is  suggested. 
Connective  tissue  and  elastic  tissue  are  constantly  present  on  a  mixed  diet, 
though  in  very  small  amounts.  They  are  readily  recognized  by  their  dense 
and  fibrillated  appearance.  Gastric  juice  readily  digests  connective  tissue, 
and  its  persistent  presence  in  large  quantity  must  be  taken  as  pointing  to 
impaired  gastric  digestion.  A  few  fat  drops  may  be  found  on  a  mixed  or 
meat  diet,  but  more  than  eight  to  ten  fat  drops  in  a  single  field  should 
attract  attention.  This  neutral  fat  is  easily  seen  as  yellowish,  oily  looking 
drops  of  varying  size  and  shape.  Constant  presence  of  the  flakes  of  the 
■'higher  melting  point"  fat,  and  the  flaky  needle-Hke  crystals  of  the  fatty 
acids,  or  of  the  flake  or  disk  crystals  of  the  soaps,  is  to  be  considered  as 
abnormal.  Gentle  heating  of  the  slide  will  dissolve  the  crystals  and  flakes 
of  the  fatty  acid  and  soap.    Triple  phosphate  crystals,  colorless  and  of 


THE  STOMACH  AND  INTESTINES.  219 

characteristic  shape,  neutral  phosphate  of  Hme  crystals,  colorless,  or  the 
yellow  calcium  salts  (sometimes  bile  stained)  are  commonly  found.  Oxal- 
ate of  hme  crystals  are  usual  in  a  mixed  diet.  Their  presence  in  the  fseces 
when  no  vegetables  are  being  eaten  is  said  to  indicate  some  intestinal 
disorder.  Cholesterin  crystals,  Charcot-Leyden  crystals,  especially  if  much 
mucin  is  present,  are  both  found  in  the  fseces.  Very  frequently  present  are 
the  so-called  ''yellow  bodies":  large  lumps  of  bright  j^ellow  material, 
structureless,  often  surrounded  by  mucus,  and  recognized  macroscopically. 
They  give  a  proteid  reaction.  They  are  considered  to  be  albumin,  bile 
stained,  and,  when  in  great  amount  together  with  much  mucus,  indicate 
some  disturbance  of  proteid  digestion. 

Casein  flocculi  are  seen  microscopically  as  almost  structureless 
masses,    finely    fibrillated    and    enclosing    fat    droplets    in   their    meshes. 

Hairs,  cotton  and  linen  fibres,  are  common  in  the  stools,  being 
taken  in  with  the  food  in  large  numbers. 

Chemical  Examination.— In  health 
the  fseces  have  a  neutral  or  faintly  alka- 
line reaction.  On  standing  this  becomes 
faintly  acid.  Stools  with  excess  of  car- 
bohydrates ferment  and  give  a  strong 
acid  reaction.  Excess  of  fat,  fatty  acid, 
gives  faintly  acid  stools.  Decomposition 
of  excess  of  proteid  matter  produces  an 
alkaline  reaction.  A  mixed  diet  in  health 
causes  neutral  faeces;  a  pure  proteid  diet 
produces  alkaline  fseces;  a  pure  carbo- 
hydrate diet  produces  acid  fseces;  a  diet 
of  fats  produces  acid  fseces.    Only  freshly 

1    r  1  1    •       i       J  •  A  Fig.  91. — Charcot-Leyden  crystals  from  the 

passed  fseces  can  be  used  m  testing.    A  stools,  x  4oo.— Emerson, 

markedly  acid   reaction   in  fresh  fseces 

suggests  fermentative  changes  from  undigested  carbohydrates.  "  Acid 
diarrhoeas,"  so-called,  may  be  associated  with  hyperacidity  of  the  stomach 
and  insufficiency  of  the  biliary  and  pancreatic  secretion. 

The  test  for  hydrobihrubin  or  the  bile  products  is  important,  since  they 
may  be  present  in  colorless  stools.  The  fseces  are  stirred  up  with  a  concen- 
trated solution  of  mercuric  chloride;  normal  fseces  are  colored  red;  fseces 
containing  unchanged  bilirubin  become  green.  The  pale  stool  of  the  leuco- 
hydrobilirubin  gives  the  red  reaction.  Absence  of  the  red  or  green  coloring 
is  seen  in  fatty  stools  with  complete  acholia. 

Composition. — From  74  to  84  per  cent,  of  the  fseces  is  water;  16-26 
per  cent,  is  dry  substance.  Of  the  dry  substance  10-20  per  cent,  can  be 
extracted  with  ether,  i.e.,  are  fats.  Over  90  per  cent,  of  fats  taken  in  are 
absorbed. 

Fats. — Qualitative  tests  only  can  be  considered.  The  fats  are  readily 
detected  macroscopically  and  microscopically.  They  are  excreted  as 
neutral  fats,  soaps,  and  fatty  acids.  These  have  been  described.  Crystals 
and  flakes  melt  readily.  Extracting  a  small  mass  of  fseces  with  ether  and 
pouring  the  ether  through  a  piece  of  filter  paper  will,  if  fats  are  in  excess, 
give  the  characteristic  appearance  of  oil  on  the  paper. 


•     ■•-,    ', 

\  ■-'      - 

-  \         ,  ^ 

f, 

/ 

-/         .                            1     -  ■ 

\ 

'•"  ^\~'~*- 

■     ^^-.   \ 

ijC/:::     ■(  :, 

220  MEDICAL  DIAGNOSIS. 

From  2  to  6  per  cent,  of  the  dry  substance  is  carbohydrate,  usually 
dextrin.  Tincture  of  iodine  or  Lugol's  solution  will  stain  unaltered  starch 
blue;  dextrin  remains  red.  There  is  no  reaction  for  sugar.  Fermentation 
is  the  simplest  test  for  excess  of  carbohydrate  or  carbohydrate  residue. 
Schmidt's  fermentation  tube  may  be  employed  or  one  may  note  carefully 
the  presence  of  gas  formation  in  the  freshly  passed  stool. 

Proteids. — More  than  85  per  cent,  of  proteids  taken  into  the  body  are 
absorbed.  The  proteid  residue  in  health  is  partly  from  the  food,  partly 
from  the  disintegration  of  proteids  of  the  body — leucin,  tyrosin,  indol, 
skatol,  mucin,  nuclein.  Albumin  and  globuHns,  and  their  transformative 
products,  albumoses,  peptones,  are  not  found  normally.  Their  presence  in 
the  stools  means  either  insufficient  proteid  digestion  and  absorption,  or  that 
the  '^  postdigestive  putrefaction"  in  the  large  intestine  has  not  had  time  to 
take  place.  The  simple  tests  for  albumin  and  albumose  can  be  applied  after 
dissolving,  mixing  a  small  amount  of  fecal  material  in  water,  and  filtering. 
Any  inflammatory  condition  of  the  lower  bowel  will  jdeld  albumin  in  the 
faeces.  Serous  exudation  higher  up  may  undergo  the  natural  digestive  proc- 
esses. Persistent  intense  diarrhoea,  choleraic  diarrhoea,  can  hurry  materials 
through  before  digestion  of  albumin  or  albumoses  has  progressed,  and  faeces 
from  these  conditions  may  give  albumin  reactions  from  food  taken  or  from 
serous  exudation  into  the  bowel  as  in  typhoid  fever,  cholera,  or  dysentery. 

"Total  nitrogen"  estimations  are  necessary  to  determine  the  relation 
of  proteid  output  and  intake.  As  of  the  fats  and  carbohydrates  one  can 
say  of  the  proteids — for  clinical  purposes  macro-  and  microscopical  exami- 
nations jrield  more  useful  information. 

Digestive  ferments  are  not  found.  The  pigmentary  remains  of  the  bile 
have  been  spoken  of.  Mention  has  been  made  of  the  various  salts  and  crys- 
tals, phosphates,  oxalates,  cholesterin,  etc.,  visible  microscopically,  remains 
of  food  digested,  or  of  digestive  procedure.  Chemical  tests  show  presence  of 
bile  salts,  bile  acids,  leucin,  tyrosin,  xanthin,  carnin,  and  proteid  derivatives. 

The  most  important  chemical  test  for  practical  purposes  is  the  test 
for  blood.  Teichman's  acid-haemin  test  may  be  used,  but  others  are  simpler 
and  more  certain.  They  all  depend  upon  altered  haemoglobin  reactions. 
No  examination  of  faeces  can  be  considered  complete  unless  a  blood  test 
has  been  made;  since  occult  bleeding  may  go  on  indefinitely  with  no  gross 
signs  of  blood  in  the  faeces  and  no  blood-corpuscles  to  be  seen  microscopi- 
cally. All  bleeding  from  the  nose,  gums,  pharynx,  lungs,  and  vagina  must 
be  excluded.  No  meat  can  be  taken  during  the  days  on  which  the  faeces 
are  tested.  It  is  best  to  wait  for  forty-eight  hours  or  to  mark  a  food  period 
by  giving  charcoal,  lycopodium,  or  carmine. 

To  perform  the  test  we  must  first  remove  gross  fat  by  shaking  with 
ether;  otherwise  the  final  ether  extract  may  be  clouded.  This  is  poured 
away  and  the  residue  is  used.  10  c.c.  of  fluid  faeces  or  5  c.c.  of  soHd  faeces, 
broken  up  in  5  c.c.  water,  are  treated  with  3  c.c.  glacial  acetic  acid,  thor- 
oughly mixed  and  shaken.  This  dissolves  red  blood-cells  and  sets  free 
haemoglobin  or  makes  acid  haematin.  After  standing  a  few  minutes  excess 
of  ether,  20-30  c.c,  is  added  and  the  mixture  vigorously  shaken  and  then 
allowed  to  separate.  The  overlying  ether  is  poured  off  and  the  tests  made 
with  it  as  follows: 


UPPER  AIR-PASSAGES  AND  EAR.  221 

Turpentine-Guaiac  Test. — To  a  few  cubic  centimetres  of  the  above 
ethereal  extract  previously  treated  with  a  httle  alcohol  are  added  10  drops 
of  freshly  made  guaiac  tincture  and  30  drops  of  turpentine.  In  the 
presence  of  blood  pigment  a  distinctly  blue  color  occurs.  Sources  of  error 
are  the  recent  eating  of  potatoes  or  other  starchy  food,  iron  as  a  medicine, 
or  the  presence  of  bile,  sahva,  milk,  pus  in  considerable  quantities,  and 
urobihn.    The  reaction  may  fail  in  the  presence  of  minute  traces  of  blood. 

Aloin  Test.  Klinge  and  Shaer. — This  test  is  extremely  deHcate.  Foods 
containing  haemoglobin  and  all  vegetables  and  drugs  must  be  avoided  for 
several  days.  The  diet  period  must  be  determined  by  charcoal  or  lycopo- 
dium,  not  carmine.  From  1  to  1.5  c.c.  of  turpentine  are  superimposed  and 
then  0.5  c.c.  of  freshly  made  3  per  cent,  aloin  solution.  The  reaction  con- 
sists in  the  rapid  development  at  the  hne  of  contact  of  a  bright  rose-red 
color.  ■  In  a  doubtful  case  both  these  tests  may  be  used  and  repeated 
several  times. 

In  ulcerating  carcinoma  ventriculi,  occult  blood  is  continually  present 
in  the  stools;  in  ulcus  ventriculi  there  are  intervals  in  which  no  occult 
blood  can  be  detected;  in  intestinal  tuberculosis  it  is  absent;  in  enteric 
fever  it  may  occur  in  the  absence  of  gross  hemorrhage  or  may  antedate 
the  latter  by  twenty-four  or  forty-eight  hours. 


IV. 

THE  EXAMINATION  OF  THE  UPPER  AIR-PASSAGES  AND 

THE  EAR. 

RHINOSCOPY.     LARYNGOSCOPY.     OTOSCOPY. 

General  Considerations. — Local  affections  of  the  nose,  throat,  or  ears 
may  give  rise  either  to  local  or  constitutional  symptoms,  while  constitu- 
tional diseases  frequently  produce  local  manifestations.  For  this  reason 
a  fair  degree  of  dexterity  in  the  use  of  the  mechanical  means  by  which  we 
are  enabled  to  distinguish  between  the  manifestations  of  local  and  con- 
stitutional diseases,  as  observed  in  these  organs,  is  of  no  less  importance 
to  the  general  clinician  than  to  the  specialist. 

The  instruments  ordinarily  employed  in  a  simple  examination  of  the 
nose,  throat,  larynx,  or  ear  are  a  head  mirror  for  reflection  of  light,  tongue 
depressor,  laryngeal  mirror,  and  nasal  and  aural  specula.  They  require 
no  special  description.  They  are  of  varied  designs,  but  any  instrument  to 
which  the  physician  has  become  accustomed  will  usually  meet  the  require- 
ments of  ordinary  cases  and  most  of  them  are  amply  efficient  in  the  hands 
of  the  skilled  examiner. 

Of  far  greater  importance  than  the  kind  of  instrument  to  be  employed  is 
its  careful  manipulation.  Every  instrument  must  be  carefully  cleansed  both 
before  and  after  using,  alike  for  the  actual  necessity  of  cleanliness  and  the 


222  MEDICAL  DIAGNOSIS. 

reassurance  it  gives  the  patient.  The  speculum  should  be  slightly  warmed 
over  a  spirit  flame  or  gas  burner  before  introduction  into  the  nose  or  ear. 
Either  natural  or  artificial  light,  if  sufficiently  strong,  can  be  con- 
densed and  reflected  by  the  mirror  to  the  point  or  area  to  be  examined,, 
and  the  source  of  the  light  may  be  either  to  the  right  or  left  of  the  patient.. 

The  Examination  of  the  Nose. 

Anterior  Rhinoscopy. — Externally  around  the  margin  of  the  nares 
may  be  noted  excoriations,  usually  produced  by  acrid  secretions,  exces- 
sively acid  or  alkaline,  which  occur  in  the  course  of  the  various  infectious 
diseases,  colds,  nasal  hydrorrhoea,  syphilis,  etc.  True  rhinoscopy  has  to 
do  with  the  examination  of  the  interior  of  the  nose,  for  which  purpose  it 
is  necessary  to  dilate  the  nostrils,  one  at  a  time,  with  a  bivalve  speculum, 
using  care  to  avoid  injury  to  the  mucous  membrane  with  the  points  of 
the  instrument,  or  unnecessarily  annoy  the  patient  by  overdistention. 

Structures  Observed.  —  Under  normal  conditions,  the  patient  sitting 
erect  before  the  operator,  with  the  head  tilted  slightly  backward,  the 
distended  alee  should  present  clearly  to  view  the  lower  turbinates,  the 
middle  and  lower -meati  on  the  outer  walls,  the  area  opposite  to  these  on  the 
septum,  and  the  floor.  This  constitutes  about  the  lower  third  or  respir- 
atory portion  of  the  nares.  The  area  just  within  the  nares  on  the  lower 
anterior  margin  of  the  septum  should  be  especially  examined  as  the  most 
frequent  location  of  the  source  of  hemorrhage,  four-fifths  of  the  cases  of 
spontaneous  epistaxis  originating  in  this  area. 

Tilting  the  patient's  head  backward  brings  into  view  the  upper  or 
olfactory  portion  of  the  nostrils,  the  middle  turbinate  and  superior  meatus, 
rarely  a  small  portion  of  the  superior  turbinate,  the  close  proximity  of  the 
septum  and  outer  wall  preventing  an  exposed  view  of  the  ethmoid  and 
sphenoid  area,  superior  turbinate  and  points  of  entrance  to  the  frontal 
sinus.  It  is  this  space  that  we  frequently  find  bathed  in  pus  in  the  case 
of  purulent  sinusitis,  ethmoiditis,  or  antrum  disease.  As  a  rule,  an  accumu- 
lation of  pus  above  the  middle  turbinate  is  an  indication  of  disease  of  the 
ethmoid  or  frontal  sinus,  while  if  pus  collects  beneath  the  middle  turbinate 
its  source  is  probably  from  the  antrum  of  Highmore.  In  case  the  whole 
naris  is  bathed  in  the  purulent  secretion,  first  cleanse  the  nostril,  then 
have  the  patient  lean  forward  or  turn  the  head  well  toward  the  side 
involved  in  order  to  favor  the  discharge  of  fresh  pus  and  determine  its  origin 
more  clearly.  Nasal  polypi  are  also  most  frequently  found  originating 
in  this  part  of  the  nares,  arising  from  the  marginal  mucosa  of  a  turbinate 
which  has  undergone  mucoid  degeneration,  from  necrotic  tissue  in  the 
ethmoid  cells;  or  less  frequently  from  the  sphenoid  sinus,  which  lies  slightly 
below  and  posterior  to  the  ethmoid  cells.  Beneath  the  middle  turbinate 
is  the  only  natural  opening  into  the  antrum  of  Highmore — the  ostium 
maxillare — which,  however,  in  many  cases  is  so  obscure  as  to  be  found 
with  difficulty  even  by  experienced  rhinologists.  There  are  occasionally 
two  or  more  openings  and  they  may  enter  the  antrum  at  variable  points, 
even  as  high  as  the  floor  of  the  orbit.  The  inferior  meatus  is  important 
for  two  reasons:    first,  it  is  beneath  the  lower  turbinate  that  we  find  the 


UPPER  AIR-PASSAGES  AND  EAR. 


223 


nasal  opening  of  the  lachrymal  duct,  which  may  become  occluded  from 
either  an  acute  or  chronic  enlargement  of  the  turbinate;  second,  because 
of  the  thinness  of  the  bony  wall  dividing  the  nares  from  the  antrum  of 
Highmore,  through  which  a  cannula  may  be  easily  introduced  for  diag- 
nostic purposes  in  suspected  purulent  infection  of  the  sinus. 

If  on  first  looking  into  the  nose  the  view  is  obstructed  by  an  intumes- 
cent  condition  of  the  membrane,  which  is  found  in  nearly  every  local  con- 
gestion, whether  active  or  passive,  th2  difficulty  of  obtaining  a  satisfactory 
view  will  be  greatly  obviated  by  the  introduction  of  a  small  pledget  of 
cotton  dipped  into  a  solution  of  cocaine  and  camphor,  each  two  grains  to 
the  ounce  of  liquid  albolene.  The  objection  to  'the  adrenalin  preparations 
in  examination  is  threefold:  first,  it  frequently  acts  as  an  irritant,  throw- 
ing the  patient  into  a  violent  state  of  sneezing;    second,  by  the  intense 


Rear  of 
Choana        pharynx 


Septum        Choana 


Upper  turbinate  bone 
Promontory  of  tube 

Rosenmiiller's  fossa 

Middle  turbinate  bone 

Opening  of  Eustachian 

tube 

Lower  turbinate  bone 


Upper  turbinate  bone 


Promontory  of  tube 

Rosenmiiller's  fossa 
Middle  turbinate  bone 

Opening  of  Eustachian 

tube 

Lower  turbinate  bone 


Soft  palate 


Uvula 
Fig.  92. — Normal  posterior  nares,  view  obtained  by  repeated  change  of  the  mirror. 


bleaching  of  the  membrane;  and,  thirdly,  because  of  the  aggravated  con- 
gestion which  follows  its  use.  All  the  accessory  cavities  herein  referred 
to  are  in  direct  communication  with  the  nares;  each  sinus  or  cell  is  lined 
by  mucous  membrane,  somewhat  modified  in  character  from  that  in  the 
nasal  chambers,  and  any  inflammatory  process  in  one  cavity  may  cause 
more  or  less  irritation  in  one  or  all  of  the  others. 

Posterior  Rhinoscopy. — To  examine  the  nasopharynx  there  are  needed 
a  head  mirror,  tongue  depressor,  and  rhinoscopic  mirror.  Some  persons 
are  able  to  depress  their  tongues  by  voluntary  muscular  efTort,  in  which 
case  the  depressor  is  not  needed.  There  is  also  a  great  difference  in  the 
ability  of  individuals  to  relax  the  soft  palate  at  will,  thus  allowing  an 
unobstructed  vision  in  the  mirror  of  the  vault  of  the  pharynx  and  the 
posterior  nares.  The  process  of  such  examinations  will  often  require  great 
patience  if  the  pharynx  be  hypersensitive,  since  the  slightest  touch  with 
the  mirror  may  produce  gagging. 

Let  the  patient  sit  comfortably  in  the  chair  and  assure  him  that  there 
will  be  nothing  connected  with  the  examination  to  cause  either  pain  or 


224  MEDICAL  DIAGNOSIS. 

discomfort.  There  is  a  general  tendency  to  hold  the  breath  and  strain  on 
the  pharyngeal  muscles.  To  obviate  these  difficulties  explain  that  it  is 
important  to  allow  the  mouth  to  open  widely  and  easil}^,  without  the 
slightest  tension  of  the  jaw,  leaving  the  tongue  at  rest  in  its  natural  posi- 
tion, and  to  breathe  quietly  and  freely  through  the  mouth.  The  prob- 
abiHty  is  that  after  this  reassurance  the  soft  palate  will  relax  to  its  normal 
position.  A  common  difhculty  consists  in  the  involuntary  retraction  of 
the  soft  palate  tightly  against  the  pharyngeal  wall  as  soon  as  the  mirror 
approaches  the  mouth,  and  its  retention  in  that  position  until  the  mirror 
is  withdrawn.  This  frequently  can  be  obviated  by  having  the  patient  close 
his  eyes.  Should  this  fail,  the  most  satisfactory  recourse  left  is  cocainiza- 
tion  to  a  degree  sufficient  to  relieve  the  hypersensitiveness,  when  with  a 
long  applicator,  bent  at  right  angles,  making  a  hook  about  three-fourths 
of  an  inch  long  on  the  end,  the  soft  palate  may  be  gently  drawn  for- 
ward, and  the  rhinoscope  placed  in  position  to  reflect  the  image  desired. 
It  is  always  better  to  twist  a  small  piece  of  cotton  on  the  retractor, 
which  being  dipped  into  a  bland  oil  will  prevent  injury  to  the  mucous 
membrane. 

Structures  Observed. — With  the  rhinoscope  just  below  and  posterior 
to  the  margin  of  the  soft  palate,  and  with  a  strong  light,  the  angle  of 
reflection  in  the  mirror  may  be  so  directed  by  manipulation  as  to  show  suc- 
cessively all  the  structures  in  the  nasopharynx,  viz.,  the  Eustachian  orifices 
on  the  extreme  outer  margins,  and  just  above  and  slightly  posterior  to 
these  the  fossse  of  Rosenmiiller,  which  are  occasionally  obstructed  b}^ 
adhesive  bands;  in  each  naris  are  seen  the  middle  and  lower  turbinates, 
the  latter  being  indistinct  except  over  its  upper  half;  and  directly  pos- 
terior and  below  the  posterior  margin  of  the  septum  on  the  pharygneal 
wall  is  the  usual  position  of  the  pharyngeal  tonsil  or  adenoids.  Since  this 
lymphoid  structure  under  normal  conditions  undergoes  atrophy  about 
the  age  of  puberty,  when  observed  in  adults,  or  when  sufficiently  large 
in  children  to  interfere  with  nasal  respiration,  it  should  be  regarded  as 
pathologic.  Polypoid  growths  in  the  nasopharynx  originate  usually  from 
mucoid  degeneration  of  the  posterior  margins  of  the  middle  or  superior 
turbinates  or  from  the  posterior  ethmoid  cells;  fibromata,  sufficiently 
large  to  ffil  the  entire  vault,  suspended  by  a  small  pedicle  and  hanging 
low  enough  in  the  oropharj^nx  for  the  lower  margin  to  be  seen  by  direct 
vision,  are  not  infrequent!}^  observed.  Posterior  rhinoscopy  is  seldom 
accomplished  in  children  with  any  degree  of  satisfaction,  in  which  case 
ocular  inspection  must  be  supplanted  by  digital  examination. 

Laryngoscopy. 

For  the  examination  of  the  laryngopharynx,  larynx,  and  trachea 
the  same  instruments  are  required  as  those  used  for  posterior  rhinoscopy, 
and  the  same  precautions  toward  preventing  nervousness  on  the  part  of 
the  patient  during  examination  are  of  even  greater  importance.  The 
tongue  depressor  will  not  be  needed  in  all  cases,  since  in  some  a  better 
view  can  be  obtained  by  grasping  the  tip  of  the  tongue  with  a  towel  or 
handkerchief  and  drawing  it  well  out  and  downward,  using  care  not  to 


UPPER  AIR-PASSAGES  AND  EAR.  225 

cause  pain  underneath  the  tongue  by  too  forceful  traction  over  the  lower 
teeth.  In  still  others  the  patient  may  be  able  voluntarily  to  depress 
the  tongue. 

The  oropharynx  is  examined  by  direct  inspection.  The  appearance 
and  color  of  the  mucous  membrane  of  the  posterior  pharyngeal  wall  vary 
greatly  according  to  the  condition  of  the  gastro-intestinal  tract.  The 
redness  frequently  observed  along  the  anterior  borders  of  the  faucial 
tonsillar  pillars  in  gouty  or  lithajmic  individuals  is  a  sign  of  diagnostic 
importance.  This  may  vary  in  color  from  a  dark  pink  blush  to  a  purplish 
crimson,  and  may  be  regular  in  outline  or  occasionally  present  the  appear- 
ance of  petechial  spots,  particularly  on  the  uvula.  Another  phenomenon 
often  observed  is  indicative  of  either  acute  or  chronic  inflammatory  Eus- 
tachian or  middle-ear  involvement.  It  consists  of  a  prominence  or  bulging 
of  the  postpharyngeal  wall,  evidently  an  inflammatory  infiltrate,  just  back 
of  the  posterior  faucial  pillar  on  the  same  side  as  that  of  the  affected  ear. 

In  the  examination  of  the  laryngopharynx  the  laryngoscope  is  used. 
Observe  the  base  of  the  tongue  carefully  to  detect  the  presence  of  an 
enlarged  lingual  tonsil,  which  gives  rise  to  various  annoying  symptoms, 
most  prominent  of  which  is  the  constant  accumulation  of  mucus  about 
the  glottis  and  the  resulting  pharyngeal  tenesmus.  Occasionally  this 
mass  of  tonsillar  tissue  is  sufficient  to  press  the  epiglottis  downward  and 
thus  interfere  with  the  examination  of  the  larynx  proper. 

Foreign  Bodies.  —  The  most  frequent  locations  of  foreign  bodies, 
such  as  broken  bits  of  toothpicks  or  match-sticks,  fish-bones,  tooth-brush 
bristles,  etc.,  in  the  laryngopharynx  are  the  glosso-epiglottidean  pouches 
at  the  base  of  the  tongue,  or  else  in  the  sinus  pyriformis  which  lies  partially 
posterior  to  and  on  either  side  of  the  glottis.  The  patient's  sensation  of 
locality  of  a  foreign  body  in  such  a  position  is  frequently  misleading;  for 
instance,  a  fish-bone  or  bristle  sticking  in  the  base  of  the  tongue  may 
give  the  sensation  of  being  farther  down  in  the  larynx,  or  perhaps  even 
in  the  nasopharynx. 

Examination.— A  strong,  well  focussed  light  is  essential,  and  whether 
the  patient  be  in  the  sitting  or  recumbent  position,  the  head  must  be  well 
extended  and  free  breathing  through  the  mouth  insisted  upon.  The  auto- 
scope,  an  instrument  devised  some  years  ago  for  the  purpose  of  making 
direct  inspection  of  the  larynx,  is  not  generally  employed  at  the  present 
time.  Proceeding  with  the  usual  method,  the  patient's  tongue  is  depressed, 
or  drawn  outward,  the  laryngoscope  is  carefully  introduced  into  the  upper 
laryngopharynx  in  a  manner  that  will  push  the  uvula  backward  out  of 
range  of  the  reflected  laryngeal  image.  The  best  angle  of  reflection  can 
be  determined  according  to  the  case  in  hand,  the  epiglottis,  owing  to  its 
variability  both  in  point  of  shape  and  position  in  different  individuals, 
being  the  principal  obstacle  to  a  clear  view  of  the  underlying  structures. 
This  difficulty,  however,  can  best  be  obviated  by  the  influence  which  the 
effort  on  the  part  of  the  patient  to  produce  certain  vocal  tones  has  upon 
the  position  of  the  larynx.  Two  vocal  sounds  are  utilized;  first,  the  classic 
"ah,"  during  the  intonation  of  which  the  larynx  is  in  the  most  natiu'al 
relation  to  the  surrounding  structures  at  rest,  except  for  the  fact  that  the 
cords  are  approximated  or  in  the  position  of  phonation.     With  the  parts 

15 


226  MEDICAL  DIAGNOSIS. 

in  this  position  there  will  be  reflected  in  the  laryngoscope  the  edge  of  the 
epiglottis  and  a  narrow  margin  of  its  underlying  surface,  the  arytenoids,. 
and  the  posterior  half  of  each  vocal  cord,  which  appears  in  the  mirror  as 
the  inferior  half. 

The  same  relation  will  still  be  preserved  if  the  patient  now  be 
instructed  simply  to  breathe,  allowing  the  arytenoids  and  hence  the  cords 
to  swing  freely  open.  But  to  obtain  an  image  of  the  junction  of  the  cords 
at  the  anterior  ends,  appearing  superiorly  in  the  mirror,  the  effort  to  pro- 
duce the  vowel  tone  "e"  must  be  made.  "This  will  so  elevate  the  larynx 
and  change  its  position  in  relation  to  the  epiglottis  and  other  structures 
as  to  expose  the  whole  length  of  the  cords  and  the  whole  inferior  surface 
of  the  epiglottis  in  one  view,  and  in  most  cases,  after  holding  the  tone  for 
a  few  seconds,  the  patient  may  breathe  freely  without  the  tongue  falling 
back  to  its  original  position,  A  good  plan  is  to  have  the  patient  hold  the 
note  for  a  moment,  followed  by  free  respiration,  and  repeat  the  process  as 
often  as  required  till  a  satisfactory  view  is  obtained  of  all  the  intralaryn- 
geal  structures.  During  respiration  the  anterior  wall  of  the  trachea  also 
may  be  seen,  in  some  cases  as  far  down  as  the  bifurcation,  though  to  be 
satisfactory  an  examination  of  the  lower  part  of  the  trachea  and  bronchial 
tubes  should  be  made  with  a  bronchoscope.  This  instrument  has  been 
perfected  in  recent  years  to  such  an  extent  as  to  be  of  great  value  in  the 
hands  of  a  skilful  operator  for  the  removal  of  foreign  bodies  or  for  the 
inspection  of  any  diseased  condition  of  the  lining  membrane.  If  during 
the  examination  the  patient  has  an  inclination  to  gag,  free  and  rapid 
respiration  may  overcome  it;  should  the  tendency  persist,  however,  with- 
draw the  mirror  and  allow  the  throat  to  be  at  rest  for  a  short  time;  under 
no  condition  will  anything  be  gained  by  forcing  or  attempting  to  prolong 
an  examination  when  the  patient  coughs,  gags,  or  the  muscles  of  the  throat 
become  fatigued. 

The  larynx  is  subject  to  the  same  inflammatory  changes  which  may  take 
place  in  any  other  mucous  membrane,  and  likewise  to  any  local  infection. 
The  histologic  structure  of  the  submucous  tissue  seems  to  favor  rapid  and 
extensive  oedema  from  local  inflammations,  due  to  traumata,  scalds,  and  the 
inhalation  of  irritant  vapors;  from  infectious  processes  involving  adjacent 
structures,  as  diphtheria,  foUicular  tonsilhtis,  and  tuberculosis;  and  from 
circulatory  disturbances  such  as  may  arise  from  cardiac  or  renal  lesions. 

Chronic  hoarseness  not  amenable  to  treatment,  particularly  in  indi- 
viduals past  forty  years  of  age,  must  be  regarded  as  suspiciously  indica- 
tive of  malignancy  and  be  kept  constantly  under  observation  in  order 
that  should  such  a  condition  exist  it  may  be  detected  at  the  earliest  stage 
possible.  Sluggishness  in  the  movement  of  the  vocal  cord,  or  even  an 
apparent  paralysis  of  the  cord  on  the  affected  side,  has  been  observed 
not  infrequently  in  laryngeal  carcinoma  long  before  any  actual  tumor 
was  visible. 

Otoscopy. 

For  convenience  in  description  the  organ  of  hearing  is  usually  divided 
into  the  external,  middle,  and  internal  ear.  The  last  embraces  that  part 
of  the  petrous  portion  of  the  temporal  bone  in  which  the  terminal  fila- 


DESCRIPTION  OF  PLATE  III. 

1.  Laryngeal  image  during  respiration. 

2.  Laryngeal  image  during  phonation. 

3.  Laryngoscopic  picture  in  a  case  of  paralysis  of  the  right  recurrent  laryngeal  nerve. 

4.  Laryngoscopic  picture  in  a  case  of  bilateral  paralysis  of  the  recurrent  laryngeal  nerves. 

5.  Laryngoscopic  picture  in  a  case  of  paralysis  of  the  interarytenoid  muscle. 

6.  Position  of  the  vocal  cords  in  unilateral  adductor  paralysis. 

7.  Position  of  the  vocal  cords  in  bilateral  adductor  paralysis— during  efforts  at  deep  inspiration. 

8.  Position  of  the  vocal  cords  in  paralysis  of  the  right  internal  tensor. 


PLATE  III. 


UPPER  AIR-PASSAGES  AND  EAR.  227 

ments  of  the  auditory  nerve  are  distributed,  and  therefore  is  also  desig- 
nated as  the  sound-perceiving  apparatus.  The  external  and  middle  ear, 
since  they  serve  the  purpose  of  transmitting  sound  impressions  to  the 
nerve,  are  called  the  sound-conducting  apparatus. 

It  is  of  importance  to  distinguish  between  diseased  conditions  of  the 
sound-perceiving  and  the  sound-conducting  apparatus,  or  between  disturb- 
ance of  hearing  caused  by  nerve  lesions  and  that  dependent  upon  diseased 
structures  of  the  ear  itself.  For  example,  in  any  case  of  deafness  the  first 
thing  to  be  ascertained  is  what  part  of  the  ear,  if  any,  is  at  fault.  Deaf- 
ness, either  partial  or  complete,  may  be  caused  by  obstructions  in  the 
external  auditory  canal,  such  as  foreign  bodies,  impacted  cerumen,  con- 
genital atresia,  exostosis,  furunculosis,  etc.,  and  also  by  hemorrhage  into 
the  semicircular  canals,  or  as  the  effect  of  certain  drugs.  The  condition 
of  the  external  canal  and  the  tympanic  membrane  can  easily  be  determined 
by  direct  ocular  inspection,  a  strong,  well  focussed  light  being  directed 
into  the  canal  through  a  suitable  speculum.  If  the  canal  be  found 
clear,  then  the  difficulty  must  lie  either  in  the  middle  or  the  internal  ear. 
To  distinguish  between  these  the  tuning-fork  test,  devised  by  Weber,  is 
usually  employed. 

External  Auditory  Canal. — The  external  auditory  canal  varies  greatly 
in  size  and  somewhat  in  direction  in  different  individuals.  The  cartilagi- 
nous portion  of  the  canal  is  usually  directed  more  or  less  downward  and 
forward,  so  that  in  order  to  bring  this  part  of  the  canal  and  the  bony  meatus 
into  the  same  axis  for  inspection  of  the  walls  of  the  canal  and  the  drum 
membrane  it  is  necessary  to  draw  the  auricle  gently  upward  and  backward. 
By  holding  the  auricle  in  this  position  with  one  hand  and  manipulating 
the  speculum  with  the  other — a  metallic  conical  speculum  is  the  most 
desirable — every  part  of  the  canal  wall  and  drum  membrane  may  be  clearly 
seen.  Note  the  size  of  the  canal  and  any  acute  inflammatory  swelling  or 
chronic  induration.  The  cartilaginous  portion  of  the  canal  comprises  a 
little  over  one-third  of  the  whole  length  of  the  meatus.  Its  junction  with 
the  bony  meatus  is  the  most  frequent  site  of  furunculosis.  In  young  chil- 
dren the  cartilaginous  meatus  comprises  about  two-thirds  of  the  whole 
extent  of  the  canal.  When  a  furuncle  is  of  deep  origin  pus  may  burrow 
beneath  the  periosteum  inward  toward  the  tympanic  cavity,  occluding 
the  osseous  meatus  entirely  and  giving  rise  to  most  excruciating  pain.  The 
pain  within  the  ear  and  swelling  extending  even  back  of  the  auricle  may 
be  confused  with  acute  mastoiditis.  In  furunculosis  the  most  acute  pain 
is  apt  to  be  elicited  by  pressing  upon  the  tragus,  or,  if  there  be  postauricular 
tenderness,  it  will  likely  be  superficial;  in  mastoiditis,  however,  the  pain 
may  be  slight  superficially  and  intensified  by  deep  pressure  over  the  mas- 
toid, and  pain  is  not  apt  to  be  elicited  on  pressure  over  the  tragus. 

When  the  cartilaginous  portion  of  the  canal  is  occluded  by  swelling, 
gently  insert  a  tightly  rolled  pledget  of  cotton  dipped  in  a  solution  com- 
posed of  camphor  and  carbolic  acid,  equal  parts,  and  allow  it  to  remain  a 
few  minutes.  The  swelling  is  thus  sufficiently  reduced  to  alloAV  the  intro- 
duction of  a  small  speculum  for  the  examination  of  the  deeper  canal  and 
tympanic  membrane.  This  solution  also  produces  partial  anaesthesia  of 
the  membrane,  thus  allowing  a  more  thorough  examination. 


228  MEDICAL  DIAGNOSIS. 

The  tympanic  membrane  separating  the  external  canal  from  the 
tympanum,  irregularly  oval  in  shape  and  slightly  concave  in  its  normal 
state,  is  affected  to  some  degree  by  every  inflammatory  disease  of  the  mid- 
dle ear,  both  acute  and  chronic,  and  should  therefore  receive  most  careful 
attention  in  every  aural  examination.  A  strong,  well  focussed  light  is  a 
necessity  and  the  largest  speculum  which  the  canal  will  admit  should  be 
used.  The  external  layer  of  the  drum  membrane  is  modified  skin,  clear 
and  almost  translucent  in  its  normal  condition,  and  through  it  can  be  seen 
the  impression  of  the  malleus  with  which  it  lies  in  direct  contact.  Acute 
inflammations  of  the  middle  ear  produce  a  pink  or  reddish  hue  along  the 
margins  of  the  malleus  and  in  some  cases  over  the  entire  membrane. 

Exudates,  serous  or  purulent,  in  the  tympanic  cavity,  even  though 
small  in  quantity,  produce  bulging  of  the  membrane  and  frequently  ter- 
minate in  spontaneous  rupture  into  the  external  canal.  In  acute  and 
chronic  inflammations  causing  occlusion  of  the  Eustachian  tube  the  tym- 
panic membrane  will  be  found  retracted.  Retraction  may  also  be  brought 
about  by  adhesions  within  the  tympanic  cavity  following  marked  inflam- 
matory involvement.  In  a  case  of  retracted  membrane  we  can  ascertain 
whether  the  tube  is  patulous  by  one  of  the  usual  methods  of  inflation, 
Valsalva's  consists  of  a  vigorous  expiratory  effort  while  the  nose  and 
mouth  are  kept  closed.  Politzer  inflates  the  tympanum  through  one  nos- 
tril by  compression  of  a  rubber  air-bag  while  the  patient  is  in  the  act  of 
swallowing.  The  opposite  nostril  and  the  mouth  are  closed.  Eustachian 
catheterization  is  the  most  satisfactory  method  in  difficult  cases.  With 
Siegel's  otoscope  the  air  within  the  external  auditory  canal  can  be 
exhausted  and  adhesions  involving  the  tympanic  membrane  observed. 
Aural  polypi  originate  most  frequently  within  the  middle  ear  from  gran- 
ular or  necrotic  tissue  and  protrude  into  the  external  canal  through  per- 
forations in  the  tympanic  membrane,  though  they  occasionally  may  be 
found  in  any  part  of  the  canal,  particularly  at  the  cartilaginous  and  osseous 
junction.  Exostoses  occur  in  any  portion  of  the  osseous  canal,  particularly 
from  the  posterior  wall  and  from  the  osseous  and  cartilaginous  junction. 
In  chronic  non-suppurative  processes  involving  the  middle  ear,  the  drum 
membrane  becomes  opaque  and  thickened,  and  usually  distorted  in  shape. 
In  cases  of  otosclerosis  white  chalky  spots  are  observed  in  the  membrane 
which  may  otherwise  appear  normal.  A  sign  of  diagnostic  importance 
in  mastoiditis  complicating  chronic  suppurations  of  the  middle  ear  is  an 
infiltration  of  the  membrane  covering  the  superior  posterior  osseous  wall 
of  the  external  auditory  canal,  presenting  the  appearance  of  a  circum- 
scribed drooping  or  bulging. 

Pharynx  and  Eustachian  Tube.  —  No  examination  of  the  ear  can  be 
considered  complete  without  a  careful  inspection  of  the  nasopharynx  at 
the  entrance  of  the  Eustachian  tube  slightly  below  and  anterior  to  the  fossa 
of  Rosenmiiller.  The  technic  of  this  procedure  is  described  under  posterior 
rhinoscopy.  Catheterization  of  the  tube  for  diagnostic  purposes  can  be 
accomplished  either  through  the  nose  or  by  way  of  the  oropharynx. 


EXAMINATION  OF  THE  BLOOD.  229 

V. 
THE  EXAMINATION   OF  THE   BLOOD. 

General  Considerations. —  Information  derived  from  blood  exami- 
nations, while  not  essential  in  the  establishment  of  a  diagnosis  in  most 
instances,  is  frequently  a  useful  aid.  Negative  blood  reports  are  often 
important  in  diagnosis,  as  in  the  exclusion  of  malaria  from  a  group  of  dis- 
eases which  have  similar  clinical  features,  such  as  malignant  endocarditis, 
septicaemia,  and  certain  types  of  tuberculosis.  Diseases  associated  with 
marked  splenic  or  glandular  enlargement  present  so  close  a  resemblance 
to  leukaemia  that  only  a  study  of  the  blood  can  exclude  the  latter 
condition.  Many  blood  examinations  elicit  results  which  assist  in  arriv- 
ing at  or  completing  a  diagnosis.  Evidence  of  a  pathognomonic  char- 
acter gained  from  haematological  studies  is  available  in  only  a  limited 
number  of  diseases,  notably  in  myelogenous  leukaemia,  malaria,  relapsing 
fever,  trypanosomiasis,  and  filariasis.  The  condition  of  the  blood  as  to 
haemoglobin  value,  the  number  of  erythrocytes  and  leucocytes,  may  serve 
as  an  index  of  body  nutrition.  Blood  counts  often  yield  information 
which  bears  upon  prognosis, — e.g.,  in  chlorosis  a  steady  haemoglobin 
rise  is  an  evidence  of  favorable  progress  of  the  patient,  while  an  erythro- 
cytic gain  in  progressive  pernicious  anaemia  or  leucocytic  decrease  in 
leukaemia  likewise  points  to  improvement.  Counts  of  the  white  corpuscles 
also  aid  in  establishing  the  leucocytic  standard  of  the  patient.  The  opsonic 
index  and  the  agglutination  phenomenon  are  recognized  adjuncts  in  the 
field  of  diagnosis. 

Methods  of   Blood   Examination. 

Obtaining  Blood.  —  For  most  clinical  examinations  a  few  drops  of 
blood,  obtained  from  a  puncture  in  the  lobe  of  the  ear  or  the  finger-tip, 
will  suffice.  The  lobe  of  the  ear  is  sometimes  selected  for  making  the 
puncture  on  account  of  its  lessened  sensibility  and  because  the  operation 
can  be  performed  without  the  patient  seeing  it,  but  the  finger-tip  is  generally 
chosen  as  this  site  is  more  convenient  for  the  examiner.  The  puncture 
should  be  made  with  a  lancet-shaped  or  triangular  surgical  needle,  an 
instrument  especially  devised  for  this  purpose,  or  a  steel  pen  with  one  of 
the  nibs  broken  off.  The  part  selected  should  be  cleansed  with  alcohol  or 
with  soap  and  water  followed  by  alcohol,  and  dried  with  a  towel  or  hand- 
kerchief. If  not  warm,  the  skin  is  warmed  by  gentle  friction,  but  forcible 
rubbing  should  be  avoided,  since  it  excites  active  hyperemia.  If  the 
individual  is  a  bleeder,  the  precaution  of  making  a  superficial  puncture 
and  of  having  measures  at  hand  to  control  hemorrhage  should  be  observed. 
It  is  obvious  that  areas  of  cedema  and  of  inflammation  must  be  avoided. 
If  the  former  be  present  about  the  hands  or  ear,  an  area  free  or  nearly  so 
of  cedema  is  chosen.  The  puncture  is  made  with  a  quick  thrust  of  the 
instrument,  which  has  previously  been  cleansed  with  alcohol  or  passed 
through  a  flame.     The  first  drop  or  two  of  blood  should  be  wiped  away. 


230  MEDICAL  DIAGNOSIS. 

Forcible  squeezing  of  the  tissues  in  the  immediate  vicinity  of  the  wound 
must  be  avoided,  as  this  may  alter  the  composition  of  the  blood  by  the 
addition  of  lymph  fluids.  As  the  blood  flows  from  the  wound,  its  gross 
appearance  as  to  color  and  fluidity  is  noted. 

Preparation  of  Fresh  Blood  for  Immediate  Examination.  —  A 
cover-glass  is  applied  to  a  droplet  of  blood  and  then  placed  upon  a  clean 
slide.  The  blood  usually  spreads  into  a  thin  layer.  Warming  the  slide 
by  friction  with  a  piece  of  gauze,  a  handkerchief,  or  tissue  paper  before 
applying  the  cover-glass  facilitates  spreading.  In  a  well-prepared  prep- 
aration the  corpuscles  are  arranged  in  a  single  layer  separated  from  each 
other  over  an  area  sufficiently  large  for  the  desired  study.  If  it  be  necessary 
to  delay  the  examination,  drying  of  the  specimen  can  be  prevented  by 
ringing  the  margins  of  the  cover-glass  with  vaseline  or  cedar  oil. 

Preparation  of  Blood  for  Staining. — Cover-glasses  which  have  clean 
polished  surfaces  are  placed  upon  a  sheet  of  paper,  or  preferably  upon 
a  folded  towel,  from  which  they  can  be  picked  up  easily.  A  cover-glass, 
held  with  the  fingers,  or  with  forceps,  is  applied  to  the  summit  of  the 
droplet  of  blood,  being  careful  to  avoid  touching  the  skin,  and  allowed  to 
fall  upon  another  cover.  As  soon  as  the  blood  has  ceased  spreading, 
the  covers  are  slid  apart.  In  performing  this  operation,  care  should  be 
exercised  not  to  lift  the  glasses  apart:  the  shding  motion  must  be  performed 
rapidly,  avoiding  a  jerky  uneven  stroke.  The  smear  may  be  made  upon 
a  slide  by  placing  a  drop  of  blood  upon  it  and  spreading  with  another 
slide  or  with  a  glass  rod  especially  designed  for  this  purpose. 

Methods  of  Fixation. — Heat  Fixation. — The  covers  are  placed  in 
an  oven,  the  ordinary  dry-heat  sterilizer  being  convenient  for  this  purpose, 
and  heated  gradually  until  the  temperature  reaches  to  120°  C,  or  up  to 
155"^  C.  and  subjected  to  this  temperature  for  from  ten  to  twenty  minutes. 
A  convenient  plan  for  fixing  the  specimens  with  heat  consists  in  placing 
the  spreads  upon  a  heated  copper  plate.  The  plate,  about  20  centimetres 
in  length,  8  centimetres  in  width,  and  from  ^  to  1  centimetre  in  thickness, 
supported  by  a  suitable  stand,  is  heated  at  one  end  with  the  flame  from  a 
Bunsen  burner  or  an  alcohol  lamp.  When  the  plate  is  thoroughly  heated, 
the  covers  are  placed  upon  it  at  a  point  where  the  temperature  is  sufficient 
to  boil  water  (which  is  previously  determined  by  dropping  water  upon 
its  surface,  beginning  at  the  end  farthest  away  from  the  flame)  and  exposed 
to  this  heat  for  about  30  minutes.  A  method  less  suitable  than  the  ones 
mentioned  consists  in  passing  the  film  rapidly  thi'ough  a  Bunsen  flame 
forty  or  fifty  times. 

Fixation  by  Wet  Methods. — Fixation  may  be  obtained  by  sub- 
merging films  in  a  mixture  of  equal  parts  of  absolute  alcohol  and  ether 
for  20  or  30  minutes,  or  in  absolute  alcohol  for  five  minutes.  The 
Futcher-Lazaer  method  subjects  the  films  to  .25  per  cent,  formalin  in 
95  per  cent,  alcohol  for  one  minute;  they  are  then  rinsed  in  water  and 
dried  with  filter-paper. 

Blood  Staining. — Many  methods  for  staining  blood  are  available. 
To  Ehrlich  belongs  the  credit  of  devising  a  mixture  by  which  all  known 
varieties  of  blood-cells  except  those  which  contain  basophilic  granules 
are    completely   colored.      At    the    present   time    certain   panoptic    fluids 


EXAMINATION  OF  THE  BLOOD.  231 

containing    eosin-methylene-blue    compounds    are    employed    extensively 
in  routine  work,   having  largely  supplanted  Ehrlich's  triple  stain. 

Ehrlich's  triple  stain  is  prepared  by  mixing  saturated  aqueous  solu- 
tions of  acid  fuchsin  of  orange  G.  and  of  methyl  green  00  with  glycerin,  ethyl 
alcohol,  and  water.     The  following  formula  is  recommended  b}"-  Emerson: 

Acid  fuchsin  solution 6-  7  c.c. 

Orange  G.  solution 13-14  c.c. 

Distilled   water 15  c.c. 

Absolute  alcohol 15  c.c. 

Add  drop  by  drop,  shaking  after  each  addition: 

Methyl  green  00  solution 12.5  c.c. 

Then  add: 

Absolute  alcohol 10  c.c. 

Glycerin 10  c.c. 

Allow  the  mixture  to  stand  for  twenty-four  hours,  and  if,  as  is  some- 
times the  case,  a  precipitate  is  present,  care  should  be  exercised  not  to 
disturb  it  when  removing  some  of  the  stain.  The  combination  of  dyes 
in  this  mixture  contains  a  neutral  staining  ingredient  in  addition  to  its 
acid  and  basic  principles. 

Staining  Technic. — The  stain  is  applied  to  the  blood-film  previously 
fixed  by  heat,  for  five  minutes,  after  which  the  excess  of  stain  is  drained 
off  and  the  cover  washed  with  water,  dried,  and  mounted  in  xylol  balsam 
or  cedar  oil.  Normal  erythrocytes  are  colored  orange,  eosinophilic  granules 
dull  red,  neutrophilic  granules  violet  or  lilac,  nuclear  structures  various 
shades  of  green,  blue,  or  black,  malarial  parasites  and  bacteria  green  or 
blue,  W'hile  basophilic  granules  are  unstained. 

Jenner's  stain  is  prepared  as  follows:  Mix  equal  parts  of  a  1  per 
cent,  aqueous  methylene-blue  solution  with  a  1.25  per  cent,  aqueous  eosin 
(water  soluble)  solution.  After  shaking  thoroughly,  the  solution  is  allowed 
to  stand  for  twenty-four  hours  and  then  filtered.  The  precipitate  is  dried. 
One  part  of  precipitate  is  dissolved  in  two  hundred  parts  of  methyl  alcohol. 
Films  are  treated  with  this  solution  without  previous  fixation  for  from 
three  to  five  minutes,  washed  with  water,  dried,  and  mounted  in  xylol 
balsam  or  cedar  oil.  The  following  tinctorial  reaction  is  secured:  Normal 
er^'throcytes  stain  terra-cotta;  nuclei,  various  shades  of  blue  or  green; 
basophilic  granules,  dark  blue;  neutrophilic  granules,  pink;  eosinophilic 
granules,  bright  red;  the  cytoplasm  of  lymphocytes  and  malarial  para- 
sites, a  deep  blue.  A  deposit  of  dark  granules  upon  the  film  which  is 
often  observed  is  an  objectionable  feature  and  interferes  with  the  useful- 
ness of  this  method. 

Leishman's  stain,  an  improvement  on  Jenner's,  is  based  on  the 
Romanowsky  method.  It  is  prepared  as  follows:  (1)  A  one  per  cent, 
aqueous  solution  of  methylene  blue  (Gruber's  medicinal),  containing  5 
per  cent,  of  sodium  carbonate,  is  heated  at  65°  C.  for  twelve  hours  and  then 
allowed  to  stand  for  ten  days.  (2)  An  equal  volume  of  a  1  per  cent,  solution 
of  eosin  in  distilled  water  is  added  to  the  methylene-blue  solution  in  an 


232  MEDICAL  DIAGNOSIS. 

open  vessel  and  the  mixture  stirred  from  time  to  time.  After  twelve  hours 
the  resultant  sediment  is  collected  on  filter-paper  and  washed  with  water 
until  the  washings  are  almost  colorless.  One  and  a  half  parts  of  dried 
powdered  precipitate  are  added  to  one  hundred  parts  of  pure  methyl 
alcohol.  Previous  fixation  is  not  required  with  Leishman's  reagent,  since 
it  possesses  the  double  property  of  fixing  and  of  staining.  Three  or  four 
drops  of  this  stain  are  placed  upon  the  blood-film  and  allowed  to  act  for 
thirty  seconds,  when  double  the  amount  of  water  (six  or  eight  drops)  is 
poured  upon  the  cover  and  mixed  with  the  stain.  After  five  minutes  the 
spread  is  washed  gently  with  water  and  a  few  drops  allowed  to  remain 
upon  the  specimen  for  about  a  minute.  The  smear  is  now  dried,  first  be- 
tween filter-paper  and  then  in  the  air,  and  mounted  in  balsam  or  cedar 
oil.  The  nuclei  of  leucocytes  and  of  erythroblasts,  and  blood-platelets  are 
stained  various  shades  of  purple,  the  protoplasm  of  lymphocytes  and  certain 
polychromatophilic  erythrocytes  various  tints  of  blue,  basophilic  granules 
dark  violet  or  royal  purple,  normal  erythrocytes  and  eosinophile  granules 
pink,  and  neutrophile  granules  a  dull  red.  Malarial  parasites  and  try- 
panosomes  are  distinctly  stained  by  this  method.  Wright's  stain,  which 
is  also  a  modification  of  the  Romanowsky  method,  contains  an  eosin-meth- 
ylene-blue  combination  held  in  solution  by  methyl  alcohol.  Wright's 
method  is  extensively  employed  in  this  country.  Hasting's  mixture, 
another  eosin-methylene-blue  stain,  is  much  used  by  some  workers.  For 
general  routine  work  Leishman's  stain  can  be  highly  recommended. 

Double  Staining.  —  The  films,  after  suitable  fixation  obtained  by 
immersion  in  absolute  alcohol,  alcohol  and  ether,  or  by  heating  as  pre- 
viously described,  are  treated  first  with  an  acid  stain  followed  by  a  basic 
dye,  rinsed  in  water,  dried,  and  mounted.  A  staining  fluid  containing 
acid  and  basic  coloring  principles  may  be  employed  for  this  purpose. 
Most  of  the  methods  of  double  staining  are  not  suitable  for  differentiating 
all  forms  of  blood-cells,  as  certain  histological  elements  remain  unstained. 
Neutrophilic  granules  are  as  a  rule  not  colored,  and  therefore  neutrophilic 
myelocytes  cannot  be  distinguished  from  large  mononuclear  leucocytes. 
If  only  the  nuclear  structures  are  to  be  studied,  double  staining  is  of  service, 
but  is  nevertheless  inferior  to  Leishman's  stain  and  similar  methods. 

Plehn's  stain  has  the  following  formula: 

Saturated  aqueous  solution  of  methylene  blue 60  c.c. 

One-half  per  cent,  eosin  solution  (in  75  per  cent,  alcohol) 20  c.c. 

Distilled  water 40  c.c. 

Twenty  per  cent,  solution  of  caustic  potash 5-1  c.c. 

Specimens  are  fixed  in  absolute  alcohol  for  from  three  to  five  minutes, 
stained  with  Plehn's  solution,  washed  in  water,  dried,  and  mounted.  This 
mixture  stains  malarial  parasites  blue  and  eosinophilic  granules  red. 

Eosin  and  Methylene  Blue. — A  convenient  plan  consists  in  treating 
the  fixed  smear  with  a  solution  consisting  of  eosin  ,5  part  in  70  per  cent, 
alcohol  100  parts,  for  a  minute  or  two;  wash  the  cover  in  water,  and  then 
counterstain  with  a  half-saturated  solution  of  methylene  blue  or  Delafield's 
hsematoxylin  solution  for  a  half  to  one  minute.  The  specimen  is  then 
rinsed  in  water,  dried  between  bibulous  paper  or  in  the  air,  and  mounted. 


EXAMINATION  OF  THE  BLOOD.  233 

Chenzinsky  recommends  a  stain  composed  of  40  cubic  centimetres 
of  satm-ated  methylene  blue,  20  cubic  centimetres  of  a  .5  per  cent,  eosin 
solution  in  70  per  cent,  alcohol  and  40  cubic  centimetres  of  distilled  water. 
Films  fixed  in  absolute  alcohol  are  subjected  to  Chenzinsky's  solution  for 
from  three  to  six  hours,  the  staining  being  done  at  37°  C.  in  an  incubator. 
Ehrlich  suggested  a  mixture  consisting  of  hematoxylin  2  grammes,  eosin 
0.5  gramme,  absolute  alcohol  100  grammes,  distilled  water  100  grammes, 
glycerin  100  grammes,  acetic  acid  10  grammes,  and  an  excess  of  alum.  The 
stain  is  not  ready  for  use  until  several  weeks  have  elapsed,  since  this  time  is 
required  for  the  ripening  of  the  stain. 

Basophilic  granules  may  be  demonstrated  by  a  stain  recommended 
by  Ehrlich  which  has  the  following  formula: 

Saturated  alcoholic  solution  of  dahlia 50  c.c. 

Acetic  acid 10-20  c.c. 

Distilled  water 100  c.c. 

Differential  Counting.  —  This  method  consists  of  determining  the 
relative  number  of  the  different  forms  of  blood-cells,  generally  expressed 
in  percentage  figures  and  sonretimes  as  the  number  per  cubic  milhmetre. 
The  leucocyte  differential  estimation  is  important  in  the  diagnosis  of  a 
number  of  conditions.  An  approximate  differential  count  can  be  made  by 
an  examination  of  fresh,  unstained  blood  by  the  experienced  worker, 
but  for  accurate  determinations  stained  films  are  essential.  A  mechanical 
stage  is  necessary  for  this  method  of  counting. 

Technic. — The  specimen  is  brought  into  focus,  and  the  shde  is  shifted 
with  the  mechanical  stage  so  as  to  bring  successive  fields  into  view,  being 
careful  not  to  pass  over  any  portion  more  than  once.  The  different  forms 
of  leucocytes  are  noted  and  their  number  recorded  until  at  least  five  hun- 
dred cells  have  been  studied.  From  these  figures  the  relative  percentages 
are  calculated.  When  nucleated  erythrocytes  are  encountered,  their  num- 
ber should  also  be  noted,  and  the  total  number  of  these  cells  per  cubic 
millimetre  can  be  determined  by  the  following  formula: 

Number  of  leucocytes  per  cu.  mm.  X  number  of  nucleated 

red  cells  counted  in  the  stained  film Number  of  nucleated  erythro- 

Number  of  leucocytes  counted  in  the  stained  film  ^ytes  per  cubic  millimetre. 

It  is  sometimes  important  to  estimate  separately  the  different  varieties 
of  abnormal  red  cells,  especially  the  varieties  of  nucleated  cells. 

Enumeration  of  the  Erythrocytes,  Leucocytes,  and  BIood=pIatelets. 

— For  clinical  purposes,  the  red  cells  are  counted  in  a  small  amount  of 
blood  of  known  quantity,  from  which  an  estimate  of  the  number  per  cubic 
millimetre  is  made,  this  figure  being  the  standard  upon  which  the  variations 
in  health  and  disease  are  based.  A  number  of  methods  are  available  for 
this  purpose.  The  one  recommended  by  Thoma  is  generally  selected,  as 
it  gives  fairly  accurate  results. 

The  Thoma=Zeiss  Haemocytometer.  —  This  apparatus  consists  of  two 
graduated  pipettes  (the  i-ed  and  white  counters)  for  measuring,  diluting,  and 
mixing  the  blood,  and  a  glass  chamber  in  which  the  corpuscles  are  counted. 


234 


MEDICAL  DIAGNOSIS. 


The  erythrocytometer  consists  of  a  graduated  capillary  tube,  upon  which 
the  figures  .5  and  1  appear.  The  tube  expands  into  a  bulb,  above 
which  the   figure  101  is  inscribed.     A  rubber   tube  with  a  mouth-piece 

attached  is  fastened  to  the  short  end  of  the 
pipette.  Filling  the  pipette  with  blood  to  the 
point  marked  .5  and  then  drawing  a  diluting 
solution  into  it  until  the  fluid  reaches  to  the 
point  marked  101,  insures  a  blood  dilution  of 
1 :200,  while  a  dilution  of  1 :  100  is  obtained  when 
the  pipette  is  filled  to  the  point  marked  1,  and 
then  with  a  diluent  to  the  mark  101.  The  white 
pipette,  or    leucocytometer,  is   similar  in   con- 

^,y;.l,.jirr.T;::7.S   tSA. ,„ 


3^ 


c  '6 


0  lOOmm. 

I 
400  qmm. 


Fig.  93. —  I,  leucocy- 
tometer ;  II,  erythrocy- 
tometer of  Thoma  -  Zeiss 
haemocytometer. 


B 

Fig.  94.- — Counting  chamber  of  the  Thoma-Zeiss 
haemocytometer.  A,  profile  view;  B,  face  view;  a, 
wall  of  cell ;  6,  central  disk  ;  c,  groove  about  disk ; 
d,  ruled  surface. 


struction  to  the  red  pipette,  but  differs  in  that  the  capillary  bore  is  larger 
and  the  bulb  smaller  so  that  dilutions  of  1 :  20  and  1 :  10  may  be  secured. 


A  B 

Fig.  95. — A,  Zappert  ruling  ;  B,  Turk's  ruling. — Emerson. 

The  counting  chamber  consists  of  a  heavy  glass  slide  upon  which 
is  cemented  a  glass  plate  having  a  circular  opening;  a  disk  is  cemented 
to  the  slide  so  that  it  occupies  a  central  position  in  the  circular  open- 


EXAMINATION  OF  THE  BLOOD.  235 

ing  of  the  plate.  The  disk  is  shghtly  thinner  (by  one-tenth  of  a  mm.) 
than  the  plate  which  surrounds  it.  When  the  cover-glass,  a  part  of 
this  instrument,  is  placed  upon  the  plate,  the  distance  between  the  disk  and 
the  cover  is  one-tenth  mm.  The  surface  of  the  disk  is  ruled  by  vertical  and 
horizontal  lines  one-twentieth  of  a  mm.  apart.  These  lines  form  four  hun- 
dred squares,  the  dimensions  of  each  being  one-twentieth  by  one-twentieth 
mm.  Groups  of  16  squares  are  indicated  by  a  double  ruling.  The  space 
overlying  each  square  between  the  surface  of  the  disk  and  the  cover-glass 
measures  twit  cu.  mm.  (-gV  mm.  X  2V  mm.  X  r(5"  =  Tir(ro"  cubic  millimetre). 
Zappert's  modified  ruling  of  the  Thoma-Zeiss  counting  chamber  divides 
the  surface  into  eight  large  squares,  immediately  surrounding  the  400 
small  squares;  each  large  square  is  equal  to  the  surface  ruling  of  the  400 
central  squares.  The  total  ruling  represents  an  area  of  3600  small  squares. 
Technic  of  Counting  the  Erythrocytes.  —  Special  fluids  are 
employed  for  diluting  the  blood.  Toisson's  solution  stains  nuclei  a  pale 
blue,  therefore  rendering  differentiation  between  non-nucleated  erythro- 
cytes and  white  corpuscles  easy.    Its  composition  is  as  follows: 

Methyl  violet,  5B 0.025  part 

Sodium  chloride 1.0      part 

Sodium  sulphate 8.0      parts 

Neutral  glycerin 30.0      parts 

Distilled  water 160.0      parts 

Hay  em's  solution: 

Mercuric  chloride 0.25  part 

Sodium  chloride 0.5  part 

Sodium  sulphate 2.5  parts 

Distilled  water 100.0  parts 

Other  diluting  fluids  recommended  for  clinical  work  are  a  2.5  per 
cent,  aqueous  solution  of  potassium  bichromate,  a  .5  per  cent,  aqueous 
solution  of  sodium  sulphate,  and  a  .7  per  cent,  aqueous  solution  of  sodium 
chloride.     These  solutions  should  be  filtered  before  using. 

The  blood  obtained  in  the  usual  manner  is  drawn  into  the  erythro- 
cytometer  to  the  point  .5,  unless  decided  oligocythemia  is  suspected, 
when  it  is  desirable  to  fill  to  the  mark  1.  after  which  the  tip  of  the  pipette 
is  wiped.  Toisson's  or  some  other  diluting  solution  is  drawn  into  the 
pipette  until  the  fluid  reaches  to  the  point  101.  The  pipette  should  be 
rotated  gently,  as  the  diluting  fluid  enters  the  bulb,  in  order  to  secure  a 
mixture.  After  filhng  the  pipette,  the  thumb  and  finger  are  immediately 
placed  over  its  ends  and  the  instrument  shaken  for  about  a  half  minute, 
in  order  to  obtain  a  thorough  mixture.  The  unmixed  fluid  in  the  capil- 
lary portion  is  then  blown  out.  The  counting  chamber  is  now  placed  upon 
a  perfectly  level  surface  and  a  droplet  of  the  mixture  is  deposited  in  the 
central  portion  of  the  ruled  disk.  The  pipette  should  be  shaken  just  before 
adjusting  the  diluted  blood,  and  the  fluid  in  the  capillary  portion  should 
always  be  expelled  after  mixing  in  this  manner,  since  corpuscles  in  the 
capillary  tube  may  gravitate  on  standing,  thus  creating  an  uneven  mixture. 
The  cover-glass  is  then  quickly  adjusted  in  its  position.  If  the  fluid  flows 
into  the  depression  surrounding  the  disk,  the  operation  must  be  repeated. 
After  the  corpuscles  have  settled,  the  counting  chamber  is  placed  upon 


236 


MEDICAL  DIAGNOSIS. 


the  stage  of  the  microscope  and  a  field  of  16  squares  is  brought  into  focus. 
In  general  routine  work,  the  calculation  of  determining  the  number  of 
erythrocytes  per  cubic  millimetre  is  usually  based  on  the  number  of  cells 
found  within  64  squares,  provided  a  uniform  distribution  of  the  cells 
exists.  The  following  plan  may  be  adopted  in  counting  the  corpuscles: 
The  cells  within  the  upper  left-hand  corner  square  of  a  group  of  16  squares 

are  first  counted,  then  the  cells  in 
each  of  the  remaining  three  squares 
in  that  Hne,  going  from  left  to 
right,  after  which  the  corpuscles 
in  the  next  row  of  squares  are 
enumerated,  proceeding  from  right 
to  left,  next  those  in  the  third 
row  and  finally  in  the  last  line  of 
squares,  as  shown  in  the  diagram 
(Fig.  96).  The  counting  chamber 
is  now  moved,  so  as  to  bring  into 
focus  another  area  of  16  squares, 
and  the  number  of  cells  in  this 
group  is  estimated.  This  process  is 
repeated  until  the  desired  number 
of  squares  (not  less  than  64)  has 
been  covered.  In  order  to  avoid 
confusion  in  counting,  the  cor- 
puscles which  touch  the  right  and 
lower  lines  are  included  in  the  count  of  the  square  in  question.  The 
formula  for  calculating   the  number   per  cubic   millimetre  is  as  follows: 


A 

B 

c 

J 

^ 

^ 

-^ 

J 

Fig.  96. — Scheme  for  counting  cells  overlying  ruled 
surface. 


:  Number  of  cells  per  cubic  mm. 


Number  of  cells  counted  X  4000  X  number  of  dilutions 
Number  of  squares 

The  greater  the  number  of  cells  counted,  especially  with  low  dilu- 
tions, assuming  that  the  mixture  is  thorough,  the  more  accurate  will  be 
the  results. 

Technic  of  Counting  the  Leucocytes. — In  determining  the  number 
of  leucocytes,  the  red  pipette  may  be  used,  but  more  accurate  results 
are  obtained  with  the  white  pipette,  as  lower  dilutions  are  secured.  A 
\  ov  \  per  cent,  aqueous  solution  of  acetic  acid  is  employed  when  using 
the  white  counter  in  order  to  dissolve  the  red  cells.  Except  in  the  case  of 
leukagmic  blood,  a  dilution  of  1 :  20  or  1 :  10  is  most  convenient  for  the  majority 
of  leucocytic  counts.  When  the  number  of  white  cells  is  estimated  with  the 
red  counter,  with  a  1:100  or  1:200  dilution,  Toisson's  solution  is  very 
useful,  since  with  it  the  leucocytes  are  tinted  blue  and  therefore  readily 
distinguished  from  erythrocytes,  which  have  a  yellowish  or  greenish  color. 
With  Zappert's  modified  ruling  the  cells  overlying  a  larger  area  can  be 
counted.  The  formula  for  estimating  the  leucocytes  per  cubic  millimetre 
is  the  same  as  that  used  for  determining  the  number  of  erj'throcytes. 
In  routine  clinical  work  the  corpuscles  overlying  the  entire  ruled  area  of 
at  least  400  squares  should  be  counted  when  employing  dilutions  of  one 
in  ten  or  twenty. 


EXAMINATION  OF  THE  BLOOD.  237 

Cleansing  the  Instrument. — After  removing  the  fluid  from  the  pipette, 
it  is  rinsed  with  water,  then  with  alcohol,  and  finally  with  ether,  and  dried 
thoroughly.  An  atomizer  bulb  is  useful  for  expelhng  the  fluid  from  the 
tube  and  for  drying,  A  simple  method  of  removing  the  fluid  from  the 
pipette  consists  in  pressing  the  end  of  the  rubber  tube  between  the  fingers 
so  as  to  occlude  its  lumen,  and  then  by  twisting  the  tube  the  fluid  is  ex- 
pelled from  the  pipette.  The  counting  chamber  should  be  cleaned  with 
water  and  dried  with  a  soft  handkerchief  or  tissue  paper.  Alcohol,  ether, 
and  xylol  should  not  be  used  for  cleaning  the  counting  chamber,  since 
these  substances  may  dissolve  the  cement  which  holds  the  parts  together. 

Qowers's  Haemocytometer. — The  principle  of  determining  the  number 
of  corpuscles  with  this  instrument  is  similar  to  that  of  the  Thoma-Zeiss 
method.  A  mixing  jar  is  used  instead  of  a  mixing  pipette.  The  instru- 
ment consists  of  a  capillary  tube  for  measuring  5  cubic  millimetres  of 
blood,  a  pipette  having  a  capacity  of  995  cubic  millimetres  for  measuring 
the  diluting  fluid,  a  mixing  jar,  a  glass  stirring  rod,  and  a  ruled  counting 
chamber.  The  counting  chamber  is  so  constructed  that  the  space  over- 
lying each  square  represents  -g-ToT  of  ^  cubic  millimetre. 

Oliver's  Haemocytometer. — With  this  method  the  number  of  corpuscles 
is  approximately  estimated  by  an  optical  effect  and  not  by  actually 
counting  the  cells  in  a  known  area.  As  the  number  of  leucocytes  cannot 
be  determined  with  this  method,  it  is  not  suitable  for  the  majority  of  blood 
examinations  and  therefore  has  not  been  adopted  for  routine  clinical  work. 

Enumeration  of  Blood-platelets. — The  blood-platelets  are  rarely 
seen  in  fresh  unstained  specimens,  as  they  disappear  almost  immediately 
after  the  blood  is  exposed  to  the  air.  They  are  colorless,  spherical,  oval, 
or  irregular,  varying  considerably  in  size,  usually  from  one  to  three  microns. 
In  fresh  blood,  platelets  are  demonstrated  by  placing  a  cover-glass  upon 
a  slide  and  bringing  their  edges  in  contact  with  the  blood  as  it  flows  from 
the  puncture.  Their  number  may  be  approximately  estimated  by  Deter- 
man's  method  as  follows:  Place  a  di^op  of  a  9  per  cent,  aqueous  solution 
of  sodium  chloride  upon  the  skin  and  make  the  puncture  through  the 
drop  of  fluid.  As  the  blood  flows  from  the  wound,  it  is  mixed  with  the 
reagent  by  stirring  with  a  cover-glass  or  slide,  and  then  a  part  of  this 
mixture  is  placed  upon  the  Thoma-Zeiss  counting  chamber  and  the  cover- 
glass  adjusted.  The  ratio  of  blood-platelets  to  erythrocytes  is  next  de- 
termined in  a  given  area.  The  number  of  red  corpuscles  per  cubic  millime- 
tre is  found  by  the  Thoma-Zeiss  method,  and  from  this  figure  the  actual 
number  of  blood-platelets  per  cubic  millimetre  can  be  calculated  by  the 
ratio  the  red  cells  bear  to  platelets. 

Hsemoglobin  Estimation. — The  principle  involved  in  the  estimation 
of  hsemoglobin  with  most  of  the  instruments  used  in  clinical  work  is  based 
upon  a  comparison  of  the  color  of  undiluted  or  diluted  blood  with  a  standard 
color  scale. 

Dare's  Method. — The  principle  of  this  method  is  based  on  matching 
the  tint  of  a  film  of  undiluted  blood  of  definite  thickness  with  a  graduated 
color  scale.  The  essential  parts  of  this  ha3moglobinometer  are  a  wedge- 
shaped  semicircle  of  glass  stained  with  Cassius's  "golden  purple"  so  that 
the  various  dej^ths  of  the  color  displayed  by  the  scale  represent  liiemoglobin 


238 


MEDICAL  DIAGNOSIS. 


values  ranging  from  10  per  cent,  to  120  per  cent,  (this  wedge  is  contained 
within  a  hard-rubber  case  so  that  it  can  be  revolved  by  operating  a  thumb- 
screw) ;  a  telescoping  camera  tube  supplied  with  a  magnifying  lens  through 
which  the  color  of  the  blood  and  that  of  a  part  of  the  wedge  is  viewed;  a 
pipette  composed  of  two  plates  of  glass,  one  being  transparent  and  the 
other  opaque  (white  glass);  a  part  of  the  surface  of  the  latter  is  slightly 
bevelled,  so  that  a  thin  compartment  is  formed  between  the  plates  when 
their  surfaces  are  opposed;  and  a  candle  holder. 

Technic.  —  The  pipette  is  brought  in  contact  with  a  large  drop  of 
blood.  It  fills  by  capillarity.  The  pipette  is  then  placed  in  its  compart- 
ment on  the  side  of  the  case.     The  light  of  a  candle  is  used  in  making 

the  color  comparison,  the  instru- 
ment being  held  in  a  position  so  as 
to  avoid  direct  sunlight.  The  rapid- 
ity with  which  an  accurate  haemo- 
globin estimation  can  be  made  is  the 
greatest  advantage  of  this  method. 
The  matching  of  the  colors  should 
be  done  immediately  after  filling  the 
pipette,  since  coagulation  may  begin 
within  three  or  four  minutes.  The 
tint  of  the  colored  wedge  of  Dare's 
hsemoglobinometer  does  not  in  every 
instance  correspond  exactly  with  the 
color  curve  of  certain  anaemic  bloods. 

TaLLQ  VIST's      H.EMOGLOBINOM- 

ETER. — With  this  method  the  color 
of  a  drop  of  blood  soaked  into  filter- 
paper  is  compared  with  a  color  scale 
lithographed  upon  paper.  The 
apparatus  consists  of  a  book  con- 
taining sheets  of  white  filter-paper 
and  a  lithographed  color  scale  of 
ten  tints  representing  haemoglobin 
values  between  10  and  100  per  cent. 
Technic. — A  piece  of  the  white  filter-paper  is  applied  to  the  drop  of 
blood,  and,  as  soon  as  the  moist  gloss  has  disappeared  from  the  surface  of 
the  blood-soaked  paper,  its  color  is  compared  with  the  scale.  Accurate 
results  are  not  claimed  for  this  simple  method.  An  error  of  at  least  ten 
per  cent,  is  unavoidable. 

Von  Fleischl  H^emometer.  —  This  instrument  is  composed  of  the 
following  parts:  A  metallic  stage  having  a  circular  opening  in  its  centre, 
supported  by  a  stand.  To  the  frame  of  this  stand  is  attached  a  plaster- 
of-Paris  reflector.  A  glass  wedge,  tinted  with  Cassius's  "golden  purple," 
fixed  within  a  metal  frame.  The  depths  of  the  color  of  the  wedge  corre- 
spond to  a  scale  of  haemoglobin  percentages  stamped  upon  the  frame,  which 
range  from  1  to  120.  A  cylindrical  metalhc  mixing  cell,  divided  into  equal 
parts  by  a  vertical  partition,  and  provided  with  a  glass  bottom.  A  capil- 
lary measuring  pipette  attached  to  a  metal  handle.     As  the  capacity  of  the 


Fig.  97. — 1.  Dare's  hsemoglobinometer.  A, 
telescope  ;  B,  pipette  in  place  ;  C,  case  enclosing 
color-prism ;  D,  milled  head  moving  prism ;  E, 
candle  ;  F,  window  admitting  light  to  color-prism. 
2.  Pipette.  A,  the  white  glass;  B,  clear  glass 
disk. — ^Emerson. 


EXAMINATION  OF  THE  BLOOD. 


239 


pipettes  varies  in  different  instruments,  a  figure  is  stamped  upon  the  handle 
of  the  pipette  and  a  similar  marking  on  the  stage  of  the  instrument  for  which 
it  is  suited.     A  finely  pointed  glass  dropper,  for  fiUing  the  metalhc  cell. 

Technic. — When  one  end  of  the  pipette  is  brought  in  contact  with 
the  blood,  secured  in  the  usual  manner,  it  fdls  automatically  by  capil- 
larity. Blood  adhering  to  the  external  surface  of  the  pipette  must  be 
wiped  away  before  emptying  its  contents.  After  partially  filling  one 
of  the  compartments  of  the  cell  with  water,  the  blood  is  washed  out 
of  the  pipette  with  water.  The  blood  and  the  water  are  then  thoroughly 
mixed  by  stirring  with  the  handle  of  the  pipette.  The  fluid  adhering 
to  the  handle  must  then  be  washed  off  with  water,  which  is  allowed  to 
drain  into  the  mixing  compartment.  The  other  division  of  the  cell  is 
filled  with  water.  Avoid  moistening  the  top  of  the  vertical  septum,  as 
this  may  cause  the  fluids  of  the  compartments  to  commingle.  The  filled 
cell  is  now  adjusted  in  its  proper  position  on  the  stage,  and  a  comparison 
of  the  color  of  the  diluted  blood  with  that  of  the  scale  is  made  in  a  dark- 
ened room,  or  with  a  light-proof  box.  A  candle  flame  placed  about  15 
or  20  centimetres  in  front  of  the  plaster-of-Paris  reflector  is  used  for  illu- 
mination. The  operator,  standing  to  one  side  of  the  instrument,  matches 
the  colors  by  turning  the  thumb-screw.  The  glass  wedge  should  be  moved 
quickly.  Never  view  the  colors  for  more  than  a  few  seconds,  since  the 
eye  is  easily  fatigued  by  prolonged  inspection.  After  two  readings  have 
been  made,  the  mean  of  these  is  taken  as  the  result.  An  attempt  should 
always  be  made  to  compare  only  the  median  portion  of  the  color  fields^ 
which  may  be  readily  accomplished  3 

by  placing  under  the  glass  bottom  of 
the  cell  a  diaphragm  of  thin  metal 
or  paper,  having  a  narrow  slit  about 
4  millimetres  in  width,  the  long 
axis  of  which  is  at  right  angles 
to  the  partition  of  the  mixing  cell. 

When  the  haemoglobin  percent- 
age is  low  (below  30),  two  or  three 
pipettes  full  of  blood  should  be  used, 
and  the  result  divided  by  the 
number  of  pipettes  employed. 
Degree  of  error  with  the  von  Fleischl 
instrument  is  between  5  and  10 
per  cent. 

The  Meischer's  H^moglo- 
BiNOMETER. — This  modification  of 
the  von  Fleischl  instrument  pos- 
sesses certain  advantages  over  the 
latter  whereby  the  degree  of  error  is 
considerably  lessened.  The  prin- 
ciple of  Meischer's  method  is  the 
same  as  that  of  von  Fleischl.  A 
mixing  pipette  is  employed  with  which  accurate  dilutions  of  1 :  200,  1 :  300,  or 
1 :400  can  be  secured.     For  normal  blood  or  nearly  so,  dilutions  of  1 :400  are 


Fig.  98. — 1.  Meischer's  modification  of  Fleischl's 
haemoglobinometer.  4.  stage  ;  /i,  color-prism  rack  ; 
C,  milled  head  ;  D,  cell ;  E,  cover-glass  ;  /'',  cap  ;  G, 
cell  seen  from  above.  2.  Mixing  pipette.  3.  Color- 
prism. — Emerson. 


240  MEDICAL  DIAGNOSIS. 

most  convenient,  but  with  low  haemoglobin  values  dilutions  of  1 :  200  or  1 :  300 
are  more  serviceable.  Two  metallic  chambers  are  employed,  each  of  which 
is  divided  by  a  vertical  partition  and  supplied  with  a  glass  bottom.  One 
compartment  receives  the  diluted  blood,  the  other  water.  One  chamber 
is  shallower  than  the  other.  The  partition  dividing  the  cells  is  slightly 
raised  so  that  the  glass  cover,  provided  with  a  groove,  may  be  slid  over 
the  top  of  the  cylinder,  thereby  preventing  the  fluids  from  commingling, 
A  lid  having  a  narrow  oblong  opening  is  used  to  cover  the  chamber  so 
that  the  width  of  the  field  exposed  when  making  the  color  comparison 
does  not  correspond  to  more  than  three  degrees  of  the  percentage  scale. 
The  tinted  wedge  of  this  instrument  is  more  accurate  than  that  of  the 
von  Fleischl.  After  securing  the  desired  dilution  and  mixture  in  the 
pipette,  one  of  the  compartments  in  each  of  the  cells  is  filled  with  the 
blood  solution,  the  other  compartment  with  water;  the  glass  cover  is 
then  slid  into  position  and  the  metal  top  adjusted.  The  reading  of  each 
cell  is  then  made  with  artificial  illumination,  using  the  same  technic  as 
with  the  original  von  Fleischl  method.  The  result  of  the  reading  of  the 
shallower  cell  is  multiplied  by  f ;  this  figure  should  correspond  closely  with 
the  reading  of  the  other  chamber,  one  result  controlling  the  other.  The 
mean  of  the  two  readings  represents  the  hsemoglobin  percentage. 

Oliver's  H.emoglobinometer. — With  this  method  the  color  of  a 
definite  quantity  of  diluted  blood  is  compared  \\ath  a  standard  color  scale, 
consisting  of  a  series  of  tinted  glass  plates.  The  instrument  is  composed 
of  the  following  parts:  A  standard  blood  scale  composed  of  12  colored 
disks,  mounted  upon  a  perfectly  white  surface  in  two  metal  frames.  Their 
tints  correspond  with  the  color  of  various  dilutions  of  blood.  These  primary 
disks  correspond  to  haemoglobin  percentages  ranging  from  10  to  120; 
two  pieces  of  tinted  glass,  called  riders,  are  supplied  with  the  instrument 
for  ordinary  clinical  purposes.  When  a  rider  is  superimposed  upon  a  pri- 
mary color,  its  shade  deepens  and  therefore  determines  intermediate 
percentages  between  those  indicated  by  the  disks.  An  error  of  2|  per 
cent,  is  unavoidable.  A  capillary  tube  having  a  capacity  of  5  cubic 
millimetres  for  measuring  blood.  A  standard  mixing  cell  provided  with  a 
glass  lid.  A  camera  tube  through  which  the  colors  are  viewed,  and  a 
pipette  for  washing  the  blood  out  of  the  measuring  pipette. 

Technic.  —  The  blood  measured  in  the  pipette  is  washed  into  the 
mixing  cell  with  water  and  mixed  with  the  handle  of  the  pipette.  The  fluid 
which  adheres  to  the  handle  is  rinsed  with  the  water  and  the  cell  filled. 
The  glass  lid  of  the  mixing  cell  is  then  adjusted  in  a  manner  so  that  a 
small  air  bubble  is  present  under  the  cover.  The  color  of  the  diluted  blood 
is  matched  with  one  of  the  disks  of  the  color  scale  in  a  darkened  room, 
illuminated  with  the  light  of  a  small  wax  candle  placed  about  10  centi- 
metres in  front  of  the  mixing  cell  and  the  color  disk.  One  or  both  riders 
may  be  required  to  intensify  the  tint  of  the  primary  disk. 

GowERs's  HiEMOGLOBiNOMETER. — With  tliis  method  a  definite  quan- 
tity of  blood  is  diluted,  until  the  color  of  the  mixture  corresponds  with 
a  standard  color  contained  in  a  tube.  This  instrument  consists  of:  A 
standard  color  tube  which  contains  glycerin  jelly  colored  with  picrocar- 
mine,  so  that  its  tint  corresponds  with  that  of  a  solution  containing  one 


EXAMINATION  OF  THE  BLOOD. 


241 


part  of  normal  blood  in  a  hundred  parts  of  water;  a  mixing  test-tube 
having  a  graduated  scale  ranging  from  5  to  120;  a  pipette  for  measuring 
20  cubic  millimetres  of  blood. 

Technic. — The  measuring  pipette,  to  which  is  attached  a  small  rubber 
tube,  is  filled  by  suction  up  to  the  point  marked  20.  A  few  drops  of 
water  are  placed  into  the  mixing  tube,  then  the  blood  in  the  pipette  is 
blown  into  the  tube.  Water  is  added  in  small  amounts,  shaking  after 
each  addition  in  order  to  secure  a  mixture,  until  the  color  of  the  solution 
corresponds  with  that  of  the  standard  tube.  The  height  of  the  fluid 
reached  indicates  the  haemoglobin  percentage.  The  color  comparison  is 
made  with  daylight  by  holding  the  tube  against  a  white  background. 

Sahli's  H^mometer.  —  The  principle  of  this  method  is  based  on 
comparing  the  tint  of  a  standard  fluid 
composed  of  a  definite  amount  of  normal 
blood  and  of  a  decinormal  solution  of 
hydrochloi'ic  acid  with  the  tint  of  a  solu- 
tion of  blood  to  be  tested  treated  with  a 
decinormal  hydrochloric  acid  solution  and 
water  in  sufficient  quantity  to  exactly 
match  the  colors.  The  height  of  the 
column  of  fluid  in  the  mixing  tube  indi- 
cates the  haemoglobin  percentage.  Sahli 
claims  that  with  this  method  the  color 
of  the  standard  solutions  and  that  of  the 
blood  properly  diluted  corresponds  quite 
accurately,  thereby  insuring  uniform 
results.  The  apparatus  is  similar  in  con- 
struction to  Gowers's  haemometer.  It 
consists  of  a  sealed  tube  containing  the 
standard  color  solution  of  decinormal 
hydrochloric  acid  holding  one  per  cent,  of 
blood;  a  graduated  test-tube  for  mixing 

the  blood  with  a  decinormal  hydrochloric  acid  solution  and  water;  a 
pipette  for  measuring  20  cubic  millimetres  of  blood;  a  perforated  stand 
with  a  white  glass  back  for  holding  the  tubes;  a  bottle  for  carrying  the 
acid  solution;  and  a  finely  pointed  pipette.  The  standard  color  fluid 
has  a  brownish-yellow  color,  due  to  haematin  hydrochlorate  held  in  sus- 
pension. Since  precipitation  of  this  substance  will  occur  on  standing, 
the  sealed  tube  is  provided  with  a  glass  ball  which  serves  to  mix  the  parti- 
cles when  the  tube  is  agitated. 

Technic. — The  graduated  tube  is  filled  with  decinormal  hydrochloric 
acid  to  the  mark  10.  Twenty  c.mm.  of  blood  measured  in  the  pipette 
are  then  blown  into  the  acid  solution  and  mixed.  The  measuring  pipette 
is  then  filled  with  water  and  discharged  into  the  mixing  tube.  The 
graduated  tube  is  now  placed  in  its  compartment  in  the  stand  alongside 
of  the  standard  tube  and  water  is  added  in  small  amounts  to  the  blood 
solution,  mixing  after  each  addition,  until  the  color  matches  the  standard 
tint.  The  height  of  the  column  of  fluid  in  the  tube,  as  indicated  by  the 
16 


Fig.  99. — a,  Sahli's  haemometer;  h,  pipette. 


242  MEDICAL  DIAGNOSIS. 

graduated  scale,  represents  the  haemoglobin  percentage.  The  test  is  con- 
ducted with  natural  or  artificial  light.  More  accurate  readings  are  possible 
when  the  test  is  made  with  artificial  light  in  a  darkened  room. 

Color  (ndex. — The  terms  color  index,  blood  decimal,  or  blood  quotient 
are  used  to  express  the  average  haemoglobin  richness  of  the  erythrocytes. 
This  factor  is  determined  by  dividing  the  haemoglobin  percentage  by  the 
percentage  of  colored  corpuscles  per  cubic  millimetre.  The  normal  color 
index  is  expressed  by  the  figure  1,  i.e.,  100  per  cent,  of  haemoglobin  divided 
by  100  per  cent,  of  red  cells.  In  anaemic  states  the  same  result  is  ob- 
tained when  the  haemoglobin  and  red  cells  are  proportionately  reduced. 
In  chlorosis  the  color  index  is  generally  decidedly  diminished,  while  in 
most  symptomatic  anaemias  it  is  slightly  and  in  some  cases  markedly  low- 
ered. In  pernicious  anaemia,  except  during  periods  of  improvement,  it 
is   generally  increased. 

Estimation  of  the  Relative  Volume  of  Plasma  and  of  Corpuscles. — 
This  determination  is  made  by  applying  centrifugal  force  to  blood  con- 
tained in  a  tube,  which  separates  the  corpuscles  from  the  plasma.  By 
estimating  the  volume  of  corpuscles,  an  approximate  idea  may  be  formed 
of  the  number  of  cells  per  cubic  millimetre. 

Daland's  Hematocrit. — This  instrument  consists  of  a  set  of  gears 
operating  a  metal  frame  into  which  are  fastened  two  capillary  tubes. 
A  hand  lever  is  connected  with  the  gears.  The  tubes  for  measuring  the 
blood,  graduated  into  100  equal  divisions,  are  50  millimetres  in  length, 
with  a  lumen  of  ^  millimetre  diameter. 

Technic. — A  piece  of  rubber  tubing  with  a  mouth-piece  is  attached 
to  one  end  of  the  graduated  tube.  Blood  is  sucked  into  the  pipette 
until  completely  filled.  After  removing  the  rubber  tubing,  the  pipettes 
containing  blood  are  fastened  into  the  metal  frame  and  immediately  the 
handle  of  the  instrument  is  turned  for  3  minutes,  at  the  rate  of  about 
77  revolutions  per  minute,  which  produces  the  speed  desired.  The 
centrifugal  force  separates  the  blood  into  three  layers;  the  one  most 
distant,  of  dark  red  color,  is  composed  of  erythrocytes,  the  middle  one, 
of  milky  color,  is  formed  of  leucocytes,  while  the  inner  clear  layer  con- 
sists of  plasma.  With  normal  blood  the  column  of  erythrocytes  reaches 
to  the  graduation  marked  50  or  51;  each  division  of  the  scale  approx- 
imately represents  100,000  corpuscles  per  cubic  millimetre.  Accurate 
estimations  of  the  number  of  cells  per  cubic  millimetre  is  impossible,  since 
the  size  of  the  erythrocytes  varies  in  pathological  conditions  and  because 
a  uniform  speed  is  almost  impossible  to  obtain.  Variations  in  the  cen- 
trifugal force  will  produce  differences  in  the  degree  of  compactness  of  the 
cells.  The  number  of  leucocytes  can  only  be  roughly  estimated  when 
there  is  a  marked  increase,  as  in  leukaemia,  but  under  normal  conditions 
or  pathological  states  with  slight  or  moderate  variations  the  leucocytic 
layer  is  too  indistinct  to  warrant  an  opinion  as  to  their  number.  The 
pipettes  of  this  instrument  should  be  cleaned  immediately  after  using  by 
passing  a  fine  wire  through  the  lumen,  then  washing  with  water,  followed 
by  alcohol  and  ether. 

Volume  Index. — Volume  index,  the  term  applied  to  represent  the 
average  volume  of  the  erythrocyte,  is  determined  by  dividing  the  per- 


EXAMINATION  OF  THE  BLOOD.  243 

centage  volume,  as  estimated  with  the  haematocrit,  by  the  percentage  of 
the  erythrocytes  per  cubic  millimetre,  obtained  with  the  haemocytometer. 

Estimation  of  Specific  Gravity. — An  accurate  estimation  of  the 
specific  gravity  of  the  blood  can  be  obtained  by  Schmaltz's  method,  which 
consists  of  weighing  a  dry  pipette  upon  a  sensitive  balance.  The  pipette 
is  then  filled  with  water  and  the  weight  determined.  After  cleaning  and 
drying,  the  pipette  is  filled  with  blood  and  again  weighed.  From  these 
figures  the  specific  gravity  is  calculated. 

Hammerschlag's  Method.  —  Hammerschlag's  modification  of  Roy's 
method  is  based  upon  the  principle  of  suspending  a  drop  of  blood  in  a 
liquid  having  the  same  specific  gravity.  The  specific  gravity  of  the  sus- 
pension fluid  is  then  determined  with  a  hydrometer,  which  corresponds 
to  that  of  the  blood. 

Technic. — Pour  benzol  and  chloroform  into  an  hydrometer  jar,  in 
such  proportions  as  to  secure  a  mixture  having  a  specific  gravitj^  of 
about  1.060.  Partially  fill  a  pipette,  or  rnedicine  dropper,  with  blood 
and  insert  it  into  the  benzol-chloroform  solution;  expel  a  droplet  into 
the  fluid.  If  the  blood  is  lighter  than  the  mixture,  it  will  rise  to  the 
top.  Benzol  should  then  be  added  and  the  fluid  carefully  stirred  with  a 
glass  rod  until  the  blood  is  suspended  in  the  mixture.  The  specific  grav- 
ity of  the  benzol-chloroform  solution  is  next  determined,  which  corre- 
sponds to  that  of  the  blood.  If  the  specific  gravity  of  the  blood  is  greater 
than  that  of  the  benzol-chloroform  mixture,  causing  the  blood  to  sink, 
the  addition  of  chloroform  is  necessary  to  cause  suspension.  This  method 
of  determining  the  specific  gravity  is  seldom  employed  in  clinical  M^ork, 
as  it  is  tedious  and  as  errors  of  technic  are  readily  made.  The  specific 
gravity  ranges  of  the  blood  correspond  quite  closely  to  definite  haemoglobin 
percentages;  notable  exceptions  to  this  rule  are  found  in  progressive  per- 
nicious anaemia,  where  the  haemoglobin  percentage  is  slightly  higher  than 
the  specific  gravity  indicates,  while  in  leukaemia  the  reverse  is  observed. 
Hammerschlag's  scale  of  specific  gravity  ranges  with  equivalent  haemoglobin 
percentages  is  as  follows: 

Spec.  Gravity.  Hamoglobin. 

1.033-1.035 25-.30  per  cent. 

1.035-1.038 30-35  per  cent. 

1.038-1.040 35-40  per  cent. 

1.040-1.045 40-45  per  cent. 

1.045-1.048 45-55  per  cent. 

1.048-1.050 55-65  per  cent. 

1.050-1.053 65-70  per  cent. 

1.053-1.055 70-75  per  cent. 

1 .055-1 .057 75-85  per  cent. 

1.057-1.060 85-95  per  cent. 

Estimation  of  the  Time  of  Coagulation. — As  a  number  of  condi- 
tions influence  the  rapidity  with  which  coagulation  of  the  blood  occurs 
after  it  is  withdrawn  from  the  blood-vessels,  such  as  the  amount  of  blood 
and  the  temperature,  the  results  obtained  by  different  methods  of  deter- 
mining the  clotting  time  are  not  available  for  comparative  studies.  In 
this  connection  it  should  also  be  borne  in  mind  that  the  factors  which 
control  intra-  and  extravascular  coagulation  are  in  all  likelihood  dissimilar. 


244 


MEDICAL  DIAGNOSIS. 


Method  of  Russell  and  Brodie. — The  coagulation  time  is  deter- 
mined by  microscopical  study  of  the  blood.  The  apparatus  needed  for 
this  method  is  provided  with  a  moist  chamber  having  a  glass  bottom.  A 
removable  glass  cone  (the  lower  surface  of  which  is  4  mm.  in  diameter) 
forms  the  upper  portion  of  the  chamber.  A  current  of  air  is  introduced 
into  the  chamber  by  means  of  a  small  tube  one  end  of  which  projects  into 
the  cell,  while  to  the  other  end  is  attached  a  rubber  tube  supplied  with  a 
bulb.  Boggs's  coagulometer,  a  modification  of  the  instrument  just  de- 
scribed, is  equipped  with  an  improved  glass  cone  and  a  metal  tube. 

Technic. — A  drop  of  blood  is  placed  upon  the  lower  surface  of  the 
cone  which  is  then  immediately  fitted  into  the  chamber.  The  instrument 
is  then  put  upon  the  stage  of  the  microscope  and  with  a  low-power  objec- 
tive the  blood  is  brought  into  focus.  At  successive  intervals  the  blood  is 
agitated  by  means  of  the  current  of  air  sent  into  the  cell  from  the  bulb. 
It  will  be  noted  that  at  first  the  stream  of  air  causes  the  corpuscles  to 


Fig.  101.- 


Diagram  to  illustrate  the   movement   of  the 
cells  during  coagulation. — Emerson. 


Fig.  100. — Coagulometer  of  Russell  and 
Brodie  as  modified  by  Boggs.  A,  moist  cham- 
ber ;  B,  cone  of  glass,  the  lower  surface  of  which 
holds  the  drop  of  blood  ;  C,  side  tube  ;  D  and 
E,  cover-glass  ;  at  £,  a  pinhole. — Emerson. 

move  freely.  A  little  later  clumps 
form  in  the  peripheral  zone  of 
the  blood  and  these  can  be  ad- 
vanced by  the  air  current.  Then 
as  clotting  progresses  masses  of 
blood-cells  cease  to  move  freely,  the  drop  alters  its  shape,  and  the  cor- 
puscles exhibit  a  concentric  motion.  Lastly,  a  radial  movement  appears, 
clumps  of  cells  being  displaced  by  the  air  current  towards  the  centre  and 
these  quickly  return  to  their  original  position.  Clotting  is  now  considered 
complete.  The  normal  coagulation  time  as  determined  by  this  method  varies 
from  three  to  eight  minutes,  the  average  time  being  about  five  minutes. 

Wright's  Method. — The  coagulometer  devised  by  Wright  consists 
of  a  cylindrical  tin  vessel  provided  with  a  perforated  partition^  the  open- 
ings of  which  are  so  arranged  as  to  support  twelve  graduated  tubes  and 
a  thermometer.  The  tubes  are  graduated  for  5  c.c.  of  blood,  and  are  num- 
bered from  one  to  twelve. 

Technic. — Water  having  a  temperature  of  18.5°  C.  is  poured  into 
the  metal  container.  The  blunt  end  of  six  or  eight  of  the  tubes 
is  then  covered  with  a  rubber  cap.  The  tubes  are  then  placed,  closed 
end  downward,  into  the  water.  After  having  acquired  the  tempera- 
ture of  the  water,  they  are  removed  separately  at  once  or  one-half 
minute  intervals,  the  cap  taken  off,  filled  with  5  c.c.  of  blood  and  imme- 
diately replaced  into  the  water  without  reapplying  the  caps.     Attempts 


EXAMINATION  OF  THE  BLOOD.  245 

at  short  intervals  are  made  to  dislodge  the  blood  from  the  tubes  by  blow- 
ing. When  the  blood  cannot  be  removed  from  one  of  the  tubes,  coagula- 
tion may  be  considered  complete.  The  clotting  time  is  the  difference  of 
time  between  the  filling  the  tube  and  the  unsuccessful  attempt  to  expel 
its  contents.  With  this  instrument  the  coagulation  time  of  normal  blood 
in  most  instances  is  from  three  to  six  minutes,  although  the  period  may 
be  as  long  as  fifteen  minutes. 

Bacteriological  Examination. — This  field  of  investigation  is  of  diag- 
nostic value  in  a  considerable  group  of  diseases.  There  are  two  methods 
of  demonstrating  bacteria  in  the  blood,  —  one  by  an  immediate  micro- 
scopical examination  of  stained  films,  the  other  by  blood  culturing.  The 
former  plan  has  given  unsatisfactory  results  in  the  hands  of  most  workers. 
R.  C.  Rosenberger  claims  that  tubercle  bacilli  can  be  detected  in  the 
blood  of  tuberculous  patients,  and  recommends  the  following  simple 
method  for  their  detection:  About  5  c.c.  of  blood,  withdrawn  from  a  vein 
in  the  arm,  are  mixed  with  an  equal  quantity  of  a  2  per  cent,  solution  of 
citrate  of  sodium  in  normal  salt  solution.  The  mixture  is  shaken  and 
placed  in  a  refrigerator  for  twenty-four  hours.  A  small  quantity  of  the 
sediment  is  spread  rather  thickly  upon  a  new  clean  glass  slide,  dried  upon 
a  copper  plate  with  moderate  heat,  and  then  placed  in  distilled  water  until 
complete  laking  of  the  blood  results.  A  delicate  film  remains  upon  the 
slide.  This  is  dried  and  fixed  through  a  Bunsen  flame  and  then  stained 
for  tubercle  bacilli,  employing  the  usual  technic.  The  blood  for  cultural 
methods  is  taken  as  a  rule  from  a  superficial  vein  at  the  bend  of  the  elbow. 

Technic. — The  skin  of  the  flexor  surface  of  the  elbow  is  cleansed 
as  for  a  surgical  operation,  by  scrubbing  thoroughly  with  soap  and 
water,  washing  with  sterilized  water,  alcohol,  and  ether,  after  which  an 
antiseptic  dressing  is  applied  and  allowed  to  remain  for  six  or  eight 
hours.  The  operator,  having  prepared  his  hands,  should,  after  removing 
the  antiseptic  dressing,  wash  the  skin  with  sterilized  water.  A  syringe 
(of  moderate  size  like  the  instrument  used  for  exploratory  puncture) 
or  a  special  "blood  aspirator"  is  required  to  remove  the  blood  from 
the  vein.  A  most  useful  instrument  employed  by  many  workers  con- 
sists of  a  graduated  glass  tube  having  a  capacity  of  about  10  cubic 
centimetres,  one  end  of  which  is  fitted  to  a  No.  42  hypodermic  needle, 
and  into  the  other  end  a  small  plug  of  cotton  is  inserted.  In  order 
to  sterilize  the  instrument,  it  is  placed  in  a  large  glass  tube,  the  ends  of 
which  are  then  plugged  wdth  cotton.  After  sterilization  a  piece  of  rubber 
tubing  is  fastened  to  the  end  of  the  aspirator  containing  the  cotton.  A 
bandage  is  wound  around  the  arm  of  the  patient  so  as  to  obstruct  the 
venous  circulation,  and  when  the  superficial  veins  at  the  elbow  become 
distended,  the  needle  of  the  syringe  or  blood  aspirator  is  inserted  into 
the  most  prominent  vessel.  When  employing  the  syringe,  the  piston  is 
withdrawn  slowly  until  the  desired  quantity  of  blood  is  obtained.  As  a 
rule,  the  blood  flows  freely  into  the  aspirator  previously  described,  but, 
should  this  not  be  the  case,  a  sufficient  amount  can  be  secured  by 
making  suction  through  the  rubber  tube.  The  bandage  about  the  arm 
is  then  removed,  the  needle  withdrawn,  and  a  sterilized  dressing  applied 
to  the  wound. 


246 


MEDICAL  DIAGNOSIS. 


The  blood  is  placed  in  a  suitable  culture  medium.  Fluid  media  such  as 
bouillon  and  litmus  milk  are  generally  selected  for  the  primary  inocula- 
tions when  certain  types  of  bacteria  are  suspected,  while  agar  may  be 
chosen  when  the  medium  is  to  be  plated.  One  or  two  cubic  centimetres 
of  blood  are  added  to  50  or  100  c.c.  of  fluid  medium  so  that  dilutions  of 
one  in  fifty  or  one  in  one  hundred  are  secured.  For  details  of 
bacteriological  technic,  which  do  not  fall  within  the  scope  of  this 
work,  special  treatises  on  bacteriology  should  be  consulted. 

Agglutination  Reaction. — The  blood  in  certain  stages  of 
typhoid  fever,  and  often  after  the  attack,  possesses  the  prop- 
erty of  checking  the  motility  of  typhoid  bacilli  and  causing 
these  organisms  to  form  into  clumps.  This  agglutination 
phenomenon  is  so  pronounced  that  high  dilutions  of  blood, 
as  one  in  fifty  or  one  hundred,  or  even  higher,  give  positive 
results.  The  blood  in  similar  dilutions  in  other  diseases  and 
in  health  does  not  act  in  this  manner  with  typhoid  bacilli. 
With  low  dilutions,  however,  a  positive  agglutination  reaction 
is  often  present  with  normal  or  abnormal  blood.  In  a  number 
of  diseases — as  pneumococcal  and  streptococcal  infections, 
paratyphoid  fever;,  Malta  fever,  tuberculosis,  cholera,  plague, 
relapsing  fever,  glanders,  and  others — specific  agglutination 
reactions  have  been  obtained.  The  agglutination  test  is 
chiefly  employed  in  the  diagnosis  of  typhoid  and  paratyphoid 
fevers  and  is  generally  spoken  of  as  the  Widal,  Gruber-Widal, 
or  Pfeiffer- Widal  reaction.  For  this  test  two  methods  are 
available,  (1)  the  microscopic  and  (2)  the  macroscopic.  In 
typhoid  fever  the  agglutination  reaction  is  positive  in  about 
97  per  cent,  of  the  cases  during  the  course  of  the  disease, 
manifesting  itself  in  a  majority  of  them  about  the  end  of  the 
first  or  during  the  second  week,  in  a  few  instances  as  early 
as  the  third  or  fourth  day,  while  in  others  it  is  not  obtained 
until  the  attack  is  far  advanced,  and  it  often  persists  long 
after  convalescence.  The  intensity  of  the  reaction  varies  in 
different  cases.  Positive  reactions  are  obtained  with  dilu- 
tions as  high  as  1 :  200.  In  some  instances  the  reactions  occur 
almost  instantly,  while  in  others  the  stoppage  of  motility 
and  clumping  take  place  slowly. 

1.  Microscopical  Serum  Test. — This  test  may  be  per- 
formed with  fluid  blood,  blood-serum,  or  dried  blood. 

Technic. — Preparing  Cultures. — From  a  slant  agar  growth 
of  typhoid  bacilli,  preferably  not  older  than  one  month,  sub- 
cultures are  made  in  sterile  bouillon  and  incubated  at  blood 
heat  for  8  to  12  hours,  when  they  are  ready  for  use.  The  stock  culture 
should  be  kept  in  a  cool  place.  Some  workers  prefer  a  suspension  of 
typhoid  bacilli  in  salt  solution  made  by  placing  a  loopful  of  a  twenty-four 
hour  agar  growth  in  saline  solution.  The  tube  containing  the  fluid  is 
agitated  until  a  uniform  suspension  of  the  germs  is  obtained. 

Collecting  and  Diluting  Serum.  —  A    capillary    pipette,  suitable    for 
measuring  the  blood,  is  made  from  a  piece  of  glass  tubing  about  30  cm. 


Fig.  102.— 
Capillary- 
pipette. 


x_' 


EXAMINATION  OF  THE  BLOOD.  247 

in  length  and  5  or  6  mm.  in  diameter.  The  middle  portion  of  this  tube 
is  heated  in  the  Bunsen  flame;  rotating  continuously  in  its  long  axis  until 
the  glass  is  thoroughly  softened  over  3  to  6  centimetres  of  its  length; 
remove  from  the  flame  and  draw  the  two  ends  apart  M'ith  a  steady  uniform 
pull  so  that  the  heated  portion  tapers  into  a  long  capillary  tube.  By 
melting  the  middle  of  the  capillary  tube  in  the  flame,  two  pipettes 
with  the  capillary  end  sealed  off  are  made.  A  AVright's  blood  capsule, 
shown  in  Fig.  103,  will  be  found  convenient  for  collecting  the  blood. 
Preparing  the  Serum. — The  patient's  finger-tip  is  cleansed  and 
rubbed  briskly  so  as  to  produce  hyperemia.  A  puncture  is  then  made 
of  sufficient  size  so  as  to  insure  a  good  flow  of  blood.  The  sealed  tips 
of  a  Wright's  capsule  are  broken  off,  and  the  end  of  the  short  curved 
portion  of  the  capsule  is  placed  into  the  blood  as  it  issues  from  the 
small  wound,  the  body  of  the  tube  slanting  downward  so  as  to  allow 
the  blood  to  enter  by  gravity.  The  capsule  is  partly  filled  {h  or  fj 
full).  The  tip  of  the  longer  arm  is  sealed  off  by  heating  in  a  flame. 
When  properly  cooled,  the  blood  is  shaken  down.  The  other  end 
may  then  be  closed  to  prevent  evaporation,  if  the  test  is  not  made 
immediately.  The  capsule  is  now  booked  upon  the  rim  of 
a  centrifuge  tube  and  centrifugalized  until  clear  serum  sepa- 
rates. Slight  turbidity  of  the  serum  does  not  interfere  with 
the  test.  The  capsule  containing  the  centrifugalized  blood  is 
opened  by  filing  a  groove  into  the  glass  tube  above  the  level  fig.  io3.— 
of  the  serum  and  breaking  off  the  end.  The  fine  end  of  a  work.-Emlrso^ 
capillary  pipette  (having  previously  been  broken  off  the  sealed 
tip)  is  inserted  into  the  capsule  and  the  serum  drawn  into  the  tube.  The 
blood -serum  may  be  diluted  and  mixed  with  the  culture  in  watch  crystals 
or  in  a  porcelain  plate  having  a  number  of  cup-shaped  depressions  as  shown 
in  Fig.  104.  One  drop  of  serum  is  now  placed  into  one  of  the  depressions 
of  the  porcelain  plate.  Dilutions  of  the  serum  with  sterilized  normal 
salt  solution  are  then  made.  The  capillary  tube,  having  been  cleaned 
with   salt   solution  or  water,  is  partly  filled  with  saline  fluid.     Into  the 

depressions  containing  a  drop  of 
serum,  24  drops  of  salt  solution  are 
allowed  to  fall  from  the  pipette  and 
mixed,  thus  making  a  dilution  of 
1-25,  since  the  drops  from  the 
pipette  are  practically  of  the  same 
size.  Into  a  second  depression  are 
^^"  '"''■l^^^^^lJtJZ-XA^:'''^'  ''''     placed    5    drops    of    salt    solution 

and  5  drops  of  the  diluted  serum 
of  1-25,  securing  a  1-50  dilution.  More  accurate  results  are  obtained 
by  measuring  and  diluting  the  serum  in  a  Thoma-Zeiss  hsemocytometer 
pipette.  Two  hanging  drop  preparations  are  prepared — one  from  each 
dilution — by  mixing  upon  a  cover-glass  a  platinum  loopful  of  bouillon 
culture  of  typhoid  bacilli  with  a  loopful  of  diluted  serum.  Since  each 
dilution  of  serum  is  again  diluted  to  h,  the  proportions  now  stand 
1-50  and  1-100.  The  cover-glasses  are  adjusted  upon  the  slides  and  the 
edges  of  the  slips  surrounded  by  petrolatum  to  prevent  evaporation.     The 


248  MEDICAL  DIAGNOSIS. 

preparations  are  allowed  to  stand  at  room  temperature  for  exactly  one 
hour.  In  order  to  secure  correct  results,  it  is  essential  that  the  motility 
of  the  bacilli  should  be  active,  and  the  density  of  the  culture  be  uniform 
and  not  show  clump-like  gatherings. 

Recording  Results. — i\.t  the  end  of  one  hour,  the  hanging  drop  slides 
are  examined  microscopically.  When  motion  of  the  bacilli  is  found  absent 
and  clumping  good  in  both  slides,  the  reaction  is  termed  ''positive,"  but 
when  the  free  motion  without  clumping  of  bacteria  is  noted,  the  test  is 
negative.  Variations  between  these  two  extremes  may  be  recorded  ac- 
cording to  the  judgment  of  the  examiner.  Thus,  if  1-50  shows  no  motion 
and  good  clumping,  but  1-100  exhibits  slight  motion  and  only  fair  clump- 
ing, the  reaction  may  be  called  "very  suggestive;"  or,  again,  if  1-50 
shows  slight  motion  and  poor  clumping,  while  1-100  free  motion  and  no 


=^^^' 


%- 


w 

™^  * 

Fig.  105.  —  Widal   test.     Field   of   motile   organ-        Fig.    106.  —  Widal    test.     Field    of    agglutinated 
isms. — Emerson.  organisms. — Emerson. 

clumping,  the  reaction  may  be  called  "slightly  suggestive."     It  is  best 
to  indicate  definitely  the  results  of  each  dilution,  as  for  example: 

1-50    Good  clumping.  No  motion. 

1-100  Fair  clumping.  Slight  motion. 

This  allows  the  diagnostician  to  form  his  own  conclusions  and  does 
away  with  dogmatic  assertions,  such  as  "Widal  positive"  or  "Widal 
negative,"  which  are  so  often  a  matter  of  personal  equation  upon  the 
part  of  the  laboratory  worker. 

The  liquid  serum  method,  unfortunately,  cannot  always  be  employed 
by  physicians  in  active  practice.  The  microscopical  test  may  be  carried 
out  with  blood  collected  upon  a  piece  of  paper,  or  upon  a  slide  and  allowed 
to  dry,  after  which  the  test  may  be  made  at  any  time.  The  blood  secured 
in  this  manner  is  moistened  and  dissolved  in  sterilized  water,  and  then  diluted 
and  mixed  v/ith  the  culture  in  the  desired  proportions.  It  is  obvious  that 
accurate  dilutions  are  impossible,  an  objection  to  this  method. 

2.  Macroscopical  Serum  Test.  —  By  aspirating  a  vein,  a  sufficient 
amount  of  blood  is  collected  in  a  sterile  test-tube  and  allowed  to  clot, 
so  as  to  separate  the  serum,  or  the  blood  may  be  centrifugated.     The 


EXAMINATION  OF  THE  BLOOD.  249 

serum  is  mixed  with  salt  solution  and  bacterial  culture  in  the  desired  pro- 
portions (1-50  or  1-100).  In  the  case  of  a  positive  reaction  a  flaky  precipi- 
tate will  separate  with  a  clear  supernatant  fluid,  while  a  negative  reaction 
shows  uniform  turbidity  of  the  fluid.  The  macroscopical  test  may  also 
be  performed  by  mixing  bouillon  and  serum  in  proper  dilutions  and  inocu- 
lating the  mixture  with  a  loopful  of  a  broth  culture.  The  presence  of  a  pre- 
cipitate in  the  tube  at  the  end  of  twenty-four  hours'  incubation  signifies 
a  positive  result.  The  chief  objection  to  the  macroscopic  method  is  the 
relatively  large  amount  of  blood  required.  The  microscopic  test  is  gen- 
erally employed  in  clinical  work.  The  macroscopical  test  may  also  be 
performed  with  dead  cultures  of  the  bacilli.  The  principle  of  the  Ficker 
"Typhus  Diagnosticum"  is  based  on  mixing  a  dead  culture  with  diluted 
blood-serum.  Bacilli  in  liquid  media  killed  with  carbolic  acid  or  formalin 
are  also  employed  for  this  test. 

Opsonic  Index  of  the  Blood  and  Its  Determination. —  Leishman 
in  1902  devised  a  method  for  estimating  the  phagocytic  activity  of  the 
leucocytes.  Extensive  researches  upon  this  subject  have  recently  been 
made  by  Wright  and  Douglas,  and  many  other  investigators.  Opsonins 
are  substances  within  the  blood  which  prepare  bacteria  for  ingestion  by 
the  white  cells.  The  power  of  the  leucocytes  alone  to  ingest  bacteria,  the 
so-called  "spontaneous"  phagocytosis,  has  been  shown  to  be  very  slight, 
and  the  role  played  by  them  in  fighting  diseases  is  merely  as  scavenger, 
collecting  bacteria  acted  upon  by  the  opsonins.  Opsonins  do  not  stim- 
ulate or  otherwise  affect  the  leucocytes.  These  substances  are  destroyed 
by  a  temperature  of  65°  C.  for  ten  minutes. 

Technic.  - —  The  special  technic  used  for  the  determination  of  the 
opsonic  power  of  the  blood  may  be  briefiy  set  forth  as  follows:  There 
must  be  on  hand  for  the  test  (1)  an  emulsion  of  the  bacteria  in  salt  solution, 
(2)  washed  white  blood-cells,  taken  from  any  source,  (3)  serum  from  the 
patient's  blood,  and  (4)  serum  of  normal  blood  or  from  a  mixture  of  healthy 
bloods  taken  as  a  standard  control. 

Preparing  the  Bacterial  Emulsion.- — The  micro-organisms  for  the  test 
are  inoculated  upon  culture  medium.  For  some  forms  of  bacteria,  as  the 
Staphylococcus  aureus,  an  agar  medium  is  selected.  After  twenty-four 
hours  of  incubation  at  37°  C.  a  fair-sized  colony,  found  on  the  culture 
medium,  is  removed  and  mixed  with  a  sterile  .85  per  cent,  salt  solution. 
The  resulting  bacterial  emulsion  is  drawn  up  and  down  in  a  small  pipette 
by  means  of  rubber  teat.  The  emulsion  is  set  aside  for  a  few  minutes  so 
as  to  allow  the  bacterial  clumps  to  settle.  The  supernatant  liquid  is  then 
removed  and  diluted  to  the  desired  density.  Centrifugalizing  may  be  neces- 
sary to  separate  bacterial  clumps.  With  bacteria  not  readily  emulsified, 
such  as  tubercle  bacilli,  grincUng  between  glass  plates  or  in  an  agate  mortar 
is  required  to  disintegrate  the  masses.  The  emulsion  in  case  of  tubercle 
bacilli  may  be  made  from  fresh  cultures  or  from  dry,  dead  germs,  such  as 
are  obtained  in  the  production  of  tuberculin.  Tubercle  bacilli  are  best 
emulsified  with  a  1.5  per  cent,  salt  solution.  The  proper  density  is  one 
which  on  mixture  with  a  normal  serum  and  with  the  leucocytes  in  equal 
proportions  will  show  that  after  incubation  an  average  of  5  or  6  germs 
have  been  phagocytozed  by  each  leucocyte.     The  density  of  the  standard 


250  MEDICAL  DIAGNOSIS. 

bacterial  mixture  may  be  fixed  by  McFarland's  nephelometer,  or  by  count- 
ing the  bacteria  in  a  given  amount  of  emulsion  in  a  Thoma-Zeiss  count- 
ing chamber. 

Obtaining  the  Washed  Leucocytes. — A  test-tube  is  filled  two-thirds  full 
with  an  aqueous  solution  containing  1.5  per  cent,  sodium  citrate  and  .85  per 
cent,  sodium  chloride.  The  finger  is  pricked  and  S  to  12  drops  of  blood 
are  allowed  to  fall  into  the  tube.  The  solution  is  shaken  and  then  the 
tube  is  i^laced  in  an  electric  centrifuge  and  centrifugalized  for  5  minutes 
at  a  speed  of  1500  to  2000  revolutions  per  minute.  The  citrate  defibrin- 
ates  the  blood  and  prevents  clotting,  while  the  sodium  chloride  solution 
washes  the  cells  free  of  serum.  Upon  removal  from  the  centrifuge,  the 
tube  is  found  to  contain  a  compact  sediment  of  blood-cells  with  a  clear 
or  very  slightly  cloudy  supernatant  fluid  which  consists  of  serum  and 
salt  solution.  Overlying  the  surface  of  the  red  sediment  will  be  found 
a  white  coating  termed  the  "creamy  layer,"  which  is  formed  principally 
of  white  cells.  The  clear  supernatant  fluid  is  now  drawn  off  with  a  capil- 
lary pipette  by  means  of  a  rubber  bulb.  The  layer  of  leucocytes,  which 
contains  some  red  cells,  is  now  carefullj^  removed  from  the  compact  la^^er 
of  erythrocytes  with  the  capillary  pipette  and  placed  in  a  small  glass 
tube  having  a  sealed  end.  The  leucocytes  may  be  washed  with  saline 
solution  several  times  in  order  to  remove  the  sodium  citrate.  This  is 
accomplished  by  placing  the  leucocytes  in  a  centrifuge  tube  or  small  test- 
tube  and  partly  filhng  it  with  .85  per  cent,  salt  solution.  The  tube  is 
then  centrifugalized,  after  which  the  supernatant  fluid  is  removed  with  a 
pipette.     This  operation  may  be  repeated. 

Obtaining  the  Serum. — A  Wright's  capsule  is  filled  two-thirds  full  of 
blood,  obtained  from  the  patient,  and  centrifugalized  until  the  serum  is 
clear.  Serum  must  also  be  obtained  from  normal  blood.  Having  on  hand 
the  bacterial  emulsion,  washed  corpuscles,  and  serum,  the  main  part  of 
the  test  may  be  carried  out.  By  means  of  a  capillary  pipette,  equal 
amounts  of  bacterial  emulsion,  white  blood-cells,  and  serum  are  measured, 
and  the  fluid  mixed  on  a  slide  or  watch  crystal  by  drawing  the  material 
up  and  forcing  it  down  the  capillary  pipette.  The  fluids  are  measured 
in  the  following  manner:  The  rubber  teat  attached  to  the  pipette  is 
compressed,  and,  by  gently  relaxing  the  pressure,  white  cells,  bacterial 
emulsion,  and  serum,  in  the  order  named,  are  drawn  into  the  capillary 
bore  up  to  the  mark  indicated  by  the  pencil  mark,  each  column  being 
separated,  by  a  small  air  bubble.  Two  pipettes  are  necessary  for  one  test, 
one  for  the  patient's  serum,  the  other  for  the  control  serum.  A  special 
pipette,  supplied  with  a  rubber  teat,  is  often  used  to  measure  and  mix 
the  bacterial  emulsion  serum  and  washed  leucocytes,  and  is  constructed  in 
such  a  manner  as  to  allow  the  worker  a  means  of  controlling  accurately 
the  amount  of  fluids  drawn  up  in  the  long  arm  of  the  pipette  and  of 
mixing  the  contents  afterwards.  The  sealed  tip  of  a  capillary  pipette 
having  been  broken  off  squarely,  a  pencil  mark  is  made  2  or  3  cm.  above 
its  extremit3^  After  the  ingredients  are  thoroughly  mixed,  the  fluid  is 
drawn  into  the  pipette  and  its  end  sealed  in  the  flame.  The  tube  is  then 
placed  in  the  incubator  at  37°  C.  for  15  minutes.  In  a  like  manner,  the 
control  test  is  prepared  with  equal  amounts  of  white  corpuscles,  bacterial 


EXAMINATION  OF  THE  BLOOD.  251 

emulsion,  and  normal  serum,  which  are  also  incubated.  After  incubation 
the  end  of  the  pipette  is  broken  off  and  the  contents  are  run  up  and  down 
so  as  to  mix  thoroughly.  Smear  preparations  are  made  of  the  material 
from  each  pipette  upon  slides  or  cover-glasses.  After  fixation  the  smears 
are  treated  with  any  reliable  stain,  such  as  Leishman's,  which  brings  out 
distinctly  the  leucocytes  and  bacteria.  For  tubercle  bacilli,  carbol  fuchsin 
and  Gabbett's  or  Pappenheim's  stain  may  be  employed.  The  specimens 
are  now  examined  with  an  oil-immersion  lens.  The  number  of  bacteria 
in  100  typical  polymorphonuclear  neutrophiles  is  determined  in  both 
specimens.  The  average  number  of  bacteria  per  leucocyte  is  then  cal- 
culated for  each  specimen,  which  constitutes  the  phagocytic  index.  The 
phagocytic  index  of  the  patient's  serum  divided  by  the  phagocytic  index 
of  the  normal  or  control  serum  gives  the  opsonic  index.  The  test  can 
only  be  carried  out  properly  in  a  well-equipped  laboratory  by  one  who  has 
mastered  opsonic  technic.  The  strength  of  the  bacterial  emulsion,  the 
length  of  incubation,  the  age  of  the  ingredients  employed,  and  the  personal 
equation  are  some  of  the  factors  which  influence  the  results.  Opsonic 
index  is  employed  in  the  diagnosis  and  prognosis  of  certain  infectious 
diseases  and  in  gauging  the  dose  and  the  frequency  of  administration 
of  bacterial  vaccines.  After  the  injection  of  therapeutic  doses  of  bacterial 
vaccines,  the  index  is  seen  primarily  to  fall  and  soon  afterwards  to  rise 
above  the  normal.  The  initial  fall  constitutes  the  ''negative  phase"  and 
the  rise  the  "positive  phase."  The  vaccine  should  not  be  repeated  until 
the  negative  phase  has  passed  into  the  positive,  and  this  can  only  be 
gauged  by  repeated  observations  of  the  index.  The  value  of  the  opsonic 
index  for  therapeutic  or  diagnostic  purposes  has  not  been  definitely  settled. 

Test  for  the  Detection  of  Diabetes  Mellitus.  —  Two  clinical  blood- 
tests  have  been  devised  for  this  purpose,  both  of  which  are  based  upon 
similar  principles. 

Williamson's  Test. — Twenty  cubic  millimetres  of  blood  measured 
with  the  pipette  of  a  Gowers's  hsemocytometer  are  mixed  with  40  cubic 
millimetres  of  distilled  water  in  a  test-tube.  One  cubic  centimetre  of  a 
solution  of  methylene  blue,  of  a  strength  of  1:6000,  and  40  cubic  centi- 
metres of  a  6  per  cent,  aqueous  solution  of  potassium  hydrate  are  then 
added  to  the  diluted  blood.  A  control  test  with  normal  blood  should 
always  be  made.  The  test-tubes  are  then  placed  in  boiling  water  for  about 
five  minutes,  after  which  the  solution  containing  the  diabetic  blood  will 
have  a  yellowish  color,  while  the  color  of  the  control  mixture  remains 
unaltered.  This  reaction  may  be  positive  in  cases  of  diabetes  mellitus 
after  sugar  disappears  from  the  urine. 

Bremer's  Test. — Cover-glass  films  of  the  suspected  blood  and  of 
normal  blood  to  be  used  as  a  control  test  are  made,  which  are  fixed  by 
heat  at  a  temperature  of  135°  C.  The  smears  are  treated  with  a  freshly 
prepared  aqueous  solution  of  Congo-red.  The  stain  is  washed  off  with 
water,  and  the  preparations  dried.  The  diabetic  blood-film  is  colored 
a  greenish-yellow,  while  the  control  film  is  stained  red.  Other  aniline 
dyes,  as  methylene  blue,  methyl  green,  may  be  employed  for  this  test. 
This  test  is  at  times  positive  with  the  blood  of  individuals  suffering  from 
-other  diseases,  as  leukaemia,  Hodgkin's  disease,  and  Graves's  disease. 


252  MEDICAL  DIAGNOSIS. 

General  Results  of  Blood  Examinations. 

Volume.  —  The  blood,  which  forms  from  4  per  cent,  to  7  per  cent, 
of  the  total  body  weight,  is  a  highly  specialized  tissue,  consisting  of  eryth- 
rocytes, leucocytes,  blood-plaques,  and  hsemokonia,  suspended  in  a  liquid 
matrix,  the  plasma.  In  health  the  total  volume  of  blood  varies  within 
narrow  limits.  The  view  formerly  entertained  that  an  increase  in  the 
total  amount  is  constantly  present  in  some  individuals — plethora — is  not 
sustained  by  recent  researches.  Oligcemia,  or  a  decrease  in  the  total  quan- 
tity,—e.g.,  due  to  a  copious  hemorrhage, — persists  only  for  a  short  time 
after  the  bleeding,  as  the  volume  is  rapidly  brought  up  to  its  normal 
standard  by  the  absorption  of  fluid  from  other  tissues,  which  dilutes  the 
remaining  blood,  producing  a  condition  termed  hydrmmia  or  serous  pleth- 
ora. Rapid  abstraction  of  watery  elements  from  the  blood  by  sweating, 
diarrhoea,  or  vomiting  causes  a  transitory  increase  in  its  density,  known 
as  anhydrcemia. 

Color. — The  color  of  the  arterial  blood  is  bright  red,  due  to  the  presence 
of  a  large  amount  of  oxyha?moglobin,  while  that  of  venous  blood,  which 
contains  less  oxyhsemoglobin  and  much  carbon  dioxide,  is  dark  red  or 
purple.  In  some  pathological  states,  as  in  diabetes  mellitus  and  in  leu- 
kaemia, the  blood  often  has  a  milky  tint;  a  peculiar  chocolate  color  is  some- 
times imparted  to  the  blood  by  poisoning  with  potassium  chlorate,  nitro- 
benzol,  and  hydrocyanic  acid.  Imperfect  aeration,  encountered  in  some 
diseases  of  the  respiratory  organs  and  heart  and  in  chronic  polycythsemia 
with  splenic  enlargement  (Osier's  disease),  causes  dark  red  blood  similar  to 
the  color  of  venous  blood.    In  carbon  monoxide  poisoning  it  is  bright  scarlet. 

Reaction. — The  reaction  of  normal  blood  is  alkaline.  The  degree  of 
alkalescence  varies  considerably  both  in  health  and  in  disease.  None  of 
the  methods  of  determining  the  intensity  of  this  reaction  has  been  gen- 
erally adopted  for  routine  cHm'cal  purposes,  and,  as  the  results  of  various 
methods  are  not  uniform,  comparative  studies  by  different  observers  are 
in  the  main  inaccurate.  The  adoption  of  some  standard  technic  may 
establish  definite  results,  but  up  to  the  present  time  the  data  bearing 
upon  this  subject  are  insufficient  to  warrant  positive  opinions.  Statistics 
indicate  that  the  alkalinity  is  lowered  in  many  pathological  conditions, 
notably  in  diabetic  coma,  in  many  of  the  infectious  diseases,  especially 
in  Asiatic  cholera,  in  organic  hepatic  disease,  in  uraemia,  in  cachectic  states, 
in  a  considerable  group  of  skin  affections,  in  poisoning  by  mineral  acids,  and 
in  a  number  of  other  conditions.  In  chlorosis  and  rheumatic  fever  it  has 
been  found  increased. 

Specific  Gravity.  —  The  specific  gravity  of  normal  blood  is  about 
1.060.  It  fluctuates  sHghtly  in  health,  while  in  disease  there  are  wide 
oscillations.  The  specific  gravity  range  is  decidedly  influenced  by  the 
amount  of  haemoglobin,  and  so  close  is  the  relation  between  the  two  that 
an  approximate  haemoglobin  estimation  can  be  made  by  determining 
its  specific  gravity.  Exceptions  to  this  rule  are  found  in  the  case  of  leu- 
kaemia, in  which  the  range  of  specific  gravity  would  indicate  a  higher 
haemoglobin  value  than  actually  exists,  while  in  pernicious  anaemia  the 
reverse  is  true. 


EXAMINATION  OF  THE  BLOOD.  253 

Coagulation  of  the  Blood.  —  Within  a  short  time  after  blood  has 
been  withdrawn  from  the  circulation  of  a  healthy  individual,  it  under- 
goes coagulation,  a  process  which  determines  the  formation  of  fibrin  and 
the  separation  of  a  clear,  straw-colored  fluid,  the  blood-serum.  In  a  num- 
ber of  diseases  considerable  importance  is  attached  to  the  determination 
of  the  time  required  for  clotting.  Delayed  coagulation  is  encountered 
in  persons  suffering  from  obstructive  jaundice,  purpura,  scurvy,  and  hfiemo- 
philia.  In  pernicious  anaemia,  in  some  cases  of  leukaemia,  and  at  times 
in  Hodgkin's  disease,  the  rate  of  coagulation  is  prolonged.  In  some  of 
the  infectious  fevers,  and  in  acute  inflammation  attended  with  abscess 
formation,  clotting  is  retarded,  while  in  chlorosis,  pneumonia,  and  scarlet 
fever  it  is  rapid. 

The  Plasma. — The  plasma,  a  complex  albuminous  body,  which  holds 
in  suspension  the  solid  elements  and  in  solution  many  organic  and  inor- 
ganic compounds,  is  the  vehicle  through  which  substances  are  transported 
to  the  tissues  and  waste  products  carried  to  the  excretory  organs.  The 
plasma  also  holds  certain  bodies  possessing  antitoxic,  bactericidal,  ag- 
glutinative, and  opsonic  properties.  Agglutinins  are  of  importance  in 
the  diagnosis  of  many  infectious  diseases,  as  in  enteric  fever,  paratyphoid 
infections,  Malta  fever,  cholera,  relapsing  fever,  and  dysentery.  Some 
observers  have  noted  this  reaction  in  tuberculosis,  pneumococcus  and 
streptococcus  infections,  plague,  and  leprosy. 

Erythrocytes.  —  The  red  blood-corpuscles  in  a  preparation  of  fresh 
blood,  taken  from  the  peripheral  circulation  of  a  healthy  person,  appear 
as  pale  yellowish-green,  non-nucleated,  flattened,  biconcave  cells  of  a 
circular  outline.  They  are  pliable,  somewhat  elastic,  non-amoeboid,  trans- 
parent, and  show  a  tendency  to  form  into  groups  or  rolls  when  withdrawn 
from  the  circulation,  and  consist  of  a  fine  stroma  which  holds  an  albu- 
minous iron  compound,  the  haemoglobin.  Structural  alterations  of  these 
cells  occur  when  blood  is  removed  from  the  circulation.  They  occasion- 
ally exhibit  amoeboid  activity  and  may  undergo  disintegration,  fragmen- 
tation, vacuolation,  and  crenation.  A  crenated  corpuscle  is  a  shrunken 
cell  from  which  knob-Hke  processes  project.  Structural  alterations  similar 
to  those  caused  by  withdrawing  the  blood  from  the  vessels  occur  within 
the  circulation  as  a  result  of  pathological  factors. 

Staining  Reaction  of  the  Erythrocyte.  —  The  normal  red  blood-cell, 
when  properly  fixed,  has  a  monochromatophilic  reaction,  showing 
a  selective  affinity  for  acid  dyes,  while  the  Hving  cell  does  not  absorb 
stains  (achromatophilic).  On  account  of  its  biconcavity,  the  central 
part  of  the  cell  stains  less  intensely  than  the  peripheral  zone.  The  long 
diameter  of  the  majority  of  the  healthy  cells  measures  about  7.5  microns, 
while  its  variations  are  between  6  and  9  microns. 

Haemogenesis  and  Haemolysis. — It  appears  to  be  definitely  established 
that  in  the  adult  the  red  bone-marrow  is  the  chief,  if  not  the  only  seat 
of  erythrocytic  formation.  The  colored  cells  develop  from  nucleated 
elements,  erythroblasts,  situated  along  the  walls  of  capillary  spaces  of 
the  marrow.  Some  authorities  contend  that  erythroblasts  and  certain 
forms  of  immature  leucocytes  are  derived  from  a  common  ancestral  cell. 
The  spleen   and  lymphatic   glands   are  regarded   by  some  as  sources  of 


254  MEDICAL  DIAGNOSIS. 

erythrocytic  formation,  a  view  which  is  not  entertained  by  man}^  writers. 
The  fairly  uniform  number  maintained  in  the  circulating  blood  of  the 
healthy  individual  depends  upon  the  existence  of  a  parallelism  between 
the  rate  of  formation  and  the  rate  of  destruction.  Pathological  erythro- 
cytic destruction,  unless  excessive  or  prolonged,  excites  augmentation 
in  the  activity  of  erythroblastic  multiplication  and  is  followed  by  an 
increase  in  the  output  of  red  cells  from  the  marrow.  Most  authorities 
maintain  that  the  liver  and  in  a  less  degree  the  spleen  and  the  gastro- 
intestinal capillary  area  are  concerned  in  destroying  weakened,  degener- 
ated, or  necrotic  cells,  while  some  hold  that  the  bone-marrow  also  has  a 
hsemolytic  function.  The  coloring  material  derived  from  the  disintegrated 
cells  is  in  part  transformed,  in  the  liver,  into  bile  pigment  and  eliminated 
through  the  biliary  channels,  in  part  discharged  by  the  kidneys,  and  prob- 
ably, to  a  considerable  extent,  stored  up  in  many  of  the  tissues  where  it- 
is  available  for  future  needs  of  the  body. 

Number  of  Red  Blood=ceIls.  —  The  normal  number  of  erythrocytes^ 
which  is  5,000,000  per  cubic  millimetre  for  an  adult  male  and  4,500,000' 
for  an  adult  female,  is  subject  to  slight  variations  under  certain  phys- 
iological conditions  and  to  pronounced  alterations  in  many  morbid  states.. 
A  decrease  in  the  number  is  termed  oligocythcemia,  while  an  increase 
is  designated  folycythamia.  High  counts  are  at  times  an  indication  of  a 
decrease  in  the  volume  of  plasma  causing  a  relative  polycythsemia.  After 
blood  transfusion,  and  after  active  blood  regeneration,  a  temporary  rise 
may  be  noted.  Polycythsemia  is  encountered  in  the  new-born,  where  it 
exists  for  some  days  after  birth — probably  not  exceeding  ten — in  indi- 
viduals residing  in  high  altitudes,  and  in  robust  and  well-developed  per- 
sons. Massage,  electricity,  and  cold  bathing  may  also  induce  an  increase 
in  the  erythrocytes  in  the  peripheral  blood.  A  slight  reduction  in  the 
erythrocytes  is  brought  about  by  pregnancy,  menstruation,  and  lactation; 
it  is  also  met  with  in  poorly  nourished  individuals,  in  those  who  are 
fatigued,  and  during  the  period  of  digestion.  Oligocythaemia,  due  tc^ 
physiological  causes,  may  sometimes  be  accounted  for  by  temporary  dilu- 
tion of  the  blood,  while  in  other  instances  an  absolute  decrease  in  the 
number  of  cells  offers  the  best  explanation. 

In  pathological  states  a  relative  transitory  increase  arises  when  the 
output  of  fluid  from  the  body  is  decidedly  in  excess  of  the  intake,  and 
is  therefore  conspicuous  in  diseases  associated  with  marked  polyuria,  as 
diabetes,  with  copious  sweating,  as  from  night  sweats  of  pulmonary  tuber- 
culosis, with  frequent  vomiting,  with  profuse  diarrhoea,  as  in  Asiatic  cholera,, 
and  after  the  withdrawal  of  a  large  quantity  of  fluid  from  a  serous  cavity, 
which  rapidly  reaccumulates,  thereby  draining  the  blood  of  much  fluid. 
The  pathological  factors  responsible  for  oligocythaemia  are  numerous, 
and  in  the  vast  majority  of  diseases  associated  with  lowered  counts  the 
reduction  depends  upon  increased  blood  destruction,  in  some  it  may  be 
due  to  defective  blood  formation,  or  to  a  combination  of  both  of  these 
factors,  while  in  others  a  slight  transitory  decrease  is  brought  about  by 
blood  dilution — whenever  the  amount  of  fluid  taken  into  the  body  is 
above  the  output  of  liquid.  Lowered  erythrocytic  standards  are  noted 
in  the  primary  anaemias,  notablj''  pernicious  anaemia,  in  which  the  figure 


EXAMINATION  OF  THE  BLOOD.  255 

often  falls  as  low  as  one  million,  and  in  occasional  instances  below  half 
a  million.  Secondary  anaemias  arise  from  a  great  variety  of  causes,  as 
from  infections  due  to  bacteria  and  animal  parasites,  metallic  poisoning, 
organic  visceral  disease,  hemorrhage,  and  many  others. 

The  Haemoglobin.  —  Haemoglobin,  a  complex  albuminous  compound 
containing  iron  which  is  a  component  of  the  red  cells,  normally  exists 
in  two  chemical  states,  in  combination  with  oxygen  (oxj^hsemoglobin) 
and  as  reduced  or  plain  haemoglobin.  Normal  blood  contains  about  14 
per  cent,  of  haemoglobin.  A  reduction  of  hasmoglobin,  termed  oligochromce- 
mia,  is  generally  associated  with  a  fall  in  the  number  of  erj'throcytes. 
This  deficiency  of  corpuscles,  as  a  rule,  is  not  so  marlced  as  the  haemo- 
globin loss,  although  sometimes  the  number  of  colored  elements  remains 
normal;  rarely  there  is  a  proportionate  reduction  of  the  coloring  matter 
and  of  the  number  of  cells,  or  the  latter  may  even  show  a  greater  percent- 
age reduction  than  the  haemoglobin.  An  insufficient  amount  of  haemo- 
globin in  the  corpuscles  is  brought  about  by  an  elfort  on  the  part  of  the 
bone-marrow  to  rapidly  regenerate  cells  at  the  expense  of  perfect  forma- 
tion (i.e.,  after  or  during  rapid  haemolysis).  A  high  color  index  occurs  in 
pernicious  anaemia.  Investigations,  both  experimental  and  clinical,  have 
demonstrated  that  the  haemoglobin  rises  in  certain  anaemic  states  by  the 
administration  of  iron  compounds. 

Hcemoglohincemia,  the  term  which  implies  the  presence  of  haemo- 
globin in  solution  in  the  plasma,  is  due  to  a  number  of  causes,  and  is  at 
times  followed  by  the  excretion  of  haemoglobin  by  the  kidneys  (haemo- 
globinuria).  The  disease  known  as  paroxysmal  haemoglobinuria  is  a 
striking  example  of  the  latter  condition.  Among  the  conditions  capable 
of  producing  haemoglobinaemia  are  poisoning  by  sulphuric  acid,  nitro- 
benzol,  phenacetin,  acetanilid,  phenol,  hydrochloric  acid,  potassium  chlorate, 
mushrooms,  and  snake  venoms.  Haemoglobinaemia  is  excited  by  some  of 
the  infectious  diseases,  as  malarial  fever,  enteric  fever,  j^ellow  fever,  typhus 
fever,  variola,  septicaemia,  diphtheria,  and  syphilis;  also  by  malignant 
jaundice,  scurvy,  sunstroke,  burns,  and  from  exposure  to  intense  cold. 

M ethcemoglohin ,  another  combination  of  oxygen  and  hiemoglobin, 
is  a  component  of  some  pathological  bloods  and  is  present  in  poisoning 
with  such  substances  as  potassium  chlorate,  aniline,  amyl  nitrite,  potas- 
sium permanganate,  antifebrin,  nitro-benzol,  hydrochinone,  potassium  ferro- 
cyanide,  and  snake  venom.  Carbon  monoxide  haemoglobine,  which  occurs 
in  coal-gas  poisoning,  gives  the  blood  a  bright  scarlet  appearance. 

Abnormal  Erythrocytes.  —  Cells  exhibiting  abnormal  variations  in 
size  are  common  in  anaemic  states,  particularly  small  erythrocytes  known 
as  microcytes,  which  have  a  diameter  of  less  than  6  microns,  and  when 
these  forms  predominate  in  the  blood  the  condition  is  termed  microcytosis 
or  microcyihcemia.  This  change  is  conspicuous  in  chlorosis  and  in  some 
secondary  anaemias  of  the  chlorotic  type.  Minute  erythrocytes,  spherical 
in  form,  with  a  deeply  colored  protoplasm,  are  often  described  as  Eich- 
horst's  corpuscles.  Cells  measuring  more  than  9  microns  are  designated 
macrocytes,  and  when  these  abnormally  large  forms  outnumber  other 
colored  elements  macrocytosis  or  macrocythdmia  exists.  Typical  cases 
of  pernicious  anaemia  show  an  average  increase  in  the  size  of  the  red  cells. 


256  MEDICAL  DIAGNOSIS. 

Kapid  or  defective  blood  formation  has  been  advanced  as  the  factor 
responsible  for  microcytosis,  although  structural  alteration  in  the  cells 
after  they  have  entered  the  circulation,  such  as  fragmentation  and  loss 
of  haemoglobin,  maj^  account  for  some  of  these  dwarfed  elements.  Macro- 
cytosis  appears  to  depend  upon  the  development  of  large  cells  in  the  mar- 
row, or  perhaps  it  is  due  to  swelling  of  the  protoplasm  of  the  erythrocytes 
while  in  the  general  circulation. 

Poikilocytes  are  cells  having  an  irregular  or  distorted  outline  and 
often  appear  as  pear-shaped,  elongated,  oval,  and  "hour-glass"  forms. 
These  pathological  cells  show  wide  variations  in  size  and  in  staining  pecu- 
liarities. The  degree  of  cell  deformity  and  the  extent  of  the  variation  in 
size  are  generally  proportionate  to  the  severity  of  the  aneemia.  Per- 
nicious anaemia  and  grave  secondary  anaemias  reveal  poikilocytosis  in 
its  most  typical  form.  Cells  so  deficient  in  haemoglobin  that  a  mere  color- 
less shell  remains  are  termed  phantom  or  shadow  corpuscles  or  achroma- 
cytes.  Erythrocytes  which  react  indifferently  and  irregularly  to  acid  and 
basic  dyes,  staining  diffusely  with  both, — termed  polychroinatophUic  cells, — ■ 
are  observed  in  profound  anaemias,  particularly  in  progressive  pernicious 
anaemia.  The}^  appear  in  specimens  stained  with  eosin-methylene-blue 
mixtures,  as  purple,  brownish,  or  bluish  cells,  their  color,  as  a  rule,  being 
unevenly  distributed,  and  in  some  instances  only  a  part  of  the  protoplasm 
exhibits  this  altered  tinctorial  reaction.  The  cj^toplasm  of  nucleated 
red  cells,  especially  of  the  megaloblast,  often  shows  this  change.  Some 
authorities  maintain  that  this  abnormal  staining  quality  is  an  indication 
of  immature  cell  development,  while  others  regard  it  as  a  sign  of  stroma 
degeneration.  Oval  or  "ring-like"  bodies  reacting  to  basic  dyes  are  occa- 
sionally observed  in  the  red  cells  which  some  students  assert  are  the  remains 
of  a  nuclear  structure.  Red  cells  which  contain  granular  areas  having 
a  basic  stain  affinity  scattered  through  the  cytoplasm,  appearing  in  some 
corpuscles  as  a  fine  stippling  and  in  others  as  coarse  irregular  granules,  are 
described  as  cells  showing  granular  basophilia.  This  condition  is  observed 
in  severe  anaemias,  especially  of  the  pernicious  type,  in  leukaemia,  and 
constantly  in  chronic  lead  poisoning.  Some  investigators  regard  it  as  an 
indication  of  degeneration  of  the  cells,  while  others  are  inclined  to  view 
this  feature  as  an  evidence  of  nuclear  fragmentation. 

Nucleated  Red  Blood-cells.  —  Nucleated  red  blood-corpuscles 
are  normally  found  in  the  blood  during  the  early  months  of  fetal  life  and 
in  the  blood-marrow  of  all  individuals.  Two  principal  types  are  found, 
normoblasts   and   megaloblasts. 

Normoblasts.  —  This  cellular  element,  a  normal  constituent  of  the 
bone-marrow  of  the  healthy  adult,  is  about  the  size  of  the  normal  erythro- 
cyte, and  consists  of  a  single  oval  or  round  nucleus  (rarely  two  or  three), 
which  reacts  intensely  to  basic  stains,  while  the  cytoplasm  has  an  acido- 
philic affinity  like  a  normal  erythrocyte.  At  times  this  cell  contains  an 
irregularly  shaped  nucleus  or  several  may  be  noted  in  a  single  cell.  The 
nucleus  is  often  eccentrically  placed,  and  sometimes  extrudes  from  the 
cell  or  may  be  found  free  in  the  plasma.  The  occurrence  of  normoblasts 
in  the  circulation  of  the  adult  is  generally  regarded  as  a  sign  of  rapid  blood 
regeneration,  well  illustrated  after  a  profuse  traumatic  hemorrhage,  where 


EXAMINATION  OF  THE  BLOOD.  257 

large  numbers  of  these  cells  often  are  present  in  the  blood,  a  condition 
which  Von  Noorden  has  termed  "blood  crisis."  Cells  having  the  diameter 
ranging  from  4  to  6  microns,  with  a  round  or  oval  nucleus  reacting  sharply 
to  basic  dyes,  and  a  shrunken  irregular  protoplasm,  called  microblasts, 
probably  represent  normoblasts  having  a  degenerated  cytoplasm.  Megal- 
ohlasts  "^ry  in  size  between  1 1  and  20  microns  in  diameter,  and  consist 
of  a  large  nucleus  of  loose  texture  staining  feebly,  surrounded  by  a  com- 
paratively small  amount  of  cytoplasm.  A  clear  hyaline  space  or  ring 
sometimes  separates  the  nucleus  from  the  protoplasm,  which  not  infre- 
quently has  a  polychromatophilic  reaction.  Fetal  bone-marrow  normally 
contains  megaloblasts.  Most  writers  regard  the  presence  of  megaloblasts  in 
the  circulating  blood  of  the  adult  an  indication  of  a  reversion  of  the  marrow 
activity  to  an  earlier  type  similar  to  that  found  in  the  foetus.  These  cells 
are  found  in  grave  forms  of  anaemia,  as  typified  in  pernicious  ana?mia. 

Blood=plateIets. — Blood-platelets,  or  blood-plaques,  are  small,  spher- 
ical, oval,  or  irregular  bodies,  having  a  pale  yellowish  color,  and  measure 
from  1  to  4  microns  in  diameter.  They  are  not  endowed  with  amoeboid 
activity,  and  stain  with  both  acid  and  basic  dyes.  Blood-plaques  disap- 
pear rapidly  after  the  blood  is  exposed  to  the  air.  Some  writers  con- 
sider these  elements  as  being  derived  from  fragmented  red  blood-cells. 
The  investigations  of  J.  H.  Wright  indicate  that  they  represent  broken- 
off  pieces  of  processes  of  giant  marrow  cells.  Hayem's  hypothesis  that 
the  blood-plates  develop  into  erythrocytes  is  rejected  by  most  authorities. 
Counts  in  the  neighborhood  of  30,800  per  cubic  milHmetre  are  consid- 
ered normal.  Variations  under  physiological  and  pathological  influences 
are  common.  In  many  severe  secondary  anaemias,  in  leukaemia,  in  chloro- 
sis, and  in  rheumatoid  arthritis  an  increase  is  encountered,  while  in  per- 
nicious anaemia  their  number  is  generally  reduced.  In  some  of  the  specific 
infectious  diseases,  particularly  in  pneumonia,  in  tuberculosis,  and  in 
bubonic  plague,  an  increase  is  found,  while  in  others,  notably  in  erysip- 
elaS;  in  malaria,  and  in  typhus  fever,  there  is  a  decrease.  A  marked  reduc- 
tion is  frequently  seen  in  purpura  and  haemophilia. 

Haemokonia. — In  fresh  unstained  blood  there  are  found,  in  the  plasma, 
;small,  transparent,  highly  refractile  bodies,  not  exceeding  one  micron  in 
diameter,  of  spherical,  oval,  or  dumb-bell  shape,  possessing  active  molec- 
ular motion,  which  are  termed  haemokonia,  or  blood  dust.  These  bodies 
are  insoluble  in  ether  or  alcohol  and  do  not  stain  with  osmic  acid.  Their 
significance  is  as  yet  unknown ;  it  has  been  suggested  that  they  represent  frag- 
ments of  cells  or  free  cell  granules,  as  eosinophilic  or  neutrophilic  granules. 

Leucocytes. — The  leucocytes,  or  white  blood-corpuscles,  in  a  wet  prepa- 
ration of  fresh  blood  taken  from  a  normal  individual,  appear  as  pale,  color- 
less, nucleated  cells,  the  greater  number  of  which  are  granular  and  endowed 
with  amoeboid  activity.  Ehrlich's  classification  is  generally  adopted  for 
clinical  work.  The  following  table  includes  the  main  varieties  of  leucocytes 
with  their  relative  percentages  present  in  the  blood  of  the  normal  adult: 

Polynuclear  neutrophiles 60-70  per  cent. 

Eosinophiles 5-  4  per  cent. 

Basophiles  or  mast-cells 025-  .5  per  cent. 

Small  lymphocytes 20-30  per  cent. 

Large  lymphocytes,  hyaline  cells,  and  transitional  forms. .        4-  8  per  cent. 
17 


258  MEDICAL  DIAGNOSIS. 

In  infancy  the  percentage  of  lymphocytes  is  greater  than  in  adult 
life,  while  eosinophiles  may  reach  as  high  as  14  per  cent,  in  childhood. 

Polynuclear  Neutrophiles. — These  cells,  the  diameter  of  which  ranges 
between  7h  and  11  microns,  have  an  irregular  nucleus,  appearing  in  various 
shapes,  as  in  the  form  of  the  letters  U,  Z,  S,  and  a  finely  granular  pro- 
toplasm. The  irregularly  shaped  nucleus,  which  is  composed  of  enlarge- 
ments or  lobes  connected  by  bands,  reacts  to  basic  dyes  with  marked 
affinity.  The  granules  are  fine,  of  an  irregular  outline,  and  absorb  acid 
dyes  (finely  granular  oxyphile  cells).  According  to  Ehrlich,  the  granules 
have  a  neutral  staining  property.  The  polynuclear  neutrophiles  possess 
amoeboid  and  phagocytic  properties. 

Eosinophiles  or  polynuclear  eosinophiles  (coarsely  granular  oxyphiles) 
are  about  the  size  of  or  slightly  larger  than  the  normal  erythrocyte, 
their  diameter  ranging  from  7  to  10  microns.  They  possess  a  nucleus 
similar  in  structure  and  tinctorial  qualities  to  that  of  the  polynuclear 
neutrophile;  their  protoplasm  contains  coarse,  highly  refractile,  oval  or 
spherical  granules,  staining  deeply  with  acid  dyes.  They  are  endowed 
with  active  amoeboid  qualities. 

Basophiles  or  Mast=cens. — Under  this  term  are  classified  leucocytes 
which  have  a  lobed  or  twisted  nucleus  like  that  of  the  neutrophiles  and  a 
cytoplasm  beset  with  very  irregularly  shaped  basophilic  granules  of  varying 
size.  The  granules  are  not  colored  with  Ehrlich's  triple  stain,  but  may  be 
plainly  seen  when  treated  with  Leishman's  or  Ehrlich's  dahlia  mixture. 

Small  Lymphocytes.  —  These  are  essentially  non-granular  cells,  the 
majority  being  about  the  size  of  the  normal  erythrocyte.  They  consist 
of  a  large  circular  or  oval  nucleus,  which  has  a  decided  basic  property 
and  a  relatively  small  amount  of  protoplasm,  reacting  feebly  to  basic 
and  occasionally  to  acid  stains.  With  Ehrlich's  triple  stain,  the  cytoplasm 
is  colored  a  pale  pink  or  gray,  while  with  Leishman's  eosin-methylene- 
blue  mixture,  a  fight  blue,  showing  less  basic  affinity  than  the  nucleus. 
Lymphocytes  treated  with  I^eishman's  stain  occasionally  show  a  few 
fine  pink  granules  in  their  cytoplasm.  These  cells  are  neither  amoeboid 
nor   phagocytic. 

Large  Lymphocytes.  —  Several  varieties  of  leucocytes  are  embraced 
under  this  heading — lymphocytes  proper  of  large  size,  generally  regarded 
as  the  product  of  lymphatic  tissue,  and  large  mononuclear  or  hyaline  cells, 
probably  of  bone-marrow  origin.  A  distinction  cannot  always  be  made 
between  large  lymphocytes  and  hyaline  cells,  since  they  resemble  each 
other  as  to  structure  and  tinctorial  reactions.  The  nucleus  of  the  latter 
cell  Is  round  or  oval.  The  protoplasm  of  the  lymphocyte  has  a  sHghtly 
stronger  basic  affinity  than  that  of  the  large  mononuclear.  From  a  clinical 
standpoint  this  differentiation  does  not  appear  important.  The  large 
lymphocytes  have  a  relatively  smaller  nucleus  than  the  small  forms,  and 
stain  less  intensely.  Transitional  forms  closely  resemble  large  lympho- 
cytes and  hyaline  cells  in  size  and  staining  quafities,  but  differ  from 
these  leucocytes  in  having  an  indented  or  distorted  nucleus,  resembling 
the  form  of  the  nucleus  of  some  of  the  polynuclear  neutrophiles. 

Hyaline  cells  are  said  to  possess  active  phagocytic  and  amoeboid 
properties. 


DESCRIPTION  OF  PLATE  IV. 

1.  Neutrophile  myelocyte. 

2.  Neutrophile  myelocyte  showing  indentation  of  its  nucleus. 
3,  4.  Neutrophile  myelocytes. 

5,  6,  7,  8,  9, 10.  Polynuclear  neutrophiles. 
11,  12.  Eosinophlle  myelocytes. 
13,  14,  15,  16.  Polynuclear  eosinophiles. 
17.  Basophile  myelocyte. 
18, 19.  Polynuclear  basophiles. 

20.  Blood  platelets. 

21.  Large  mononuclear  form. 
22,  23.  Transitional  forms. 

24,  25.  Large  lymphocytes. 

26.  Lymphocyte  showing  acidophilic  granules  in  its  protoplasm. 
27,  28,  29.  Small  lymphocytes. 
30,  31,  32.  Normal  erythrocytes. 
33,  34.  Mlcrocytes. 
35.  Macrocyte. 
36,  37,  38,  39,  40,  41.  Poikilocytes. 

42,  43,  44,  45.  Erythrocytes  containing  basophilic  granules. 

46.  Erythrocyte  exhibiting  polychromatophilia  and  granular  basophilia. 

47.  Megaloblast. 
48,  49,  50.  Normoblasts. 

51,  52,  53.  Erythrocytes  with  polychromatophilic  protoplasm. 


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EXAMINATION  OF  THE  BLOOD.  259 

Myelocytes. — These  cells,  which  are  normal  constituents  of  the  bone- 
marrow  and  only  present  in  the  blood  in  pathological  states,  are  in  the 
main  large  cells  supplied  with  a  large  circular,  oval,  or  slightly  indented 
nucleus,  staining  feebly  with  basic  principles,  and  surrounded  by  a  granular 
protoplasm. 

These  cells  are  classified  into  three  groups,  depending  on  the 
microchemical  reaction  of  the  cell-granules,  namely  into  neutrophilic, 
eosinophilic,  and  basophilic  varieties.  The  neutrophilic  myelocyte  is  the 
commonest  form.  Neutrophilic  granules  of  myelocytes  do  not  stain  as 
distinctly  as  those  found  in  the  polynuclear  cells.  Types  intermediate 
between  typical  polynuclear  neutrophiles  and  typical  neutrophilic  myelo- 
cytes are  observed  in  some  pathological  conditions,  especially  myelogenous 
leukaemia  and  not  infrequently  in  leucocytosis.  Myelocytes  often  show 
indistinct  granulations  embedded  in  a  feebly  basic  protoplasm;  these 
forms  are  considered  by  some  to  be  closely  related  to  cells  farther  back 
in  their  ancestral  development. 

There  are  a  number  of  special  varieties  of  leucocytes  described  by 
different  authors  which  are  occasionally  detected  in  blood-films  and 
probably  represent  atypical  forms.  Because  of  their  uncommon  occur- 
rence and  difficulty  of  recognition,  these  cells  will  merely  be  mentioned. 

Atypical  lymphocytes  are  not  infrequently  encountered  in  severe 
anaemias,  particularly  in  lymphatic  leukaemia.  Some  of  these  cells  are 
almost  devoid  of  protoplasm,  while  others  contain  a  distorted  nucleus. 
The  term  neutrophilic  pseudolymphocyte  has  been  suggested  for  those 
cells  which  have  a  round  nucleus,  rich  in  chromatin,  surrounded  by  a 
narrow  rim  of  protoplasm,  filled  with  neutrophilic  granules.  These 
leucocytes  may  represent  small  myelocytes,  as  their  color  character- 
istics, excluding  the  strong  basic  nucleus,  suggest  neutrophile  myelo- 
cytes. Tiirk  employs  the  name  "stimulation  form"  for  moderately 
large  leucocytes  having  a  single  round  weakly  basophilic  nucleus,  and 
a  non-granular  cytoplasm,  which  stains  a  brown  color  with  the  triple 
mixture. 

Development  of  Leucocytes. — Most  authorities  regard  the  bone-mar- 
row and  the  lymphatic  tissues  as  the  seats  of  leucocyte  formation,  the 
former  being  concerned  in  the  development  of  polynuclear  neutrophiles, 
eosinophiles,  basophilic  and  hyaline  cells,  while  the  latter  appear  respon- 
sible for  the  production  of  lymphocytes.  In  the  bone-marrow  are  found 
groups  of  cells,  " leucoblastic  areas,"  consisting  of  myelocytes  surrounded 
by  polynuclear  elements,  while  erythroblastic  zones  are  present  princi- 
pally along  the  margins  of  vascular  spaces.  It  is  conceded  by  most  author- 
ities that  the  polynuclear  neutrophile  is  developed  from  the  neutrophile 
myelocyte,  the  polynuclear  eosinophile  from  the  eosinophile  myelocyte, 
and  a  basophilic  cell  from  its  parent  marrow  cell.  In  the  transformation 
of  the  myelocyte  into  the  polynuclear  leucocyte,  the  nucleus  undergoes 
condensation  and  lobulation,  the  size  of  the  cell  decreases,  and  the  stain- 
ing reaction  of  the  nucleus  and  of  the  granules  intensifies.  The  large 
mononuclear  or  h3^aline  and  transitional  leucocytes  are  probably  formed  in 
the  marrow.  The  lymphocytes  are  derived  from  lymphatic  tissue,  the 
small  form  being  the  progeny  of  the  large  cell. 


260  MEDICAL  DIAGNOSIS. 

Number  of  Leucocytes.  —  Many  circumstances  affect  the  number 
of  leucocytes  in  the  circulation.  The  colorless  corpuscles  range  between 
6000  and  8000  per  cubic  millimetre  in  a  healthy  person;  this  standard 
is,  however,  subject  to  slight  variations,  beyond  these  limits,  in  certain 
physiological,  and  often  to  pronounced  alterations  in  pathological  states. 
The  number  is  influenced  by  the  condition  of  body  nutrition,  e.g.,  in  pro- 
longed starvation  low  counts  are  conspicuous,  by  unequal  distribution 
of  the  cells,  by  blood  dilution  and  by  blood  inspissation.  The  most  ac- 
ceptable theory,  advanced  to  explain  the  occurrence  of  an  increase  in  the 
number  of  colorless  elements  (leucocytosis)  in  disease,  points  out  that 
irritants  acting  in  the  tissues  produce  chemical  substances  which  attract 
certain  leucocytes  towards  the  seat  of  mischief,  and  cause  the  leucocyte 
forming  organs  to  pour  out  an  increased  number  of  cells.  This  attraction 
force  has  been  termed  "'positive  chemotaxis,"  in  contradistinction  to  a 
repelling  action  set  up  by  some  irritants  called  '^negative  chemotaxis." 
The  degree  of  leucocytosis  depends  mainly  upon  the  intensity  of  the  chemo- 
tactic  force  and  the  responding  powers  of  the  individual. 

Leucocytosis. — The  term  leucocytosis  or  hyperleucocytosis  designates 
an  increase  in  the  number  of  leucocytes  in  the  peripheral  blood  over  the 
normal  standard.  This  increase,  as  a  rule,  involves  a  marked  percentage 
gain  in  the  polynuclear  neutrophile  elements  with  a  fall  in  the  percentage 
of  other  forms,  but  sometimes  comprises  a  proportionate  rise  in  all  the 
varieties,  or  a  percentage  gain  in  the  lymphocytes,  eosinophiles,  or  baso- 
phils. Leucocytosis  is  classified  into  special  forms,  depending  on  physi- 
ological or  pathological  disturbances;  these  types  being  further  subdivided 
into  special  varieties,  dependent  upon  certain  etiological  factors,— e.g-., 
digestive,  inflammatory,  toxic,  malignant,  and  post-hemorrhagic  leucocy- 
tosis. A  rise  in  the  number  of  polynuclear  neutrophile  cells  is  called  polynu- 
clear neutrophile  leucocytosis;  an  augmentation  in  lymphocytes  is  termed 
lymphocytosis;  an  increase  of  eosinophiles  is  known  as  eosinophilia;  the 
latter  forms  also  being  sub-grouped  into  (a)  an  absolute  and  (b)  a  relative 
increase;  e.g.,  absolute  lymphocytosis  is  shown  by  a  gain  in  the  total  count 
with  a  rise  in  the  percentage  of  lymphocytes,  while  relative  lymphocytosis 
implies  a  percentage  gain  without  an  increase  in  the  total  number  of  these 
cells.  The  terms  absolute  and  relative  as  applied  to  leucocytosis  are  often 
misleading  to  the  student. 

Physiological  Leucocytosis. — The  leucocytosis  which  depends  upon  phys- 
iological factors  is,  in  the  main,  slight,  of  short  duration,  and  commonly 
involves  a  proportionate  increase  in  all  of  the  forms  of  leucocytes,  less  often 
an  absolute  and  a  relative  gain  in  the  polynuclear  neutrophile  elements. 
Leucocytosis  of  Digestion.  • —  In  nearly  all  healthy  individuals, 
during  the  period  of  digestion,  from  one  to  four  hours  after  taking  food, 
a  slight  rise  in  the  number  of  leucocytes  is  present,  which  generally  consists 
of  an  absolute  increase.  Some  claim  that  the  gain  principally  involves 
the  neutrophiles,  while  others  assert  the  lymphocytes  are  responsible. 
In  the  new-born,  leucocytosis  of  digestion  is  pronounced.  In  starvation 
and  frequently  in  the  morbid  states  associated  with  faulty  nutrition,  the 
number  of  white  corpuscles  decreases.  The  rapidity  with  which  digestion 
leucocytosis  manifests  itself  after  taking  food  is  regarded  by  some  writers 


EXAMINATION  OF  THE  BLOOD.  261 

as  bearing  a  direct  relation  to  the  activity  of  the  digestive  function.  In 
persons  suffering  from  gastric  ulcer,  leucocytosis  sometimes  comes  on  very 
soon  after  taking  food,  pointing  to  rapid  digestion;  while  in  gastric  cancer, 
it  may  be  delayed  or  absent.  This  rule  is  not  constant  and  httle  importance 
should  be  attached  to  digestion  leucocytosis  in  diagnosis. 

Leucocytosis  Occureing  during  Pregnancy  and  after  Parturi- 
tion.— A  moderate  rise  in  the  number  of  leucocytes  occurs  during  the  later 
months  of  pregnancy,*  and  persists  for  about  two  weeks  after  parturition. 

Leucocytosis  of  the  New-born. — The  high  counts  observed  for 
about  ten  days  after  birth  are  attributed  to  blood  inspissation  and  to  the 
establishment  of  digestion  leucocytosis.  Higher  counts  are  present  in 
early  childhood  than  in  the  advanced  periods  of  life.  Leucocytic  oscilla- 
tions of  a  very  moderate  character  occur  after  exercise,  massage,  after 
cold  or  hot  bathing,  and  after  the  use  of  electricity. 

Pathological  Leucocytosis.  —  Inflammatory  and  Infectious  Leuco- 
cytosis.— The  presence  or  the  absence  of  a  leucocytosis  in  many  of  the 
infectious  and  inflammatory  diseases  is  a  sign  of  considerable  importance 
in  diagnosis.  Its  clinical  value  is  comparable  in  a  measure  with  other 
signs,  such  as  temperature  range  and  pulse,  certain  physical  signs,  etc. 
This  pathological  increase,  which  is  essentially  a  polynuclear  neutrophile 
leucocytosis,  is  as  a  general  rule  encountered  in  acute  local  inflamma- 
tions, as  in  furuncles,  cellulitis,  abscesses,  in  general  sepsis,  and  in  nearly 
all  of  the  specific  infectious  diseases,  except  in  uncomplicated  cases  of 
enteric  fever,  paratyphoid  infections,  tuberculosis,  malaria,  measles, 
German  measles,  influenza,  leprosy,  and  Malta  fever.  High  leucocytic 
ranges  are  often  attributable  to  suppurative  inflammation.  Duration 
and  height  of  fever  have  no  direct  relation  to  the  leucocyte  curve.  Counts 
between  15,000  and  20,000  are  common,  while  ranges  above  30,000  are 
uncommon  and  above  50,000  very  rare. 

Preagonistic  or  Terminal  Leucocytosis.  —  The  exact  nature  of 
the  leucocytosis  which  so  often  precedes  death  is  still  a  mooted  question; 
many  investigators  attribute  this  rise  to  terminal  infections. 

Malignant  Leucocytosis. — Different  opinions  have  been  advanced 
to  explain  the  gain  of  colorless  elements  so  frequently  noted  in  individuals 
suffering  from  carcinoma  and  sarcoma.  Some  writers  contend  that  asso- 
ciated_  inflammatory  disturbance  about  the  growth  or  septic  absorption 
from  the  tumor  induces  the  leucocytic  gain,  while  others  hold  that  the 
direct  effect  of  the  tumor  is  the  responsible  factor.  In  rapidly  spreading 
malignant  growths,  especially  when  metastasis  has  occurred,  counts  are 
generally  high  and  much  above  those  noted  in  slowly  growing  tumors; 
in  sarcomata  the  gain  is  usually  more  pronounced  than  in  carcinomata. 
The  cellular  rise  in  the  majority  involves  mainly  the  neutrophiles,  although 
lymphocytosis,  especially  in  sarcomata,  has  been  recorded.  In  cases  of 
carcinoma  of  the  stomach,  leucocytosis  is  often  absent. 

Post-hemorrhagic  Leucocytosis. — The  gain  in  the  white  corpus- 
cles which  follows  and  persists  for  some  days  after  a  profuse  hemorrhage 
is  generally  accounted  for  Iiy  an  increased  production  and  output  of  poly- 
nuclear neutrophiles.  Some  observers  hold  that  the  lymph  (rich  in  cells) 
which  passes  into   the   blood   after  blood  loss  is  the  responsible  factor. 


262  MEDICAL  DIAGNOSIS. 

A  leucopenia,  lasting  for  a  few  hours,  precedes  the  leucocytosis  due  to 
hemorrhage.    Leucocytosis  is  present  in  many  cases  of  secondary  anaemia. 

Leucocytosis  due  to  Toxic  and  Therapeutic  Agents. —  Among 
the  substances  capable  of  producing  a  rise  in  the  leucocytic  standard  may 
be  mentioned  quininO;  ether,  chloroform,  potassium  chlorate,  illuminat- 
ing gas,  salicylates,  uric  acid,  and  various  organic  extracts. 

Lymphocytosis.  —  This  condition,  an  increase  of  lymphocytes,  is 
normal  in  infants  and  in  young  children.  A  relative  lymphocytosis 
due  to  diminution  of  the  polynuclear  elements  has  been  recorded  in  the 
following  conditions:  chlorosis,  pernicious  ansemia,  severe  secondary 
angemia,  and  in  some  of  the  infectious  diseases,  as  tuberculosis,  enteric 
fever,  malaria,  and  influenza.  A  lymphocytosis  is  sometimes  observed 
in  Hodgkin's  disease,  and  often  in  children  suffering  from  syphilis,  ansemia, 
pseudoleukaemia  infantum,  rickets,  whooping-cough,  and  gastro-intestinal 
diseases.  Diseases  of  the  lymphatic  glands  and  spleen  are  sometimes 
attended  by  an  increase  in  these  cells.  Lymphocytosis  in  most  instances 
is  a  relative  condition.  Absolute  lymphocytosis  of  high  grade  is  a  constant 
feature  of  lymphatic  leukaemia.  In  myelogenous  leukaemia  the  percentage 
of  lymphocytes  is  reduced,  although  the  total  number  is  increased. 

EosiNOPHiLiA. — An  increase  in  the  number  of  eosinophiles  has  been 
observed  in  the  blood  of  normal  infants,  in  anaemia  pseudoleukaemia 
infantum,  in  splenomedullary  leukaemia,  in  bronchial  asthma,  after  hemor- 
rhage, in  diseases  of  the  sldn,  as  urticaria,  lupus,  eczema,  leprosy,  and 
pemphigus,  after  coitus,  during  convalescence  from  many  of  the  acute 
infectious  diseases,  in  bone  diseases  and  in  morbid  states  caused  by 
intestinal  worms,  particularly  in  trichiniasis.  Definite  conclusions  regard- 
ing the  clinical  significance  of  fluctuations  in  these  cells  in  morbid  states 
cannot  be  drawn  from  our  present  knowledge,  although  some  diagnostic 
importance  should  be  attached  to  the  almost  constant  eosinophilia  in 
trichiniasis,  in  ankylostomiasis,   and  in  bilharzial  infection. 

Basophilia. — This  term  is  used  to  express  an  increase  in  the  number 
of  basophiles  in  the  circulating  blood,  which  is  frequently  noted  in  spleno- 
medullary leukaemia.  Some  writers  have  reported  basophilia  in  splenic 
anaemia,  in  certain  skin  diseases,  in  acute  bone  inflammation,  and  in 
gonorrhoea.     The  clinical  significance  of  basophilia  remains  unsettled. 

Leucopenia. — A  decrease  in  the  number  of  leucocytes  is  termed  leuco- 
penia,  or  hypoleucocytosis,  and  may  be  brought  about  by  physiological 
and  pathological  factors.  A  deficiency  in  the  number  of  colorless  cells 
is  seen  in  starvation  and  in  malnutrition,  and  almost  constantly  in  the 
infectious  diseases  not  associated  with  leucocytosis,  as  tuberculosis,  malaria, 
measles,  influenza,  enteric  fever,  Malta  fever,  and  German  measles.  Low 
leucocyte  counts  are  common  in  pernicious  ansemia,  in  chlorosis,  in  splenic 
anaemia,  and  in  profound  symptomatic  anaemias. 

Myelsemia. — The  appearance  of  myelocytes  in  the  blood,  spoken  of 
as  myelaemia,  points  to  rapid  leucocyte  proliferation  in  the  bone-marrow. 
Myelocytes  are  often  found  in  the  circulation  when  leucocytosis  is  present. 
In  splenomedullary  leukaemia  this  condition  is  most  striking,  in  pernicious 
ansemia,  cholorsis,  lymphatic  leukaemia,  Hodgkin's  disease,  and  in  profound 
secondary  anaemias,  a  small  number  of  myelocytes  is  not  infrequent. 


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AHOBniroBsltrrttore 


EXAMINATION  OF  THE  BLOOD.  263 

Parasites — Bacteraemia. — Bacteria  frequently  gain  access  to  the  cir- 
culation, either  from  an  infected  area  within  the  body  or  from  without. 
Bacteria  are  seldom  found  by  a  microscopical  examination  of  the  fresh 
unstained  blood;  culturing  methods  being  required  to  reveal  their  pres- 
ence. From  a  clinical  view-point  the  demonstration  of  bacteria  in  the 
circulation  may  be  regarded  as  evidence  of  disease.  The  detection  of 
micro-organisms  in  the  blood  is  often  essential  in  establishing  a  diagnosis 
of  septicaemia,  malignant  endocarditis,  puerperal  sepsis,  and  pyaemia.  In 
some  of  the  specific  infectious  diseases  the  exciting  principle  has  been 
isolated  from  the  blood.  In  over  80  per  cent,  of  the  cases  of  enteric  fever, 
Eberth's  bacillus  can  be  recovered  from  the  blood  by  culturing  methods. 
The  specific  micro-organisms  of  paratyphoid  fever,  croupous  pneumonia, 
anthrax,  glanders,  leprosy,  influenza,  plague,  tuberculosis,  and  Malta  fever 
have  been  isolated  from  the  blood.  In  septicaemia  or  septicopyaemia  staph- 
ylococci, streptococci,  and  gonococci  have  been  separated  from  the  blood. 

Recently  R.  C.  Rosenberger  discovered  tubercle  bacilli  in  the  blood  of 
fifty  cases  of  tuberculosis.  In  some  of  the  blood  spreads  examined  only  a 
few  bacilli  were  seen,  while  in  other  instances  large  numbers,  generally 
arranged  in  clumps  of  30  or  more,  were  present,  especially  in  the  cases  of 
acute  miliary  tuberculosis. 

Animal  Parasites.  —  From  our  present  knowledge  it  is  impossible  to 
fix  a  sharp  dividing  line  separating  some  of  the  lower  vegetable  and  animal 
parasites.  Investigators  seem  to  favor  placing  the  Treponema  pallidum 
and  the  spirochaeta  of  relapsing  fever  among  the  animal  parasites.  For 
a  description  of  the  animal  parasites  found  in  the  blood,  the  reader  is 
referred  to  the  section  which  deals  with  diseases  caused  by  animal  parasites. 

Method  of  Examination  for  Malarial  Parasites. — Fresh,  unstained  blood 
is  more  suitable  for  study  than  stained  blood,  because  it  enables  the 
examiner  to  observe  the  activity  of  the  parasites.  The  most  desirable 
time  for  conducting  the  examination  is  during  the  period  when  pigmented 
forms  are  present.  The  intracellular  pigmented  bodies  are  usually  most 
abundant  about  6  or  8  hours  before  a  paroxysm.  Considerable  experience 
is  necessary  before  the  various  types  can  be  differentiated;  especially  is 
this  true  of  hyaline  unpigmented  forms.  The  skilled  microscopist  must 
often  make  a  prolonged  search  before  parasites  are  detected  in  malarial 
•blood.  The  fresh  blood  is  prepared  in  the  usual  manner,  between  a  cover- 
glass  and  slide,  and  the  examination  is  made  with  an  oil-immersion  lens 
with  moderate  illumination. 


264  MEDICAL  DIAGNOSIS. 


VI. 
THE  EXAMINATION  OF  THE  URINE. 

The  essential  diagnostic  principles  of  urinalysis,  coupled  with  certain 
methods  of  examination  required  for  general  clinical  work,  are  detailed 
in  the  following  section.  Tests  suitable  for  the  general  practitioner  must 
in  the  main  be  simple  and  easily  applied.  The  importance  of  the  findings 
obtained  by  careful  and  systematic  studies  of  the  urine,  w^hen  correctly 
interpreted  and  given  their  proper  place  in  a  symptom-complex,  can  scarcely 
be  overestimated  in  diagnosis.  In  a  considerable  group  of  morbid  states 
the  urinary  picture  is  absolutely  necessary  in  establishing  a  final  diagnosis, 
while  in  a  large  number  of  cases  the  results  of  the  examination  form  a  link 
in  the  chain  of  symptoms  completing  the  diagnosis.  Negative  reports  in 
some  instances  are  essential  for  the  solution  of  certain  clinical  problems. 
For  an  exhaustive  account  of  the  urine,  which  does  not  fall  within  the  scope 
of  this  book,  the  reader  is  referred  to  special  treatises  on  this  subject. 

PHYSICAL    EXAMINATION. 

Amount. — The  daily  standard  for  a  healthy  adult,  as  estimated  by 
different  authorities,  varies  between  900  and  2000  c.c.  Most  observers 
fix  the  amount  between  1000  and  1500  c.c,  although  temporary  oscilla- 
tions beyond  these  limits,  of  slight,  moderate,  or  even  of  an  excessive  degree, 
are  often  physiological.  The  urinary  secretion  is  greater  during  the  day 
than  through  the  night,  more  abundant  in  cold  than  in  hot  weather,  and 
relatively  more  active  in  children  and  infants  than  in  adults.  Polyuria 
depends  in  the  main  on,  (a)  increased  ingestion  of  water,  (b)  heightened 
blood-pressure,  and  (c)  on  increased  activity  of  the  renal  epithehum,  while 
oliguria  results  from  (a)  lessened  consumption  of  water,  (b)  lowered  blood- 
pressure,  and  (c)  impaired  function  of  kidney  epithehum. 

Specific  Gravity. — In  health  the  specific  gravity  ranges  between  1.015 
and  1.025  while  the  daily  output  of  urine  is  within  normal  limits.  In 
general  terms  the  specific  gravity  is  a  fair  index  of  the  bulk  of  solids  elimi- 
nated. An  approximate  estimate  of  the  weight  of  urinary  sohds  expressed 
in  grammes  for  a  thousand  cubic  centimetres  of  urine  may  be  determined 
by  multiplying  the  second  and  third  decimal  figures  of  the  specific  gravity 
by  two.  Pathologically,  wide  variations,  as  low  as  1.002  and  as  high  as 
1.040,  are  frequent.  Ranges  above  1.050  are  extremely  uncommon.  The 
volume  of  urine  and  the  specific  gravity  in  the  main  fluctuate  in  an  inverse 
manner;  therefore,  without  a  knowledge  of  the  daily  output  the  density 
has  practically  no  cHnical  significance.  A  correct  specific  gravity  determi- 
nation can  only  be  made  from  a  mixed  twenty-four  hours'  sample.  In  dis- 
eases associated  with  polyuria  lowered  ranges  are  the  rule.  A  notable  ex- 
ception is  found  in  the  case  of  diabetes  mellitus,  in  which  the  increased 
density  is  caused  by  the  presence  of  glucose.  A  diminished  volume  of 
urine  of  low  specific  gravity  is  seen  in  a  number  of  chronic  diseases,  and 


EXAMINATION  OF  THE  URINE.  265 

often  in  cases  of  oedema.  Large  urinometers  are  preferable  to  small  instru- 
ments for  measuring  the  specific  gravity,  since  the  divisions  of  the  scale 
can  be  read  with  greater  accuracy.  The  large  amount  of  urine  necessary 
to  float  these  hydrometers  is,  however,  an  objectionable  feature.  This 
may  be  overcome  by  estimating  the  density  with  a  set  of  two  or  three 
pycnometers  of  moderate  size,  each  of  which  represents  a  portion  of  the 
scale.  In  measuring  the  specific  gravity  the  following  precautions  are 
essential  for  accurate  results:  The  hydrometer  should  be  placed  into  cool 
urine,  the  surface  of  which  is  free  from  foam;  the  instrument  should 
not  touch  the  sides  of  the  hydrometer  jar. 

Color. — Normal  urine  owes  its  color  to  urochrome  and  urobilin,  chiefly 
to  the  former,  while  the  tints  of  many  pathological  urines  depend  upon 
such  substances  as  biliary  pigment,  ha3moglobin,  methsemoglobin,  hsematin, 
hsematoporphyrin,  melanin,  indican  and  alkaptone.  After  the  ingestion  of 
iodine,  phenol,  salol,  senna,  santonin,  and  methylene  blue,  the  urine  often 
has  an  abnormal  hue.  The  shade  of  the  color  depends  chiefly  upon  the 
amount  of  urinary  water,  so  that  concentrated  specimens  are  usually  dark, 
while  those  of  low  specific  gravity  are  generally  pale.  An  exception  to  this 
rule  is  noted  in  diabetic  urine,  which  is  light  yellow  or  pale  greenish-yellow, 
of  increased  density  and  of  excessive  quantity.  In  acute  febrile  diseases 
and  pernicious  anaemia  the  urine  is  high  colored,  while  in  chlorosis,  dia- 
betes insipidus,  and  contracted  kidney  it  is  pale.  Bile  pigment  is  respon- 
sible for  dark  yellow,  yellowish-green,  dark  brown,  and  rarely,  black  urine, 
which  on  shaking  develops  a  yellowish  foam;  blood  pigment  stains  the 
urine  bright  red,  dark  red,  reddish-brown,  or  rarely,  black.  Melanotic 
pigment  imparts  a  brown  or  black  appearance  which  generally  develops 
some  time  after  the  urine  is  voided,  but  occasionally  is  noted  in  the  fresh 
specimen.  A  similar  color  occurs  in  alkaptonuria,  which  condition  can  be 
differentiated  from  melanuria  by  testing  with  Fehling's  solution;  the  alkap- 
tone bodies  reduce  the  copper  salt,  while  the  latter  gives  a  negative  reac- 
tion. The  ingestion  of  phenol  and  its  allied  compounds  may  cause  a  green- 
ish-black discoloration,  of  methylene  blue  a  green  or  blue  urine,  of  santonin 
a  yellow,  and  of  rhubarb  an  orange-colored  urine.  A  milky  appearance  is 
noted  in  chyluria  and  at  times  in  phosphaturia  and  pyuria.  The  presence 
of  hgematoporphyrin  may  impart  a  dark  red  color. 

Transparency.  —  Normal  urine  immediately  after  being  voided  is 
generally  clear;  on  cooling  it  occasionally  becomes  turbid,  due  to  pre- 
cipitation of  urates  or  phosphates.  Turbidity,  associated  with  a  sediment, 
is  one  of  the  characteristic  features  of  many  abnormal  urines,  and  may 
depend  upon  an  excess  of  urates  or  phosphates,  or  on  the  presence  of 
epithelial  elements,  pus-cells,  red  blood-corpuscles,  chyle,  or  bacteria. 

Odor.— This  property  of  the  urine,  although  of  little  clinical  signifi- 
cance, except  in  a  few  instances,  occasionally  attracts  the  attention  of  the 
patient  who  suspects  that  an  abnormal  state  of  the  kidneys  exists.  The 
odor  of  normal  urine  is  sufficiently  familiar  to  require  no  special  description. 
Urine  decomposed  by  bacterial  growth  within  the  bladder,  or  after  it  has 
been  voided,  emits  an  ammoniacal  stench.  Acetone,  when  present  in  large 
amount,  may  give  the  urine  a  sweetish,  fruit-like  odor.  The  ingestion  of 
turpentine,   terebene,   asparagus,    and   onions   imparts   peculiar  odors. 


266  MEDICAL  DIAGNOSIS. 

Reaction. — A  normal,  mixed  twenty-four  hour  sample  in  nearly  every 
instance  is  acid,  while  individual  specimens  passed  during  the  day  vary 
considerably  in  reaction.  For  clinical  purposes  the  reaction  may  be  deter- 
mined with  litmus  paper.  An  alkaline  reaction  after  a  heavy  meal  is 
attributed  to  the  increased  alkalinity  of  the  blood  during  gastric  digestion. 
The  ingestion  of  food  rich  in  vegetables,  or  the  administration  of  tartaric, 
citric,  or  acetic  acid  lessens  acidity,  or  produces  alkalinity,  while  a  diet 
rich  in  meat  or  the  taking  of  mineral  acids  intensifies  the  acidity.  The 
reaction  of  normal  urine  is  held  to  be  due  to  diacid  phosphate;  Folin, 
however,  contends  that  free  organic  acids  are  in  part  responsible.  The 
total  acidity  of  a  twenty-four  hour  collection  of  healthy  urine  is  equal  to 
from  1.5  to  2.3  grammes  of  hydrochloric  acid.  Alkalinity  is  caused  by 
the  presence  of  alkalies  in  excess  of  acids.  An  amphoteric  reaction  depends 
on  a  balance  existing  between  the  acid  and  basic  equivalent  of  the  urinary 
salts.  Urine  that  has  been  exposed  to  the  air  for  some  time  becomes  alka- 
line from  ammoniacal  decomposition.  Alkaline  urine  is  frequently  seen  in 
cystitis,  but  in  a  number  of  cases  of  bladder  inflammation,  both  acute  and 
chronic,  the  urine  is  acid.  A  strongly  acid  urine  occurs  in  gout,  diabetes, 
rheumatic  fever,  in  some  varieties  of  nephrolithiasis,  in  leukaemia,  in  intes- 
tinal and  stomach  diseases  associated  with  diminished  or  abolished  gastric 
secretion,  in  scurvy,  in  chronic  nephritis,  and  often  in  febrile  states.  Low- 
ered acidity,  and  occasionally  alkalinity,  is  seen  in  ansemia,  notably  per- 
nicious anaemia  and  chlorosis,  following  the  crisis  of  pneumonia,  after 
blood  transfusion  with  saline  solution,  in  haematuria,  and  when  transudates 
are  rapidly  absorbed. 

Sediments.  —  Occasionally  deposits  of  uric  acid,  amorphous  urates, 
carbonates  and  phosphates,  and  invariably  those  consisting  of  pus,  epi- 
thelial and  red  blood-cells,  are  significant  of  morbid  states.  The  presence 
of  a  sediment  of  uric  acid  crystals,  amorphous  urates,  or  phosphates  need 
not,  and  as  a  rule  does  not,  imply  an  increased  output  of  these  salts,  but 
may  depend  on  changes  in  the  reaction  of  the  urine. 

MICROSCOPICAL    EXAMINATION. 

Microscopical  examination  of  sediments  is  of  cardinal  importance  in 
urinalysis.  A  sediment  best  suited  for  this  method  of  study  should  be 
secured  from  a  fresh  specimen  of  urine  by  centrifugalization.  When  the  ex- 
amination cannot  be  made  immediately  after  the  urine  is  voided,  it  is  advis- 
able to  add  an  antiseptic  to  it,  such  as  a  little  powdered  camphor,  a  few  drops 
of  formaldehyde  solution,  or  thymol,  in  order  to  prevent  decomposition. 

Crystalline  and  Amorphous  Substances  Present  in  Acid  Urine. — 
Calcium  Oxalate. — Crystals  of  calcium  oxalate  are  found  in  many  sedi- 
ments and  appear  in  various  sizes,  mostly  in  the  form  of  colorless  octahedra, 
generally  designated  "envelope  crystals,"  sometimes  as  dumb-bell  figures 
and  rarely  as  oval  disks.  These  crystals  are  soluble  in  hydrochloric  acid, 
but  not  in  acetic  acid  or  sodium  hydrate.  Normal  urine  may  contain  these 
crystals,  after  the  eating  of  tomatoes,  asparagus,  garlic,  rhubarb,  or  oranges. 
After  the  ingestion  of  bicarbonate  of  soda,  in  certain  forms  of  gastro- 
intestinal neuroses,  in  jaundice,  in  phthisis,  and  in  diabetes  meUitus,  oxa- 


EXAMINATION  OF  THE  URINE. 


267 


late  crystals  are  sometimes  noted.  Renal  calculi  composed  of  this  substance 
are  not  uncommon.  Oxaluria  can  only  be  regarded  as  pathological  when 
a  chemical  examination  shows  an  increased  quantity  of  oxalic  acid,  provided 
the  factors  responsible  for  its  occurrence  in  health  can  be  excluded. 

Uric  Acid. — This  substance,  as  a  rule,  crystallizes  in  the  form  of  whet- 
stone shaped  crystals,  arranged  singly  or  in  clusters,  and  occasionally  in 
the  form  of  dumb-bell  figures,  or  as  rhombic  plates.  These  crystals  vary 
considerably  in  size,  and  their  color  ranges  from  a  pale  yellow  to  a  dark 
brown.  Uric  acid  crystals  dissolve  in  a  sodium  hydrate  solution,  and  when 
this  test  is  followed  by  the  addition  of  hydrochloric  acid  to  the  alkaline 
solution,  rhombic  plates  appear.  Uric  acid  crystals  are  frequently  seen  in 
the  urine  when  the  uric  acid  output  is  normal  or  even  decreased,  since  this 
substance  is  more  readily  soluble  in  warm  than  in  cold  solution.  Urinary 
inspissation  is  another  factor  which  determines  precipitation.    In  leukaemia; 


Fig.  107. — Calcium  oxalate  crystals. 


Fig.  108. — Uric  acid  crystals. 


and  during  or  immediately  following  acute  gout,  the  urine  contains  an 
excess  of  uric  acid,  and  may  reveal  an  abundant  precipitate  of  these  crys- 
tals (brick-dust  sediment).  Calculi  formed  of  uric  acid  are  among  the  most 
common  renal  concretions.  When  amorphous  granules  of  sodium  and 
potassium  urate  occur  in  the  urine  in  abundance,  they  impart  a  turbidity 
to  it,  which  is  often  associated  with  a  light  yellow  or  pink  sediment.  This 
precipitate  disappears  upon  heating  the  urine  to  a  temperature  of  50°  C; 
on  the  addition  of  hydrochloric  acid  to  the  urine,  amorphous  urates  are 
converted  into  uric  acid  crystals.  Amorphous  sediments  of  urates  are 
frequently  present  in  scanty,  concentrated  urines,  such  as  occur  in  fevers. 
Calcium  sulphate  is  seen  in  the  form  of  long,  transparent  colorless 
needles,  or  elongated  platelets,  arranged  singly  or  in  crystalline  masses. 
They  are  insoluble  in  ammonia,  acetic  acid,  and  alcohol.  Von  Jaksch  found 
these  crystals  in  association  with  triple  phosphates  and  calcium  carbonate 
in  the  urine  of  a  patient  who  showed  a  tendency  to  calculus  formation. 
No  special  clinical  significance  has  as  yet  been  attached  to  the  presence 
of  these  crystals. 


268 


MEDICAL  DIAGNOSIS. 


HiPPURic  ACID  occurs  as  rhombic  prisms  or  slender  needles  arranged 
separately  or  in  clusters.  These  crystals  are  soluble  in  ammonia  and 
insoluble  in  hydrochloric  acid.  They  have  been  noted,  though  very  infre- 
quently, in  febrile  diseases,  in  diabetes,  and  after  the  ingestion  of  benzoic 
acid,  salicylic  acid,  cranberries,  mulberries,  blueberries,  and  prunes. 

BiLiRUBix  is  found  as  fine  needles  arranged  in  clusters  or  rhombic 
plates  having  a  yellow  or  ruby  color,  or  as  an  amorphous  substance.  This 
sediment  is  soluble  in  sodium  hydrate  and  chloroform;  on  treating  the 
crystals  with  nitric  acid  a  green  color  appears  about  them.  Von  Jaksch 
contends  that  the  presence  of  crj^stals  of  bilirubin  in  the  urine,  as  a  rule, 
points  to  antecedent  hemorrhage  into  the  urinary  tract  or  to  the  rupture 
of  an  abscess.  Their  presence,  either  free  or  imbedded  in  cells  or  tube- 
casts,  has  been  recorded  in  acute  nephritis,  chronic  interstitial  nephritis, 
amyloid  kidney,  jaundice,  acute   j'ellow  atrophy  of  the  liver,  hepatic  cir- 


FiG.  109. — Leucin  spheres  and  tjTOsin  crystals. 


Fig.  110. — Cystin  crystals. 


rhosis,   phosphorous  poisoning,   carcinoma  of  the   bladder,   and  after  the 
rupture  of  a  suppurating  hydatid  cj^st  into  the  urinary  tract. 

Leucin  and  Tyrosix. — These  substances  are  never  found  in  normal 
urine.  They  are  generally  held  in  solution  unless  present  in  considerable 
quantities,  when  they  separate  in  a  crystalline  form.  Their  precipitation 
can  be  brought  about  by  treating  the  urine  with  an  excess  of  basic  plumbic 
acetate;  then  filtering;  and  to  filtrate  hydrogen  sulphide  is  added  to  remove 
the  excess  of  lead  acetate.  The  filtrate  is  then  evaporated  to  a  small  volume. 
Absolute  alcohol  is  used  to  remove  traces  of  urea.  The  insoluble  residue 
is  finally  extracted  with  alcohol  containing  a  little  ammonia.  Leucin  and 
tyrosin  will  precipitate  in  this  concentrated  solution.  Leucin  presents  the 
appearance  of  spheres  of  varying  sizes,  sometimes  termed  ''leucin  balls." 
These  spheres  have  a  brown  color  and  show  delicate  lines  radiating  from 
their  centre  to  the  periphery.  Leucin  spheres  are  insoluble  in  ether. 
Tyrosin  crystals  are  noted  in  the  form  of  slender  needles,  frequently 
grouped  in  bundles.  They  dissolve  in  ammonia  and  hydrochloric  acid, 
but   are   insoluble   in  acetic  acid.     Leucin  and  tyrosin  occurring   mostly 


EXAMINATION  OF  THE  URINE. 


269 


together  have  been  observed  almost  constantly  in  acute  yellow  atrophy 
of  the  liver,  phosphorous  poisoning,  and  Weil's  disease,  occasionally 
in  catarrhal  jaundice,  cholelithiasis,  cirrhosis  and  cancer  of  the  liver, 
enteric  fever,  gout,  and  diabetes,  and  rarely  in  a  limited  number  of 
other   conditions. 

Xanthin  is  found  in  the  form  of  colorless  crystals  resembling  those  of 
uric  acid  in  outline.  The}'  are  soluble  in  ammonia.  These  crystals  are 
rare  ingredients  of  urinaiy  sediments;  calculi  consisting  of  xanthin  have 
been  found  by  some  investigators. 

Cystix  crv'stals  are  six-sided  colorless  plates,  which  are  soluble  in 
ammonia  and  insoluble  in  acetic  acid  and  water.  Von  Jaksch  recommends 
the  following  microchemic^l  test  for  their  detection:  A  drop  of  hydrochloric 
acid  is  added  to  the  urinary  sediment.  When  the  acid  comes  in  contact 
with    cystin,  there  develop   prismatic    crj'stals  (hydrochlorate  of   cystin) 


Fig.  111. — Triple  phosphate  crystals 


Fig.  112. — Neutral  calcium  phosphate  crystals. 


which  are  grouped  in  masses  suggesting  a  rosette  form.  Cystinuria  is  a 
rare  condition.  In  some  cases  it  is  unattended  mth  symptoms,  while  in 
others  it  is  responsible  for  calculus  formation. 

Soaps  of  lime  and  magnesia  consist  of  needles  arranged  in  bundles  or 
sheaves,  sometimes  radiating  from  a  central  point  forming  a  sphere.  They 
resemble  tyrosin  crystals  in  form  and  arrangement.  These  crA'stals  are 
rarely  found.    They  have  been  noted  in  septicaemia. 

Fat  globules  can  be  recognized  by  their  highly  refractive  appearance ' 
and  solubihty  in  ether.     Among  the  conditions  in  which  lipuria  is  seen, 
may  be  mentioned,  acute  and  chronic  parenchymatous  nephritis,  diabetes 
mellitus,  bone   disease   and    injury,  chyluria,  phosphorus   poisoning,  and 
certain  diseases  of  the  liver  and  pancreas. 

Crystalline  and  Amorphous  Substances  found  in  Alkaline  Urine. — 
Ammoxiomagxesium  phosphate  or  triple  phosphate  crystals  are  color- 
less and  vary  considerabh^  in  size  and  appearance.  In  their  most  char- 
acteristic form  they  occur  as  the  so-called  "coffin-lid"  crystals;  others 
resemble  fern  leaves  in  outline,  while  some  are  arranged  in  the  shape  of 


270 


MEDICAL  DIAGNOSIS. 


the  letter  ''X."  Triple  phosphate  crystals  are  found  in  association  with 
amorphous  deposits  of  phosphates,  carbonates,  and  at  times  with  ammo- 
nium urate. 

Neutral  calcium  phosphate  occurs  in  alkaline,  faintly  acid,  or 
amphoteric  urine  in  the  form  of  sheets  or  needle-like  crystals,  the  latter 
being  arranged  singly  or  in  masses  forming  dumb-bell  or  star-shaped 
figures.     These  bodies  are  soluble  in  acetic  acid. 

Neutral  magnesium  phosphate  crystals  are  colorless,  refractile,  elon- 
gated plates  with  irregular  or  bevelled  edges;  they  are  soluble  in  acetic  acid. 

Calcium  carbonate  crystals  are  found  in  alkaline  urine  associated 
with  amorphous  carbonates.  They  are  dumb-bell  shaped  bodies  which 
dissolve  in  acetic  acid  with  the  liberation  of  gas. 

Amorphous  phosphates  of  calcium  and  magnesium  and  amorphous 
CARBONATES  are  of  common  occurrence  in  alkaline  urine.     The  addition 


Fig.  113. — Ammonium  urate  crystals. 


Fig.  114. — Cholesterin  crystals. 


of  a  fixed  alkali  to  urine  will  precipitate  amorphous  phosphates  and  car- 
bonates. On  heating  urine  having  a  low  acid  or  alkaline  reaction,  a  white 
cloud  simiij.r  to  that  produced  by  albumin  appears  which  consists  of 
phosphates  or  carbonates.  On  the  addition  of  acetic  acid,  phosphates 
and  carbonates  are  dissolved.  The  solution  of  the  latter  is  attended  with 
the  evolution  of  gas.  Amorphous  phosphates  or  carbonates  are  often 
responsible  for  a  turbid  urine  with  a  heavy  sediment.  Microscopically, 
these  bodies  appear  as  colorless,  coarse  granules,  which  are  soluble  in  acetic 
acid.  Phosphatic  sediments  are  occasionally  symptomatic  of  certain 
types  of  dyspepsia,  of  neurasthenia,  of  diseases  associated  with  marked 
gastric  acidity,  and  of  some  cases  of  cystitis.  A  deposit  of  phosphates 
does  not  of  itself  indicate  an  increased  output  of  phosphoric  acid;  this  can 
only  be  determined  by  quantitative  analysis. 

Ammonium  biurate  appears  as  dark  brown  spheroidal  bodies  from  the 
surface  of  which  spicules  project,  the  so-called  ''thorn-apple"  or  "hedge- 
hog "  crystals,  and  in  the  form  of  coarse  yellow  needles  grouped  in  clusters. 
Ammonia  biurate  may  be  associated  with  triple  and  amorphous  phosphates. 


EXAMINATION  OF  THE  URINE.  271 

Acetic  acid  will  cause  solution  of  these  crystals  with  the  formation  of  uric 
acid.  Ammoniacal  fermentation  of  the  urine,  occurring  in  the  bladder  or 
after  it  has  been  voided,  is  responsible  for  the  precipitation  of  ammonium 
biurate. 

Cholesterin  crystals  occur  as  colorless  thin  plates.  They  are  rare 
constituents  of  urinary  sediment  and  have  been  observed  in  hydatid  cystic 
kidney,  pyonephrosis,  hydronephrosis,  and  cystitis. 

Indigo,  a  rare  ingredient  of  the  urinary  sediments,  is  found  in  the 
form  of  a  blue  crystalline  body  consisting  of  needles  grouped  in  a  stellate 
manner  or  as  rhombic  plates,  and  also  as  bluish  amorphous  granules. 
The  amorphous  material  is  not  infrequently  present  in  decomposing  urine. 
Indigo  is  a  rare  constituent  of  urinary  calculi. 

Cellular  Deposits.  —  Epithelial    Cells. — Epithehal    cells   in   small 
numbers,  not  sufficient  to  impart  a  sediment  or  cloudiness  to  the  urine, 
can  be  found  in  every  speci- 
men.     In    many    instances     "  _,.-;     ^   ^    ,         u   "j.lil|Tli 


their  number  is  so  large  as  a  iMFWIP^  ''■''  '  •      ''      ' 

to  justify  a  diagnosis  of  an  W^ ^  ^    —     <-<  | 

inflammatory,    atrophic,    or  .-^^^  §1^1 

degenerative   lesion   involv-  '- _  ^    *  f    ^^'^^  ^  '^''  •  v- 

ing  the  genito-urinary  tract.  ,  '      ^^   ,^.,  ,<<?%,  ^^  '■ 

The  predominance  of  one  or        ,  /.;   "/  ■  •'     'i^'*   ^^ 

several  of  the  types  of  epi-        >••  '/         -         '-  .  ,  ';ivi> 

thelial  elements,  unless  cor-  .,/    ■,'^  ,  ^  '       ^^^    /.^^ 

related   with    other    clinical  "'v  ,    -  "^^^  I 

data,  has  little  significance.  '  '"   c'      '    "        ■.<;■        z^':^''^^. \ 

It  is  impossible  to  locate  |  '  '  (^  '  ^  I 
definitely    a    lesion    of    the     }                                                             '  . 

genito-urinary  tract  from  the     j                r  | 

morphological  characters  of     [^  -   '  j 

epithelium  alone.     This  diffi-  Fig.  115.— Epithelial  cells,    a,  flattened  cells;  6,  conical  cells 

CUlty    is     apparent    when    we       digeneS'cellsI°"^^*'°°''    '=-  ™^"d  and  polygonal  cells;    d, 

consider,    (1)     similarity    of 

many  of  the  cells  of  different  parts  of  the  tract,  notably  those  derived 
from  the  pelvis  of  the  kidney,  ureters,  and  bladder,  (2)  alterations  in  the 
shape  of  these  delicate  formations  due  to  the  action  of  the  urine,  and  (3) 
the  influence  exerted  on  these  cells  by  morbific  factors,  such  as  necrosis, 
pressure,  etc.  Therefore,  little  importance  should  be  attached  to  their 
histological  structure.  Round  cells,  having  a  relatively  large  nucleus,  are 
derived  from  the  tubular  structures  of  the  kidney  and  the  deeper  layers 
of  the  renal  pelvis.  When  casts  are  beset  with  round  cells  it  points  to  a 
renal  origin  of  this  epithelium.  An  abundance  of  round  cells  in  the  absence 
of  casts,  especially  when  pus-cells  and  subjective  symptoms  pointing  to 
pyelitis  are  present,  is  suggestive  of  origin  from  the  renal  pelvis.  This 
opinion  is  strengthened  by  the  presence  of  polygonal  and  conical  cells, 
some  of  which  have  a  tail-like  elongation  of  their  protoplasm;  these  cells 
are  often  arranged  in  a  stratified  manner.  Round  cells  are  also  derived 
from  the  male  urethra,  while  small  conical  and  polygonal  cells  originate 
in  the  superficial  layers  of  the  pelvis  of  the  Kidney.     Cylindrical  cells  with 


272  MEDICAL  DIAGNOSIS. 

bluntly  pointed  ends  are  found  in  the  superficial  layers  of  the  male  urethra. 
Flattened,  oval  or  circular,  or  polygonal  cells  line  the  superficial  layers  of 
the  ureter,  bladder,  prepuce,  fossa  navicularis,  and  vagina.  Large  squa- 
mous cells  are  generally  derived  from  the  vagina  or  prepuce.  Protoplasmic 
degeneration  of  the  epithelial  cells  is  extremely  common.  A  final  diagnosis 
should  never  depend  on  the  characters  of  the  epithelia  in  the  absence  of 
clinical  findings. 

Leucocytes. — A  careful  search  in  every  normal  or  morbid  specimen 
of  urine  will  reveal  a  few  leucocytes.  The  action  of  the  urine  upon  these 
cells  causes  alterations  in  their  structure.  In  acid  urine  they  have  a  distinct 
nucleus,  while  in  alkaline  urine  their  protoplasm  is  swollen  and  cloudy, 
obscuring  the  nucleus.  By  treating  a  specimen  of  urine  having  a  weakly 
acid  or  alkaline  reaction  with  acetic  acid,  the  nuclear  outline  becomes  sharply 
marked.    The  leucocytes  stain  a  mahogany  brown  with  a  solution  of  iodo- 

potassic  iodide  (glycogen  reaction), 
V  >».        _^  while    epithelial   cells    are   tinted  a 

('  '   ''  ;\  light  yellow  with  this  reagent.     Pus- 

cells  in  considerable  or  large  numbers 
frequently  indicate  inflammatory 
disease  of  some  part  of  the  genito- 
urinary tract.  They  occur  in  renal 
hyperaemia,  nephritis,  abscess  and 
)  /  tuberculosis  of  the  kidney,  pyelitis, 

urethritis,  cystitis,  prostatitis,  epi- 
didymitis, and  orchitis.  A  leucor- 
rhoeal  discharge  is  a  common  cause  of 
pyuria.  Urine  containing  many  pus- 
corpuscles  generally  gives  a  positive 
reaction  for  albumin.  Renal  and  ex- 
L  J      trarenal  albuminuria  may  coexist. 

Fig.  116.— Red  blood-cells  and  leucocytes.  ReD  BlOOD-CELLS. Hsematuria, 

or  the  presence  of  red  corpuscles  in 
the  urine,  is  always  pathological  except  during  menstruation.  In  cer- 
tain uterine  diseases  attended  with  bloody  discharge  some  of  the  eryth- 
rocytes may  be  washed  into  the  urine.  A  microscopic  inspection  serves 
to  recognize  red  blood-cells  in  almost  every  instance,  so  that  chemical 
tests  for  their  detection  are  rarely  required.  In  some  urines  the  red  cells 
are  unaltered,  while  in  others  changes  in  their  structure  are  found,  such  as 
decided  shrinkage  of  the  cell,  or  crenation,  or  they  may  be  partially  or 
completely  decolorized,  and  appear  as  pale  yellow  disks  or  as  faintly  out- 
lined rings  (phantom  corpuscles).  The  quantity  of  blood  may  be  sufficient 
to  tinge  the  urine  pale  or  dark  red,  but  in  many  cases  the  amount  is  so 
small  that  the  microscopic  test  is  essential  in  the  diagnosis  of  hfematuria. 
When  the  erythrocytes  are  intimately  mixed  with  the  urine,  this  suggests 
a  hemorrhage  in  the  kidneys,  renal  pelvis,  or  ureters.  The  presence  of 
•dehsemoglobinized  corpuscles  is  noted  in  kidney  lesions,  such  as  congestion 
and  inflammation.  Unaltered  blood  or  blood-tinged  urine  passed  at  the 
beginning  of  micturition  is  of  urethral  origin;  on  the  other  hand,  when 
.blood  appears  at  the  end  of  urination,  its  source  is  generally  the  neck  of 


EXAMINATION  OF  THE  URINE.  273 

the  bladder.  Bleeding  may  cause  coagula  of  certain  shapes;  cyhndrical 
clots  of  large  size  suggest  urethral  hemorrhage,  those  of  small  diameter 
may  indicate  ureteral  hemorrhage,  while  irregular  clots  often  form  in  the 
bladder.  Neither  the  morphological  characters  of  red  blood-cells  nor  the 
size  and  outline  of  clot  can  be  rehed  upon  to  definitely  determine  the 
site  of  a  hemorrhage,  unless  these  findings  are  supported  by  other  chnical 
data.  The  use  of  the  cystoscope,  urethral  and  ureteral  catherization,  and 
examination  with  X-rays,  especially  for  renal  calculus,  afford  valuable 
adjuncts  in  the  diagnosis  of  hsematuria.  An  albumin  reaction  is  invariably 
obtained  when  red  blood-cells  are  abundant  in  the  urine,  but  when  only 
small  numbers  exist,  a  negative  test  is  the  rule.  The  quantity  of  albumin 
is  proportionate  to  the  amount  of  blood. 

Tube=casts. — These  are  cyhndrical  bodies  moulded  in  the  uriniferous 
tubules.  Their  structure  is  variable,  and  may  consist  of  a  hyaline  or  waxy 
material,  of  cellular  bodies,  of  granular  elements,  of  fat  globules,  and  in 
rare  instances  of  bacteria  or  of  amorphous  substances. 

Hyaline  Casts. — These,  by  far  the  most  common,  are  slightly  refrac- 
tile,  transparent,  of  regular  outhne,  with  rounded  ends.  They  are  invisible 
in  a  brightly  illuminated  field  on  the  microscope,  so  that  it  is  necessary 
to  cut  off  much  of  the  reflected  light  with  the  iris  diaphragm  in  order  to 
bring  out  their  outline.  Epithelial  cells,  leucocytes,  red  blood-corpuscles, 
and  granules  frequently  beset  these  casts,  and,  indeed,  it  is  not  uncommon 
to  find  adherent  cells  or  granules  so  numerous  that  the  hyaline  material 
is  obscured.  Casts  covered  with  granules  are  termed  hyalogranular.  This 
appearance  may  make  it  impossible  to  distinguish  hyaline  casts  from  those 
composed  principally  of  granules.  Clinically,  however,  the  significance  of 
hyaline  casts  coated  with  granules  and  those  composed  wholly  or  mostly  of 
granules  is  identical.  It  should  be  remembered  that  a  sharp  distinction  can- 
not be  drawn  between  these  forms.    Hyaline  casts  are  soluble  in  acetic  acid. 

Waxy  casts  appear  as  highly  refractile,  sharply  defined,  colorless 
or  yellowish  cylinders,  showing  a  tendency  to  transverse  fragmentation. 
Like  hyaline  casts  they  may  be  studded  with  cells  or  granules.  They 
may  exhibit  an  amyloid  reaction,  but  this  is  no  criterion  that  lardaceous 
renal  disease  exists,  but,  on  the  contrary,  amyloid  disease  of  the  kidney  is, 
as  a  rule,  not  associated  with  casts  giving  this  reaction.  Not  infrequently, 
casts  are  observed  that  cannot  be  definitely  classified  as  belonging  to  the 
waxy  or  hyaline  varieties. 

Granular  casts  are  composed  of  fine  or  coarse  granules.  Cells  form- 
ing leucocytic  or  epithelial  casts  may  show  a  decided  granular  protoplasm, 
so  that  it  becomes  difficult  to  distinguish  their  outline;  these  types  consti- 
tute border  line  varieties  between  cellular  and  granular  casts.  Clinicallj^, 
this  is  of  little  moment,  since  the  granular  or  fatty  casts  represent  products 
of  degenerated  cells.     Acetic  acid  dissolves  granular  casts. 

Fatty  casts  consist  of  fat  globules  derived  from  degenerated  cells. 
Ether  dissolves  fatty  casts. 

Epithelial  casts  are  made  up  of  renal  epithelial  cells,  many  of  which 
present  degenerative  changes.     These  casts  may  have  tubular  form. 

Leucocytic  casts  consist  of  white  blood-cells.  They  are  generally 
recognized  at  a  glance,  but  should  uncertainty  arise  as  to  the  character  of 

18 


274  MEDICAL  DIAGNOSIS. 

the  cells  forming  these  cylinders,  this  doubt  can  be  settled  by  treating  the 
specimen  with  a  droplet  of  acetic  acid,  which  clarifies  the  protoplasm  of 
the  leucocytes  and  causes  the  nucleus  to  become  distinct. 


f^i 


3 


10 

6 
5 


II  '^ 


14- 

15 


12  16 


'[  Id 

Fig.  117. — Tube-casts  1,  2,  3,  5,  hyaline  casts;  4,  6,  hyaline  casts  beset  with  epithelial  cells; 
7,  hyaline  cast — one  end  of  which  is  coated  with  fine  granules  ;  8,  hyaline  cast  beset  with  leucocytes ; 
9,  finely  granular  cast;  10,  coarsely  granular  cast;  11,  12,  13,  waxy  casts;  14,  fatty  cast;  15,  16, 
epithelial  casts  ;   17,  blood-cast ;    18,  leucocytic  cast. 

Blood-casts  consist  of  erythrocytes,  many  of  which  may  be  alteifed 
by  crenation  or  dehamoglobinization.  Pus-  and  blood-casts  are  rarely 
encountered.    Casts  formed  of  haemoglobin,  of  bacteria,  or  of  urates  are  rare. 

Cylindeoids  are  of  two  forms;  one  variety  appears  as  long  twisted 
or  curved  ribbon-like  structures,  composed  of  mucus,  and  therefore  insolu- 
ble in  acetic  acid.    This  cyUndroid  is  readily  distinguished  from  true  hya- 


EXAMINATION  OF  THE  URINE.  275 

line  casts,  because  of  its  length  and  flattened  appearance.  A  second  group 
consists  of  elongated  cylindrical  bodies.  They  show  considerable  varia- 
tion in  their  short  diameter,  and  are  composed  of  a  hyaline  material.  This 
cylindroid  often  tapers  into  a  long  thread-like  tail.  Some  of  the  latter 
variety  closely  resemble  hyaline  casts,  but  can  generally  be  distinguished 
from  glassy  casts  by  their  irregular  diameter.  The  material  composing 
the  latter  type  is  soluble  in  acetic  acid.  Some  authorities  contend  that 
this  form  of  cylindroid  has  the  same  clinical  significance  as  the  hyaline 
cast.  The  mucous  cylindroids  are  in  the  main  formed  in  the  bladder. 
Clinical  Significance  of  Tube=casts. — Tube-casts,  especially  of  the 
hyaline  variety,  are  often  _^ 

found  in    the    urine    of  I 

morbid  states  and  occa-  '  ■ 

sionally    of    apparently  ^'v 

healthy  persons.     Some  '.  / 

observers  maintain  that 

their    presence    in    the  , 

urine  of  so-called  healthy 

persons  can  be  explained  ; 

by    temporary    circula-  2        '  j 

tory   disturbances,  such  j  \ 

as    result    from    violent  i 

physical  exercise  or  from 
overstimulation,  as  with 
alcohol.      These  circula-        .'  ! 

tory  derangements,  al- 
though of  a  temporarj^ 
nature,  cannot  be  re- 
garded as  strictly  physi- 
ological; therefore,  the  3 
presence  of  casts  under 

such    circumstances    re-  ! 

fleets  an  abnormality  of         ,  2 

the  renal  function.    The 

finding    of    casts    over     a  Fig.  IIS.— Cyllndroids.     l,  Cyllndroids  resembling  hyaline  tube- 

Inrirt-  T^oTirirl  n-onofQlKr  casts;  2,  cylindroids  stippled  with  granules;  3,  ribbon-iike  mucous 
long        peilOa       geneiauy        cylindroids;  4,  spiral  form  of  cylindroid.— Modified  from  Emerson. 

warrants  a  diagnosis  of 

structural  changes  in  the  kidneys.  The  number  of  casts  present  in  a  speci- 
men of  urine  is  sometimes  an  index  of  the  extent  or  severity  of  renal  involve- 
ment. In  acute  diffuse  nephritis  their  number  is  generally  large,  in  chronic 
parenchymatous  nephritis  they  are  usually  fairly  abundant,  while  in  the 
interstitial  form  only  a  small  number  is  noted.  In  passive  renal  conges- 
tion, amyloid  disease,  and  in  the  degenerations  attending  febrile  diseases, 
casts  are  generally  few  in  number,  but  occasionally  plentiful.  The  size  of 
casts  varies  considerably.  Large  cyUnders  at  times  exceed  1  mm.  in  length. 
The  size  of  tube-casts  has  no  special  diagnostic  significance.  The  predomi- 
nance of  one  or  several  varieties  of  casts  may  be  of  value  in  deciding 
the  character  of  a  renal  lesion.  Hyaline  casts  do  not  signify  any  special 
morbid  change,  as  they  occur  under  a  variety  of   circumstances.     Often 


276  MEDICAL  DIAGNOSIS. 

they  appear  when  there  is  only  a  slight  functional  derangement  of  the 
kidneys,  but  they  are  invariably  present  in  organic  renal  disease.  Waxy, 
granular,  epithelial,  and  fatty  casts  point  to  degeneration  of  the  renal 
parenchyma,  while  pus-casts  may  indicate  purulent  kidney  disease. 
Blood-casts  signify  hemorrhage. 

Spermatozoa  and  Testicular  Casts.  —  Spermatozoa  are  found  in 
the  urine  after  coitus,  pollution,  and  rarely  after  convulsions.  The  urine 
which  contains  spermatozoa  occasionally  reveals  testicular  casts.  These 
casts  closely  resemble  renal  casts.  Thej^  can,  however,  be  distinguished 
from  the  latter,  since  they  occur  only  in  the  first  part  of  the  urine  voided 
while  renal  casts  are  present  in  the  entire  specimen.  Their  recognition 
depends  mainly  upon  the  finding  of  spermatozoa  with  these  casts  in  the 
first  urine  of  a  two-glass  test,  and  an  absence  of  both  of  these  elements  in 
the  second  specimen  of  urine. 

Irregular  shreds  and  ribbon-like  threads  (tripperfaden)  are  seen 
without  magnification  in  the  urine  after  acute  gonorrhoea  and  in  chronic 
urethritis.  They  consist  of  shreds  of  coagulated  mucus,  to  which  are 
generally  adherent  leucocytes  and  epithelial  cells. 

Bacteria  ;  Animal  Parasites. — Bacteria. — The  presence  of  bacteria  in 
abnormal  urine  depends  upon,  (1)  contamination  of  urine  after  it  is  voided, 
(2)  existence  of  infectious  lesions  of  the  genito-urinary  tract  or  communi- 
cating with  it,  and  (3)  elimination  of  bacteria  from  the  blood  by  the  kidneys. 
In  large  numbers  bacteria  impart  turbidity  to  the  urine,  which  does  not  clear 
up  completely  by  centrifugating  or  by  passing  the  urine  through  filter-paper. 

The  Micrococcus  ureee  is  considered  responsible  for  ammoniacal 
fermentation.  The  colon  bacillus,  tubercle  bacillus,  typhoid  and  paraty- 
phoid bacillus,  plague  bacillus,  ray  fungus,  sarcina?  and  moulds  are  the  com- 
moner micro-organisms  found  in  pathological  urine.  The  typhoid  bacillus, 
which  is  eliminated  by  the  kidney  in  every  case  of  enteric  fever,  is  occasion- 
ally the  exciting  factor  of  inflammatory  disease  of  the  bladder  and  renal 
pelvis.  Tubercle  bacilli  in  the  urine  may  indicate  a  tuberculous  focus  in 
the  urinary  tract.  Their  elimination  by  the  kidneys  from  the  blood  in  the 
absence  of  genito-urinary  tuberculosis  has  been  suggested.  The  smegma 
bacillus,  which  exists  in  the  secretions  of  the  external  genitals,  is  at  times 
washed  into  the  urine.  This  contamination  can  be  avoided  by  carefully 
cleansing  the  external  genitals,  or  by  securing  the  urine  with  a  catheter. 
Pappenheim's  stain  is  highly  recommended  as  means  of  differentiating  the 
tubercle  from  the  smegma  bacillus.  Yeast  cells  are  often  found  in  diabetic 
urine  and  may  give  rise  to  pneumaturia. 

Animal  Parasites. — The  Trichomonas  vaginalis  is  rarely  noted  and 
its  presence  is  probably  dependent  upon  contamination  of  the  urine  with 
a  vulvovaginal  discharge  containing  this  parasite.  Ova  of  the  Distoma 
haematobium  are  sometimes  seen  in  the  urine  when  the  adult  worm  resides 
in  the  mucous  membrane  of  the  renal  passages.  Distomiasis  is  essentially 
a  tropical  disease  which  is  occasionally  responsible  for  hsematuria.  Filarial 
embryos  have  been  found  in  certain  cases  of  tropical  hsematuria.  Echino- 
coccus  booklets  or  fragments  of  cysts  may  be  present  in  cases  of  hydatid 
disease  of  the  urinary  system.  There  are  a  few  instances  on  record  in 
which  the  Eustrongylus  gigas  was  noted  in  the  urine. 


EXAMINATION  OF  THE  URINE.  277 

Calculi. — Urinary  calculi  of  renal  and  vesical  origin  vary  as  to  si^ 
and  outline.  Stones  small  enough  to  pass  through  the  urinary  passages 
are  more  common  than  the  large  calculi  found  in  the  renal  pelvis  or 
bladder. 

Uric  acid  stones  vary  in  size  from  that  of  a  grain  of  sand  to  concre- 
tions large  enough  to  fill  up  the  renal  pelvis.  These  calculi  are  reddish- 
brown  or  dark  gray,  very  dense,  have  a  smooth  or  slightly  roughened  sur- 
face, dissolve  in  alkalies,  and,  when  treated  with  sodium  hydrate,  generate 
ammonia.  They  give  murexide  test.  Sometimes  calcium  oxalate  is  present 
in  uric  acid  concretions.  Ammonium  urate  stones  have  a  waxy  consist- 
ence, give  the  murexide  test  and  liberate  ammonia  when  treated  with 
sodium  hydrate.  These  calculi  are  rare.  At  times  they  are  found  in 
adults,  and  are  occasionally  discovered  in  the  new-born.  Calcium  oxalate 
stones  are  responsible  for  severe  attacks  of  renal  colic  and  heematuria. 
These  calculi  are  very  hard,  their  surface  is  generally  irregular,  often 
showing  sharp  projections,  and  their  color  is  dark  gray  or  black.  Hydro- 
chloric acid  dissolves  them,  and  acetic  acid  will  also  cause  solution  when 
added  to  the  powdered  stone.  Phosphate  stones  have  a  soft  texture,  are 
white  or  pale  yellow,  and  have  a  rough  surface.  They  are  soluble  in  acetic 
acid  without  gas  formation.  They  are  formed  in  the  bladder  much  more 
frequently  than  in  the  renal  pelvis.  Cystin  stones  have  a  wax-like  consist- 
ency, are  white  or  yellowish  in  color,  dissolve  in  ammonia,  and  give  the 
reaction  for  cystin.  They  are  of  rare  occurrence.  Xanthin  stones  are 
hard,  of  a  white  or  yellowish-brown  color,  and  dissolve  in  ammonia.  Indigo 
stones  have  a  blue  or  bluish-gray  color.  Xanthin  and  indigo  calcuH  are 
extremely  rare.  Calcium  carbonate  stones  are  white,  have  a  chalk-like 
consistency,  and  are  soluble  in  acetic  acid  with  gas  formation.  Stones  con- 
sisting of  fatty  acids  and  cholesterin  have  been  recorded  in  a  few  instances. 

Tumor  fragments  from  carcinoma  or  sarcoma  of  the  urinary  tract 
are  rarely  present  in  the  urine.  Fecal  matter  has  been  found  in  the  urine 
in  cases  of  enterovesical  fistula. 

CHEMICAL    EXAMINATION. 

Nitrogenous  Bodies. — The  normal  amount  of  nitrogen  eliminated  by 
the  kidneys  per  day  varies  between  10  and  16  grammes.  It  may  be 
reduced  to  5  or  6  grammes  on  a  vegetable  diet.  Nitrogen,  the  best  index 
of  proteid  metabolism,  is  principally  eliminated  in  the  form  of  urea,  and 
to  some  extent  as  ammonia,  uric  acid,  and  extractives.  Hammarsten's 
estimation  of  the  percentage  of  nitrogen  excreted  in  the  principal  nitroge- 
nous bodies  is  as  follows: 


Adults,  per  cent. 


Infants,  per  cent. 


Urea 84  to  91 

NH3 2  to  5 

Uric  acid 1  to  3 

Extractives 7  to  12 


73  to  76 
7.8  to  9.6 
3  to  8.5 
7.3  to  14.7 


278 


MEDICAL  DIAGNOSIS. 


Nitrogen  is  increased  by  a  rich  proteid  diet,  active  exercise,  in  fevers, 
in  cachexia,  in  diabetes,  in  poisoning  by  arsenic,  antimony,  phosphorus, 
and  certain  organic  poisons,  after  hemorrhage,  in  dyspepsia,  during  the 
resolution  stage  of  pneumonia,  and  from  the  absorption  of  exudates  and 
transudates.  It  is  lowered  from  lack  of  exercise,  by  a  vegetable  diet  or 
one  containing  much  carbohydrate,  during  the  convalescence  of  fevers,  in 
persons  gaining  weight  rapidly,  during  pregnancy,  during  the  formation 
of  exudates  and  transudates,  and  in  nephritis. 

Urea. — Quantitative  Estimation;  Hypobromite  Method.  —  This 
quantitative  test  is  based  upon  the  principle  that  an  alkaline  solution  of 

hypobromite  of  soda  will  decompose  urea  into 
nitrogen,  and  carbon  dioxide,  which  is  absorbed  in 
the  excess  of  alkah.  The  amount  of  urea  is  esti- 
mated by  the  volume  of  nitrogen  set  free.  Hiifner 
has  shown  that  one  cubic  centimetre  of  nitrogen 
(at  0°  C.  and  760  mm.  pressure)  represents  .00268 
gramme  of  urea.  A  convenient  method  (Rice)  of 
preparing  the  hypobromite  reagent  is  as  follows: 
(1)  A  solution  is  made  by  dissolving  100  grammes 
of  NaOH  in  250  c.c.  of  water;  (2)  a  solution  of 
bromine  one  part,  potassium  bromide  one  part,  and 
water  eight  parts.  These  solutions  are  mixed  in 
equal  amounts.  Special  forms  of  apparatus  have 
been  devised  for  collecting  the  nitrogen  and  meas- 
uring its  volume.  The  Heintz  modification  of  the 
Doremus  apparatus  can  be  highly  recommended 
because  it  is  easy  to  operate  and  is  sufficiently 
accurate  for  clinical  purposes.  With  this  apparatus 
the  test  is  conducted  as  follows:  The  large  tube  is 
filled  with  hypobromite  reagent  and  the  small  tube 
with  urine  up  to  the  point  indicated  by  the  mark  1. 
By  opening  the  stop-cock,  one  cubic  centimetre  of 
urine  is  allowed  to  flow  very  slowly  into  the  large 
tube.  The  reaction  occurs  immediately  and  nitro- 
gen gas  is  set  free  and  collects  in  the  upper  part 
of  the  tube  by  displacing  the  fluid.  The  apparatus 
is  then  set  aside  for  fifteen  minutes,  when  the  reading  is  taken.  The  amount 
of  urea  for  one  cubic  centimetre  of  urine  is  indicated  by  a  graduated  scale 
at  the  upper  level  of  the  fluid.  Albumin  should  always  be  removed  before 
making  this  test.  A  considerable  error  will  occur  when  the  urine  is  rich  in 
ammonia.  There  are  other  methods  for  estimating  urea  which  give  more 
accurate  results,  but  they  are  objectionable  because  they  are  tedious  and 
entirely"  too  compHcated  for  the  general  practitioner. 

On  an  ordinary  diet  the  daily  amount  of  urea  varies  between  20 
and  40  grammes,  on  a  rich  diet  it  may  reach  100  grammes,  while  on  a 
restricted  diet  it  is  sometimes  reduced  to  15  grammes.  As  a  rule  the 
quantity  of  urea  and  the  total  nitrogen  output  are  parallel,  so  that  for 
cHnical  purposes  the  amount  of  urea  is  generally  determined  instead  of 
the  total  nitrogen.    Urea  may  show  a  reduction  with  a  rise  in  the  am- 


FiG.  119. — Heintz  modifica- 
tion of  Hiifner  apparatus  for 
urea  determination.  A,  bulb; 
B,  graduated  tube  to  collect 
and  measure  the  nitrogen;  C, 
tube   for  urine;    D,  stop-cock. 


EXAMINATION  OF  THE  URINE.  279 

monia  elimination.    This  is  observed  in  certain  forms  of  liver  disorders, 
although  in  many  cases  of  hepatic  disease  the  urea  output  is  unaltered. 

Uric  Acid.  —  Folin's  Modification  of  Hopkins's  Test.  —  Three 
hundred  cubic  centimetres  of  urine  are  treated  with  75  c.c.  of  a  reagent 
prepared  as  follows:  500  grammes  of  ammonium  sulphate  and  5  grammes 
of  uranium  acetate  are  dissolved  in  650  c.c.  of  water,  to  which  are  added 
60  c.c.  of  a  10  per  cent,  acetic  acid  solution,  and  water  enough  to  bring 
the  amount  up  to  1  litre.  After  standing  for  about  five  minutes  the  urine 
so  treated  is  filtered  through  two  thicknesses  of  filter-paper.  Into  each  of 
two  beakers  125  c.c.  of  filtrate  are  poured,  treated  with  5  c.c.  of  concen- 
trated ammonia,  and  set  aside  for  twenty-four  hours.  The  ammonium 
urate  precipitate  is  next  washed  with  a  small  quantity  of  a  10  per  cent, 
solution  of  ammonium  sulphate.  The  precipitate  of  ammonium  urate 
collected  on  filter-paper  is  washed  with  100  c.c.  of  water  into  a  beaker, 
after  perforating  the  filter-paper.  The  solution  is  finally  treated  with 
15  c.c.  of  concentrated  sulphuric  acid  and  then  immediately  titrated  with 
a  1/20  normal  solution  of  potassium  permanganate,  until  a  faint  red  color 
tints  the  entire  solution.  This  color  disappears  rapidly.  Each  cubic  centi- 
metre of  a  1/20  normal  permanganate  solution  represents  .00375  gramme 
of  uric  acid. 

Uric  acid  is  an  oxidation  product  of  the  xanthin  bases.  Its  origin 
depends  upon  the  nucleins  derived  from  the  food  (exogenous  uric  acid)  and 
from  the  body  tissues  (endogenous  uric  acid).  The  normal  daily  amount 
of  uric  acid  found  in  the  urine  varies  between  .2  and  1.25  grammes, 
which  represents  from  1  to  2  per  cent,  of  the  total  nitrogen  output. 
Uric  acid  is  increased  by  a  diet  rich  in  nuclear  proteids,  active  muscular 
exercise,  in  fevers,  in  anaemia,  in  leukaemia,  in  pneumonia  during  the  stage 
of  resolution,  in  cirrhosis  of  the  liver,  and  in  diabetes  mellitus.  In  gout  the 
amount  of  uric  acid  is  generally  decreased  between  the  acute  attacks,  and 
rises  during  and  immediately  after  the  paroxysm.  In  gout  an  increase  of 
uric  acid  is  found  in  the  blood  (uratsemia) .  The  circumstances  which  bring 
about  the  separation  of  uric  acid  crystals  in  and  about  the  joints  and  in 
other  tissues  are  not  definitely  known.  The  mere  existence  of  urataemia 
does  not  justify  the  conclusion  that  it  is  the  principal  or  primary  factor 
of  this  disease;  on  the  contrary  it  would  appear  that  an  increase  of  urates 
which  occurs  in  a  number  of  conditions,  as  anaemia,  leukaemia,  and  during 
the  resolution  stage  of  pneumonia,  does  not  in  itself  favor  precipitation 
of  biurate  of  sodium.  It  has  been  suggested  that  an  excess  of  sodium 
salts  in  the  blood,  lymph,  and  especially  in  synovial  fluid,  determines  the 
precipitation  of  urates.  Solutions  of  uric  acid  have  been  shown  to  possess 
only  slightly  toxic  or  harmless  properties  when  injected  into  the  tissues  of 
animals. 

The  quantity  of  uric  acid  in  the  urine  is  decreased  on  a  restricted  diet, 
especially  one  poor  in  substances  containing  nucleins,  after  the  adminis- 
tration of  large  doses  of  quinine,  in  nephritis,  and  in  certain  chronic  diseases. 
At  the  present  time  a  final  opinion  as  to  the  role  played  by  uric  acid  in  the 
so-called  uric  acid  diathesis  cannot  be  given. 

Xanthin  Bases. — Under  this  heading  is  included  a  group  of  substances 
found  in  the  urine  in  very  small  amounts  and  regarded  as  being  formed 
from  nucleins.     In  this  group   may  be  included  xanthin,  hypoxanthin. 


280  MEDICAL  DIAGNOSIS. 

heteroxanthin,  paraxanthin,  guanin  and  adenin.  In  the  main  it  may  be 
said  that  the  amounts  of  uric  acid  and  the  xanthin  bases  fluctuate  in  a  paral- 
lel manner.  The  xanthin  bases  are  increased  in  the  urine  in  leukaemia,  after 
a  diet  rich  in  nucleins,  and  in  pneumonia.    Rarely,  calculi  consist  of  xanthin. 

Ammonia. — The  normal  daily  output  of  ammonia  is  about  0.7  gramme, 
wliich  represents  slightly  over  four  per  cent,  of  the  total  nitrogen  elimina- 
tion. It  exists  in  combination  with  some  of  the  urinary  acids.  Its  presence 
in  the  urine  is  accounted  for  by  a  small  amount  of  ammonia  which  is  not 
transformed  into  urea  in  the  liver.  Ammonia  is  increased  in  conditions 
associated  with  deficient  oxidation,  as  cardiac  dyspncea,  in  certain  diseases 
of  the  parenchyma  of  the  liver,  such  as  acute  j^ellow  atrophy  and  phos- 
phorous poisoning,  in  diabetes  mellitus,  and,  notablj^,  in  pernicious  vomit- 
ing of  pregnancy. 

Chlorides. — Quantitative  Determination. — Ten  cubic  centimetres 
of  urine  are  diluted  with  90  c.c.  of  water,  to  which  are  then  added  a  few 
drops  of  a  strong  potassium  chromate  solution.  A  standard  silver  solution 
(1  c.c.  of  which  represents  .0035  gramme  of  chlorine,  or  .0058  gramme  of 
NaCl)  is  then  slowly  added  from  a  graduated  burette.  The  development  of  a 
permanent  orange  color  indicates  that  all  the  chlorine  has  been  precipitated. 

The  excretion  of  chlorides,  which  varies  from  10  to  15  grammes  per  day, 
depends  almost  exclusively  upon  the  quantity  of  chlorides  ingested.  A 
decreased  elimination  is  present  on  a  diet  poor  in  chlorides,  in  the  acute 
fevers  (probably  due  to  a  deficiency  of  chlorides  in  the  fever  diet),  before 
the  crisis  in  pneumonia,  in  acute  and  chronic  nephritis,  in  many  chronic 
diseases,  in  gastric  disorders  associated  with  vomiting,  in  diseases  attended 
with  diarrhoea,  and  during  the  formation  of  transudates  and  exudates. 
An  augmented  ehmination  is  observed  after  a  diet  rich  in  chlorides,  after 
the  acute  fevers,  especially  during  the  stage  of  resolution  of  pneumonia, 
in  diabetes  insipidus,  and  from  rapid  resorption  of  transudates  and  exudates. 

Phosphates. — Phosphoric  acid  of  the  urine  is  combined  T\ith  sodium, 
potassium,  ammonium,  calcium,  and  magnesium.  The  daily  amount  of 
phosphoric  acid  excreted  by  the  kidneys  varies  between  two  and  three 
grammes.  A  cUminished  excretion  has  been  noted  in  some  febrile  diseases, 
in  cases  of  arthritis,  between  the  paroxysms  of  gout,  in  pregnancy,  in. acute 
yellow  atrophy  of  the  liver,  in  nephritis,  in  Addison's  disease,  and  in  chronic 
lead  poisoning.  An  increased  ehmination  has  been  noted  on  a  diet  rich 
in  meat,  during  the  attack  of  gout,  in  diabetes  melhtus,  in  neurasthenia, 
in  hysteria,  in  leukaemia,  and  after  active  muscular  exercise.  The  existence 
of  a  phosphatic  deposit  in  the  urine  is  not  necessarily  a  sign  of  increased 
elimination,  and  is  frequently  due  to  alkalinity  of  the  urine.  A  quantita- 
tive estimation  of  phosphoric  acid  is  necessary  to  estabUsh  an  increased 
output.  Xeubauer's  method  consists  in  titrating  the  urine  with  a  uranium 
nitrate  solution,  using  cochineal  as  an  indicator.  For  the  details  of  this 
method  special  works  on  urinary  chemistry  should  be  consulted. 

Sulphates.— Sulphuric  acid  exists  in  the  urine  as  mineral,  preformed 
or  neutral  sulphates,  and  as  conjugate  or  ethereal  sulphates.  The  total 
daily  output  of  sulphuric  acid  varies  between  2  and  3  grammes,  nine-tenths 
of  which  is  eliminated  as  mineral  sulphates  and  the  remainder  as  ethereal 
sulphates.     Ethereal  sulphates  occur  in  combination  with  certain  aromatic 


EXAMINATION  OF  THE  URINE.  281 

bodies,  the  most  important  of  these  being  phenol,  indoxyl,  skatoxyl,  and 
cresol.  The  sulphate  ehmination  is  controlled  principally  by  proteid  metab- 
olism, so  that  the  amount  is  increased  after  a  diet  rich  in  meat,  by  muscular 
exercise,  in  the  acute  febrile  diseases,  in  acute  inflammator}^  diseases  of 
the  brain  and  spinal  cord,  and  by  certain  poisons  which  augment  proteid 
destruction.  The  output  of  sulphates  is  reduced  by  a  vegetable  diet  or 
one  poor  in  proteids,  during  the  period  of  convalescence  from  the  acute 
fevers,  and  in  many  chronic  diseases.  The  quantity  of  ethereal  sulphates 
depends  mainly  upon  putrefactive  changes  occurring  in  the  intestinal  tract, 
and  sometimes  in  other  parts  of  the  body.  The  normal  proportion  of 
ethereal  sulphate  to  neutral  sulphate  varies  considerably.  The  conjuoate 
sulphates  are  diminished  by  starvation,  by  the  administration  of  calomel 
and  hydrochloric  acid,  and  are  increased  by  the  ingestion  of  alkalies  and 
carbolic  acid,  in  intestinal  diseases  associated  with  increased  putrefaction, 
as  in  constipation,  enteric  fever,  and  tuberculous  enteritis. 

Indican. — Obermayer's  Test. — The  reagent  for  this  method  is  made 
by  dissolving  two  parts  of  ferric  chloride  in  1000  parts  of  concentrated 
hydrochloric  acid.  A  small  amount  of  urine  is  treated  with  an  equal  part 
of  Obermayer's  reagent  and  the  mixture  shaken  with  2  or  3  cubic  centi- 
metres of  chloroform,  which  extracts  indican.  It  is  light  blue  or  colorless 
when  a  normal  amount  is  present,  while  an  increased  quantity  is  shown 
by  a  dark  blue  color. 

Jaffe's  Test  Modified  by  Stokvis. — Equal  volumes  of  hydrochloric 
acid  and  urine  are  mixed.  The  Hquid  is  treated  with  a  droplet  of  a  con- 
centrated solution  of  sodium  or  calcium  hypochlorite  and  then  shaken  with 
a  few  c.c.  of  chloroform.  A  blue  color  is  imparted  to  the  chloroform  by  the 
indigo.  An  approximate  estimate  of  the  amount  may  be  formed  by  the 
depth  of  this  color.  Iodine  in  the  urine  tints  the  chloroform  pink.  Bile 
pigment  should  always  be  removed  with  lead  subacetate  before  testing 
for  indican.  Indol  is  formed  in  the  intestines  as  a  result  of  putrefactive 
processes;  in  the  blood  it  is  oxidized  and  combines  with  sulphuric  acid, 
being  eliminated  as  sodium  or  potassium  indoxyl  sulphate  or  indican.  As 
putrefaction  is  essential  for  the  formation  of  indican,  only  small  traces  of 
this  substance  occur  in  the  urine  of  healthy  persons,  since  intestinal  decom- 
position is  slight  under  normal  conditions.  The  quantity  of  indican  is 
influenced  by  the  character  of  food,  being  smaller  upon  a  milk  than  on  a 
full  mixed  diet.  Jaffe  found  that  6.6  mg.  was  the  average  normal  amount 
for  1000  c.c.  of  urine. 

Pathological  indicanuria  occurs  in  carcinoma  of  the  stomach,  in  cer- 
tain forms  of  gastritis,  and  in  conditions  associated  with  inhibited  intes- 
tinal peristalsis,  as  constipation,  intestinal  obstruction,  and  peritonitis. 
The  amount  of  indican  is  augmented  in  putrid  bronchitis,  in  empyema,  and 
in  gangrene  and  abscess  of  the  lungs. 

Urinary  Pigments. — The  color  of  normal  urine  depends  chiefly  upon 
urochrome.  The  following  pigments  are  responsible  for  the  color  of  many 
abnormal  urines:  pathological  urobilin,  uroerythrin,  haemoglobin,  methaem- 
oglobin,  urohsematin,  uroroseinogen,  biliary  pigment,  and  melanin.  After 
the  ingestion  of  senna,  santonin,  iodine,  phenol,  and  creosote  abnormal 
pigmentation  of  the  urine  often  occurs. 


282  MEDICAL  DIAGNOSIS. 

Biliary  Pigments. — Rosenbach's  Modification  of  Gmelin's  Method. 
— The  urine  is  filtered  through  thick  filter-paper.  A  drop  of  concentrated 
nitric  acid  is  then  placed  upon  the  urine-soaked  filter-paper.  A  play  of 
colors,  consisting  of  red,  yellow,  green,  blue,  and  violet,  in  which  the  green 
predominates,  will  develop  in  the  presence  of  biliary  pigment. 

Smith's  Test. — A  small  amount  of  tincture  of  iodine  diluted  with  10 
parts  of  alcohol  is  added  to  5  or  10  c.c.  of  urine,  so  that  the  iodine  solution 
forms  a  layer  above  the  urine.  An  emerald  color  forms  at  the  zone  of 
contact  of  two  fluids  when  bilirubin  is  present.  Biliary  acids  are  associated 
with  bilirubin  so  that  their  clinical  significance  is  practically  the  same. 
The  tests  for  biliary  acids  are  attended  with  considerable  difficulty. 

The  biliary  pigments  are  bilirubin,  biliverdin,  bilifuscin,  and  biliprasin. 
Bilirubin  is  found  in  freshly  voided  urine  only,  while  the  other  pigments 
may  appear  after  the  urine  has  stood  for  a  time.  Biliary  pigment  occurs 
in  the  urine  in  both  toxsemic  and  obstructive  jaundice. 

Phenol. — Salkow^ski's  Test. — About  10  c.c.  of  urine  are  treated  with 
a  few  c.c.  of  nitric  acid  and  boiled.  On  cooling,  bromine  water  is  added. 
An  increased  amount  of  phenol  is  shown  by  the  development  of  a  decided 
cloudiness  or  precipitate. 

The  amount  of  phenol  eliminated  is  very  small  (.03  gramme  daily 
under  normal  conditions).  This  substance  is  increased  whenever  putrefac- 
tive processes  occur  in  the  body,  as  in  gangrene,  putrid  bronchitis,  em- 
pyema, and,  rarely,  from  intestinal  decomposition.  It  has  also  been 
•demonstrated  in  tuberculosis,  meningitis,  peritonitis,  erysipelas,  scarlet 
fever,  and  from  poisoning  with  phenol  or  some  of  its  derivatives,  such 
as  salicylic  acid,  pyrocatechin  and  hydroquinone.  The  urine  containing 
phenol  may  become  dark  brown  or  black  on  standing. 

Pathological  Urobilin. — Braunstein's  Test. — About  20  c.c.  of  urine 
are  mixed  with  5  c.c.  of  a  reagent  which  consists  of  100  parts  of  a  con- 
centrated solution  of  cupric  sulphate,  6  parts  of  hydrochloric  acid,  and  3 
parts  of  ferric  chloride.  A  small  amount  of  chloroform  is  added  to  the 
mixture.     On  shaking,  the  chloroform  becomes  rose  colored. 

This  pigment  is  closely  related  to  urochrome  and  can  be  differentiated 
from  the  latter  by  the  spectroscope.  Urobilin  and  its  chromogen  are  solu- 
b)le  in  chloroform  and  precipitated  with  ammonium  sulphate.  Patho- 
logical urobilin  is  sometimes  encountered  in  the  urine  in  febrile  diseases, 
cirrhosis  of  the  liver,  pernicious  anaemia,  cancer,  cerebral  hemorrhage, 
scurvy,  Addison's  disease,  haemophilia,  and  syphilis. 

Melanin  and  Melanogen. — These  substances  are  occasionally  found  in 
the  urine  of  persons  suffering  from  melanotic  tumors,  chronic  malaria,  and 
certain  wasting  diseases.  The  urine  containing  melanin  and  melanogen 
may  have  a  normal  yellow  color  when  voided,  but  becomes  darker  when 
exposed  to  the  air. 

Albumins. — The  proteids  found  in  the  urine  are  serum  albumin, 
serum  globulin,  nucleo-albumin,  albumose,  Bence-Jones's  albumin,  haemo- 
globin, fibrin  and  histon.  The  most  important  of  these  from  a  clinical 
standpoint  is  serum  albumin. 

Serum  Albumin. — The  most  useful  tests  for  the  detection  of  albumin 
are  the  boiling  and  acidulation  tests  and  Heller's  test,  because  they  afford 


EXAMINATION  OF  THE  URINE.  283 

uniformly  satisfactory  results,  are  simple  and  easily  applied.  It  is  claimed 
that  these  tests  are  less  sensitive  than  many  others,  such  as  Speigler's  and 
Tanret's.  Before  testing  for  albumin  the  urine  should  be  clear,  and,  if 
cloudy,  must  be  filtered  through  several  layers  of  filter-paper.  Bacteria 
cannot  be  completely  removed  by  filtration  through  ordinary  filter-paper. 
It  is  desirable  to  have  a  fresh  specimen  for  testing.  In  certain  cases  several 
samples  should  be  secured,  i.e.,  the  first  urine  passed  in  the  morning  on 
arising,  and  that  voided  late  in  the  afternoon.  Albumin  reactions  are 
sometimes  less  distinct  in  concentrated  specimens  than  in  those  of  low 
specific  gravity,  and  it  is,  therefore,  advisable  to  dilute  an  inspissated 
urine  before  applying  albumin  tests. 

Boiling  and  Acidulation  Test. — Clear  urine  is  boiled  in  a  test-tube. 
When  a  precipitate  forms  this  is  generally  due  to  either  phosphates  or 
albumin  (serum  albumin  in  conjunction  with  serum  globulin).  The  tur- 
bidity caused  by  phosphates  clears  on  the  addition  of  a  few  drops  of  color- 
less nitric  acid,  while  the  cloud  due  to  albumin  remains  or  even  is  intensi- 
fied after  acidulation.  A  precipitate  of  carbonates,  developing  on  heating, 
will  disappear  upon  the  addition  of  nitric  acid  with  the  liberation  of  gas 
(CO2).  If  on  boiling  the  urine  remains  clear  but  subsequently  on  cooling 
a  cloud  develops,  this  is  due  to  albumose.  This  turbidity  will  again 
disappear  on  heating.  Certain  resinous  bodies,  as  copaiba,  benzoin, 
cubebs,  and  turpentine,  also  produce  a  precipitate  on  heating.  This  cloud 
can  be  distinguished  from  that  produced  by  albumin  by  the  fact  that 
alcohol  dissolves  the  turbidity  produced  by  these  substances.  When 
employing  acetic  acid.,  it  is  best  to  add  a  few  drops  before  boiling,  care 
being  taken  to  avoid  an  excess,  since  albumin  may  not  precipitate  on 
boiling.  If  a  cloud  forms  after  the  urine  is  treated  with  acetic  acid, 
this  is  caused  by  nucleo-albumin  and  should  be  removed  by  filtration  before 
testing  for  serum  albumin.  The  most  accurate  results  are  obtained  with 
this  method  when  a  dilute  acetic  acid  solution  is  employed  (25  per  cent.). 

Heller's  Test. — Colorless  nitric  acid  is  allowed  to  flow  slowdy  from 
a  pipette  into  a  test-tube  or  a  conical  glass  vessel  containing  a  small  quan- 
tity of  urine,  so  that  the  urine  forms  a  distinct  layer  above  the  acid.  In 
order  to  prevent  mixing  the  acid  and  urine,  the  test-tube  or  conical  vessel 
should  be  inclined  while  adding  the  nitric  acid.  When  serum  albumin  is 
present  a  white  disk  appears  at  the  zone  of  contact  between  the  urine  and 
acid.  When  a  small  amount  of  albumin  exists  the  precipitate  does  not 
form  immediately  but  in  the  course  of  several  minutes.  An  approximate 
quantitative  estimate  of  albumin  can  be  formed  from  the  thickness  of  the 
coagulated  layer.  A  pale  red  or  reddish-violet  disk,  at  or  above  the  plane 
of  contact,  is  noted  in  many  normal  and  abnormal  urines.  A  white  pre- 
cipitate is  also  caused  by  serum  globulin  and  albumose.  The  latter  dis- 
appears on  heating  and  reappears  on  cooling.  Nucleo-albumin  in  large 
amounts  may  give  a  positive  reaction,  but  this  is  so  uncommon  that  it 
can  be  disregarded  for  practical  purposes.  Certain  resinous  bodies,  indi- 
cated in  the  discussion  of  the  boihng  and  acidulation  test,  produce  a 
white  cloud  which  disappears  when  treated  with  alcohol. 

Acetic  Acid  and  Potassium  Ferrocyanide  Test. — A  few  drops 
of  10  per  cent,  solution  of  potassium  ferrocyanide  or  platinocyanide  are 


284 


MEDICAL  DIAGNOSIS. 


added  to  a  small  amount  of  urine  previously  acidified  with  acetic  acid. 
A  precipitate  indicates  albumin  or  albumose.  If,  on  heating,  the  turbid- 
ity disappears  completely,  the  presence  of  the  latter  substance  is  indi- 
cated, or,  if  the  cloud  partly  clears  on  warming,  the  presence  of  both 
substances  may  be  inferred.  When  a  precipitate,  due  to  nucleo-albumin, 
forms  on  addition  of  acetic  acid,  the  urine  should  be  filtered  and  the 
test  repeated. 

Spiegler's  Test. — The  test  solution  as  modified  by  Jolles  consists 
of  mercuric  chloride  10  grammes,  succinic  acid  20  grammes,  sodium  chlo- 
ride 20  grammes,  and  distilled  water  500  c.c.  The  reagent  is  added  slowly 
by  means  of  a  pipette  to  a  small  amount  of  urine  contained  in  a  test-tube, 
so  that  the  urine  forms  a  layer  above  the  test  solution.  A  white  cloud 
at  the  junction  of  the  fluids  indicates  albumin,  nucleo-albumin 
\  ]  or  albumose.  When  the  urine  contains  iodine,  a  precipitate  of 
mercuric  iodide  forms,  which  is  soluble  in  alcohol.  This  test 
is  very  sensitive. 

Many  other  methods  for  the  detection  of  albumin  are  recom- 
mended by  different  authorities,  as  tests  with  picric  acid,  meta- 
phosphoric  acid,  phosphotungstic  acid,  and  trichloracetic  acid. 
Quantitative  Determination  of  Albumin.  Esbach's 
Method. — The  test  solution  is  prepared  by  dissolving  10 
grammes  of  picric  acid  and  20  grammes  of  citric  acid  in  1000 
c.c.  of  distilled  water.  A  special  graduated  test-tube  devised 
by  Esbach  and  known  as  an  albuminometer  is  required  for  this 
method.  The  urine  should  have  an  acid  reaction.  It  is  poured 
into  the  albuminometer  to  the  mark  ''U  ";  the  reagent  is  then 
added  until  the  fluid  reaches  to  the  mark  "R. "  The  fluids 
are  then  mixed  and  the  test-tube  set  aside  for  twenty-four 
hours,  when  the  reading  is  taken.  The  height  of  the  column 
of  coagulated  albumin,  as  measured  by  the  scale  on  the  tube, 
represents  the  amount  pro  mille.  Esbach's  reagent  precipi- 
tates serum  albumin,  serum  globulin,  albumose,  uric  acid,  and 
creatinin.  When  the  specific  gravity  exceeds  1.008,  or  when  a 
large  amount  of  albumin  exists,  the  urine  should  be  diluted 
with  one  or  several  volumes  of  water  before  applying  the  test. 
The  reading  is  multiplied  by  the  number  of  dilutions.  Esbach's 
method,  although  not  so  accurate  as  the  gravimetric  determination,  is  quite 
satisfactory  for  general  clinical  purposes. 

Boiling  Test. — An  approximate  estimate  of  the  quantity  of  albumin 
can  be  formed  by  boiling  acidified  urine  in  a  test-tube  and  allowing  the 
precipitate  to  settle  for  twenty-four  hours.  The  error  with  this  method 
may  be  considerable,  because  albumin  sometimes  separates  in  large  and 
at  other  times  in  small  flakes. 

Gravimetric  Method. — One  hundred  cubic  centimetres  of  urine  are 
sufficiently  acidulated  with  acetic  acid  to  insure  separation  of  all  the 
albumin.  It  is  then  boiled  and  passed  through  a  filter  of  known  weight. 
The  precipitate  collected  on  the  filter  is  washed  with  hot  water  until  the 
washings  cease  to  give  a  reaction  for  chlorides.  The  precipitate  is  next 
washed  successively  with  alcohol  and  ether  to  remove  fat.     The  filter 


-u 


Fig.  120.— 
Esbach's  albu- 
minometer. — 
Eraerson. 


EXAMINATION  OF  THE  URINE.  285 

containing  the  precipitate  is  now  dried  at  a  temperature  of  120°  to  130° 
and  then  carefully  weighed.  The  weight  of  the  albumin  is  obtained  by 
subtracting  the  weight  of  the  filter-paper  from  the  combined  weight  of  the 
filter-paper  and  dried  precipitate. 

Albuminuria.  —  The  term  albuminuria  implies  the  presence  in  the 
urine  of  coagulable  albumin,  and  refers  particularly  to  serum  albumin. 
One  or  more  albuminous  bodies  are  almost  invariably  associated  with 
serum  albumin.  Albuminuria  is  symptomatic  of  a  large  number  of  morbid 
states,  from  minor  disturbances  in  health  to  malignant  diseases. 

1.  Renal  Albuminuria. — When  albumin  is  eliminated  by  the  kid- 
neys the  condition  is  termed  renal  albuminuria. 

(a)  So-called  'physiological  albuminuria  is  occasionally  noted  in  healthy 
individuals  after  violent  exercise  or  severe  nervous  stress.  Whether  albu- 
minuria is  ever  physiological  is  still  a  mooted  question.  Albuminuria 
often  occurs  in  pregnancy,  esiDecially  in  the  later  stages.  The  so-called 
albuminuria  of  adolescents  is  probably  pathological. 

(b)  Albuminuria  of  Organic  Kidney  Disease.  —  In  this  variety  the 
presence  of  albumin  in  the  urine  depends  directly  on  structural  changes 
in  the  renal  tissues,  and  in  nephritis,  and  amyloid,  tuberculous,  malignant 
and  cystic  disease  of  the  kidney.  In  acute  and  chronic  parenchymatous 
nephritis  the  amount  is  generally  large,  while  in  amyloid  disease  it  is  moder- 
ate or  small,  and  in  contracted  kidney  it  is  small.  The  mere  presence  of 
albumin  in_th^jirine^,ne.VJ£C_JSJ^arxan±s^^~dia^nosis..  of  organic  renal,  disease; 
on  the  other  hand  mere  traces  occur  in  granular  kidney,  and,  indeed,  albumin 
may  be  absent  for  a  time  in  this  disease.  Large  quantities  of  albumin 
usually  justify  a  diagnosis  of  organic  kidney  disease. 

(c)  Febrile  Albuminuria. — A  discharge  of  albumin  of  slight  or  moderate 
degree  in  fevers  and  inflammatory  diseases  is  suggestive  of  a  simple  paren- 
chymatous degeneration  of  the  kidney  and  of  vascular  derangements, 
incident  to  the  febrile  or  inflammatory  process,  while  a  high  grade  of  al- 
buminuria, noted  in  a  limited  number  of  these  cases,  points  to  marked  renal 
degeneration,  often  associated  with  decided  congestion.  The  difference 
between  albuminuria  of  febrile  and  inflammatory  disorders  and  that  of 
acute  Bright's  disease  is  essentially  one  of  degree,  so  that  a  sharp  distinc- 
tion cannot  be  made  between  these  forms.  Albuminuria  is  symptomatic 
of  many  of  the  infectious  diseases,  especially  enteric  fever,  typhus  fever, 
pneumonia,  cerebrospinal  fever,  yellow  fever,  plague,  cholera,  malignant 
endocarditis,  diphtheria,  erysipelas,  and  variola. 

(d)  Toxic  Albuminuria. — Under  this  heading  is  included  the  albu- 
minuria produced  by  drugs,  such  as  salicylic  acid,  potassium  iodide,  salol, 
urotropine,  phenol,  alcohol,  ether,  chloroform,  lead,  mercury,  phosphorus, 
and  a  number  of  other  toxic  substances. 

(e)  Albuminuria  occurring  in  blood  disorders  is  seen  in  severe  second- 
a.ry  anaemias,  pernicious  anaemia,  chlorosis,  and  leukaemia. 

(f)  Alimentary  Albuminuria. — The  ingestion  of  very  large  amounts  of 
albumin,  such  as  raw  eggs,  may  excite  albuminuria,  but  a  moderate  quan- 
tity of  albuminous  food  will  never  produce  albuminuria  in  a  healthy  person. 
An  antecedent  chronic  albuminuria  may  be  intensified  by  a  moderate 
consumption  of  albumin. 


286  MEDICAL  DIAGNOSIS. 

(g)  Albuminuria  dependent  upon  circulatory  disturbances  of  the  kid- 
neys is  seen  in  cardiac  disease,  especially  during  the  stage  of  ruptured 
compensation,  in  pulmonary  disease  with  venous  stasis,  from  pressure  on 
the  renal  veins  by  a  tumor,  cyst  or  peritoneal  effusion,  and  by  a  thrombus  in 
these  vessels.  In  floating  kidney  albuminuria  sometimes  depends  on  kink- 
ing of  the  renal  veins  so  that  it  may  be  present  only  while  the  individual 
is  in  the  erect  posture,  disappearing  when  in  the  recumbent  position  (ortho- 
static albuminuria). 

(h)  Albuminuria  in  nervous  diseases  is  common  when  organic  lesions 
of  the  nervous  system  exist,  such  as  apoplexy,  brain  tumor,  and  spinal 
sclerosis,  but  it  is  infrequent  in  functional  disorders,  such  as  neurasthenia 
and  migraine. 

(i)  Albuminuria  caused  by  obstruction  in  the  urinary  passages  occurs 
in  nephrolithiasis,  when  the  stone  blocks  up  the  ureter  for  a  time,  and  also 
when  the  ureter  is  compressed  by  a  tumor  or  is  twisted.  The  urine  which 
has  been  impeded  in  its  passage  shows  albumin  in  many  instances. 

2.  Accidental  Albuminuria. — When  the  urine  contains  albumin 
derived  from  the  renal  passages  or  genital  organs  it  is  designated  accidental 
or  extrarenal  albuminuria.  The  presence  of  pus,  blood,  leucorrhoeal 
discharge,  and  chyle  in  the  urine,  as  a  rule,  causes  a  slight,  and  rarely,  a 
moderate  albumin  reaction.  This  type  occurs  in  pyehtis,  ureteritis,  cystitis, 
prostatitis,  vesicuhtis,  epididymitis,  urethritis,  vulvovaginitis,  and  during 
menstruation.  A  vaginal  discharge  is  often  washed  into  the  urine.  The 
diagnosis  of  accidental  albuminuria  is  generally  unattended  with  difficulty, 
provided  the  results  of  microscopic  examination  and  the  clinical  investi- 
gation are  carefully  considered.  In  general  terms  it  may  be  said  that  the 
intensity  of  the  albumin  reaction  is  directly  proportionate  to  the  amount 
of  cellular  deposit.  The  differentiation  between  renal  and  extrarenal 
albuminuria  rests  on  the  data  obtained  by  a  careful  urinalysis  with  other 
clinical  findings.  Both  conditions  often  coexist.  The  presence  of  tube- 
casts  and  many  pus-cells  with  an  albumin  reaction  greater  than  the  number 
of  leucocytes  would  indicate,  argues  in  favor  of  a  coexistent  renal  and 
accidental  albuminuria. 

Serum  Globulin. — Kauder's  Test. — The  urine  is  treated  with  a  sufii- 
cient  quantity  of  ammonia  to  separate  the  phosphates,  which  are  removed 
by  filtration.  An  equal  bulk  of  a  saturated  solution  of  ammonium  sulphate 
and  filtrate  are  mixed.     A  precipitate  represents  serum  globulin. 

Serum  globuHn  and  serum  albumin  are  almost  invariably  associated,, 
so  that  their  cHnical  significance  is  similar.  As  a  rule  serum  albumin  is 
found  in  excess  of  serum  globulin,  although  exceptions  to  this  rule  are 
recorded  in  amyloid  disease,  diabetes,  and  severe  nephritis. 

Nucleo=.albumin.  —  This  body  is  precipitated  by  strong  acetic  acid. 
Concentrated  urines  should  always  be  diluted  with  two  or  three  volumes 
of  water  before  applying  this  test.  Urine  containing  much  serum  albumin 
and  serum  globulin  should  be  boiled  and  filtered  in  order  to  remove  these 
substances  before  testing  for  nucleo-albumin. 

Ott's  Method. — Add  to  the  urine  an  equal  volume  of  saturated  solu- 
tion of  sodium  chloride,  and  treat  the  mixture  with  Almen's  tannin  solution. 
The  presence  of  nucleo-albumin  is  shown  by  the  formation  of  an  abundant 


EXAMINATION  OF  THE  URINE.  287 

precipitate.  Almen's  solution  consists  of  5  grammes  of  tannic  acid,  10  c.c.  of 
a  25  per  cent,  solution  of  acetic  acid,  and  240  c.c.  of  50  per  cent,  ethyl  alcohol. 
Nucleo-albumin  can  be  removed  from  the  urine  with  neutral  lead  acetate. 

With  certain  delicate  tests  nucleo-albumin  can  be  demonstrated  in 
many  normal  and  abnormal  specimens,  so  that  its  presence  in  small  amount 
may  be  regarded  as  physiological.  When  nucleo-albumin  can  be  de- 
tected by  tests  generally  employed  in  routine  clinical  work,  it  is  probably 
pathological.  Nucleo-albuminuria  occurs  in  inflammatory  diseases,  espe- 
cially of  a  catarrhal  nature,  of  the  urinary  tract,  as  cystitis  and  pyelitis.  In 
febrile  diseases  associated  with  albuminuria,  in  leukaemia,  in  jaundice,  and  in 
acute  nephritis,  nucleo-albuminuria  is  not  uncommon.  In  the  last  named  dis- 
ease nucleo-albuminuria  sometimes  precedes  and  follows  serum  albuminuria. 

Albumose. — To  the  urine  strongly  acidulated  with  acetic  acid,  is  added 
an  equal  amount  of  a  saturated  solution  of  sodium  chloride.  The  presence 
of  a  precipitate,  which  disappears  on  boiling  and  returns  on  cooling  the 
urine,  consists  of  albumose.  When  serum  albumin  coexists  with  albumose^ 
this  must  be  removed  by  boiling  and  filtering  before  applying  the  test. 

Albumosuria  is  referred  to  by  some  writers  as  peptonuria,  a  term  which. 
Kiihne  restricts  to  the  presence  of  true  peptone.  According  to  Kiihne, 
peptonuria  has  been  found  in  pneumonia,  phthisis,  and  gastric  ulcer.  The 
chief  clinical  significance  of  albumose  in  the  urine  relates  to  morbid  lesions, 
characterized  by  a  destruction  of  leucocytes,  with  the  absorption  of  the 
disintegrated  products.  In  many  diseases  showing  these  pathological 
features,  ^especially  in  purulent  collections,  the  occurrence  of  albumosuria 
may  be  a  useful  sign  in  diagnosis.  In  this  connection  it  must  be  pointed 
out  that,  since  the  group  of  conditions  in  which  it  occurs  is  a  vast  one,  its 
significance  is  of  less  value  in  diagnosis  than  any  other  urinary  findings. 
Albumosuria  has  been  noted  in  pneumonia  during  the  period  of  resolution, 
in  suppurative  meningitis,  in  liver  abscess,  in  septicaemia,  in  leukaemia, 
in  endocarditis,  in  myxoedema,  in  diphtheria,  in  measles,  in  rheumatic 
fever,  in  scarlet  fever,  in  acute  yellow  atrophy  of  the  liver,  in  scurvy,  in 
dermatitis,  and  in  intestinal  diseases  characterized  by  ulceration,  as  enteric 
fever,  tuberculosis,  and  carcinoma.  Albumosuria  may  be  associated  with, 
or  occur  independently  of,  serum  albuminuria. 

Bence= Jones's  Albumose. — The  recognition  of  this  proteid  depends  upon 
the  fact  that  its  precipitation  occurs  at  a  temperature  of  59°  to  60°  C. 
Upon  boiling,  the  cloud  entirely  or  partially  disappears,  to  return  again  on 
cooling.  With  Heller's  nitric  acid  test  Bence-Jones's  albumin  gives  a  reac- 
tion like  that  of  serum  albumin. 

This  proteid,  first  described  by  Bence-Jones,  occurs  with  considerable 
frequency  in  myeloma  of  the  bones.  It  is  generally  designated  as  albumose, 
but  probably  incorrectly.  The  researches  of  Simon  and  Magnus  Levy 
indicate  that  it  is  a  true  albumin. 

Haemoglobin. — The  spectroscopic  examination,  as  a  rule,  shows  absorp- 
tion bands  of  methaemogiobin,  sometimes  of  oxyhaemoglobin. 

Donogany's  Test. — If,  on  the  addition  of  1  c.c.  of  ammonium  sulphide 
solution  and  an  equal  quantity  of  pyridine  to  10  c.c.  of  urine,  an  orange  color 
develops,  the  presence  of  blood  may  be  inferred.  When  the  result  is 
doubtful,  a  spectroscopic  examination  should  be  made  of  the  mixture. 


288  MEDICAL  DIAGNOSIS. 

The  physiological  destruction  of  red  corpuscles  is  not  followed  by 
hsemoglobinuria,  because  the  coloring  matter  set  free  from  the  disintegrated 
erythrocytes  is  converted  wholly,  or  in  part,  in  the  liver  into  bile,  and,  per- 
haps, a  fraction  of  the  amount  is  redeposited  in  the  tissues  and  stored 
there  for  the  future  demands  of  the  system.  The  explanation  generally 
offered  to  elucidate  hemoglobinuria  is  based  upon  an  erythrocytolysis  so 
excessive  that  a  part  of  the  hasmoglobin  liberated  into  the  plasma  (hamo- 
globinsemia)  is  secreted  by  the  kidneys.  Hemoglobinuria  occurs  in  some 
cases  of  malarial  fever  (black  water  fever) .  It  has  been  observed  in  yellow 
fever,  variola,  icterus  gravis,  scarlet  fever,  enteric  fever,  syphilis,  Raynaud's 
disease,  and  from  the  toxic  action  of  phenol,  potassium  chlorate,  snake 
venom,  hydrogen  sulphide,  carbon  monoxide,  and  after  exposure  to  the 
cold.  The  etiological  factor  responsible  for  paroxysmal  hsemoglobinuria 
has  not  been  definitely  determined.  Some  writers  claim  that  exposure  to 
cold  is  the  exciting  cause,  while  others  hold  that  it  is  of  nervous  origin. 
Hsematuria  is  much  more  common  than  hsemoglobinuria. 

Fibrin. — The  suspected  fibrin  clots  are  separated  from  the  .urine  by 
filtration,  then  thoroughly  washed  with  water  and  dissolved  by  boiling  in 
a  5  per  cent,  solution  of  hydrochloric  acid.  '  The  solution  thus  secured 
gives  the  test  for  serum  albumin  when  the  coagulum  consists  of  fibrin. 

Fibrinuria  has  been  noted  in  hsematuria,  chyluria,  and  in  pseudomem- 
branous inflammation  of  the  urinary  tract. 

An  acetosoluble  albumin  referred  to  by  Simon  as  Patein's  albumin 
has  been  reported  in  cystic  kidney  and  nephritis. 

Glucose. — Fresh  urine  is  desirable  for  quantitative  examinations  for 
sugar.  When  albumin  is  present,  this  should  be  removed  from  the  urine 
before  testing  for  glucose. 

Trommer's  Test. — To  a  small  amount  of  urine  rendered  strongly 
alkaline  with  a  solution  of  sodium  hydrate,  is  added  drop  bj^  drop  a  10  per 
cent,  solution  of  cupric  sulphate,  until  the  cupric  oxide  which  forms  ceases 
to  be  dissolved.  On  heating  the  urine,  treated  in  this  manner,  a  yellow  or 
red  precipitate  develops  when  sugar  is  present.  Small  traces  of  sugar 
often  give  negative  results  unless  the  urine  is  boiled.  Cupric  oxide  is  often 
reduced  by  other  substances.  This  may  occur  after  the  ingestion  of  benzoic 
acid,  chloral,  salicylic  acid,  sulphonal,  chloroform,  and  from  the  presence 
in  the  urine  of  uric  acid,  creatinin,  creatin,  bile  pigment,  and  hydroquinone. 
Glucose  causes  precipitation  of  cupric  oxide  at  a  temperature  below  the 
boiling  point,  which  affords  a  means  of  distinguishing  it  from  other  reducing 
sub.stances. 

Fehling's  Test. — This  method  is  a  modification  of  Trommer's  test. 
Two  solutions  are  required,  an  alkaline  and  a  copper  solution,  which  should 
be  mixed  just  before  applying  the  test.  Fehling's  reagent  deteriorates  in 
a  few  days  to  such  an  extent  that  it  is  unsuited  for  testing;  therefore,  it  is 
necessary  to  keep  the  alkaline  and  copper  solutions  in  separate  bottles  sup- 
plied with  well-fitting  rubber  corks.  The  alkaline  solution  consists  of  potas- 
sium and  sodium  tartrate  173  grammes,  potassium  hydrate  60  grammes, 
and  500  c.c.  of  distilled  water.  The  copper  solution  consists  of  cupric 
sulphate  34.64  grammes,  dissolved  in  500  c.c.  of  distilled  water.  Equal 
volumes  of  these  solutions  are  poured  into  a  test-tube  and  shaken;    the 


EXAMINATION  OF  THE  URINE.  289 

mixture  is  then  diluted  with  four  parts  of  water  and  boiled.  After  remov- 
ing the  test-tube  from  the  flame  the  urine  is  added  in  small  amounts,  and 
after  each  addition  the  mixture  heated  but  not  boiled.  When  sugar 
is  present  a  yellow  or  red  precipitate  of  cupric  suboxide  separates.  A 
change  of  the  blue  color  of  Fehling's  solution  to  green,  with  a  slight 
turbidity  of  the  liquid  after  the  addition  of  the  urine,  is  very  often  seen, 
and  may  not  be  caused  by  glucose.  Nearly  every  reduci&g  substance 
except  sugar  requires  boiling  to  produce  precipitation  of  cupric  suboxide. 

Phenylhydrazine  Test. — About  .5  gramme  of  phenylhydrazine  hydro- 
chloride and  1  gramme  of  sodium  acetate  are  added  to  about  8  c.c.  of  urine 
contained  in  a  test-tube.  If  the  salts  do  not  dissolve  on  warming  the  urine, 
water  is  added  to  effect  solution.  The  tube  is  now  placed  in  boiling  water 
for  20  or  30  minutes,  then  removed,  and  rapidly  cooled  by  placing  the  test- 
tube  in  cold  water.  The  formation  of  a  bright  yellow  precipitate  indicates 
the  presence  of  sugar.  Mere  traces  of  glucose  cause  a  small  amount  of 
precipitate  which  should  be  examined  microscopically  for  phenylglucosa- 
zone  crystals.  These  consist  of  yellow  needles  arranged  singly  or  in  clus- 
ters. Their  melting  point  is  205°  C.  In  experienced  hands  this  test  is 
generally  considered  the  most  sensitive. 

Nylander's  Modification  of  Boettger's  Test. — Almen's  reagent, 
required  for  this  method,  consists  of  4  grammes  of  potassium  and  sodium 
tartrate,  2  grammes  of  bismuth  subnitrate,  and  10  grammes  of  sodium 
hydrate  dissolved  in  90  c.c.  of  water.  This  solution  is  then  boiled  and,  after 
cooling,  it  is  filtered.  A  small  quantity  of  Almen's  reagent  is  added  to  the 
urine,  approximately  in  the  proportion  of  1  to  11,  and  the  resultant  mix- 
ture is  boiled.  In  the  presence  of  sugar  a  dark  gray  or  black  precipitate  of 
metallic  bismuth  separates.  A  positive  reaction  may  be  given  by  albumin, 
melanin,  melanogen,  and  other  reducing  substances  found  in  the  urine 
after  the  ingestion  of  salol,  benzol,  sulphonal,  trional,  turpentine,  quinine, 
rhubarb,  and  senna. 

Fermentation  Test. — The  principle  of  this  method  is  based  on  the 
fact  that  glucose  is  decomposed  by  yeast  into  alcohol  and  carbon  dioxide. 
Special  fermentation  tubes,  as  designed  by  Einhorn,  are  convenient  in 
conducting  this  test.  The  method  is  carried  out  by  mixing  a  bit  of  a  cake 
of  compressed  yeast  with  urine  in  a  test-tube.  Einhorn's  fermentation 
tube  is  filled  with  this  mixture,  care  being  taken  to  exclude  air  bubbles 
from  the  top  of  the  tube.  The  saccharometer  is  kept  at  a  temperature  of 
from  25°  to  38°  for  twenty-four  hours,  during  which  time  the  CO2  collects 
in  the  upper  part  of  the  tube,  A  temperature  of  34°  C.  gives  the  most 
satisfactory  results.  A  control  test  should  always  be  made  with  normal 
urine,  since  slight  fermentation  occurs  in  every  specimen.  With  Einhorn's 
tube,  an  approximate  estimate  of  the  quantity  of  sugar  can  be  formed, 
but  for  accurate  quantitative  analysis  Robert's  differential  method  is  to 
be  preferred.  The  fermentation  test  serves  to  differentiate  fermentable 
sugar  from  other  reducing  substances. 

Quantitative  Estimation  of  Sugar.  Fehling's  Titration 
Method. — 10  c.c.  of  Fehling's  solution  diluted  with  40  c.c.  of  water  are 
boiled.  At  this  temperature  saccharine  urine  is  added  drop  by  drop  from 
a  graduated  burette,  until  the  blue  color  of  the  test  solution  disappears, 

19 


290  MEDICAL  DIAGNOSIS. 

which  indicates  complete  reduction  of  cupric  oxide.  The  presence  of 
reduced  copper  held  in  suspension  obscures  the  color  of  the  solution,  so 
that  it  is  necessary  to  allow  the  cuprous  oxide  granules  to  settle  from  time 
to  time  in  order  to  detect  the  tint  of  the  fluid.  The  cupric  oxide  contained 
in  10  c.c.  of  Fehling's  solution  is  reduced  by  .05  gramme  of  glucose. 

Robert's  Differential  Density  Method.  • —  For  general  clinical 
work,  Robert's  method  is  most  satisfactory.  The  principle  of  this  method 
rests  on  determining  the  specific  gravity  before  and  after  fermentation; 
each  .001  degree  of  difference  in  the  specific  gravity  represents  .23  per 
cent,  of  sugar.  The  test  is  carried  out  by  noting  the  specific  gravity  of 
200  c.c.  of  urine  taken  from  a  mixed  24-hour  specimen.  A  portion  of  a 
cake  of  compressed  yeast  is  mixed  with  the  urine,  which  is  then  set  aside 
for  24  or  48  hours.  The  glucose  generally  disappears  in  24  hours,  but,  in 
order  to  ascertain  whether  all  the  sugar  has  been  decomposed,  the  urine 
is  tested  by  Fehling's  method.  After  all  the  sugar  has  been  decomposed, 
the  specific  gravity  of  the  fermented  urine  is  taken  and  the  difference 
between  the  two  readings  determined.  The  small  urinometers  employed 
in  clinical  work  are  not  suited  for  exact  determination,  therefore  it  is 
convenient  to  use  larger  instruments.  Accurate  estimations  can  be  taken 
with  a  set  of  four  or  five  hydrometers,  each  of  which  represents  a  part  of 
the  specific  gravity  range  ordinarily  encountered  in  diabetic  urine.  For 
example,  hydrometer  number  1  indicates  the  scale  from  1.000  to  1.010; 
number  2  ranges  from  1.010  to  1.020;  number  3  ranges  from  1.020  to 
1.030;  number  4  ranges  from  1.030  to  1.040,  number  5  ranges  from 
1.040  to  1.050.  The  specific  gravity  observations  should  be  taken  at, 
or  nearly,  the  same  temperature.  Evaporation  of  the  urine  should  be 
reduced  to  a  minimum  during  fermentation.  The  first  specific  gravity 
determination  is  taken  before  the  yeast  is  added  to  the  urine,  and  the 
second  reading  is  made  after  the  fermented  urine  has  been  filtered. 

The  quantitative  determination  for  sugar  by  the  polariscope  is  rec- 
ommended highly  by  many  workers,  A  polariscope  designed  for  this 
estimation  is  an  expensive  instrument.  The  rapidity  with  which  a  deter- 
mination can  be  made  is  one  of  its  chief  advantages  over  other  methods. 

Physiological  Glycosuria. — The  presence  of  traces  (.5  pro  mille)  of  glu- 
cose in  the  urine  of  healthy  persons  is  conceded  by  most  authorities.  This 
quantity  cannot,  however,  be  detected  by  the  tests  employed  in  routine  work. 

Pathological  Glycosuria. — This  condition  may  be  said  to  exist  when 
glucose  can  be  recognized  by  the  tests  generally  in  vogue  in  clinical  work. 
Glycosuria  may  be  transitory,  intermittent,  or  constant.  The  latter  variety 
is  one  of  the  cardinal  symptoms  of  diabetes  melhtus. 

Glycosuria  depends  directly  on  an  excess  of  sugar  (above  .2  per  cent.) 
in  the  blood.  A  possible  exception  to  this  rule  relates  to  the  glycosuria  fol- 
lowing the  administration  of  phloridzin.  It  is  thought  that  this  substance 
produces  such  alterations  in  the  renal  epithehum  as  to  permit  of  increased 
glucose  ehmination.  A  renal  form  of  diabetes  has  been  suggested.  The 
sugar  of  the  blood  is  derived  principally  from  the  carbohydrates  of 
the  food,  and  in  all  likehhood  some  glucose  is  produced  from  the 
albumins  of  the  food.  In  certain  cases  of  diabetes,  characterized  by  rapid 
emaciation,  body  proteids  are  concerned  in  its  formation.     Although  many 


EXAMINATION  OF  THE  URINE.  291 

factors  involved  in  the  physiology  of  glucose  metabohsni  remain  unex- 
plained, much  clinical  and  experimental  evidence  supports  the  view,  (1) 
that  sugar  metabolism  is  to  a  great  extent  regulated  by  the  nervous  system, 
(2)  that  the  liver  is  chiefly  concerned  in  converting  sugar  into  glycogen, 
and  also  in  forming  glucose,  and  (3)  that  the  pancreas  secretes  a  sugar- 
destroying  ferment.  A  hypothetical  conception  of  pathological  glycosuria 
based  on  this  theory  may  be  said  to  depend  on  a  failure  on  the  part  of  the 
liver  to  form  and  store  up  glycogen,  a  disturbance  which  might  result  from 
a  loss  of  nervous  control  or  from  disease  of  the  hepatic  cells;  or  on  an  in- 
abihty  on  the  part  of  the  system  to  consume  sugar,  which  is  ascribed  to  a 
disturbance  in  the  function  of  the  pancreas  inhibiting  or  suppressing  the 
secretion  of  the  glycolytic  substance.  Clinically,  glycosuria  occurs  under 
a  variety  of  circumstances:  Disorders  of  the  nervous  system.  Tempo- 
rary or  permanent  glycosuria  is  observed  in  brain  tumors,  meningitis, 
injuries  to  the  nervous  system,  neurasthenia,  exophthalmic  goitre,  and 
may  follow  worry,  fright,  or  mental  overwork.  Diseases  of  the  pancreas. 
Permanent  glycosuria  is  often  associated  with  sclerosis,  and  sometimes 
with  atrophy  or  tumors  of  the  pancreas,  while  temporary  glycosuria  is  at 
times  symptomatic  of  acute  inflammation  of  this  organ.  Hepatic  disease, 
abscess  and  cirrhosis  of  the  liver  may  be  attended  with  the  temporary  or 
constant  presence  of  sugar  in  the  urine.  Toxic  agents.  The  occasional 
occurrence  of  glucose  in  the  urine  is  noted  in  the  infectious  diseases,  as 
syphilis,  influenza,  enteric  fever,  diphtheria,  rheumatic  fever,  and  malaria, 
and  from  poisoning  by  chloral,  alcohol,  and  morphine.  The  explanation 
of  glycosuria  occurring  under  these  circumstances  might  be  found  in  the 
development  of  a  disorder  of  the  function  of  the  liver,  the  pancreas,  or  the 
nervous  system,  produced  by  these  toxic  agents.  This  variety  is  mainly 
observed  as  a  transitory  form,  although  occasionally  diabetes  develops 
after  an  acute  infectious  disease,  which  suggests  permanent  morbid  proc- 
esses of  the  hepatic  or  pancreatic  tissues  excited  during  the  acute  stage 
of  the  disease. 

The  power  possessed  by  the  system  to  consume  sugar  varies  in  health 
and  in  disease.  Carbohydrate  tolerance  can  be  determined  by  the  admin- 
istration of  glucose  by  the  mouth.  The  urine  of  healthy  persons  generally 
does  not  show  glucose  unless  the  amount  ingested  exceeds  250  grammes. 
When  glycosuria  follows  the  taking  of  100  grammes,  an  abnormal  sugar 
metabolism  probably  exists  (pathological  alimentary  glycosuria).  Car- 
bohydrate tolerance  is  lessened  by  age,  and  is  often  reduced  in  obesity 
and  gout. 

Lactose. — The  presence  of  milk  sugar  in  the  urine  is  indicated  by  a 
positive  reaction  with  Trommer's  and  Nylander's  tests  after  prolonged 
boiling,  when  negative  results  are  obtained  with  the  phenylhydrazine  and 
fermentation  tests.  Lactose  is  found  in  the  urine  during  the  last  weeks  of 
pregnancy  and  in  nursing  women.  Glycosuria  and  lactosuria  are  occa- 
vsionally  associated.  The  ingestion  of  more  than  120  grammes  of  lactose 
often  causes  a  lactosuria. 

Levulose. — The  presence  of  fruit  sugar  may  be  inferred  when  the  urine 
gives  sugar  reactions  with  Trommer's,  Fehling's,  the  fermentation  and 
phenylhydrazine  tests,  and  does  not  rotate  polarized  light  to  the  right. 


292 


MEDICAL  DIAGNOSIS. 


Levulose  at  times  rotates  polarised  light  to  the  left.  Levulose  occurs  in 
the  urine  in  some  cases  of  diabetes  and,  at  times,  in  the  urine  of  healthy- 
persons  after  the  ingestion  of  levulose. 

Pentose. — Pentose  can  be  recognized  by  the  fact  that  it  does  not 
undergo  fermentation  with  yeast,  but  gives  a  positive  reaction  with 
Fehling's,  Nylander's,  and  the  phenylhydrazine  tests.  Pentose  has  been 
discovered  in  the  urine  after  eating  plums,  pears,  apples,  cherries,  and 
huckleberries,  from  the  ingestion  of  50  grammes  or  more  of  pentose,  and 
occasionally  in  diabetes.    A  family  tendency  has  been  recorded. 

Dextrin. — This  substance  reduces  Fehling's  solution,  the  copper  separat- 
ing first  as  a  green,  then  changing  to  a  yellow  precipitate,  and  sometimes  as  a 
dark  brown  sediment.  Dextrin  has  been  found  in  the  urine  in  the  absence  of 
glucose.  Some  authorities  regard  the  presence  of  traces  of  dextrin  as  normal. 
Acetone. — Legal's  Test. — A  few  drops  of  freshly  prepared  concen- 
trated solution  of  sodium  nitroprusside  are  added  to  a  small  amount  of  uri- 
nary distillate,  and  the  mixture  treated  with  sodium  or  potassium  hydrate. 

When  a  ruby  color  develops,  rapidly  changing  to 
yellow,  it  signifies  the  presence  of  acetone.  This  test 
is  usually  negative  with  mere  traces  of  acetone. 

Lieben's  Test. — A  few  drops  of  potassium 
hydrate  solution  and  a  small  quantity  of  iodopo- 
tassic  iodide  are  added  to  the  urinary  distillate, 
and  the  mixture  warmed.  Acetone  is  indicated 
by  the  formation  of  iodoform,  which  appears  as 
hexagonal  or  stellate  crystals,  and  can  be  recog- 
nized by  its  characteristic  odor. 

Dunning's  Test.  —  Tincture  of  iodine,  or 
Lugol's  solution,  is  added  to  the  urinary  distillate, 
and  the  mixture  treated  wdth  ammonia  until  a  black 
precipitate  develops,  which  slowly  disappears,  leav- 
ing a  3^ellow  deposit  of  iodoform  crystals. 
Acetone  occurs  in  normal  urine  in  small  quantities,  not  exceeding 
10  mg.  in  twenty-four  hours.  It  is  increased  by  restricting  or  withholding 
carbohydrates  from  the  diet,  especially  when  large  amounts  of  proteids 
are  consumed.  It  is  also  augmented  in  febrile  diseases,  in  certain  cachexias, 
in  gastric  ulcer,  and  follows  the  administration  of  phloridzin,  and  chloro- 
form narcosis,  and  in  severe  forms  of  diabetes  mellitus,  notably  before 
and  during  diabetic  coma. 

Diacetic  or  Aceto=acetic  Acid. — Gerhardt's  Test. — 10  or  15  c.c.  of 
urine  are  subjected  to  the  action  of  a  solution  of  ferric  chloride.  When  a 
precipitate  forms  on  the  addition  of  the  ferric  chloride,  it  is  removed  by 
filtration,  and  to  filtrate  is  again  added  the  test  solution.  Diacetic  acid 
may  be  inferred  when  a  Bordeaux  red  color  develops,  which  maj^  com- 
pletely disappear  in  from  24  to  48  hours.  Sahcylic  acid,  salol,  aspirin, 
diuretin,  sodium  acetate,  and  antipyrin  may  give  a  similar  reaction. 
Prolonged  boiling  of  the  urine  containing  diacetic  acid  will  cause  a  com- 
plete or  partial  disappearance  of  this  substance. 

Diacetic  acid  is  rarely  found  in  normal  urine.  It  occurs  in  conjunction 
with  large  amounts  of  acetone,  and  the  clinical  significance  of  aceto-acetic 


Fig.  121. — Iodoform  crystals 
formed  from  the  distillate  of 
the  urine  of  a  case  of  diabetes. 
— Emerson. 


EXAMINATION  OF  THE  URINE.  293 

acid  is  similar  to  that  of  acetone.  Oxybutyric  acid  may  also  be  associated 
with  diacetic  acid.  Diaceturia  is  of  special  importance  in  diabetics,  since 
it  is  a  trustworthy  sign  of  acidosis,  and  is  always  a  forerunner  of  diabetic 
coma.  Aceto-acetic  acid  has  been  noted  in  the  urine  in  febrile  diseases,  in 
gastro-intestinal  disturbances,  especially  those  attended  with  starvation, 
and  occasionally  in  individuals  who  have  consumed  a  rich  proteid  diet  for 
a  number  of  days. 

^-Oxybutyric  Acid. — The  urine  is  evaporated  to  the  consistency  of  a 
syrup,  and  an  equal  volume  of  concentrated  sulphuric  acid  is  added.  By 
distillation  crotonic  acid  is  obtained.  Crystals  of  crotonic  acid  separate 
on  cooling  the  distillate.  If  crystallization  does  not  occur  readily,  an 
ethereal  extract  is  obtained,  evaporated,  and  the  residue  dissolved  in  water 
and  allowed  to  crystalHze.  The  presence  of  /?-oxybutyric  acid  may  be 
inferred  by  these  crystals.  If  fermented  diabetic  urine  containing  oxy- 
butyric acid  be  subjected  to  polariscopic  examination,  polarized  light  is 
rotated  to  the  left. 

/J-oxybutyric  acid  is  the  mother  substance  of  diacetic  acid,  while  ace- 
tone is  derived  from  the  latter  substance.  Its  presence  may  be  suspected 
when  diacetic  acid  exists  in  the  urine  in  large  amounts.  /9-oxybutyric  acid 
occurs  less  frequently  than  diacetic  acid  and  acetone,  and  in  general  terms 
paay  be  said  to  arise  under  conditions  similar  to  those  causing  acetonuria. 
It  is  found  in  the  urine  in  severe  infectious  fevers,  during  starvation,  and 
in  grave  forms  of  diabetes.  /9-oxybutyric  acid  is  generally  regarded  as  the 
cause  of  diabetic  coma.  Some  attribute  the  symptoms  of  this  condition 
to  a  lowering  of  the  alkalinity  of  the  blood  (alkali  starvation),  others  con- 
tend that  its  toxic  action  is  responsible. 

Alkaptone  Bodies. — The  urine  containing  alkaptone  bodies  reduces 
Fehling's  reagent,  causing  this  test  solution  to  blacken.  This  reaction 
serves  to  differentiate  it  from  glucose.  Nylander's,  the  phenylhydrazine 
and  the  fermentation  tests  are  negative  with  urine  containing  alkaptone 
bodies. 

Urine  of  alkaptonuric  individuals  appears  normal  when  voided,  but 
on  standing  its  color  changes  to  a  reddish-brown  or  black.  This  peculiar 
characteristic  of  the  urine  is  thought  to  be  due  to  homogentisinic  acid  and 
uroleucinic  acid.  The  cause  of  this  condition  is  not  known.  The  condition 
is  compatible  with  good  health,  and  is  often  peculiar  to  several  members 
of  a  family,  but  inheritance  does  not  seem  to  be  an  important  factor  in  its 
production. 

Ehrlich's  Diazo  Reaction. — This  test,  introduced  by  Ehrlich,  depends , 
on  certain  diazo  bodies,  which  probably  combine  with  aromatic  compounds, 
giving  a  color  reaction.  The  test  is  conducted  as  follows:  A  solution  con- 
sisting of  5  parts  of  sulphaniUc  acid,  50  parts  of  hydrochloric  acid,  and  1000 
parts  of  water,  is  mixed  with  a  .5  per  cent,  solution  of  sodium  nitrite  in  the 
proportion  of  50  of  the  former  to  1  of  the  latter.  An  equal  volume  of  urine 
is  added  to  this  mixture  and  shaken.  Upon  the  addition  of  a  few  drops 
of  ammonia,  a  cherry-red  color  develops  at  the  zone  of  contact,  indicating 
a  positive  diazo  reaction.  On  shaking,  the  entire  fluid  becomes  red.  A 
brown  or  salmon  color  constitutes  a  negative  reaction.  The  chief  clinical 
significance   of  this   reaction   relates  to   its   almost   constant  presence  in 


294  MEDICAL  DIAGNOSIS. 

enteric  fever,  but  is  without  value  as  a  differential  sign,  since  it  occurs  in 
a  number  of  diseases.  It  is  frequently  present  in  measles,  and  occasionally 
in  pneumonia,  scarlet  fever,  diphtheria,  phthisis,  rheumatic  fever,  menin- 
gitis, and  at  times  in  non-febrile  diseases,  such  as  chronic  nephritis,  car- 
cinoma of  the  stomach,  and  leukaemia.  The  administration  of  salol,  phenol, 
and  betanaphthol  may  interfere  with  this  reaction. 

Fat. — Normal  urine  does  not  contain  fat,  but  it  is  present  in  small 
amounts,  rarely  in  large  quantities  in  chronic  parenchymatous  nephritis, 
occasionally  when  fat  occurs  in  excessive  amounts  in  the  blood,  and  after 
the  administration  of  large  doses  of  cod-liver  oil.  It  has  been  observed 
in  bone  diseases  in  which  there  is  a  destruction  of  the  bone-marrow,  in 
diabetes  mellitus,  leukaemia,  pancreatic  diseases,  chronic  tuberculosis  of 
the  lungs,  and  obesity.  In  chyluria  or  galacturia  the  milky  appearance 
of  the  urine  is  due  to  fat  globules.  Chylous  or  chyhform  urine,  in  addition 
to  fat,  may  also  contain  leucocytes,  red  blood-cells,  fibrin,  albumin,  and 
occasionally  leucin,  tyrosin,  and  cholesterin. 

Cryoscopy  of  the  Urine. — The  determination  of  the  freezing  point  of 
the  urine  permits  one  to  measure  its  molecular  concentration.  The  appa- 
ratus devised  by  Beckmann  is  generally  employed  in  ascertaining  the  freez- 
ing point.  The  average  freezing  point  in  normal  individuals,  as  determined 
by  Koranyi,  is  —1.7°  C,  although  wide  variations  are  noted.  Cryoscopy  of 
the  urine  is  rarely  employed  in  routine  clinical  work,  since  the  results  have 
not  been  satisfactory. 

Cam  midge's  Test. — A  test  for  the  detection  of  pancreatic  disease  has 
been  suggested  by  Cammidge.  He  holds  that  this  reaction  is  due  to  the 
presence  in  the  urine  of  a  peculiar  body,  probably  pentose. 

The  following  is  the  technic  as  described  by  Cammidge :  "  A  specimen 
of  the  twenty-four  hours'  urine,  or  of  the  mixed  morning  and  evening 
secretions,  is  filtered  several  times  through  the  same  filter-paper  and 
examined  for  albumin,  sugar,  bile,  urobilin,  and  inclican.  A  quantitative 
estimation  of  the  chlorides,  phosphates,  and  urea  is  also  made,  and  the 
cent rifugali zed  deposit  from  the  urine  examined  microscopically  for  calcium 
oxalate  crystals.  If  the  urine  is  found  to  be  free  from  sugar  and  albumin, 
and  of  an  acid  reaction,  1  cm.  of  strong  hydrochloric  acid  (specific  gravity 
1.16)  is  mixed  with  20  c.c.  of  the  clear  filtrate,  and  the  mixture  gently 
boiled  on  the  sand-bath  in  a  small  flask  having  a  long-stemmed  funnel  in 
the  neck  to  act  as  a  condenser.  After  ten  minutes'  boiling  the  flask  is  well 
cooled  in  a  stream  of  water,  and  the  contents  made  up  to  20  c.c.  with  cold 
distilled  water.  The  excess  of  acid  present  is  neutralized  by  slowly  adding 
4  grammes  of  lead  carbonate.  After  standing  for  a  few  minutes  to  allow 
of  the  completion  of  reaction,  the  flask  is  again  cooled  in  running  water 
and  the  contents  filtered  through  a  well-moistened,  close-grained  filter- 
paper  until  a  perfectly  clear  filtrate  is  secured.  The  filtrate  is  then  well 
shaken  with  4  grammes  of  powdered  tribasic  lead  acetate  and  the  result- 
ing precipitate  removed  by  filtration,  an  absolutely  clear  filtrate  being 
obtained  by  repeating  the  filtration  several  times  if  necessary.  Since  the 
large  amount  of  lead  now  in  solution  would  interfere  with  the  subsequent 
steps  of  the  experiment,  it  is  removed  either  by  treatment  with  a  stream 
of  sulphuretted  hydrogen  or,  what  I  have  found  to  be  equally  satisfactory 


EXAMINATION  OF  THE  URINE.  295 

and  less  disagreeable,  by  precipitating  the  lead  as  a  sulphate.  For  this 
purpose  the  clear  filtrate  is  well  shaken  with  2  grammes  of  finely  powdered 
sodium  sulphate,  the  mixture  heated  to  the  boiling  point,  then  cooled  to 
as  low  a  temperature  as  possible  in  a  stream  of  cold  water,  and  the  white 
precipitate  removed  by  careful  filtration;  10  c.c.  of  the  perfectly  clear 
transparent  filtrate  is  made  up  to  .18  c.c.  with  distilled  water  and  added 
to  0.8  gramme  of  phenylhydrazine  hydrochloride,  2  grammes  of  powdered 
sodium  acetate  and  1  c.c.  of  50  per  cent,  acetic  acid  contained  in  a  small 
flask  fitted  with  a  funnel  condenser.  The  mixture  is  boiled  on  a  sand-bath 
for  ten  minutes,  and  then  filtered  hot  through  a  filter-paper  moistened  with 
hot  water  into  a  test-tube  provided  with  a  15  c.c.  mark.  Should  the 
filtrate  fail  to  reach  the  mark,  it  is  made  up  to  15  c.c.  with  hot  distilled 
water.  In  well-marked  cases  of  pancreatic  inflammation  a  light  yellow, 
flocculent  precipitate  should  form  in  a  few  hours;  but  it  may  be  necessary 
to  leave  the  preparation  to  stand  overnight  before  a  deposit  occurs.  Under 
the  microscope  the  precipitate  is  seen  to  consist  of  long,  light  yellow,  flexi- 
ble, hair-like  crystals,  arranged  in  sheaves  which,  when  irrigated  with  33 
per  cent,  sulphuric  acid,  melt  away  and  disappear  in  ten  to  fifteen  seconds 
after  the  acid  first  touches  them.  The  precipitate  should  always  be  exam- 
ined microscopically,  as  it  may  be  difficult  to  determine  the  characters  of 
a  small  deposit  with  the  naked  eye,  and  so  cases  giving  only  a  slight  reac- 
tion may  be  overlooked.  To  exclude  traces  of  sugar,  undetected  by  the 
preliminary  reduction  tests,  a  control  experiment  is  carried  out  by  treating 
20  c.c.  of  the  urine  in  the  same  way  as  in  the  test  described,  excepting  for 
the  addition  of  the  hydrochloric  acid. 

"  The  urine  employed  for  the  experiment  should  be  fresh,  and  not  have 
unc^rgone  fermentative  changes.  If  alkaline  in  reaction,  it  should  be  made 
acid  with  hydrochloric  acid  before  the  test  is  commenced;  any  glucose 
that  may  be  present  should  be  removed  by  fermentation  after  the  urine 
has  been  boiled  with  the  acid,  and  the  excess  neutralized." 


296  MEDICAL  DIAGNOSIS. 


VII. 
THE  EXAMINATION  OF  THE  SPUTUM. 

Systematic  examination  of  the  sputum  furnishes  important  chnical 
data  in  a  considerable  group  of  diseases. 

MICROSCOPICAL  EXAMINATION. 

Leucocytes. — The  mere  presence  of  leucocj^tes  has  no  special  signifi- 
cance, since  they  occur  in  every  specimen.  A  sputum  containing  an 
abundance  of  white  blood-corpuscles  generally  indicates  a  pathological 
disturbance  of  some  part  of  the  respiratory  tract,  as  chronic  bronchitis, 
bronchiectasis,  pulmonary  abscess,  tuberculosis  with  cavity  formation,  or 
may  be  due  to  a  rupture  of  an  extrapulmonary  purulent  collection  into 
the  lungs.  The  polynuclear  neutrophile  leucocytes  are  most  often  found  in 
sputum,  although  in  a  limited  number  of  diseases,  particularly  bronchial 
asthma,  eosinophiles  are  noted.  The  sputum  in  asthma  is  usually  loaded 
with  eosinophiles,  some  of  which  have  the  characteristic  morphology  and 
staining  reaction  of  the  hsemic  eosinophiles,  while  others  are  supplied  with 
a  circular  nucleus.  In  certain  cases  of  bronchitis,  tuberculosis,  and  after 
haemoptysis,  eosinophiles  are  present  in  the  expectoration. 

Epithelial  Cells. — Every  specimen  of  sputum  contains  epithelial  cells. 
Pavement  epithelium  may  be  derived  from  the  mouth,  the  pharynx,  and 
the  upper  half  of  the  larynx,  while  cylindrical  cells  may  come  from  the 
nose,  the  lower  part  of  the  larynx,  trachea,  and  bronchi.  Catarrhal  inflam- 
mation, especially  in  its  early  stages,  generally  determines  the  presence  of 
large  numbers  of  epithelial  elements.  Ciliated  cells  are  occasionally  found 
in  asthma  and  acute  bronchitis,  provided  the  specimen  be  examined  im- 
mediately after  expectoration.  Alveolar  epithelial  cells  which  occur  in 
the  sputum  in  almost  every  pulmonary  disease,  as  well  as  in  the  "so-called" 
normal  expectoration,  are  large,  of  an  oval,  round,  or  polygonal  shape, 
supplied  with  one  or  several  relatively  small  vesicular  nuclei,  imbedded  in 
protoplasm  which  often  contains  albuminous  granules,  myelin  droplets, 
fat  globules,  particles  derived  from  hsemoglobin,  or  coal  pigment.  These 
cells  occur  in  abundance  in  acute  inflammatory  pulmonary  disease  and 
tuberculosis.  Myelin  granules  have  an  irregular  outline,  often  present  a 
concentric  arrangement,  and  are  found  either  intra-  or  extracellularly. 
Myelin  probably  consists  mainly  of  protagon  and  of  small  amounts  of 
lecithin  and  of  cholesterin.  These  droplets  dissolve  in  alcohol,  stain  hght 
yellow  with  iodine,  poorly  with  aniline  dyes,  and  are  not  blackened  with 
osmic  acid.  Alveolar  epithelium,  containing  granules  of  altered  blood 
pigment,  is  seen  in  the  sputum  of  congestion  of  the  lungs,  notably  in 
that  form  due  to  heart  disease,  hence  the  term  "heart  disease  cells"  is 
applied  to  them. 

Red  blood=cells  occurring  in  small  numbers  are  commonly  observed 
in  the  sputum  of  many  diseases  of  the  respiratory  tract  and,  therefore,  have 


EXAMINATION  OF  THE  SPUTUM. 


297 


r^^s^,,^f^^*.:,'  ■•>' 

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v!v 

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-Elastic  tissue  from  luni 
ment.      X  50. — J 


'   allowing  alveolar   arriinge- 
L,nierson. 


no  special  importance,  but  when  present  in  considerable  or  large  numbers 
indicate  a  morbid  lesion.  Expectoration  of  blood  (haemoptysis)  is  due  to  a 
variety  of  causes  (see  page  458).  Erythrocytes  in  the  sputum,  as  a  rule,  ex- 
hibit alteration  of  structure,  so  that  crenated,  dehsemoglobinized,  and  frac- 
tured cells  are  common. 
Elastic  tissue,  in 
considerable  amounts, 
can  be  readily  demon- 
strated by  the  following 
method:  A  thin  layer  of 
sputum,  obtained  by 
pressing  it  between  two 
glass  plates,  is  examined 
with  the  aid  of  a  hand 
lens.  When  elastic  tissue  ^'°'  ^""" 
cannot  be  recognized  by 

this  method,  the  microscope  should  be  employed;  a  suspected  particle^ 
which  generally  has  a  gray  or  yellow  color,  is  placed  upon  a  slide  and 
studied  by  low  magnification.  Elastic  tissue  may  also  be  demonstrated 
by  treating  the  sputum  with  an  equal  quantity  of  a  10  per  cent,  solu- 
tion of  potassium  or  sodium  hydroxide  and  boiling  the  mixture  until 
it  becomes  homogeneous.  The  solution  is  shaken  with  four  or  five  parts 
of  water  and  the  mixture  centrifugated.  The  sediment  is  then  examined 
microscopically.  Elastic  tissue  is  found  as  long  slender  threads,  generally 
having  a  waxy  appearance,  and  at  times  these  fibres  conform  to  the 
outline  of  alveoli.     The  presence  of  elastic  fibres  indicates  disintegration 

of  bronchial  or  pulmonary  tissue,  the  latter 
being  positively  affirmed  when  the  fibres 
have  an  alveolar  arrangement.  Elastic 
tissue  is  noted  in  bronchiectasis,  pulmon- 
ary abscess,  gangrene,  tuberculosis,  and 
tumors  of  the  lungs. 

Curschmann's  spirals  are  noted  in 
the  sputum  in  cases  of  bronchial  asthma, 
occasionally  in  tuberculosis,  croupous 
pneumonia,  and  bronchitis.  Upon  micro- 
scopic examination,  they  consist  of  delicate 
twisted  threads,  often  wound  around  a 
central  core.  Many  of  these  spirals  are  coated  with  mucus  in  which 
epithelial  cells,  eosinophiles,  neutrophile  leucocytes,  and  Charcot-Leyden 
crystals  are  imbedded.  Curschmann's  spirals  consist  chiefly  of  mucus, 
while  the  central  core  is  held  to  be  fibrin  in  some  instances.  Many  author- 
ities claim  that  these  bodies  are  formed  in  the  bronchioles. 

Crystals. — With  the  exception  of  Charcot-Leyden  crystals,  very  little 
importance  can  as  yet  be  attached  to  the  presence  of  crystalline  bodies. 
Charcot-Leyden  crystals  are  colorless  and  have  the  shape  of  two  elongated, 
sharply  pointed,  hexagonal,  pyramidal  figures  with  bases  opposed.  They 
stain  with  eosin.  It  was  formerly  thought  that  they  were  the  exciting 
factor  of  bronchial  asthma.    This  view  is  no  longer  entertained,  since  these 


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a-" 

r  - 
\ 

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m 

|):~ 

i>>i' 

V, 

^  \ 

^ " 

:x„ 

^'" 

H'&,\ 

Fig.  123. — Curschmann's  spiral,  from 
the  sputum  of  a  case  of  asthma.  X  200. — 
Emerson. 


298  MEDICAL  DIAGNOSIS. 

crystals  are  occasionally  found  in  other  diseases,  such  a  bronchitis  and 
tuberculosis.  They  are  probably  formed  from  eosinophile  cells.  Crystals 
of  fattj^  acids  are  noted  in  the  sputum  of  tuberculosis,  gangrene,  bron- 
cliiectasis,  and  fetid  bronchitis. 

Cholesterin  plates,  which  are  rarely  seen  in  the  sputum,  have  been 
found  in  conjunction  with  fatty  acid  crystals  in  abscess  of  the  lung,  and 
phthisis. 

H.EMATOiDiN  CRYSTALS  occur  in  the  putrid  sputum  of  certain  lung 
diseases,  and  in  empyema  and  hepatic  abscess  with  a  bronchial  outlet,  and 
occasionally  after  haemoptysis.  Leucin  and  tyrosin  crj^stals  are  at  times 
present  in  purulent  sputum,  while  calcium  oxalate  and  triple  phosphate 
crystals  are  rare  ingredients  of  sputum. 

Animal  Parasites. — The  Trichomonas  pulmonalis  has  been  reported 
in  a  few  instances  in  the  sputum  in  lung  gangrene,  tuberculosis,  abscess, 
and  putrid  bronchitis,  while  circomonads  have  been  recorded  in  pulmonary 
gangrene.  The  sputum  in  cases  of  Hver  abscess  perforating  into  the  lung 
may  show  the  Amoeba  coli. 

T^NiA  EcHiNOCOCCUS. — Hydatid  disease  may  cause  pulmonary  ab- 
scess or  gangrene  and  is  sometimes  responsible  for  copious  haemoptysis. 
The  sputum  in  this  condition  may  contain  shreds  of  cyst  membrane, 
daughter  cysts,  scohces  and  hooklets  of  the  worm. 

DiSTOMA  Pulmonale. — This  parasite  is  responsible  for  a  form  of 
chronic  pulmonary  disease,  characterized  by  haemoptysis,  seen  in  Japan, 
China,  and  Korea.    This  fluke  and  its  ova  are  found  in  the  sputum. 

Vegetable  Parasites. — A  large  number  of  micro-organisms  have  been 
found  in  the  sputum.  Among  these  may  be  mentioned:  the  tubercle 
bacillus,  Diplococcus  pneumoniae,  staphylococci,  streptococci,  sarcinae, 
streptothrix,  actinemyces,  Micrococcus  catarrhalis,  and  the  influenza, 
smegma,  typhoid,  plague,  diphtheria,  and  Friedlander's  bacillus. 

In  the  case  of  tubercle  bacilli,  their  staining  reaction,  outline,  and 
size,  in  the  absence  of  biological  tests,  generally  afford  sufficient  evidence 
to  establish  the  diagnosis  of  this  organism.  With  most  bacteria  occur- 
ring in  the  sputum  this  is  not  the  case,  so  that  their  identity  can  only 
be  determined  provisionally  but  not  finalty  b}'  their  tinctorial  and  mor- 
phological characteristics.  This  tentative  opinion  is,  however,  often 
strengthened  by  the  correlation  of  the  chnical  data  of  the  underlying 
pathological  process.  Cultural  studies  are  as  a  rule  essential,  and  inocula- 
tion experiments  often  required  for  a  bacteriological  diagnosis.  Works  on 
bacteriology  should  be  consulted  for  bacteriological  investigations. 

Tubercle  Bacillus. — The  finding  of  tubercle  bacilli  in  the  sputum 
is  a  valuable  sign  in  establishing  the  diagnosis  of  tuberculosis  of  the  lungs, 
although  the  absence  of  these  organisms  in  the  expectoration  of  an  individ- 
ual presenting  pulmonary  symptoms  does  not  necessarily  negative  the 
diagnosis.  The  failure  to  find  bacilli  on  a  number  of  examinations  in  a 
suspected  case,  particularly  of  a  chronic  nature,  is  strong  evidence  against 
the  existence  of  phthisis.  In  acute  tuberculosis,  especially  in  the  early 
stages,  they  are  frequently  wanting  in  the  sputum.  There  is  no  single 
characteristic  presented  by  macroscopic  examination  of  the  sputum  by 
which  its  tuberculous  nature  can  be  recognized.      Rosenberger  holds  the 


PLATE  YI. 


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Tubercle  bacilli  in  sputum  stained  with  carbol  fuchsin  and  Pap^enheim's  reagent. 


EXAMINATION  OF  THE  SPUTUM.  299 

view  based  on  repeated  observations  that  tubercle  bacilli  are  present 
in  the  fgeces  of  persons  suffering  from  active  pulmonary  tuberculosis,  even 
in  the  acute  miliary  form.  The  technic  of  the  examination  for  tubercle 
bacilli  is  as  follows:  Preferably  a  caseous  mass  or  a  bit  of  purulent  or 
hemorrhagic  sputum  is  placed  upon  a  slide  or  cover-slip.  As  it  is  often  im- 
possible to  find  cheesy  particles,  the  sputum  is  selected  from  different 
parts  of  the  specimen.  A  thin  smear  is  then  made,  carefully  dried  and 
fixed  by  rapidly  passing  the  slide  or  cover-glass  through  a  flame  several 
times.  The  tubercle  bacillus  belongs  to  the  group  of  organisms,  generally 
designated  acid-fast  bacteria,  which,  after  staining,  resist  to  a  marked 
degree  decolorization  with  solutions  of  mineral  acids. 

If  it  be  desired  to  concentrate  the  bacteria  in  the  specimen  of  the 
sputum,  the  method  of  Miilhauser-Czaplewski  will  be  found  most  service- 
able. From  four  to  eight  volumes  of  a  .25  per  cent,  solution  of  sodium 
hydrate  are  added  to  the  sputum,  placed  in  a  bottle,  and  shaken  until  the 
fluid  has  a  uniform  mucilaginous  appearance.  A  few  drops  of  phenol- 
phthalein  solution  are  added  and  the  liquid  is  boiled.  A  2  per  cent,  solution 
of  acetic  acid  is  now  added  drop  by  drop  until  the  pink  color  of  the  liquid 
just  disappears.  The  material  can  now  be  centrifugated  and  the  sediment 
examined. 

Ziehl-N eelsen  Method. — The  stain  for  this  method  consists  of  10  c.c. 
of  a  concentrated  alcoholic  solution  of  fuchsin,  dissolved  in  90  cubic  centi- 
metres of  a  5  per  cent,  solution  of  carbolic  acid.  The  film  of  sputum  upon 
the  cover  or  slide  is  covered  with  the  stain.  The  cover  or  slide  is  then 
held  over  a  flame  until  the  solution  is  brought  to  the  boiling  point;  or  the 
specimen  may  be  stained  in  cold  carbol  fuchsin  for  24  hours.  After  a  half 
minute,  the  excess  of  hot  stain  is  poured  off  and  the  specimen  washed  with 
water.  The  stained  preparation-  is  next  placed  in  a  25  per  cent,  solution 
of  nitric  acid  for  several  seconds  until  the  bright  red  color  disappears, 
then  washed  in  water  and  dried.  The  specimen  may  be  counterstained 
with  a  watery  solution  of  Bismarck  brown  or  methylene  blue  for  a  minute 
or  two.  The  cover-glass  film  is  mounted  on  a  slide  in  balsam  or  cedar  oil. 
The  specimen  spread  and  stained  upon  a  slide,  the  most  convenient  method, 
may  be  examined  without  a  cover-glass. 

Gahbett's  Method. — The  sputum  properly  spread  and  fixed  upon  a  slide 
or  cover-glass  is  covered  with  a  reagent  consisting  of  fuchsin  1  gramme, 
alcohol  10  cubic  centimetres,  and  a  5  per  cent,  solution  of  carbolic  acid  100 
cubic  centimetres,  and  held  over  a  flame  until  the  stain  boils.  After  drain- 
ing off  the  carbol  fuchsin  from  the  slide,  the  specimen  is  treated  for  two 
minutes  with  Gabbett's  reagent,  composed  of  methylene  blue,  2  parts,  dis- 
solved in  100  parts  of  a  25  per  cent,  solution  of  sulphuric  acid;  then  washed 
with  water,  thoroughly  dried,  and  examined  microscopically. 

Pappenheim'  s  Method.  —  Competent  bacteriologists  consider  this 
method  the  most  reliable,  since  it  is  claimed  that  it  offers  the  means  of 
distinguishing  tubercle  bacilli  from  other  acid-fast  organisms.  Pappen- 
heim's  stain  is  prepared  by  dissolving  1  part  of  corallin  in  100  parts  of 
absolute  alcohol.  This  solution  is  then  saturated  with  methylene  blue, 
after  which  20  parts  of  glycerin  are  added.  After  staining  the  specimen 
with  a  heated  carbol  fuchsin  solution  in  the  manner  previously  described, 


300  MEDICAL  DIAGNOSIS. 

the  excess  of  stain  is  drained  from  the  slide  and  immediately  Pappenheim's 
solution  is  placed  upon  it  and  aUowed  to  act  for  a  few  minutes.  Fresh 
solutions  may  be  added  several  times  if  the  spread  is  tinged  red  in  any 
part.    The  sUde  is  next  washed  in  water,  dried,  and  examined. 

With  these  methods,  tubercle  bacilli  appear  as  straight  or  shghtly 
bent  red  rods,  varying  from  1.5  to  4  microns  in  length  and  from  .1  to  .2 
micron  in  thickness.  Occasionally  ihej  are  tinted  more  deeply  in  certain 
parts,  having  the  appearance  of  a  streptococcus  (beaded  forms).  Branch- 
ing forms  are  rarely  found.  The  older  varieties  of  bacilli  are  thought  to 
stain  more  intensely  than  the  younger  forms.  As  a  rule  a  number  of  organ- 
isms can  be  found  in  preparations,  many  of  which  are  frequently  arranged 
in  groups  containing  several  or  more  organisms.  It  is  most  uncommon  ta 
find  but  a  single  bacillus  in  a  specimen  and,  when  this  occurs,  the  possi- 
bility of  contamination  of  the  sputum  from  dust  should  be  remembered. 
The  number  of  germs  in  chronic  cases  often  is  an  index  to  the  extent  of 
the  ulceration  in  the  lung,  although,  in  acute  cases,  the  degree  of  the  tuber- 
cle involvement  bears  no  relation  to  the  abundance  of  bacilli.  A  lessening 
in  the  number  of  bacilli  ofttimes  is  associated  with  a  steady  improvement 
in  the  patient,  and  a  disappearance  of  the  micro-organisms  frequently 
points  to  quiescent  or  healed  lesions. 

DiPLOcoccus  Pneumoniae. — The  finding  of  pneumococci  in  the  sputum,, 
in  the  absence  of  other  clinical  data,  is  without  diagnostic  significance, 
since  these  organisms  exist  in  the  saliva  of  a  considerable  proportion  of 
healthy  individuals,  as  well  as  in  the  expectorated  material  in  several 
diseases.  Their  presence  in  the  sputum  of  a  case  exhibiting  pulmonary- 
symptoms  often  establishes  an  etiological  diagnosis.  Pneumococci  are 
found  in  large  numbers  in  the  sputum  of  croupous  pneumonia  and  occa- 
sionally^ in  bronchopneumonia.  This  organism  reacts  positively  to  solutions 
of  basic  dyes.  Stained  specimens  frequently  show  a  colorless  capsule 
about  the  diplococci. 


VIII. 

THE  EXAMINATION  OF  TRANSUDATES,  EXUDATES,  AND  THE 

CONTENTS  OF  CYSTS. 

The  results  of  the  examination  of  transudates,  exudates,  and  the 
contents  of  cysts  bj"  physical,  chemical,  microscopical,  and  bacteriologi- 
cal methods  are  diagnostic  auxiliaries. 

Exploratory  Puncture. — An  exploratory  syringe,  equipped  with  a 
large  stout  needle,  is  generally  used  for  this  purpose,  but  for  some  explora- 
tions the  aspirator  needle  alone  is  employed,  since  the  positive  internal 
pressure  of  certain  effusions  expels  the  fluid.  The  operation  of  explora- 
tory puncture  must  be  performed  under  strict  antiseptic  precautions; 
the  skin  should  be  sterihzed  by  thoroughly  scrubbing  with  soap  and  hot 
sterihzed  water,  followed  by  washing  with  hot  sterilized  water  and  then 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.       301 

with  an  antiseptic  solution.  When  possible  an  antiseptic  dressing  should 
be  applied  for  some  hours  prior  to  performing  the  operation.  The  hands 
of  the  operator  should  be  surgically  clean  and  the  instrument  should  be 
sterile.  The  technic  of  peritoneal,  pleural,  pericardial,  and  lumbar  punc- 
ture is  discussed  in  Part  IV. 

The  differentiation  between  exudates  and  transudates  is  not,  as  a  rule, 
difficult,  since  the  internist  is  guided  by  associated  clinical  phenomena  in 
determining  the  origin  of  the  fluid.  There  are,  however,  cases  in  which 
the  character  (whether  it  be  inflammatory  or  non-inflammatory)  of  the 
material  cannot  be  ascertained  by  the  symptoms  or  the  history  of  the  case, 
and  the  final  distinction  must  rest  with  the  laboratory,  although  in  a  few 
instances  the  various  methods  of  laboratory  research  fail  to  solve  the 
problem. 

Transudates  are  generally  light  yellow  or  pale  yellowish-green,  at  times 
reddish,  due  to  blood  staining,  milky  as  noted  in  chylous  effusions,  and 
dark  yellow  when  deeply  tinged  with  biliary  pigment. 

The  composition  of  transudates  of  the  peritoneal,  pleural,  and  peri- 
cardial sacs  is  nearly  the  same.  They  consist  of  water  (95-96  per  cent.), 
solids,  proteids,  extractives,  inorganic  salts,  and  uric  acid.  Allantoin, 
dextrose,  fructose,  urobilin,  and  biliary  pigment  have  also  been  demon- 
strated in  transudates.  Their  specific  gravity  is  generally  below  1.018,  in 
many  cases  as  low  or  even  below  1.010,  and  occasionally  above  1.020.  Hy- 
drsemic  transudates  are  of  lighter  specific  gravity  than  those  due  to  stasis. 
The  specific  gravity  is  influenced  mainly  by  the  proteids  contained  in  the 
fluid,  so  that  exudates,  which  are  generally  richer  in  albuminous  bodies 
than  dropsical  fluids,  are  as  a  rule  of  higher  gravity  than  transudates. 
The  estimation  of  the  total  proteids  content  is  therefore  of  value  in  dif- 
ferentiating between  transudates  and  exudates.  The  percentage  of  pro- 
teids in  stasis  transudates  generally  ranges  from  1  to  3,  while  in  hydrsemic 
effusion  it  is  much  lower,  usually  not  above  .5.  Transudates  either  contain 
no  fibrin  or  it  exists  only  in  minute  amounts.  A  few  endothelial  cells  and 
leucocytes,  at  times  erythrocytes  and  cholesterin  crystals,  are  found. 
In  hydroperitoneum  occurring  in  leukaemia,  Charcot-Leyden  crystals, 
mast  cells,  and  eosinophiles  have  been  recorded.  In  the  main  the  chlorides 
exist  in  greater  concentration  in  transudates  than  in  exudates,  and  as  a 
rule  the  degree  of  alkalinity  of  dropsical  fluids  is  about  that  of  the  blood  of 
the  individual  in  question,  while  in  an  exudate  it  is  lowered. 

Exudates. — The  chief  varieties  of  exudates  are  serous,  hemorrhagic, 
purulent,  and  putrid,  and  between  these  types  there  are  gradations  and 
combinations.  The  recognition  by  macroscopic  inspection  of  purulent 
collections  is  generally  a  simple  matter,  although  serous  exudates,  which 
contain  a  large  number  of  fine  fibrin  flakes  and  chylous  fluids,  are  of  similar 
appearance.  The  uniform  turbidity  of  purulent  effusions  serves  to  dis- 
tinguish them  from  serofibrinous  effusions,  while  the  presence  of  fine 
granules  of  fat  is  characteristic  of  chylous  fluids.  In  many  inflammatory 
collections  a  coagulum  forms  immediately  after  the  fluid  is  withdrawn 
from  the  body.  Their  specific  gravity  is  generally  above  1.018,  the  proteid 
content  is  usually  above  4  per  cent,  and  at  times  as  high  as  6  per  cent. 
Serum  albumin  and  globulin  in  considerable  amounts,  traces  of  fibrinogen 


302  MEDICAL  DIAGNOSIS. 

and  serosamucin  are  present  in  exudates;  nucleo-albumin.  albumoses, 
leucin,  and  tyrosin  have  also  been  noted. 

Rivalta's  Test. — The  principle  of  this  test  is  based  on  the  precipita- 
tion in  many  exudates  of  a  peculiar  body,  the  character  of  which  has  not 
been  definitely  determined,  although  regarded  by  some  authorities  as  mucin 
and  denominated  serosamucin,  while  others  hold  that  it  is  a  globuhn. 
This  test  is  carried  out  by  allowing  a  drop  of  the  fluid  to  fall  into  a  weak 
acetic  acid  solution  (two  drops  of  glacial  acetic  acid  in  100  c.c.  of  distilled 
water).  When  the  drop  sinks  and  leaves  a  turbidity  it  indicates  the  pres- 
ence of  tliis  substance,  while  the  failure  to  produce  cloudiness  denotes  the 
absence  of  this  body  (serosamucin).  The  intensity-  of  the  cloudiness  and 
the  rapidity  with  which  it  forms  are  an  index  to  the  amount  present.  This 
test  is  of  importance  in  differentiating  exudates  from  transudates. 

Animal  parasites,  bacteria,  many  cellular  elements,  lymphocytes,  poly- 
nuclear  cells,  endothelial  cells,  erythrocytes,  and  deti'itus  occur  in  exudates. 

Bacteriological  Examination.  —  Bacteria  rarely  exist  in  transu- 
dates, but  their  presence  in  exudates,  which  is  frequent,  furnishes  a  most 
useful  field  for  diagnosis  and  prognosis.  The  fluid  for  bacteriological 
examination  is  collected  in  a  sterile  flask,  the  neck  of  which  is  then  immedi- 
ately plugged  with  sterile  cotton.  (For  technic  consult  works  on  bacteriol- 
ogy.)     A  diagnosis  of  tubercle  bacilli  can  often  be  made  by  staining  methods. 

Collecting  Sediment. — Fluids  removed  by  puncture  often  coagulate 
spontaneously.  Since  the  coagulum  entangles  some  of  the  cellular  bodies 
and  bacteria,  the  elements  which  I'emain  in  the  fluid  portion  do  not  form 
an  accurate  basis  for  calculating  the  number  or  the  percentages  of  the  dif- 
ferent varieties  of  cells.  In  order  to  prevent  coagulation  one-third  or 
fourth  volume  of  a  2  per  cent,  sodium  citrate  salt  solution  is  added  to  the 
specimen.  After  centrifugalization  or  sedimentation  the  supernatant  fluid 
is  removed  and  the  tube  is  filled  with  saline  solution,  then  gently  agitated 
and  recentrifugated.  Much  of  the  albumin  is  removed  from  the  fluid  by 
this  procedure,  which  insures  better  results  in  staining. 

Inoscopy,  the  method  introduced  by  Jousset,  was  designed  to  aid  in 
the  diagnosis  of  tuberculosis.  The  exudate  is  allowed  to  coagulate  spon- 
taneously, but  should  this  not  occur  the  addition  of  horse  serum  will  bring 
about  clotting.  The  coagulum  which  holds  many  of  the  tubercle  bacilli 
is  then  removed,  broken  up,  and  digested  by  means  of  a  fluid  consisting  of 
NaF  3  grammes,  pepsin  1  or  2  grammes,  glycerin  10  c.c,  HCl  40  per  cent. 
15  c.c,  water  1000  c.c  The  resulting  liquid  is  then  centrifugated  and  the 
sediment  examined  in  the  usual  manner  for  tubercle  bacilli. 

Cytological  Examination.  —  After  securing  the  sediment  of  the 
citrated  material,  or  the  digested  coagulum,  it  should  be  properly  fixed. 
Treating  the  sediment  with  a  |  or  1  per  cent,  formaldeh^'de  solution  for 
several  minutes  is  highly  recommended  by  some  workers.  The  sediment 
is  spread  into  a  thin  film  upon  a  slide  or  cover-glass,  dried,  and  if  not  pre- 
viously fixed  is  now  subjected  to  such  fixatives  as  methyl  alcohol,  or  alcohol 
and  ether,  heat,  or  formalin  solutions.  The  selection  of  the  stain  depends 
upon  the  structures  desired  to  be  demonstrated  and  upon  the  choice  of 
the  worker.  Most  of  the  Romanowsky  modifications  or  double  stains,  as 
eosin  and  hsmatoxylon  or  methylene  blue,  give  satisfactory  results.     The 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.       303 

principle  which  involves  the  determination  of  the  percentages  of  the  vari- 
ous types  of  cells  is  the  same  as  for  differential  leucocyte  counting.  Im- 
mediate citration  of  fresh  specimens,  followed  by  centrifugating,  probably 
offers  the  best  means  of  studying  cellular  elements  and  bacteria. 

Cytodiagnosis.— The  cytological  formula  does  not  diagnose  a  disease, 
but  rather  suggests  the  acuteness  or  chronicity  of  a  pathological  condi- 
tion, the  stage  and  intensity  of  a  morbid  process,  or  the  absence  of  inflam- 
mation. A  rare  exception  relates  to  effusions  which  contain  tumor  frag- 
ments, the  histology  of  which  may  be  diagnostic. 

The  most  important  cellular  elements  entering  into  cytological  studies 
are  lymphocytes,  polynuclear  cells,  endothehal  cells,  eosinophile  cells,  mast 
cells,  erythrocytes,  and  tumor  cells. 

Endothelial  Cells. — An  increase  of  endothehal  cells  in  a  fluid  is  generally 
associated  with  non-inflammatory  effusions  of  the  serous  cavities.  Drop- 
sical effusion  due  to  passive  congestion  and  hydremic  transudates  shows 
endotheliocytosis.  In  the  early  stages  of  a  tuberculous  effusion  a  high 
percentage  of  endothehal  elements  is  sometimes  noted. 

Lymphocytes.  —  An  irritant  of  mild  intensity  is  responsible  for  a 
lymphocyte  predominance  in  an  effusion.  Such  a  reaction  is  essentially 
local  and  does  not  provoke  a  general  stimulus.  An  irritation  of  low  grade, 
especially  when  protracted  over  a  long  period,  calls  forth  these  cells.  Lym- 
phocytosis is  the  rule  in  tuberculosis,  although  a  polynucleosis  may  precede 
a  lymphocytic  phase  or  in  some  instances  it  may  follow.  These  variations 
are  attributed  to  increased  virulence  of  bacteria  and  to  secondary  or  mixed 
infections.  A  lymphocyte  preponderance  preceded  by  a  polynucleosis  is 
regarded  as  having  a  favorable  prognostic  significance.  The  development 
of  a  polynucleosis  taking  the  place  of  a  lymphocytosis  is  suggestive  of  a 
complication.  In  the  late  stages  of  acute  inflammations  or  when  these  tend 
to  become  chronic,  a  high  lymphocyte  percentage  is  often  noted.  Lym- 
phocytosis is  noted  almost  constantly  in  effusions  of  tuberculous  origin  and 
sometimes  in  those  due  to  syphilis,  ursemia,  malignant  tumors,  and  paresis. 

Polynuclear  Cells. — The  exudates  in  acute  inflammation  or  infections 
of  serous  sacs,  such  as  are  produced  by  staphylococci,  pneumococci,  strep- 
tococci, meningococci,  colon  bacilli,  and  typhoid  bacilli,  contain  a  high  per- 
centage of  polynuclear  leucocytes.  In  the  early  stage  of  tuberculosis  a 
polynucleosis  is  sometimes  noted,  and  frequently  in  tuberculosis  pericardial 
effusions.  As  an  acute  inflammation  subsides  polynuclear  preponderance 
becomes  less  marked,  and  this  is  often  followed  by  a  rise  in  the  number  of 
the  lymphocytes,  which  may  outnumber  the  multinuclear  elements. 

Eosinophilic  cell  increase  has  been  recorded  in  effusion  occurring  in 
the  course  of  rheumatic  fever,  tuberculosis,  nephritis,  syphilis,  carcinoma, 
and  following  trauma. 

Mast  cells  have  been  noted  occasionally  in  effusions,  especially  those 
of  long  standing. 

Erythrocytes. — Contamination  of  the  fluid  with  blood  from  the  wound 
made  by  puncture  is  unavoidable  in  many  instances,  but  aside  from  this 
source  red  corpuscles  in  an  effusion  are  at  times  the  expression  of  malig- 
nant, renal,  or  tuberculous  disease.  They  are  also  seen  in  effusion  due  to 
acute  infections.    The  possibility  of  a  hemorrhage,  as  in  cerebral  apoplexy 


304 


MEDICAL  DIAGNOSIS. 


with  effusion  into  the  ventricles  of  the  brain,  or  a  small  leak  of  an  aneurism 
into  a  serous  sac,  should  always  be  borne  in  mind. 

Cells  derived  from  carcinoynata  and  sarcomata  when  found  singly  in 
effusions  of  serous  cavities  are  believed  by  some  writers  to  possess  certain 
features  which  may  be  of  diagnostic  value.  These  cells  may  show  mitotic 
figures.  The  results  of  an  histological  examination  of  a  tumor  fragment 
may  warrant  a  final  diagnosis. 

The  recognition  of  some  of  the  varieties  of  cells  just  described  may  not 
be  so  simple  a  matter.  A  cell  having  a  single  nucleus  undergoing  degenera- 
tion and  fragmentation  may  resemble  a  multinuclear  element.  Polynuclear 
cells  may  be  difficult  to  detect  when  the  cell  body  undergoes  shrinkage 
and  becomes  disintegrated. 

Chylous  fluids  owe  their  turbidity  to  fine  particles  of  fat.  The  amount 
of  fat  varies;  it  is  often  under  1  per  cent.,  but  in  a  case  reported  by  Hammer- 
fahr  it  reached  2.95  per  cent.  Other  constituents  of  this  variety  of  effu- 
sion are  water  (90  per  cent.  +),  albumin,  fibrin,  globulin,  cholesterin, 
lecithin,  salts,  soaps,  fatty  acids,  and  other  substances.  The  fat  is  soluble 
in  ether  and  gives  the  tests  for  this  substance. 

There  are  certain  effusions  designated  chyloid  or  pseudochylous  which 
closely  resemble  chylous  fluids  in  their  gross  appearance  but  differ  from 
them  since  the  free,  fine,  fat  particles  are  absent.  The  opalescence  of  these 
fluids  probably  depends  on  a  variety  of  causes,  while  in  some  instances 
the  milky  appearance  cannot  be  explained.  The  presence  of  endothelial 
or  epithelioid  cells  with  a  fatty  degenerated  protoplasm  is  the  explanation 
suggested  by  Quincke  in  some  of  these  cases.  Other  observers  hold  that 
bacteria,    globulins,    lecithin,    mucin,    and    certain    proteids    (other    than 

globulin)  are  responsible  for  the  turbidity 
which  may  in  some  instances  suggest  a  puru- 
lent character  rather  than  a  milky  appearance. 
Chylous  collections  are  not  uncommonly 
noted,  especially  in  the  peritoneal  cavity  and 
pleural  sacs,  rarely  in  the  pericardium.  These 
effusions  arise  in  a  number  of  diseases  in  which 
pressure  is  exerted  on  the  thoracic  duct  or  the 
lymphatic  vessels. 

Cerebrospinal  Fluid. — In  health  the  cere- 
brospinal fluid  obtained  by  lumbar  puncture 
is  colorless,  clear,  of  alkaline  reaction,  has  a 
low  specific  gravity,  ranging  from  1.003  to 
1.007  due  to  the  presence  of  from  1  to  1.5  per 
cent,  of  solids  and  cellular  elements  (endothelial 
cells  and  leucocytes),  not  exceeding  5  per  c. 
mm.  The  amount  under  normal  conditions 
has  been  set  as  varying  between  5  and  10  c.c. 
although  these  figures  are  only  approximate.  The  dural  pressure  as  deter- 
mined with  an  ordinary  water  manometer  in  the  dorsal  position  ranges 
from  60  to  100  mm.  in  health,  while  in  disease,  as  in  meningitis  and  cere- 
bral tumor,  it  may  reach  from  200  to  800  mm.  Serious  symptoms  may 
arise  on  withdrawing  the  fluid  when  the  pressure  falls  below  60  mm. 


Fig.  124. — Smear  of  the  spinal 
fluid  of  a  case  of  epidemic  cerebro- 
spinal meningitis. — Emerson. 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.       305 

Urea,  globulin,  protalbumose,  nucleoproteid,  and  a  reducing  substance 
probably  similar  to  pyrocatechin,  and  sodium  chloride  and  other  inorganic 
salts  are  present.  Serum  albumin  is  said  never  to  exist  in  the  normal 
fluid.  There  is  some  doubt  as  to  the  presence  of  glucose;  some  author- 
ities claim  that  it  is  a  normal  constituent  (.4  to  .5  per  cent.),  which  dis- 
appears when  meningitis  develops  (Lannois  and  Boulard),  while  others 
hold  that  it  does  not  exist  in  health. 

In  pathological  conditions  the  cerebrospinal  fluid  is  often  altered. 

In  disease  the  quantity  varies  from  a  few  c.c.  to  more  than  100  c.c. 
The  amount  is  increased  in  acute  hydrocephalus,  in  general  paresis,  dementia 
prsecox,  in  some  of  the  infectious  diseases,  in  brain  tumors,  and  in  menin- 
gitis. It  should  be  borne  in  mind  that  interference  with  the  circulation  of 
the  cerebrospinal  fluid  from  increased  intracranial  pressure,  as  in  brain 
tumor,  which  cuts  off  the  communication  between  the  subarachnoid 
basilar  spaces  of  the  brain  and  those  of  the  cord,  may  result  in  an  absence 
or  diminished  amount. 

The  fluid  is  often  pale  yellow,  cloudy,  or  creamy  in  appearance  in  acute 
meningitis,  while  in  tuberculous  meningitis,  hydrocephalus,  and  brain 
tumors  it  is  generally  clear  and  colorless.  In  hemorrhage  into  the  ven- 
tricles fluid  blood  may  be  obtained  by  puncture,  while  in  icterus  the  fluid  is 
yellowish.  As  a  rule  a  turbid  fluid  points  to  an  acute  meningitis.  Albumin 
may  be  present  and  the  specific  gravity  is  raised  when  acute  inflammation 
of  the  meninges  exists.  Cholin,  a  substance  which  is  derived  from  the 
destruction  of  nerve  tissue,  is  present  in  the  spinal  fluid  in  cases  of  organic 
disease  of  the  nervous  system,  notably  in  paresis,  tabes  dorsalis,  syphilitic 
epilepsy,  dementia  paralytica,  cerebral  abscess,  brain  syphilis,  myelitis, 
and  spina  bifida. 

Bacteriological  studies  of  the  spinal  fluid  are  most  essential  in  diag- 
nosis. The  following  are  the  more  important  bacteria  which  have  been 
found  by  lumbar  puncture:  meningococcus,  pneumococcus,  staphylo- 
coccus, streptococcus,  B.  tuberculosis,  B.  coli  communis,  B.  influenzae,  B. 
mallei,  B.  pyogenes  foetidus. 

Trypanosomes  are  present  in  the  spinal  fluid  in  African  sleeping 
sickness. 

Cytological  Examination. — The  results  of  cytological  studies  of  the 
cerebrospinal  fluid  fall  in  line  with  those  previously  mentioned.  In  tuber- 
culosis a  high  lymphocyte  count  is  the  rule.  Lymphocyte  preponderance 
has  also  been  noted  in  paresis,  tabes,  cerebrospinal  syphilis,  syringomyelia, 
cerebral  tumors,  pressure  myelitis,  in  chronic  and  in  later  stages  of  cere- 
brospinal meningitis,  in  epilepsy,  and  in  sleeping  sickness.  In  acute 
meningitis,  such  as  is  determined  by  the  meningococcus,  staphylococcus, 
streptococcus,  pneumococcus,  B.  typhosus,  B.  coli  communis,  a  multi- 
nuclear  cellular  predominance  exists. 

Contents  of  Cysts. — Pancreatic  Cysts. — The  evidence  that  the  fluid 
from  an  abdominal  cyst  has  the  property  of  digesting  albumin  in  an 
alkaline  medium  suggests  a  pancreatic  origin.  A  negative  result  does  not 
rule  out  the  possibility  of  pancreatic  cyst,  since  trypsin  disappears  in  collec- 
tions of  long  standing. 

Ovarian  Cyst. — Fluid  of  ovarian  cysts  is  often  pale  yellow,  sometimes 
20 


306  MEDICAL  DIAGNOSIS. 

reddish  or  dark  brown;  the  specific  gravit}'  shows  wide  fluctuation  between 
1.010  to  1.038;  the  consistency  varies  from  a  watery  fluid  to  dense,  viscid, 
''jelly-like"  material. 

Cystic  collections  of  low  specific  gravity  contain  little  albumin  (serum 
albumin  and  globulin),  while  those  of  high  specific  gravity  have  large 
amounts  of  albumin.  Puramucin  is  present  in  colloid  cysts.  Pseudo- 
mucin  or  metalbumin  also  exists  in  these  cysts. 

Ciliated  cylindrical  epithelial  cells,  squamous  epithelium,  erythrocytes, 
fat,  fatty  acid  crystals,  cholesterin  plates,  and  hsematoidin  are  also  noted 
in  the  cysts. 

Hydatid  Cysts. — They  may  be  recognized  by  the  presence  of  cyst 
membrane,  scolices,  and  booklets.  The  fluid  of  these  cysts  is  almost  color- 
less, of  very  low  specific  gravity,  contains  little  or  no  albumin,  shows  a 
considerable  amount  of  sodium  chloride,  has  a  neutral  or  faintly  acid  reac- 
tion, and  traces  of  sugar  and  succinic  acid  may  be  present.  Granular  and 
fatty  detritus,  calcareous  fragments,  hsematoidin,  cholesterin  crystals,  and 
granular  cells  are  frequently  found.  In  the  event  of  suppuration  leuco- 
cytes appear  in  the  fluid. 

Hydronephrosis. — The  fluid  of  hydronephrosis  does  not  always  pre- 
sent features  which  are  diagnostic.  This  applies  especially  to  chronic 
hydronephrosis  with  complete  occlusion  of  the  ureter.  In  acute  cases 
or  those  associated  with  partial  occlusion  of  the  ureter  so  that  the  kidney 
still  functionates,  the  presence  of  a  high  urea  content  and  uric  acid, 
and  especially  when  renal  tube-casts  and  cells  are  found,  renders  the 
diagnosis  a  comparatively  simple  matter. 


IX. 
THE  EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

PRELIMINARY   CONSIDERATIONS. 

The  diagnosis  of  disease  of  the  nervous  system  demands  an  accurate 
knowledge  of  the  anatomy  and  physiology  of  the  structures  involved  and 
of  the  pathological  processes  to  which  they  are  liable.  It  is  essential 
to  determine  not  only  the  location  but  also  when  possible  the  nature 
of  the  lesion. 

The  nervous  system,  by  which  the  organism  is  brought  into  relation 
with  its  environment  and  by  which  its  functions  are  made  manifest  and 
controlled,  is  essentially  composed  of  morphological  units  having  a  similar 
structure — the  neurons — and  held  together  and  supported  by  a  special 
tissue — the  neuroglia. 

The  Neuron.  —  Each  neuron  consists  of  (a)  a  nucleated  proto- 
plasmic mass — the  cell-body — which  presides  over  the  nutrition  of  the  neu- 
ron and  is  the  seat  of  origin  of  nervous  impulse,  and  (b)  processes  which 
form  outgrowths  from  the  cell-body  and  constitute  the  elements  along  which 
impulses  are  conveyed.     These  processes  are  of  two  kinds,  (a)  branched 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  307 

protoplasmic  outgrowths,  dendrites,  which  may  be  multiple  and  form 
arborescent  interlacing  ramifications  with  similar  processes  from  other 
neurons,  and  (b)  the  single  elongated  process,  axon,  commonly  prolonged 
to  form  the  axis-cylinder  process. 

The  dendrites,  uneven  in  contour  and  relatively  thick  as  they  arise 
from  the  cell-body,  rapidly  become  more  slender  in  consequence  of  their 
repeated  branching  until  they  terminate  in  dehcate  end  branches  with 
terminal  bead-like  thickenings. 

The  axons  are  slender  thread-like  extensions  of  uniform  diameter 
and  variable  length,  sometimes  reaching  only  to  adjacent  neurons,  some- 
times extending  to  distant  neurons  within  the  cerebrospinal  axis,  as  from 
the  cerebral  cortex  to  the  lower  part  of  the  spinal  cord,  sometimes  beyond 
as  from  the  lower  part  of  the  cord  to  the  muscles  of  the  foot.  The  axons, 
like  the  dendrites,  finally  terminate  in  end  arborizations — telodendria. 
Most  of  them,  shortly  after  leaving  the  cell-body,  give  off  processes  termed 
collaterals  which  after  a  variable  course  terminate  in  end  arborizations 
which  interlace  with  the  processes  of  other  and  sometimes  distant  neurons. 
Less  frequently  short  axons  arise  which  are  not  continued  as  axis-cylinders 
but  at  once  terminate  in  complex  branching  end  brushes  within  the  sub- 
stance of  the  gray  matter. 

Histologists  are  not  of  accord  as  to  whether  the  relation  between 
the  neurons  is  that  of  continuity  or  simple  contiguity.  The  weight  of 
opinion  is  at  present  in  favor  of  the  view  that  the  neurons  are  separate 
and  distinct  morphological  units,  their  processes  interlaced  to  form  paths 
of  conduction  but  probably  never  actually  continuous  in  the  anatomical 
sense.  The  axis-cyhnders,  usually  supplied  with  a  medullary  sheath,  are 
described  as  nerve-fibres.  Collected  into  bundles  they  form  the  nerve- 
trunks  which  ramify  to  the  various  muscles  and  other  organs. 

Divisions  of  the  Nervous  System. — Central  Portion. — In  verte- 
brates there  is  an  axial  accumulation  of  the  cell-bodies  in  the  cerebrospinal 
axis  from  and  to  which  the  processes  pass.  This  includes  the  brain  and 
spinal  cord  and  contains  the  principal  axial  collections  of  neurons. 

Peripheral  Portion. — This  division  embraces  the  nerve-cells  of  the 
sensory  gangha  and  is  chiefly  made  up  of  the  nerve-fibres  which  pass  to 
and  from  the  end  organs. 

Sympathetic  Nervous  System. — This  division  is  intimately  correlated 
with  the  peripheral  nervous  system,  but  possesses  a  certain  degree  of 
physiological  independence  and  supplies  the  unstriped  muscular  and  the 
glandular  tissues  of  the  body  and  the  muscle  of  the  heart. 

Nerve  Terminations. — The  terminal  end  arborizations  of  the  pe- 
ripheral nerves  constitute  the  mechanism  by  which  the  various  structures 
of  the  body  are  combined  in  consistent  and  harmonious  relation  with  the 
nervous  system.  Certain  of  these  terminations  transmit  impulses  which 
give  rise  to  muscular  contraction;  others  originate  impulses  which  cause 
various  sensations  of  pain,  temperature,  pressure,  or  the  special  senses. 
The  nerve  terminations  may  therefore  be  divided  according  to  their  func- 
tion into  motor  and  sensory. 

Motor  Nerve  Endings. — These  include  three  groups:  (a)  The  terminal 
arborization  of  the  axons  of  neurons  in  the  motor  nuclei  of  the  spinal  cord 


308 


MEDICAL  DIAGNOSIS. 


and  brain  stem  that  pass  to  voluntary  muscle;  (b)  those  of  sympathetic 
neurons  that  pass  to  involuntary  muscle;  (c)  the  muscle  of  the  heart. 
Sensory  Nerve  Endings. — These  are  the  peripheral  terminal  arboriza- 
tions of  the  neurons,  the  cell-bodies  of  which  are  in  the  spinal  and  other 
sensory  ganglia.  They  therefore  constitute  the  point  of  departure  of  the 
paths  which  conduct  sensory  stimuli  to  the  central  nervous  system. 

The  function  of  the  neuron  is  to  conduct  nervous  impulses.  In  its 
simplest  form  the  nervous  system  consists  of  (a)  the  sensory  neuron, 
which  receives  the  external  stimulus  acting  upon  the  integument  and 
other  sensory  surfaces  and  by  means  of  its  process  conducts  it  from  the 
periphery  to  the  cell-body  which  commonly  lies  in  the  cerebrospinal  axis. 
Such  a  process  constitutes  functionally  a  centripetal  or  afferent  fibre. 
The  stimulus  thus  received  is  transmitted  from  the  cell-body  of  the  sensory 

neuron  by  means  of  its  dendrites  which  inter- 
lace with  those  of  the  associated  cell-body  of 
(b)  a  motor  neuron  to  the  latter,  in  which  a 
responsive  impulse  originates  and  is  conveyed 
along  its  axis-cylinder  process — nerve-fibre — 
to  the  muscle-cell  and  causes  contraction. 
The  latter  process  is  therefore  known  as  a 
centrifugal  or  efferent  fibre.  This  elementary 
conception  of  the  relation  and  functions  of 
the  sensory  and  motor  neurons  is  greatly 
modified  by  the  fact  that  the  centripetal 
impulses  are  conveyed  to  the  cell-bodies  of 
other  neurons  not  only  in  the  immediate 
neighborhood  but  also  at  different  and  even 
distant  levels.  Neurons  of  the  same  function 
are  usually  grouped  together,  aggregations  of 
cell-bodies  forming  nuclei,  and  collections  of  the  fibres  forming  bundles, 
tracts,  or  systems.  The  former  are  situated  in  the  gray  matter  of  the 
brain  and  spinal  cord,  the  latter  run  in  the  white  substance  of  the  brain 
and  spinal  cord  and  in  the  peripheral  nerves.  By  this  means  the  various 
parts  of  the  central  nervous  system  are  connected  with  each  other  and 
with  the  muscles  and  viscera. 

Many  of  the  tracts  are  highly  complicated  and  obscure  both  as  to  their 
course  and  formation.  Others  are  simpler  and,  as  the  result  of  studies  of 
the  degenerations  caused  by  injury  or  disease,  have  been  traced  in  their 
course  through  the  cerebrospinal  axis.  Chief  among  the  latter  group  is 
the  pyramidal  tract  which  transmits  motor  impulses  from  the  cortex  to 
the  periphery. 

The  Motor  System. — A  muscular  movement  depends  upon  the  com- 
bined functional  activity  of  many  associated  neurons.  It  follows  that  the 
movements  of  the  various  parts  of  the  body  are  represented  in  the  central 
nervous  system  by  localized  aggregations  of  correlated  neurons,  or  centres. 
Muscular  movements  are  not  only  localized  in  the  motor  areas  of  the 
cerebral  cortex  but  they  are  also  localized  in  the  different  levels  of  the 
ventral  horns  of  the  spinal  cord  and  the  motor  nuclei  of  the  cerebral 
nerves.      Voluntary  motor  impulses  originating  in  the  cortex  of  the  brain 


Fig.  125. — Diagram  showing  fun- 
damental units  of  nervous  system.  A, 
sensory  neuron,  conducting  afferent 
impulses  by  its  process  (o)  from  pe- 
riphery (S);  B,  motor  neuron  sending 
eiferent  impulses  by  its  process  (e)  to 
muscle. — Piersol. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


309 


pass  through  at  least  two  neurons   before  they  reach  the  muscles.     For 
"this  reason  the  motor  tract  is  divided  into  an  upper  and  a  lower  segment. 

The   Upper  Motor  Seg-  i    e  G 

ME  NT. —  Clinical  researches  ~ 

(Hughlings    Jackson),    experi- 
mental studies  (Hitzig,  Ferrier, 
Horsley   and  others),  and  the 
studies  of  tract  myelination  at 
progressive  periods  in  the  devel- 
o  p  m  e  n  t  of  the  cerebrum  by 
Flechsig,    have   thrown    much 
light    upon    the    functions    of 
many  of  the  cortical  regions  of 
the  brain  and  the  sensory  and 
motor  tracts.     The  cell-bodies 
■of    the    upper    motor    neurons 
are    arranged    in   functionally 
allied   groups    in   the    cerebral 
cortex  over  the  ascending  fron- 
tal convolution  and  extending 
deeply  into  the  fissure  of  Ro- 
lando.   In  this  region  the  move- 
ments of  the  body  are  definitely 
represented.     It  has  been  dem- 
onstrated that  motor  impulses  are  excited  by  stimu" 
lation  over  these  areas  in  a  definite  order  from  above 
downward,   as  follows:   leg,  trunk,   arm,   neck,  face; 
the  areas  for  the  leg,  trunk,  and  arm  covering  the 
upper   half,  including   the   Rolandic   surface   of    the 
convolution,  and  those  for  the  head  and  face,  together 
with  those  for  the  jaws,  lips,  tongue,  and  larynx,  the 
lower  half,  likewise  the  surface  extending  into  the 
fissure.     The  centre  for  motor  speech  lies  in  the  left 
"fcliird  frontal,  Broca's,  convolution. 

The  axis-cylinder  processes  of  the  upper  motor 
neurons  pass   from  the   gray  matter   of  the   motor 
cortex  into  the  white  matter  of  the  brain  and  form 
part  of  the  extensive  converging  tract  known  as  the 
corona  radiata.    Collected  into 
a  compact  bundle — the  pyram- 
idal tract — they  pass  between 
the  basal  ganglia  in  the  internal 
capsule  occupying  the  knee  and 
the  anterior  two-thirds  of  the 
posterior  limb.     The  move- 
ments of  the  opposite  side  of  the 
body  are    represented   at   this 
level  from  before  backward  in  the  following  order:   eyes,  head,  tongue, 
mouth;  shoulder,  elbow,  wrist,  fingers,  thumb;  trunk;  hip,  ankle,  knee,  toes. 


Fig.  126. — Diagram  of  motor  path  from  right  cortex. 
Upper  segment  black;  lower  red.  A  destructive  lesion  at  1 
causes  upper  segment  paralysis  of  the  arm  of  the  opposite 
side;  at  2  upper  segment  paralysis  of  the  opposite  side — 
hemiplegia;  at  3  upper  segment  paralysis  of  the  face,  arm, 
and  leg  of  the  opposite  side  and  lower  segment  paralysis  of 
the  eye  muscles  of  the  same  side— crossed  paralysis;  at  4 
upper  segment  paralysis  of  arm  and  leg  of  the  opposite  side 
and  lower  segment  paralysis  of  the  face  and  external  rectus 
of  the  same  side— crossed  paralysis;  at  5  uppersegment  paral- 
ysis of  all  muscles  below  lesion  and  lower  segment  paralysis  of 
muscles  represented  at  level  of  lesion — spinal  paraplegia;  at 
6  lower  segment  paralysis  of  muscles  represented  at  level 
of  lesion — anterior  poliomyelitis. — VanGehuchten  modified. 


310 


MEDICAL  DIAGNOSIS. 


Emerging  from  the  internal  capsule  the  fibres  of  the  pyramidal  (cor- 
ticospinal) tract  pass  into  the  crus.    At  this  point  some  of  them  leave  the 


Fig.  127. — Diagram  of  cortical  centres. 


tract  and  crossing  the  middle  line  end  in  arborizations  among  the  ganglion 
cells  in  the  nucleus  of  the  third  nerve  upon  the  opposite  side,  and  at  succes- 
sive levels  fibres  are  given  off  which 
terminate  in  the  nuclei  of  all  the  motor 
cerebral  nerves  of  the  opposite  side, 
while  a  limited  number  of  fibres  are 
distributed  to  the  corresponding  nuclei 
of  the  same  side.  From  the  crus  the 
pyramidal  tract  enters  the  pons  and 
passes  to  the  medulla  oblongata  form- 
ing its  anterior  area — the  pyramid. 
At  the  lower  limit  of  the  medulla, 
after  the  fibres  to  the  nuclei  of  the 
cerebral  nerves  have  been  given  off, 
five  to  seven  coarse  strands  pass 
obliquely  across  the  anterior  median 
fissure,  interlacing  with  similar  strands 
from  the  opposite  side  and  thus 
constituting  the  decussation  of  the 
pyramids.  In  consequence  of  this 
arrangement  the  greater  number  of 
the  fibres  of  the  important  motor 
paths  pass  to  the  opposite  sides  to  reach  the  lateral  columns  of  the  cord  in 
which  they  descend  as  the  lateral  or  crossed  pyramidal  tracts.  The  fibres 
that  remain  upon  the  same  side  as  the  pyramid  from  which  they  emerge 


Fig.  128.- 


-Diagram  of  internal  capsule  showing 
motor  and  sensory  paths. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


311 


are  collected  in  its  lateral  portion  and  descend  in  the  ventral  columns  as 
the  direct  pyramidal  tracts  or  Tiirck's  columns.  At  every  level  of  the 
spinal  cord  axis-cylinder  processes  emerge  from  the  crossed  pyramidal 
tract  to  enter  the  ventral  horns  and  end  in  arborizations  about  the  cell- 
bodies  of  the  lower  motor  neurons.  In  consequence  of  this  arrangement 
the  tract  diminishes  in  size  as  it  descends  in  the  cord.  In  a  somewhat 
similar  manner  the  fibres  of  the  direct  pyramidal  tract  cross  at  different 
levels  in  the  ventral  white  commissure  and  end  in  arborizations  about  cell- 
bodies  in  the  ventral  horns  on  the  opposite  side.  The  direct  pyramidal 
tract  also  diminishes  in  size  as  it  descends  and  commonly  ends  about  the 
middle  of  the  thoracic  portion  of  the  cord. 

Motor  impulses  originating  in  the  right 
cerebral  cortex  cause  muscular  contractions 
upon  the  left  side  of  the  body,  while  those 
starting  from  the  left  side  of  the  brain 
cause  contraction  of  the  muscles  upon  the 
right  side  of  the  body.  As  a  rule,  to  which 
there  are  few  exceptions,  the  motor  paths 
are  crossed  chiefly  at  the  decussation  of  the 
pyramids  and  to  a  less  extent  at  different 
levels  of  the  cord  by  fibres  given  oE  from 
the  direct  pyramidal  tracts  t9  the  cell- 
bodies  of  the  opposite  side.  This  crossing  in 
either  case  is  in  the  upper  motor  segment. 

The  Lower  Motor  Segment. — The 
cell-bodies  and  processes  of  the  neurons  of 
the  lower  motor  segment  lie  in  the  nuclei 
of  the  cerebral  motor  nerves  and  in  the 
various  levels  of  the  ventral  horns  of  the 
spinal  cord.  The  axis-cylinder  processes 
of  the  neurons  of  this  segment  leave  the 
spinal  cord  in  the  ventral  roots  and  pass 
in  the  peripheral  "nerves  to  the  muscles  of 
the  body,  in  which  they  end  in  brush-like 
arborizations  in  the  motor  end  plates. 
These  neurons,  in  contradistinction  from 
the  neurons  of  the  upper  motor  segment,  which  are  crossed,  are  direct, 
that  is,  the  cell-bodies,  their  protoplasmic  processes,  and  the  muscles  to 
which  their  axis-cylinders  are  distributed  are  upon  the  same  side  of  the  body. 

The  Segments  of  the  Spinal  Cord. — The  spinal  nerves  are  con- 
nected with  the  lateral  surfaces  of  the  cord  by  fan-shaped  bundles  of  an- 
terior and  posterior  roots  which  are  collected  into  compact  strands  as  they 
are  assembled  to  form  a  common  trunk.  That  portion  of  the  cord  to  which 
the  root  fibres  of  a  spinal  nerve  are  attached  constitutes  its  cord  segment, 
the  limits  of  which  correspond  to  the  interval  which  separates  the  extreme 
fibres  of  the  nerve  and  those  of  the  adjacent  nerves.  The  spinal  cord  is 
thus  seen  to  consist  of  a  series  of  segments,  each  of  which  gives  origin  to 
the  anterior  or  motor  and  receives  the  posterior  or  sensory  root  fibres  of 
one  pair  of  spinal  nerves.     These  nerves,  commonly  numbering  thirty-one 


Fig.  129. — Diagram  of  motor  path, 
showing  the  crossing  of  tlie  path  in  the 
upper  segment. 


312 


MEDICAL  DIAGNOSIS. 


First  cervical nrui ■ 

vertebra         i^  r  'j^'^f 


First  thoracic 
vertebra 


First  thoracic 
spine 


First  lumbar 
spine 


Sacrum 


First  sacral 
vertebra 


Coccyx  • 


Fig.  130. — Diagram  .showing  relations  of  bodies 
and  spines  of  vertebise  to  levels  at  which  spinal  nerves 
escape  from  vertebral  canal. — Piersol. 


pairs,  are  eight  cervical,  twelve 
thoracic,  five  lumbar,  five  sacral, 
and  one  coccygeal.  In  the  cervi- 
cal region  all  the  nerve-roots  but 
the  eighth  emerge  above  the  ver- 
tebra, while  throughout  the 
thoracic,  lumbar,  and  sacral  re- 
gions the  roots  for  each  segment 
of  the  cord  leave  the  spinal  canal 
below  the  vertebra  of  correspond- 
ing number.  Owing  to  the  fact 
that  the  vertebral  column  in- 
creases in  length  to  a  greater 
extent  than  the  cord,  there  is 
a  progressive  disparity  from 
above  downwards  between  the 
cord  segments  and  their  respec- 
tive vertebrae.  In  point  of  fact 
the  segment  corresponds  to  the 
nerve  which  is  connected  with 
it,  and  not  to  the  level  of  the 
vertebra  opposite  to  it.  The 
position  of  a  lesion  involving  a 
particular  spinal  segment  is 
therefore,  except  in  the  upper 
cervical  region,  some  distance 
above  the  vertebra  of  corre- 
sponding number.  Ziehen  has 
formulated  the  following  rule 
to  determine  the  levels  of  origin 
of  the  cervical  and  thoracic 
nerve-roots:  For  the  cervical 
nerves  subtract  one  from  the 
number  of  the  nerve,  and  the 
remainder  will  indicate  the  corre- 
sponding spinous  process;  for  the 
upper  thoracic  nerves  (I-V)  sub- 
tract two;  for  the  lower  thoracic 
nerves  (V-XII)  subtract  three. 
Axis-cylinder  processes  from  more 
than  one  segment  of  the  cord 
may  enter  into  the  formation  of 
a  peripheral  nerve  and  the  greater 
number  of  the  long  striped  mus- 
cles are  supplied  with  nerve-fibres 
from  more  than  one  segment. 

The  cutaneous  distribution 
of  the  peripheral  nerves  has 
been  accurately  worked  out  and 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


313 


is  of  diagnostic  value  in  lesions  of  the  main  trunks  and  their  ramifi- 
cations. The  segmental  areas  which  correspond  to  the  dorsal  roots, 
though  less  definitely  determined,  are  suflaciently  known  to  be  of  great 
service  in  the  segmental  locaHzation  of  lesions  of  the  dorsal  roots  and 
the  cord.     These   skin-fields   or   dermatomes   have  been  mapped  out  as 

The  Localization  of  the  Functions  in  the  Segments  of  the  Spinal  Cord. 
Based  upon  the  studies  of  Starr,  Edinger,  Wuhmanu,  and  others. 


Segment. 


Muscles. 


Reflex. 


I,  II,  and  III 

Cervical 

IV  Cervical . . 

V  Cervical  . . . 

VI  Cervical  . . 

VII  Cervical.. 

VIU  Cervical 

I  Thoracic  . . . 

II  to  XII  Tho- 
racic 

I  Lumbar 

II  Lumbar  . . . 

III  Lumbar  . . 

IV  Lumbar  . . 

V  Lumbar  . . . 

I  to  II  Sacral . 
Ill  to  V  Sacral 


Diaphragmatic. 

Dilatation  of  the  pupil  (0. 
IV- VII  J. 

Scapular  (C.  V-T.  I),  supi- 
nator longus  (C.  V),  and 
biceps  (C.  V-Vl). 

Triceps  and  posterior  wrist 
(C.VI-VIII). 


Splenius  capitis,  trapezius,  hyoid  muscles,  diaphragm  (C.  III- 
V),  sternomastoid,  levator  "scapulae  (C.  III-V) 

Trapezius,  scaleni  (C.  IV-T.  I),  rhomboid,  diaphragm,  teres 
minor,  levator  scapulae,  supraspinatus 

Diaphragm,  rhomboid,  biceps,  supinator  brevis  (C.  V-VII), 
teres  minor,  subscapularis,  brachialis  anticus,  pectoralis 
(clavicularpart),  supra- and  infraspinatus  (C.  V-Vl},  deltoid, 
supinator  longus  (C.  V-VII),  serratus  magnus  j 

Teres  minor  and  major,  biceps,  supinator  brevis,  coraeo-brach- 
ialis,  extensors  of  wrist  (C.  VI-VIII),  infraspinatus,  b  achialis 
anticus,  pectoralis  'clavicularpart),  pronator  teres,  deltoid, 
supinator  longus,  serratus  magnus  (C.  V-VIII),  triceps  (outer 
and  long  heads) 

Teres  major,  pectoralis  major  (costal  part),  pronators  of  wrist, 
flexors  of  wrist,  subscapularis,  pectoralis  minor,  triceps,  latis- 
simus  dorsi  (C.  Vl-VIII),  deltoid  (posterior  part),  serratus 
magnus,  extensors  of  wrist  and  Augers 

Pectoralis  major  (costal  part),  latissimus,  pronator  quadratus, 
radial  lumbricales  and  interossei,  flexors  of  wrist  and  fingers 

Lumbricales  and  interossei,  thenar  and  hj'pothenar  eminences 
(C.  VII-T.  I) 

Muscles  of  back  and  abdomen,  rectus  abdominis  (T.  V-T.  XII), 
transversalis  (T.  Vll-L.  I),  erectores  spinse  (T.  I-L.  V),  ex- 
ternal oblique  (T.  V-XII),  intercostals  (T.  I-T.  XII),  internal 
oblique  (T.  VII-L.  I) 

Lower  part  of  external  and  internal  oblique  and  transversalis,  j  Cremasteric  (L.  I-III). 
psoas  major  and  minor  (?),  quadratus  lumborum  (L.  l-II), 
cremaster 

Psoas  major  and  minor,  sartorius  (lower part),  iliacus,  flexors 
of  knee  ( Remak) ,  pectineus,  adductor  longus  and  brevis 


Scapulohumeral    and  ante- 
rior wrist  (C.  VIl-VIlI). 


Palmar(C.  VII-T.  I). 


Epigastric  (T.  IV-VIT),  ab- 
dominal (T.  VII-XII). 


Sartorixis  (lower  part),  inner  rotators  of  thigh,  adductors  of 
thigh,  abductors  of  thigh,  quadriceps  femoris  (L.  Il-L.  IV) 

Flexors  of  knee  (Ferrier),  abductors  of  thigh,  quadriceps 
femoris,  extensors  of  ankle  (tibialis  anticus),  adductors  of 
thigh,  glutei  (medius  and  minor) 

Flexors  of  knee  (hamstring  muscles)  (L.  IV-S.  II),  flexors 
of  ankle  (gastrocnemius  and  soleus)  (L.  IV-S.  II),  outward 
rotatois  of  thigh,  extensors  of  toes  (L.  IV-S.  I),  glutei, 
peroiisei 

Flexors  of  ankle  (L.  V-S.  II),  intrinsic  muscles  of  foot,  long 
flexor  of  toes  (L.  V-S.  II),  perona^i 

Perineal  muscles,  levator  and  sphincter  ani  (S.  I-III) 


PateUar  tendon  (L.  H-IV). 
Gluteal  (L.  IV-V). 


Foot  reflex  (S.  I-II),  plantar 
(S.  II-IIl). 

Vesical  (L.  IV-V)  and  anal 
(S.  I-III). 


the  result  of  observations  by  Henry  Head  in  the  distribution  of  the 
cutaneous  lesions  of  herpes  zoster  and  the  areas  of  referred  pain  and  tender- 
ness corresponding  to  certain  visceral  lesions,  and  in  cases  of  gross  lesions 
of  the  cord  by  Starr,  Kocher  and  others;  as  the  result  of  studies  of  anaes- 
thesia under  similar  conditions;  and  of  morphological  investigations,  ana- 
tomical dissections,  and  experimental  physiological  researches.  The  skin 
areas  upon  the  trunk  form  irregularly  parallel  zones,  somewhat  horizontal 
in  the  erect  posture,  and  even  more  irregularly  distributed  elongated  tracts 


314 


MEDICAL  DIAGNOSIS. 


Ce' 


.Or 


Ct 


Ct 


Ti, 


Li 


iGm 


upon  the  extremities.  The  technic  consists  in  the  use  of  a  blunt  instru- 
ment, as  the  head  of  an  ordinary  toilet  pin,  in  determining  the  presence  of 
areas  of  abnormal  sensation  and  defining  their  boundaries. 

The  Sensory  System. — The 
path  for  sensor}*  conduction  is 
much  more  complicated  than 
that  for  motor  conduction  and 
is  composed  of  three  or  more 
associated  neurons,  one  above 
the  other.  The  cell-bodies  of 
the  lowest  neurons  are  situated 
in  the  ganglia  of  the  sensory 
cerebral  nerves  and  the  gangha 
of  the  dorsal  roots  of  the  spinal 
nerves.  The  latter  gangha  cells 
have  a  single  process  which,  after 
leaving  the  cell-body,  undergoes 
a  T-shaped  division,  one  portion 
being  the  peripherally  directed 
process  or  dendrite  (sensory 
nerve)  which  conducts  impulses 
from  the  integument,  mu- 
cous membranes,  muscles, 
tendons,  and  joints  of 
parts  of  the  body  with 
which  it  may  be  related; 
the  other  the  axon  or  axis- 
cylinder  process  which 
enters  the  spinal  cord  by  way  of  the 
posterior  root  fibre  and  conveys  the 
various  impulses  to  the  central  nervous 
system  to  be  transformed  into  sensations 
of  temperature,  touch,  muscle-sense,  and 
pain.  The  larger  number  of  the  sen- 
sory neurons  lie  outside  of  the  spinal 
cord.  The  portions  of  those  neurons 
within  the  cord  constitute  the  paf'S  of 
sensory  conduction,  which  become  more 
intricate  as  the  various  tracts  approach 
the  brain.  Upon  entering  the  cord  the 
axons  of  the  sensory  neurons  of  the  first 
order  divide  into  an  ascending  and  a 
descending  branch  which  run  in  the 
dorsal  fasciculi.  The  short  descending 
branch,  after  giving  off  a  number  of 
collaterals,  terminates  in  the  gray  matter  of  the  cord.  The  ascending  branch 
is  of  variable  length.  It  may  soon  terminate  in  the  gray  matter  or  may  reach 
to  the  nuclei  of  the  medulla.  The  lower  sensory  neuron  does  not  cross  the 
middle  fine.     The  cell-bodies  about  which  the  axis-cylinders  of  the  neurons 


'Sffl' 


Set 


Lm 


'Lh/ 


bi 


.Le 


LttN 


5ii 


6i 


/Si/ 


Fig.  131. — Anterior  and   posterior  segmental 
skin-fields. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  315 

of  the  first  order  and  their  collaterals  end  are  the  sensory  neurons  of  the 
second  order.  The  axis-cylinder  processes  of  many  of  those  cells  cross  to 
the  opposite  side  of  the  cord  and  run  in  the  ventrolateral  ascending  column 
of  Gowers  and  the  ground  bundles.  The  lemniscus  is  probably  the  principal 
sensory  tract  in  the  medulla,  pons,  and  cerebral  peduncles.  The  fibres  are 
not,  however,  continued  directly  to  the  cefebral  cortex  but  terminate  about 
cells  in  the  ventrolateral  portion  of  the  optic  thalamus,  from  which  point 
the  path  of  sensory  conduction  is  continued  by  a  higher  order  of  neurons, 
the  processes  of  which  terminate  in  the  postcentral  and  parietal  convolu- 
tions of  the  cortex.  Other  but  less  direct  sensory  paths  lie  in  series  ol 
neurons  in  the  gray  matter  of  the  cord  and  in  the  direct  cerebellar  tract 
and  the  tract  of  Gowers,  and  pass  onward  through  the  cerebellum.  Some 
of  the  axis-cylinder  processes  of  the  sensory  neurons  of  the  first  order  ana 
their  collaterals  terminate  in  arborizations  about  the  cell-bodies  of  the 
lower  motor  neurons  and  thus  complete  the  path  for  reflexes. 

It  is  probable  that  the  conduction  paths  for  cutaneous  sensory 
impulses  reach  the  opposite  side  soon  after  entering  the  cord,  and 
that  the  paths  for  muscular  sense  lie  upon  the  same  side  of  the  cord 
in  the  tracts  of  Goll,  crossing  by  way  of  the  axons  of  the  second  order 
in  the  medulla. 

Fibre  Tracts  of  the  White  Matter  of  the  Cord. — Of  these  there  are 
three  sets:  (1)  Those  which  enter  the  cord  from  the  periphery,  viscera, 
and  other  parts  of  the  body;  (2)  those  which  enter  it  from  the  brain;  (3) 
those  which  have  their  origin  in  the  cell-bodies  of  the  neurons  which  lie 
within  the  cord.  The  fibres  which  arise  from  the  same  group  of  nerve- 
cells  or  nucleus  have  the  same  function  and  a  similar  destination  and 
proceed  together  in  the  same  course,  thus  constituting  a  tract,  column, 
or  fasciculus.  Some  of  these  fibres  are  the  pathways  for  the  transmission 
of  impulses  from  lower  to  higher  levels,  and  the  strands  which  these  form 
constitute  ascending  tracts,  while  others  which  convey  impulses  from  above 
downward  enter  into  the  formation  of  descending  tracts.  These  tracts  are 
not  sharply  defined,  nor  do  their  boundaries  and  areas,  since  they  are  sub- 
ject to  increase  and  diminution  by  the  continual  accession  or  departure 
of  nerve-fibres,  remain  the  same  at  different  levels  of  the  cord.  In  fact 
the  borders  of  those  tracts  often  overlap.  Their  anatomical  differentiation 
has  been  accomplished  partly  by  the  study  of  degenerative  processes  caused 
by  experimental  methods — Wallerian  degeneration — and  partly  by  re- 
searches in  myelination  at  progressive  periods  of  development — embryo- 
logical  method.  Pathologically  they  are  differentiated  in  a  corresponding 
manner  by  the  degenerations  which  follow  traumatism  of  the  cord  and  the 
definite  and  constant  reaction  of  certain  tracts  to  pathogenic  influences 
as  in  tabes  and  other  diseases. 

Relation  of  Diseases  of  the  Cord  to  Lesions  of  the  Fibre  Tracts.— In 
tabes  and  Friedreich's  ataxia  the  posterior  columns  are  principally  in- 
volved; in  combined  sclerosis  the  posterior  columns  and  lateral  pyramidal 
tracts;  in  lateral  sclerosis  the  lateral  pyramidal  tracts;  in  amyotrophic 
lateral  sclerosis  the  lateral  pyramidal  tracts  and  the  anterior  horns, 
and  in  anterior  poliomyelitis  and  progressive  muscular  atrophy  the 
anterior  horns. 


316 


MEDICAL  DIAGNOSIS. 


Sensory  Areas  of  the  Cerebral  Cortex. — The  cortical  representation 
of  sensory  stimuli  is  less  definite  than  that  of  motion.  It  lies  posterior  to 
the  fissure  of  Rolando  and  is  extensively  distributed  over  the  post-central 
and  parietal  convolutions. 


Fig.  132. — Diagram  of  spinal  cord,  showing  the  relation  of  the  piincipal  tracts. 

I.  Goll's  or  postero-internal  column — fasciculus  graciius.  Terniinoiion. — Fibres  end  around  neurons 
of  gray  matter  of  cord  or  in  nuclei  of  medulla.  Function  — Sensory  impulses  from  muscles,  tendons  and 
joints  of  same  side.     Deneneration  followed  by  ataxia  and  loss  of  muscle  sense. 

II.  Burdach's  or  posterolateral  column — fasciculus  cuneatus.  Tenninntion. — Nucleus  cuneatus  in 
the  medulla;  Clark's  column.  Collaterals  to  neurons  of  posterior  horn.  The  root  fibres  passing  to  Clark's 
column  traverse  the  middle  and  median  part  of  this  tract.  Function. — Tactile  impulses  from  opposite 
side.  Various  afferent  impressions  of  muscle  sense,  heat,  cold  and  pain.  Degeneration  causes  pain,  anes- 
thesia, ataxia,  and  loss  of  reflexes. 

III.  lissauer's  tract  or  marginal  zone.  This  fasciculus  is  situated  immediately  dorsal  to  the  inner 
side  of  the  posterior  horn.  Composed  of  some  of  the  more  external  root  fibres  which  do  not  enter  Burdach's 
column.  Fibres  of  small  size  and  short  course.  They  penetrate  the  substantia  Rolandi  and  end  in  arbori- 
zations about  its  cells  and  those  of  the  caput  cornu. 

IV.  Direct  cerebellar  tract — fasciculus  cerebellospinalis.  Terminatioyi. — Ascending  path  of  the  second 
order  conveying  impulses  from  Clark's  cells  to  the  cerebellum.  Function. — Impulses  from  %iscera,  which 
prolDably  influence  maintenance  of  equihbrium. 

V.  Gowers's  tract — fasciculus  anterolateralis  superficialis.  Termination. — Sensory  pathway  of  second 
order  connecting  cord  with  cerebellum  and  probably  with  cerebrum.  Fibres  are  chiefly  axons  of  neurons 
in  the  posterior  horn,  partly  upon  the  same  and  partly  upon  the  opposite  side.  Boundaries  not  well  defined. 
Function. — The  conveyance  of  sensory  impulses — tactile  pain  and  temperature — from  opposite  side  by 
■way  of  the  anterior  commissure. 

VI.  Lateral  or  crossed  pyramidal  tract — fasciculus  cerebrospinalis  lateralis.  Termination. -^Fihrea 
are  axons  of  cortical  motor  neurons.  They  extend  from  superficial  gray  matter  of  cerebrum  to  various 
levels  of  cord,  undergoing  decussation  at  lower  part  of  medulla.  Function. — Conveyance  of  motor  impulses 
of  brain. 

VII.  Lateral  ground  bundle — fasciculus  lateralis  proprius.  Terminations. — Composition  very  com- 
plex. Long  descending  paths;  one  long  ascending  strand  and  many  short  strands  both  ascending  and 
descending.  Functions. — Both  motor  and  sensory.  Connects,  by  means  of  its  intersegmental  association 
fibres,  different  levels  of  the  cord  and  forms  a  direct  sensory  link  between  cord  and  higher  centres — meduUa 
and  cerebrum. 

VIII.  Anterior  ground  bundle — fasciculus  anterior  proprius.  Constitutes  with  lateral  ground  bundle, 
with  which  it  is  continuous,  a  single  anterolateral  tract  or  fundamental  column.  Its  composition  and  func- 
tions are  the  same  as  those  of  the  lateral  ground  bundle. 

IX.  .interior  or  direct  pyramidal  tract — fasciculus  cerebrospinalis  anterior.  Termination. — Composed 
of  pyramidal  filDres  which  do  not  undergo  decussation  in  medulla  oblongata.  Made  up  of  15  to  20  per  cent, 
of  pyramidal  fibres.  Almost  all  fibres  cross  in  anterior  white  commissure  at  successive  levels  to  terminate  in 
arborizations  about  root  cells  of  anterior  horn  of  opposite  side.    Function. — Motor  tract  from  cerebral  cortex. 

X.  Gray  matter  of  the  cord,  a,  a',  anterior  horns;  emergences  of  anterior  motor  root  fibres;  b,  b', 
posterior  horns;  entrance  of  po.aiterior  root  fibres;  c,  posterior  commissure;  d,  anterior  commissure.  Function. 
— Anterior  horns  motor;  posterior  sensory.  Cells  of  anterior  horns  trophic;  those  in  angle  of  posterior  com- 
missure probably  influence  automatic  movements  while  those  near  by  are  trophic  vasomotor,  and  secretory. 

Of  the  foregoing,  I,  II,  and  III  comprise  the  fibre  tracts  of  the  posterior  column;  IV,  V,  VI,  and  VII  the 
fibre  tracts  of  the  lateral  column,  and  VIII  and  IX  the  fibre  tracts  of  the  anterior  column  of  the  cord. 


The  Cortical  Areas  for  the  Special  Senses. — The  individual  sensory 
paths  terminate  in  circumscribed  regions  which  are  as  a  rule  widely  removed 
from  one  another.  As  mapped  out  by  myelination  these  areas  correspond 
to  regions  of  the  cortex  which  pathological  lesions  have  shown  to  be  related 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  317 

to  the  various  special  forms  of  sensation.  According  to  Flechsig  olfactory 
fibres  end  mainly  in  the  uncinate  gyrus;  visual  fibres  have  been  traced  to 
the  occipital  lobe  in  the  region  of  the  calcarine  fissure,  while  auditory  fibres 
run  to  the  temporal  lobe. 

It  is  in  accordance  with  these  observations  that  the  cuneus  and  cal- 
carine fissure  together  constitute  the  primary  or  lower  cortical  visual 
centre  in  which  are  represented  the  opposite  visual  half  fields,  while  the 
outer  surface  of  the  occipital  lobe  contains  centres  for  higher  visual  proc- 
esses in  which  the  vision  of  the  eye  of  the  opposite  side  is  represented. 
Mind  blindness  results  from  a  destructive  lesion  of  the  lateral  lobe  in  the 
left  hemisphere  if  both  occipital  lobes  are  involved.  A  lesion  of  the  cuneo- 
calcarine  cortex  results  in  lateral  homonymous  hemianopsia.  The  centre 
for  memory  of  the  meaning  of  printed  words,  letters,  figures,  and  objects 
seen  is  probably  in  the  left  angular  gyrus.  A  destructive  lesion  in  this 
area  is  attended  by  inability  to  read  or  comprehend  written  language 
although  ordinary  vision  is  not  impaired.  This  area  is*known  as  the  visual 
speech  centre.  The  auditory  centre  is  in  the  upper  temporal  convolution 
and  transverse  temporal  gyri  and  it  is  in  this  region  upon  the  left  side  that 
the  memories  of  the  meaning  of  heard  words  and  sounds  are  stored.  A 
special  centre  for  musical  memories  lies  anterior  to  the  auditory  centre. 
It  is  probable  that  the  centre  of  each  side  is  connected  with  both  auditory 
nerves.  The  olfactory  centre  probably  comprises  a  portion  of  the  base 
of  the  frontal  lobe  and  the  uncinate  gyrus.  The  gustatory  centre  has 
been  thought  to  be  in  the  anterior  portion  of  the  gyrus  fornicatus  near 
the  centre  for  smell.  Our  knowledge  in  regard  to  these  two  centres  is 
not  definite. 

The  centres  for  the  "  higher  psychical  functions"  are  generally  assumed 
to  lie  in  the  prefrontal  lobes,  particularly  upon  the  left  side.  Extensive 
unilateral  lesions  of  the  anterior  portion  of  the  frontal  lobe  may  be  present 
without  causing  marked  symptoms  of  any  kind.  Atrophy  of  this  portion 
of  the  brain  is  often  marked  in  various  forms  of  dementia. 

Symptoms  due  to  derangements  of  the  motor  tracts  constitute  the 
most  important  group  of  localizing  phenomena.  They  are  objective  on 
the  one  hand  and  are  upon  the  other  caused  by  lesions  of  conduction  paths 
that  are  comparatively  well  understood.  Lesions  involving  the  motor 
path  are  irritative  or  destructive.  The  greater  number  of  the  lesions  of 
the  motor  cortex  are  at  the  same  time  destructive  and  irritative.  They 
destroy  the  nerve-cells  and  their  processes  in  a  particular  centre  and  by 
their  presence  and  advance  stimulate  those  of  adjacent  centres  into  morbid 
or  disordered  activity.  The  clinical  manifestation  of  a  destructive  lesion 
of  a  motor  centre  is  loss  of  function— paralysis;  that  of  an  irritative  lesion 
abnormal  muscular  contraction.  Important  differences  in  the  paralysis 
or  abnormal  contraction  are  dependent  upon  the  position  of  the  lesion  as 
regards  the  motor  segments.  These  differences  are  due  first  to  anatomical 
relations  and  second  to  secondary  degenerations. 

The  cortical  motor  centres  are  more  or  less  widely  separated  from  one 
another,  and  a  circumscribed  destructive  lesion  of  the  motor  area  may 
therefore  give  rise  to  a  limited  paralysis  involving  a  limb  oi-  a  group  of 
muscles  in  a  limb — cerebral  monoplegia.     As  the  axis-cylinder  processes 


318  MEDICAL  DIAGNOSIS. 

converge  to  form  the  pyramidal  tract  in  the  internal  capsule,  a  lesion  of 
limited  extent  causes  paralysis  of  most  of  the  muscles  upon  the  opposite 
side  of  the  body — hemiplegia.  A  lesion  in  the  pyramidal  tract  as  it 
descends,  giving  off  fibres  to  the  motor  nuclei  at  various  levels,  causes 
paralysis  of  the  muscles  having  their  spinal  centres  below  the  seat  of  the 
lesion.  It  follows  from  the  decussation  of  the  pyramids  that  when  the 
lesion  is  above  the  crossing  the  paralysis  is  upon  the  opposite  side  of  the 
body,  and  when  it  is  below  it,  upon  the  same  side. 

The  cell-body  and  particularly  its  nucleus  maintain  the  nutrition  of 
all  parts  of  the  neuron.  If  the  cell-body  be  destroyed  its  processes  undergo 
degeneration,  or  if  any  process  be  separated  from  its  cell-body  it  likewise 
undergoes  degenerative  changes  throughout  its  whole  extent — secondary 
degeneration.  Degeneration  of  the  axons  of  the  upper  motor  segment 
ceases,  however,  at  the  lower  motor  segment.  The  muscles  are  paralyzed 
but  do  not  undergo  degenerative  atrophy;  they  are  spastic;  their  reflexes 
are  exaggerated  arid  they  do  not  show  qualitative  changes  in  their 
electrical  reactions. 

In  complete  transverse  lesion  of  the  cord — complete  spinal  para- 
plegia— the  muscles  upon  both  sides  are  paralyzed  below  the  lesion,  but 
they  are  flaccid;  the  deep  reflexes  are  abolished;  the  muscles  undergo 
rapid  atrophy  with  loss  of  faradic  excitability. 

Irritative  lesions  of  the  upper  motor  segment  involving  the  motor 
cortex  give  rise  to  the  convulsive  phenomena  known  as  cortical  or  Jack- 
sonian  epilepsy. 

Destructive  lesions  of  the  lower  motor  segment  cause  degeneration 
alike  of  the  axis-cylinder  processes  in  the  peripheral  nerves  and  of  the 
muscle-fibres  with  which  they  are  connected.  The  anatomical  distribution 
of  the  cell-bodies  of  the  segment  gives  rise  to  special  peculiarities  in  the 
distribution  of  the  paralysis  which  are  strongly  in  contrast  to  that  result- 
ing from  lesions  of  the  upper  motor  segment  and  which  have  important 
bearings  upon  the  localization  of  the  lesion.  These  cell-bodies  are  col- 
lected in  groups  or  nuclei  from  the  peduncles  of  the  brain  throughout 
the  entire  extent  of  the  spinal  cord  and  send  axis-cylinder  processes  to  all 
the  muscles  of  the  body.  Certain  groups  of  the  neurons  which  make  up 
the  lower  segment  are  therefore  widely  separated,  and  a  circumscribed 
lesion  may  result  in  paralysis  of  a  limited  number  of  muscles  or  a  group 
of  muscles  instead  of  one-half  of  the  body  as  in  upper  segment  paralysis — 
hemiplegia.  A  lesion  causing  lower  segment  paralysis  may  be  situated 
either  in  the  cord  or  in  the  peripheral  nerve.  If  in  the  cord  or  its  nerve- 
roots  the  paralyzed  muscles  are  not  supplied  by  a  single  nerve  but  are 
represented  in  adjacent  cord  segments  and  the  accompanying  sensory 
derangements  involve  the  skin  fields  related  to  those  segments;  if  on  the 
contrary  the  lesion  is  in  the  nerve,  the  paralyzed  muscles  and  the  anaes- 
thetic area  are  those  supplied  by  that  particular  nerve  and  its  branches. 
The  neurons  of  the  lower  motor  segment  maintain  not  only  the  nutrition 
of  their  axis-cylinder  processes  which  make  up  the  peripheral  nerves  but 
also  that  of  the  muscle-fibres  in  which  their  processes  terminate.  The 
degeneration  which  results  from  injury  of  the  cell-bodies  or  their  processes 
involves  the  muscles  to  which  they  are  distributed.    In  lower  motor  segment 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  319 

paralysis  the  affected  muscles  are  the  seat  of  degenerative  atrophy, 
manifest  in  diminished  tension,  aboHtion  of  their  refiexes  and  reaction  of 
degeneration — flaccid  paralysis. 

Irritative  lesions  of  the  lower  motor  segment  cause  fibrillary  con- 
tractions which  may  be  due  to  stimulation  either  of  the  cell-bodies  or  of 
their  axis-cylinder  process  in  the  peripheral  nerves;  or  they  may  give  rise 
to  spasmodic  contractions  when  the  lesion  affects  the  motor  nerve-roots 
as  they  emerge  from  the  cord. 

Symptoms  due  to  derangements  of  sensory  paths  are  of  far  less  local- 
izing value  than  motor  symptoms.  This  is  partly  due  to  the  greater  com- 
plexity of  the  sensory  tracts,  partly  to  less  exact  knowledge  concerning 
them.  If  sensory  symptoms  are  limited  to  the  distribution  of  a  peripheral 
nerve  it  is  evident  that  the  lesion  is  in  the  nerve-trunk  or  its  branches; 
if  restricted  to  the  fields  corresponding  to  one  or  more  spinal  segments 
the  cord  is  at  fault;  if  they  chiefly  affect  one  side  of  the  body,  the  brain. 
The  nature  of  the  sensory  phenomena  has  little  value.  Intense  pain,  for 
example,  may  be  symptomatic  of  peripheral  nerve  disease  as  in  some 
forms  of  neuritis,  or  of  a  degenerative  process  within  the  cerebrospinal 
axis  as  in  tabes. 

Irritative  lesions  cause  disordered  subjective  sensations  of  heat,  cold, 
formication,  and  the  like — the  paraesthesias — and  pain  of  every  variety  as 
to  kind  and  degree. 

Destructive  lesions,  if  they  completely  interrupt  the  sensory  path, 
wholly  abolish  sensation  in  the  parts  of  the  body  involved.  A  lesion  of  a 
peripheral  sensory  neuron  in  the  course  of  the  nerve  gives  rise  to  anaes- 
thesia in  the  area  of  distribution  of  the  nerve;  a  complete  transverse  lesion 
of  the  spinal  cord  gives  rise  to  total  loss  of  sensation  of  all  parts  below  its 
level.  Destructive  lesions  of  the  central  nervous  system  do  not  however 
usually  interrupt  all  the  sensory  conduction  paths,  and  sensation  may  not 
be  wholly  abolished  even  in  extensive  disease.  Sensation  may  be  diminished 
or  lost  in  all  its  phases  as  in  complete  transverse  lesions  of  the  cord,  or  there 
may  be  dissociation  sensory  paralysis  as  in  certain  diseases  of  the  cord  in 
which  pain-sense  and  temperature-sense  are  abolished  while  tactile  sensa- 
tion remains  unimpaired,  or  in  some  lesions  of  the  cerebral  cortex  in  which 
there  may  be  a  loss  of  the  muscular  sense  and  astereognosis — the  loss  of 
the  ability  to  recognize  an  object  placed  in  the  hand — while  other  phases 
of  sensation  are  fully  preserved. 

EXAMINATION    OF   THE   PATIENT. 

The  Anamnesis. — An  accurate  history  of  the  case  is  of  the  highest 
importance  in  disease  of  the  nervous  system.  This  must  include  in 
many  cases  the  facts  relating  to  the  antecedents  of  the  patient,  which 
bear  upon  hereditary  predisposition,  as  the  occurrence  of  nervous  or 
mental  disease  in  the  parents,  children,  or  collateral  members  of  his  fam- 
ily. Peculiarities,  idiosyncrasies,  and  psychoses  are  especially  to  be 
ascertained,  often  a  matter  of  no  little  difficulty.  A  histoi-y  of  gout, 
alcoholism,  or  syphilis  in  a  parent,  when  it  can  be  obtained,  may  give 
the  key  to  the  situation. 


320  MEDICAL  DIAGNOSIS. 

The  investigation  of  the  personal  history  must  bear  upon  any  pre- 
vious serious  illness  and  its  nature,  whether  nervous  or  not,  and  especially 
whether  or  not  such  an  illness  was  of  a  similar  nature  to  that  from  which 
the  patient  is  suffering. 

It  may  be  necessary  to  follow  in  our  investigation  a  chronological 
order,  ascertaining  whether  or  not  nervous  symptoms  have  occurred  in 
infancy  and  childhood,  such  as  convulsions,  enuresis,  night  terrors.  The 
period  of  school  life  is  to  be  studied  in  obscure  cases.  The  neurasthenic 
may  have  been  bright  and  successful  at  school,  but  shy,  retiring,  and  not 
disposed  to  make  friends;  the  sufferer  from  petit  mat,  sometimes  confused 
and  forgetful;  the  hysterical  girl,  especially  at  puberty,  nervous  and  emo- 
tional. The  occupation  is  next  to  be  considered.  Is  it  one  that  involves 
continuous  monotony,  mental  strain,  extreme  responsibility?  Have  there 
been  prolonged  or  cumulative  depressing  emotions,  disappointment,  fear, 
sorrow,  or  grief?  Wounds  and  injuries,  alcoholism,  and  abnormal  sexual 
matters,  especially  syphilis,  are  of  etiological  importance  in  many  neuro- 
logical cases.  Severe  infectious  processes,  particularly  enteric  fever,  may 
have  been  the  point  of  departure  for  visceral  and  vascular  changes  which 
after  a  time  manifest  themselves  in  the  guise  of  nervous  disease.  Of  special 
importance  are  such  maladies  in  their  relation  to  postinfective  psychoses 
and  neurasthenia.  The  part  played  by  obscure  toxaemias  due  to  chronic 
gastro-intestinal  or  other  visceral  diseases  in  the  etiology  of  certain  spinal 
cord  degenerations  is  not  to  be  disregarded.  Notwithstanding  the  number 
of  points  to  be  considered  the  value  of  the  history  cannot  be  measured  by 
its  length.  On  the  contrary  it  is  most  important  to  briefly  record  only  the 
facts  which  are  pertinent  and  significant. 

Status  Praesens. — While  investigation  on  every  side  is  necessary  for 
a  full  understanding  of  many  nervous  cases,  yet  there  are  certain  special 
paths  of  approach  which  experience  has  taught  us  lead  most  directly  to  a 
diagnosis  in  the  average  case;  in.  other  words  certain  distinctly  neuro- 
logical methods  of  investigation.  These  methods  may  be  grouped  according 
to  the  character  of  the  symptoms  and  signs  that  each  brings  into  view, 
the  most  important  being,  (1)  motor  and  (2)  sensory  symptoms;  (3)  cere- 
bral symptoms,  of  which,  on  account  of  comprehensive  and  special  char- 
acters, (4)  asphasia  requires  separate  consideration;  (5)  spinal  symptoms 
in  so  far  as  they  connect  segments  of  the  cord  with  particular  regions  of 
the  body;  (6)  the  reflexes;  (7)  electrical  phenomena;  (8)  trophic  disturb- 
ances;   (9)  pain  and  temperature;    (10)  muscular  sense. 

1.   Motor  Symptoms. 

Paralysis. — Motor  paralysis  signifies  impairment  of  some  portion  of 
the  motor  pathway.  When  partial  it  is  to  be  distinguished  from  akinesia, 
common  in  states  of  mental  stupor,  and  from  incoordination,  often  mis- 
taken by  the  patient  and  his  friends  for  true  weakness.  The  practical 
tests  for  muscular  weakness  consist,  for  the  hand  and  forearm,  in  estimat- 
ing the  patient's  "  grip"  as  he  squeezes  the  hand  of  the  examiner,  especially 
in  comparing  the  grip  of  an  affected  hand  with  the  other,  which  may  be 
normal  or  less  affected.     Of  mechanical  devices  the  dynamometer  of  Math- 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  321 

ieu  is  most  commonly  used.  The  power  of  arms  and  legs  is  tested  by  having 
the  patient  make  various  movements  while  the  examiner,  grasping  the 
part,   offers  resistance. 

A  general  surmise  as  to  the  location  of  the  lesion  (cerebral  or  spinal) 
causing  the  impairment  of  the  motor  path  is  made  by  observing  whether 
the  affected  part  is  flaccid  or  spastic.  Flaccidity  nearly  always  denotes 
a  lesion  of  lower  motor  neurons  (ganglion  cells  of  ventral  gray  horns, 
peripheral  nerves  with  their  terminals)  as  seen  in  poliomyelitis  and  neu- 
ritis, while  spasticity  signifies  a  lesion  of  central  or  upper  motor  neurons 
(cell-bodies  of  motor  cortex,  fibre  tracts  through  subcortex,  internal  cap- 
sule, pons,  medulla,  ventral  and  lateral  pyramidal  tracts  of  spinal  cord),  as 
in  old  brain  hemorrhage. 

A  notable  exception  to  this  broad  rule  is  that  in  lesion  of  the  spinal 
cord,  complete  or  nearly  complete  transversely,  especially  one  high  up  in 
the  cord,  the  effect  is  as  if  all  motor  neurons  below  it  were  destroyed, 
i.e.,  there  is  total  flaccid  paralysis  below  the  level  of  the  lesion.  The  expla- 
nations of  this  phenomenon  are  numerous  but  unsatisfactory.  Another 
exception  to  this  rule  is  readily  correlated  with  it  by  bearing  in  mind 
that  the  superior  motor  neurons  of  the  pyramidal  tract  are  not  wholly 
cerebral  but  have  a  spinal  portion  which  is  mostly  contained  in  the 
lateral  tract;  hence  it  follows  that  a  spinal  palsy  is  spastic  if  the  lateral 
tracts  are  involved. 

To  decide  whether  a  member  be  flaccid  or  spastic,  all  the  patient's 
active  movements,  including  gait,  are  to  be  studied,  as  well  as  various 
passive  motions  which  may  suggest  themselves  to  the  examiner.  His 
opinion  will  be  rather  one  of  judgment  than  of  definite  methods. 

Monoplegia  is  a  paralysis  restricted  to  one  member,  whether  this  be 
disabled  entirely  or  only  in  one  group  of  muscles.  Hemiplegia,  or  paraly- 
sis of  one  side  of  the  body,  is  nearly  always  due  to  a  brain  lesion,  and, 
when  so,  the  upper  face  will  be  found  unaffected  or  slightly  affected, 
except  in  recent  cases  where  the  paralysis  in  the  upper  distribution  of  the 
facial  nerve  may  be  very  distinct  for  a  time.  The  slight  implication  of 
the  upper  face  is  characteristic  of  a  long-standing  cerebral  hemiplegia. 
Diplegia — double  hemiplegia — occurs  particularly  in  childhood.  Para- 
plegia is  a  symmetrical  paralysis  involving  the  upper  or  lower  limbs,  but 
when  the  term  is  used  without  qualification  it  refers  to  paralysis  of  the 
lower  limbs.  The  term  brachial  paraplegia  is  employed  to  denote  paralysis 
of  the  upper  hmbs;  crural  paraplegia  that  of  the  lower.  It  is  generally 
a  spinal  palsy. 

Contracture.  —  In  paralysis  of  long  duration  contractures  appear 
which  are  generally  characteristic.  Those  which  arise  in  spastic  paralyses 
depend  upon  shortening  of  the  paralyzed  muscles,  the  stronger  muscles 
contracting  more  than  the  weaker,  and  produce  such  postures  of  the  limbs 
as  are  seen  in  hemiplegia''(flexion  of  elbow,  wrist  and  fingers,  adduction  of 
arm  to  chest,  extension  of  the  leg  on  the  thigh,  adduction  of  the  knees, 
extension  of  the  foot  and  inversion  with  plantar  flexion  of  toes).  According 
to  some  investigators  the  contractures  of  cerebral  hemiplegia  are  the  result 
of  the  greater  paralysis  in  certain  groups  of  muscles.  The  contractures 
in  flaccid  paralyses  depend  upon  the  unbalanced  action  of  the  opposing 

21 


322  MEDICAL  DIAGNOSIS. 

sound  muscles,  as  seen  in  the  accentuated  wrist-drop  and  foot-drop  of  old 
peripheral  neuritis,  or  depend  upon  the  contraction  of  the  paralyzed 
muscles  themselves. 

Convulsions  and  spasm  (see  Part  III,  p.  588). 

Jacksonian   epilepsy    (see  p.  589). 

Athetosis  or  mobile  spasm  consists  of  irregular  writhing  movements, 
especially  of  the  fingers  but  also  of  the  arms  and  other  parts.  It  is  almost 
pathognomonic  of  the  cerebral  palsies  of  childhood,  in  which  affections  the 
symptom  may  mislead  by  being  more  prominent  than  the  hemiplegia  or 
diplegia  which  underlies  it.  Occurring  in  adult  hemiplegics  these  movements 
are  sometimes  called  posthemiplegic  chorea,  but  are  less  prominent  than  the 
weakness  and  rigidity  of  the  limb.  Athetosis  is  usually  aggravated  by  volun- 
tary movements,  as  when  the  patient  attempts  to  pick  up  a  small  object. 

Tremor  (see  p.   592). 

Fibrillary  tremor  or  fibrillary  twitching   (see  p.   593). 

Tics. — Twitching  simultaneous  over  a  large  area,  inducing  a  purposive 
movement  at  intervals  and  habitually,  is  called  a  "tic."  It  is  not  a  sign 
of  any  known  lesion  but  is  functional  (a  neurosis). 

Ataxia. — In  the  course  of  investigation  of  motor  signs  the  examiner  may 
observe  irregularity  and  uncertainty  in  various  acts  which  require  a  degree 
of  precision.  Ataxia  results  from  inharmonious  action  of  muscle-groups 
even  when  disorder  of  motility,  either  excess  or  deficiency,  is  not  present. 

The  defect  is  largely  in  the  muscular  sense,  which  is  discussed  in  its 
relation  to  astereognosis.  Yet  the  practical  tests  for  the  symptom  are 
motor.  In  the  arm  ataxia  is  discovered  by  directing  the  patient  to  close 
his  ej^es  and  then  with  his  index  finger  to  touch  the  tip  of  his  nose,  or  to 
meet  the  tip  of  the  other  index  finger  in  sweeping  the  arms  around  hori- 
zontally in  front;  in  the  leg,  by  having  him  attempt  to  touch  one  knee 
with  the  heel  of  the  other  foot.  If  there  be  considerable  ataxia  the  patient 
touches  wide  of  the  mark.  Ataxia  of  the  legs  is  better  revealed  in  the 
patient's  manner  of  walking,  which  is  considered  in  connection  with  other 
disorders  of  gait. 

2.   Sensory  Symptoms. 

Studies  of  sensation  involve  a  subjective  element  which  makes  them 
at  best  uncertain.  Scientific  methods  aim  to  diminish  this  uncertainty 
by  magnifying  the  objective  element  through  the  use  of  technical  pro- 
cedures which  render  the  examiner  less  dependent  upon  the  patient's 
statements.  In  children,  and  in  stuporous  and  demented  patients,  the 
objective  element  alone  is  considered — a  start,  a  vocal  sound,  or  the  with- 
drawal of  a  member  when  the  patient  is  touched,  pricked,  etc. 

Paraesthesia, — "  Numbness  and  tingling,"  "  pins  and  needles,"  ''crawl- 
ing sensations" — formication — and  burning  sensations  are  symptoms  of 
sensory  irritation.  They  are  prominent  in  neuritis,  and  in  spinal  diseases 
which  implicate  the  posterior  nerve-roots  (see  also  p.  582). 

Delayed  Sensation. — Recognition  of  any  artificial  sensation  is,  for 
the  purposes  of  the  clinician,  instantaneous;  if  an  interval  occurs  between 
the  application  of  a  stimulus  and  the  patient's  response  to  it,  we  speak  of 
"delayed  sensation,"  which  is  common  especially  in  tabes  dorsalis. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  323 

Pain. — Pain  is  a  prominent  symptom  of  many  nervous  diseases. 

The  objective  study  of  sensation  comprises  the  testing  of  the  senses  of 
touch — common  sensibihty — of  pain,  and  of  temperature.  The  muscular 
sense  is  of  interest  cHnically  in  relation  to  astereognosis,  and  also  in  relation 
to  ataxia  of  movement,  which  may  arise  from  defect  of  the  muscular  sense. 

In  testing  the  sense  of  touch  it  is  well  to  blindfold  the  patient,  to  take 
care  that  the  surface  examined  shall  not  be  chilled  by  exposure,  and  to 
touch  the  part  with  light  pressure  and  without  causing  pain.  The  instru- 
ment most  commonly  used  for  this  purpose  is  Carroll's  sesthesiometer, 
but  a  tooth-pick  or  a  feather  will  serve.  The  patient  is  directed  to  say 
"now"  when  the  touch  is  felt;  or  to  count  successive  touches  a  short 
distance  apart,  ''one,  two,  three,"  etc.,  and  the  failure  to  note  one  or  more 
touches  will  mark  the  boundary  of  an  area  of  anaesthesia.  Sensibility  to 
touch  is  more  acute  on  the  back  than  on  the  front  of  the  body.  Loss  of 
tactile  sensibility,  either  total — ancesthesia — or  partial — hypcesthesia — may 
be  functional  and  a  sign  of  hysteria,  in  which  case  it  commonly  affects 
half  the  body — hysterical  hemianaesthesia — or  a  segment  of  one  limb,  or 
all  of  one  extremity  up  to  a  certain  level — "  glove-anaesthesia"  and  "stock- 
ing-anaesthesia;" or  anaesthesia  and  hypaesthesia  may  constitute  a  sign  of 
organic  nervous  disease  which  is  destructive  in  character  or  is  at  an  ad- 
vanced stage.  In  the  case  of  hemihypaesthesia  or  hemianaesthesia,  the 
hemorrhage  or  other  destructive  lesion  may  be  in  the  posterior  part  of  the 
internal  capsule — where  according  to  some  anatomists  sensory  fibres  are 
collected  into  a  bundle  (carrefoure  sensitif) — in  the  tegmentum  of  the 
pons,  or  in  the  spinal  cord,  provided  one  lateral  half  of  the  pons  or  cord 
be  severed.  In  any  of  the  cases  mentioned  the  lesion  is  situated  on  the 
side  opposite  to  that  of  the  anaesthesia. 

In  testing  the  pain  sense,  a  needle-point  or  one  of  the  sharp  points 
of  the  sesthesiometer  is  employed,  and  the  skin  is  "pricked,"  not  scored, 
with  the  instrument.  Remind  the  patient  that  actual  pain,  not  the  mere 
sense  of  being  touched,  is  to  call  forth  his  response;  or  instruct  him  to  say 
"touch,"  or  "pain,"  according  as  the  one  or  the  other  sensation  is  excited 
by  the  sharp  point. 

The  temperature  sense  is  well  studied  by  the  use  of  two  test-tubes  of 
water,  one  heated  to  about  100°  F.  or  above,  the  other  cooled  to  60°  F.  or 
lower,  the  tubes  being  applied  alternately,  and  each  being  held  in  contact 
with  the  skin-surface  for  several  moments,  since  recognition  of  heat  or  of 
cold  is  commonly  less  prompt  than  that  of  touch  and  of  pain.  The  heat 
of  the  one  tube  should  not  be  sufficient  to  burn,  as  that  would  introduce 
the  factor  of  pain;  yet  practically  this  distinction  is  of  little  consequence, 
because  the  thermic  sense  and  the  pain  sense,  being  conducted  in  adjacent 
tracts  of  the  coi-d,  are  commonl}'  abolished  together.  Ordinarily  when 
tactile  anaesthesia  has  been  demonstrated  in  a  certain  area,  we  may  expect 
to  find  thermo-anaesthesia  and  analgesia  associated  with  it.  But  the  con- 
verse of  this  does  not  always  hold  true;  for  over  surfaces  which  betray  no 
tactile  anaesthesia,  or  at  most  only  hypaesthesia,  we  may  find  areas  of  anal- 
gesia and  thermo-anaesthesia.  This  is  that  dissociated  sensory  loss  which 
is  most  common  in  syringomyelia,  though  other  lesions  of  the  central 
part  of  the  gray  matter  of  the  cord  may  cause  the  phenomenon. 


324  MEDICAL  DIAGNOSIS. 

3.   Regional   Diagnosis   of  Cerebral   Disease. 

General  Symptoms. — The  general  symptoms  of  intracranial  disease — 
vomiting,  headache,  and  optic  neuritis — have  little  value  in  cerebral  locali- 
zation. Headache  is  more  likely  to  be  frontal  in  lesions  of  the  fore-brain 
and  occipital  in  those  in  or  about  the  cerebellum,  but  this  is  not  constant. 
Dense  tumors  of  some  size,  well  above  the  base  of  the  skull,  may  yield  a 
shadow  on  the  X-ray  plate. 

Predominant  mental  symptoms  are  suggestive  of  lesion  of  the  pre- 
frontal lobes,  particularly  the  left;  but  it  must  be  remembered  that  after 
head  injuries  delirium,  confusion,  or  stupor  may  ensue  from  shock,  with- 
out reference  to  severity  or  site  of  the  trauma,  and  moreover  that  demon- 
strable brain  lesions  are  comparatively  rare  causes  of  insanity. 

Paralysis. — Of  motor  signs  indicating  lesion  of  the  precentral  con- 
volution, anterior  to  the  fissure  of  Rolando,  paralysis  has  the  greatest 
localizing  value.  Paralyses  in  the  distribution  of  cranial  nerves,  especially 
of  several,  commonly  indicate  lesion  at  the  base  of  the  brain.  If  a  single 
cranial  nerve  is  implicated,  the  lesion  is  probably  outside  of  the  central 
nervous  system;  if  one  arm  or  leg  is  paralyzed,  a  cortical  lesion  should  be 
suspected,  and  this  is  rendered  probable  if  the  paralyzed  part  is  the  seat 
of  clonic  spasm.  Paralj^sis  of  the  face  indicates  lesion  in  the  lower  third  of 
the  Rolandic  cortex;  paralysis  of  an  arm  or  leg,  lesion  of  the  middle  or 
upper  third  respectively. 

Astereognosis. — Pure  motor  phenomena  point  to  a  lesion  anterior  to 
the  fissure  of  Rolando;  if  the  lesion  be  posterior  to  this  fissure  (postcentral) 
the  motor  signs  are  likely  to  be  associated  with  the  phenomenon  called 
astereognosis,  which  becomes  more  prominent  as  the  pai^ietal  lobe  is  en- 
croached upon.  By  study  of  the  ''  stereognostic  sense"  which  is  the  physio- 
logic process  by  which  solid  objects  are  recognized  by  contact,  neurologic 
diagnosis  has  made  a  distinct  advance.  Astereognosis,  or  want  of  this 
sense,  may  be  diagnostic  of  lesion  of  the  superior  parietal  lobule.  To  test 
for  this  phenomenon  it  is  well  to  study  separately  the  several  processes  by 
which  normally  the  hand  recognizes  the  shape  and  size  of  objects,  especially 
the  ''spacing  sense,"  the  sense  of  position,  and  the  pressure  sense,  the 
last  two  of  which  are  the  chief  components  of  the  muscular  sense. 

The  "spacing  sense"  is  tested  by  touching  the  skin  at  two  points 
simultaneously,  as  with  the  two  arms  of  the  sesthesiometer,  and  observing 
how  near  together  they  may  be  while  still  recognized  as  two  points.  The 
examiner  compares  his  results  with  those  obtained  in  a  normal  subject. 

The  sense  of  position  is  studied  by  asking  the  patient  (blindfolded)  to 
tell  where  his  hand  or  foot  is,  after  the  examiner  has  quietly  placed  it  in 
a  particular  attitude,  or  to  imitate  with  one  limb  an  attitude  given  to  the 
other  by  the  examiner. 

The  pressure  sense  is  tested  by  bhndfolding  the  patient,  placing  his 
hand  supine  upon  a  table,  and  laying  in  his  palm,  one  after  another, 
small  objects  identical  save  in  their  Weight,  which  is  graded  in  a  series. 
For  this  purpose  cartridges  filled  with  layers  of  cotton  and  regulated 
numbers  of  buckshot  may  be  used.  The  main  test,  which  reveals 
astereognosis   directly   if  it   be   at   all   pronounced,    consists    in    handing 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  325 

the  patient  various  common  objects, — watch,  spool,  block  of  wood,  pen- 
knife,— each  of  which  he  essays  to  name  or  to  describe. 

Deafness,  in  the  absence  of  disease  of  the  external,  middle  or  internal 
ear,  may  be  due  to  lesion  of  the  first  or  second  temporal  convolution, 
particularly  that  of  the  left  side. 

Blindness  without  demonstrable  cause  in  the  eye  may  be  due  to  lesion 
anywhere  in  the  course  of  the  optic  nerves,  tracts  or  "radiations"  as  far 
as  the  cunei  lobes,  which  face  one  another  across  the  great  longitudinal 
fissure  in  the  occipital  lobe.  Unilateral  blindness  of  both  eyes  and  in  the 
same  side  of  each  eye  (lateral  homonymous  hemianopsia)  indicates  that 
the  lesion  is  unilateral,  that  it  is  back  of  the  optic  chiasm  and  is  on  the 
side  opposite  to  that  on  which  the  patient's  vision  has  failed — that  is,  on 
the  same  side  as  the  blind  half-retina.  To  determine  how  far  back  of  the 
chiasm  such  a  lesion  is  we  must  rely  on  signs  and  symptoms  arising  from 
involvement  of  contiguous  structures,  especially  (in  lesions  at  the  base  of 
the  brain)  the  cranial  nerves,  which  are  spared  in  lesion  of  the  optic  radia- 
tions, or  of  the  cuneus — subcortical  or  cortical  lesions.  A  theoretically 
positive  means  of  distinguishing  basal  from  cortical  lesions  causing  hemi- 
anopsia is  Wernicke's  pupillary-inaction  sign,  which  consists  in  the 
absence  of  the  light  reflex  of  the  iris  when  only  the  blind  half  of  the  retina 
is  illuminated.  The  finding  of  this  condition  points  to  a  basal  lesion, 
i.e.,  at  or  below  the  optic  thalamus  and  external  geniculate  body,  for  con- 
traction of  the  iris  is  a  function  of  the  third  nerve,  and  no  part  of  this 
nerve  extends  above  the  ''primary  optic  centres,"  which  are  at  the  base 
of  the  brain. 

Partial  loss  of  vision,  not  accounted  for  by  eye  disease,  may  be  due 
to  lesion  of  the  angular  gyrus,  visual  acuity — macular  vision — being  im- 
paired; or  it  may  be  due  to  lesion  in  front  of  the  optic  chiasm,  in  the 
angle  between  the  optic  nerves,  where  by  interfering  with  the  internal 
fibres  of  each  nerve  it  causes  blindness  of  each  inner  (nasal)  half-retina,  a 
condition  called  (from  the  blind  half-fields)  temporal  hemianopsia,  which 
is  pathognomonic  of  lesion  in  the  situation  described. 

Symptoms  of  Cerebellar  Disease. — The  cerebellum  is  to  the  clinician 
chiefly  an  organ  of  coordination,  and  this  function  resides  mainly  in  the 
middle  lobe.  The  cardinal  signs  of  cerebellar  disease  are  nystagmus  and 
a  peculiar  ataxia  which  gives  a  staggering  character,  or  tituhation,  to  the 
patient's  gait.  This  ataxia  disappears  when  the  patient  lies  down,  and 
the  knee-jerks  are  often  preserved.  Neoplasms  beneath  the  middle  lobe 
of  the  cerebellum  are  likely  to  cause  this  form  of  ataxia  together  with 
external  ocular  palsies  from  pressure  upon  the  nuclei  of  the  third  and  fourth 
nerves  beneath  the  quadrigeminal  bodies.  A  tumor  arising  from  these 
bodies  can  hardly  be  distinguished  from  cerebellar  tumor  implicating 
the  vermis. 

The  Internal  Capsule. — Of  the  great  interior  structures  of  the  l^rain 
only  the  posterior  limb  of  the  internal  capsule  has  functions  so  definite  that 
certain  symptoms  may  be  referred  to  it.  Sudden  hemiplegia,  with  hemi- 
anaesthesia  and  hemianopsia,  is  generally  indicative  of  lesion  in  the  internal 
capsule,  since  this  complex  of  symptoms  from  cortical  or  even  subcortical 
lesion   could   be  induced   only   by   uncommonly  extensive  damage.      The 


326  MEDICAL  DIAGNOSIS. 

symptoms  referable  to  single  minute  destructive  foci  in  the  posterior  limb 
of  the  capsule,  from  the  "knee"  backwards,  are,  so  far  as  is  known,  (1) 
paralysis  of  the  face  from  above  downwards,  (2)  of  the  arm  and  (3)  of  the 
leg,  also  from  above  downwards,  (4)  anaesthesia  of  varying  extent  up  to 
hemiansesthesia,  which  probably  indicates  destruction  of  the  posterior 
third  of  the  posterior  hmb,   (5)  hemianopsia. 

Cerebral  Ganglia. — Of  the  great  cerebral  ganglia  none  has  an  independ- 
ent symptomatology.  Lesions  affecting  the  corpus  striatum  cause  pre- 
dominant motor  signs  because  of  pressure  upon  the  motor  bundles  of  the 
capsule,  while  affections  of  the  optic  thalamus  commonly  cause  hemi- 
ansesthesia from  pressure  upon  the  posterior  fibres  of  the  capsule — 
carrefour  sensitif — or  destruction  of  sensory  fibres  within  the  thalamus 
and  often  hemianopsia  from  involvement  of  the  optic  radiations,  which  are 
collected  into  a  bundle  posterior  to  the  capsule  and  enter  the  optic  thala- 
mus. Mobile  spasm  or  athetosis,  associated  with  these  paralyses,  is  in 
favor  of  thalamic  lesion.  Weakness  of  the  articulatory  muscles  resembling 
bulbar  paralysis,  but  not  due  to  lesion  of  the  medulla  oblongata,  is  called 
pseudobulbar  paralysis.  It  is  most  often  due  to  multiple  hemorrhages  or 
softening  in  the  outer  part  of  the  lenticula. 

Lesions  of  the  corpus  callosum  are  revealed  by  disturbance  of  the 
functions  of  surrounding  parts,  notably  of  the  motor  zone, — as  shown  by 
early  epileptic  seizures,  by  paralyses,  and  symptoms  referable  to  the  pre- 
frontal region.  From  the  latter  arise  the  pseudoparetic  mental  states 
which  are  characteristic  of  callosal  lesion. 

4.   Aphasia  and   Other   Defects  of  Speech. 

Though  endowed  with  a  normal  brain,  the  individual  born  deaf  and 
blind  becomes  an  imbecile  by  deprivation  of  the  sense-impressions  out  of 
which  knowledge  grows,  unless  he  be  trained  like  Laura  Bridgman  through 
the  touch-sense.  The  cochlea,  the  retina,  etc.,  begin  the  transformation, 
from  mere  contact  with  the  external  world,  into  the  higher  special  sense- 
impressions.  These,  carried  by  their  separate  paths  to  the  cortex,  are 
elaborated  in  the  special-sense  centres  into  perceptions  of  things.  Roughly 
speaking,  each  cortical  centre  is  opposite  the  organ  of  that  sense.  Taldng 
one  sense,  vision,  rays  of  light  from  an  object,  for  example  a  cow,  received 
by  the  retina  are  carried  through  the  visual  system  to  the  cuneus  as  sensa- 
tions of  form,  color,  etc.  Thence  passing  still  higher,  in  the  angular  gyrus 
is  formed  a  visual  image  of  a  cow — object-seeing — and  this  is  associated 
with  an  image  of  the  word  cow  written  or  printed — word-seeing.  Lesion 
of  angular  gyrus  then  does  not  cause  ordinary  blindness — as  lesion  of  the 
cuneus  does  in  one  half-field — but  loss  of  these  visual  images,  so  that  the 
patient  seeing  a  cow  can  hardly  tell  it  from  a  horse — object  mind-blind- 
ness; and  seeing  the  word  cow  fails  to  get  the  meaning  from  it,  as  if  it  were 
a  foreign  word — word-blindness.  In  like  manner,  close  to  the  auditory 
centre  is  a  higher  centre  for  the  formation  of  auditory  images,  by  which  a 
peculiar  sound  is  identified,  for  example,  as  the  lowing  of  a  cow — object- 
hearing — and  by  which  the  spoken  word  cow  is  recognized  as  the  name  of 
that   animal — word-hearing.      With    a   lesion   then   in   the   first   temporal 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  327 

convolution,  sparing  the  main  auditory  centre,  so  that  the  patient  is  still 
capable  of  hearing  noises,  there  may  be  loss  of  these  auditory  images  with 
consequent  object-deafness  and  word-deafness;  sounds  and  words  heard 
are  meaningless. 

To  speak  of  a  cow  it  is  necessary  to  recall  the  word  cow.  Many  persons 
are  likely  to  recall  a  word  as  it  sounds;  some  as  it  appears  written;  but 
most  revive  it  in  both  ways,  so  that  impairment  of  either  the  auditory  or 
the  visual  word-image  interfering  with  the  recollection  of  words  causes 
aphasia,  in  the  one  case,  from  lesion  of  the  angular  gyrus — visual  or  optic 
aphasia;  in  the  other,  from  lesion  of  the  first  temporal  convolution — audi- 
tory aphasia.  In  either  case  due  to  a  lesion  of  a  sensory  centre  it  is  spoken 
of  as  sensory  aphasia;  and  because  the  essential  defect  is  inability  to  recol- 
lect words  (verbal  amnesia)  both  are  included  under  the  term  amnesic 
aphasia.  The  act  of  speaking  involves  several  groups  of  muscles,  and  is 
interfered  with,  therefore,  in  various  forms  of  paralysis.  In  bulbar  paraly- 
sis, the  hps,  tongue,  etc.,  becoming  atrophied  and  paretic,  there  is  defect 
of  articulation,  incidentally;  and  in  the  similar  paralysis  from  cerebral 
lesion  (pseudobulbar  paralysis)  the  patient  may  be  inarticulate.  In  hke 
manner  lesion  in  the  cortical  centres  for  the  lips,  tongue,  etc.,  at  the  foot 
of  the  motor  zone,  cripples  the  speech  just  as  lesion  in  the  leg  centre  causes 
limping;  so  here  on  the  emissive  side  of  the  speech-process  there  is  set 
apart  a  higher  centre  for  the  fine  adjustment  of  movements  in  uttering 
words,  and  for  the  memory  of  these  movements.  This  is  Broca's  centre, 
in  the  posterior  part  of  the  third  frontal  convolution.  By  lesion  here,  the 
muscles  of  articulation  still  intact,  the  patient  loses  his  motor  memories 
and  his  power  to  utter  words.     This  is  motor  aphasia — or  aphemia. 

Parallel  to  these  defects  of  articulation  are  defects  in  the  act  of  writing 
which  has  its  higher  centre  in  the  second  frontal  convolution,  related  to 
the  arm  centre  as  Broca's  is  to  the  centres  for  the  tongue,  lips,  etc.  Lesion 
in  the  writing  centre  causes  motor  agraphia,  even  though  the  arm  be  still 
useful  otherwise.  In  lesion  of  the  angular  gyrus,  as  the  appearance  of  words 
is  forgotten,  writing  is  imperfect;  there  is  sensory  agraphia.  In  reading 
aloud,  the  image  of  the  printed  word  must  be  conducted  from  the  angular 
gyrus  to  Broca's  centre,  there  to  be  matched  with  the  motor  image  used  in 
uttering  the  word;  and  the  utterance  must  be  guided,  too,  by  the  auditory 
image  conducted  from  its  centre.  For  this  purpose  Broca's  centre  is  con- 
nected with  the  others  by  tracts  of  fibres  which  being  damaged,  particu- 
larly in  the  insula — island  of  Reil,  there  is  interference  with  the  conduction 
referred  to,  and  hence,  with  reading  aloud  and  with  similar  uses  of  speech, 
conduction-aphasia.  For  perfect  speech  all  the  centres  must  act  in  unison 
through  conduction-paths  connecting  each  centre  with  the  rest,  and  con- 
sidering such  multiple  connections  it  is  evident  that  aphasia  of  some  kind 
may  result  from  lesion  at  any  point  within  a  wide  area.  This  ''  zone  of 
language"  is  nearly  coextensive  with  the  distribution  of  the  middle  cere- 
bral artery,  and  aphasia  is  generally  a  consequence  of  apoplexy  from  this 
vessel,  commonly  in  association  with  hemiplegia.  This  same  region,  acting 
as  a  unit,  forms  a  complete  image  not  alone  of  the  word  but  of  the  object 
also,  as  it  looks,  sounds,  feels,  smells,  tastes — in  short,  a  concept  of  the 
object;   so  that  this  is  a  concept  area  (Mills). 


328  MEDICAL  DIAGNOSIS. 

Aphasia  being  a  curtailment  of  the  power  to  comprehend  as  well  as 
of  the  power  to  emit  language,  spoken,  written  or  by  signs — pantomime — 
care  and  system  in  testing  for  it  are  very  important.  ''Impediments"  of 
speech,  mechanical  imperfections  of  the  vocal  organs,  are  first  to  be  elimi- 
nated by  examination  of  the  mouth,  throat,  and  nasal  cavities.  In  cleft 
palate,  hypertrophic  rhinitis,  and  in  tongue-tie,  the  difficulty  is  mainly  in 
the  enunciation  of  consonants,  such  as  m,  n,  b,  etc. 

Dysarthrias,  from  paralysis  or  defective  innervation  of  the  muscles 
of  articulation,  are  to  be  recognized  partly  by  finding  additional  signs  of 
cerebral  paralysis  or  other  organic  nervous  disease,  and  partly  by  special 
characters  of  the  speech  in  certain  affections.  Somewhat  suggesting 
mechanical  impediment  is  the  speech  of  bulbar  paralysis,  marked  as  it  is 
by  labored  pronunciation  of  consonant-sounds. 

Elision  of  syllables  by  running  words  together,  may  be  observed  in 
hereditary  ataxia,  in  which  disease  speech  is  at  the  same  time  monotonous. 
These  two  characters  belong  also  to  the  speech  of  general  paresis,  forming 
with  the  difficulty  of  enunciating  the  r's  and  I's,  as  in  "  artillery,"  and  with 
its  tremulous,  measured  drawl,  the  peculiar  "paretic  speech"  which  is 
one  of  the  cardinal  signs  of  this  disease.  The  measured  character  of  such 
speech  exists  in  purer  form — scanning — in  disseminated  sclerosis. 

Ordinary  stuttering  is  a  pure  neurosis.  It  manifests  itself  by  spas- 
modic halting  in  attempts  to  utter  certain  words,  usually  those  beginning 
with  consonants. 

In  differentiating  aphasia  from  other  speech  defects  the  greatest 
difficulty  arises  in  the  case  of  actual  mental  loss — dementia — which  indeed 
may  coincide  with  aphasia,  as  in  hemiplegia  and  senility,  or  may  have 
aphasia  for  an  episodic  manifestation,  as  in  paresis. 

The  stubborn  speechlessness  frequently  met  with  in  paranoia  and 
melancholia  is  nearly  always  accompanied  by  other  signs  of  negativism, 
as  refusal  of  food  and  resistance  to  the  attentions  of  the  nurse.  Hysterical 
aphasia  is  intermittent  and  its  victim  exhibits  the  stigmata  of  the  neurosis. 

In  testing  an  apparent  aphasic  it  is  well  to  begin  on  the  sensory  side,  as- 
certaining whether  the  centres  for  word-hearing  and  word-seeing  are  impaired. 
A  number  of  common  objects  may  be  placed  before  the  patient  who  endeav- 
ors to  pick  out  those  named  in  turn  by  the  examiner  and  then  to  select  from 
a  list  of  names  on  paper,  that  of  the  object  selected  by  the  examiner. 

As  the  purpose  is  to  determine  the  clearness  of  word-images,  these 
simple  tests  are  essential;  but  the  examiner  may  progress  to  words  and 
sentences  of  any  complexity.  Rarely  being  complete,  aphasia  is  often 
betrayed  by  persistent,  helpless  misapplication  of  words,  the  patient  say- 
ing or  writing  for  instance  ''dog"  when  a  hat  is  showed  to  him  and  its 
uses  demonstrated  by  him.  Paraphasia  and  paragraphia  are  forms  of 
aphasia  rather  characteristic  of  sensory  aphasia. 

To  test  a  patient's  emissive  power  of  language,  that  is,  to  discover 
motor  aphasia  and  agraphia,  objects  are  shown  to  him,  and  he  endeavors 
to  utter  and  write  their  names.  Simple  acts  performed  in  the  patient's 
presence  are  described  by  him  both  orally  and  in  writing.  In  motor  aphasia 
"recurring  utterances"  are  common,  a  patient  repeating  "any  one  any" 
or  other  meaningless  phrase  on  all  occasions  when  attempting  to  talk. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  329 

Even  after  demonstrating  that  a  patient  hears,  reads,  utters,  and 
writes  words  correctly,  and  thus  that  the  widely  separated  cortical  speech- 
areas  in  the  first  and  second  left  temporal  convolutions,  the  angular  gyrus, 
the  third  frontal  and  the  second  frontal  convolutions  are  probably  intact, 
together  with  the  subcortical  region  corresponding  to  each  centre,  we  may 
still  find  that  the  patient  is  much  crippled  in  the  use  of  language.  In  such 
a  case  we  conclude  that  some  of  the  fibres  connecting  these  cortical  centres 
with  one  another  are  cut  off,  and  that  we  are  dealing  with  a  case  of  "  con- 
duction aphasia"  or  "transcortical  aphasia."  The  prominent  features  of 
this  form  are  paraphasia,  paralexia,  etc.,  so  extreme  that  the  jumbHng  of 
words  and  syllables  is  spoken  of  as  '^  jargon-speech." 

So  entangled  in  these  "  association-systems"  are  all  the  cortical  centres 
that  speech-defect  from  cortical  lesion  always  betrays  some  features  of 
conduction  aphasia.  If  our  tests  reveal  uncompHcated  word-deafness  or 
word-blindness,  or  simple  loss  of  the  power  of  utterance,  we  recognize 
that  the  lesion  is  deep  in  the  brain,  beneath  the  level  of  association- 
systems,  where  the  fibres  radiating  to  or  from  the  particular  centre 
are  bundled  together.  This  is  called  "subcortical"  or  "pure"  aphasia, 
and  yet  some  evidence  exists  that  this  form  of  aphasia  may  result  from 
cortical  lesions. 

As  an  auxihary  test  for  this  form,  the  study  of  pantomime  is  of  value. 
In  pure  motor  aphasia,  for  instance,  the  patient  though  speechless  as 
regards  utterance,  may  when  asked  how  old  he  is,  open  and  shut  his  hand 
the  proper  number  of  times.    In  ordinary  motor  aphasia  this  is  impossible. 

5.   Spinal   Localization. 

One  of  the  consequences  of  modern  clinico-pathological  study  is  the 
tendency  to  interpret  nervous  symptoms  and  signs  in  relation  to  anatomical 
structure,  rather  than  in  relation  to  empirical  disease  forms.  This  tend- 
ency in  the  field  of  brain  disease  has  created  cerebral  localization;  and  it 
has  affected  our  conceptions  of  spinal  disease  to  the  extent  that  we  speak 
less  of  "locomotor  ataxia,"  of  "spastic  paraplegia"  or  of  "progressive 
muscular  atrophy"  as  disease  entities  than  as  dominant  symptoms  of 
various  lesions  affecting  certain  structures  of  the  spinal  cord.  Assuming 
in  this  connection  that  the  symptoms  in  a  given  case  are  of  spinal  origin, 
we  infer  from  "ataxia"  of  a  limb  that  the  dorsal  column  of  the  cord  is 
affected;  from  spasticity  with  increased  reflexes,  the  pyramidal  tract; 
from  atrophy,  the  ventral  horns  of  the  gray  matter;  from  anaesthesia,  the 
dorsolateral  column  again;  from  loss  of  pain-  and  temperature-sense  with- 
out anaesthesia — dissociation  of  sensation — the  central  part  of  the  gray 
matter;  from  pain,  the  dorsal  roots.  Then  we  endeavor  to  determine  the 
lesion  which  has  caused  the  particular  symptom-complex  which  confronts 
us  by  bringing  to  bear  our  knowledge  of  the  natural  history  of  nervous 
disease  and  by  collating  the  spinal  symptoms  with  any  cerebral  mani- 
festations which  may  be  present.  By  this  method  we  may  find  that  our 
"locomotor  ataxia"  case  is  really  one  of  combined  degeneration  of  the 
cord  or  one  of  paresis,  and  that  "progressive  muscular  atrophy"  is  symp- 
tomatic of  syringomyelia  or  of  tumor. 


330  MEDICAL  DIAGNOSIS. 

Spinal  localization  in  the  ordinary  sense,  however,  relates  to  diagnosis 
of  the  level  of  a  lesion  in  the  cord.  It  is  based  upon  our  accumulated 
knowledge  of  the  motor  sensory  reflex  and  sympathetic  control  exercised  by 
each  segment  of  the  spinal  cord  over  a  corresponding  segment  of  the  body. 

Injury  to  the  spinal  cord  at  any  point  involving  the  motor  tracts — 
unless  it  be  completely  severed — causes  paralysis,  with  increase  of  reflexes, 
below  that  point;  but  at  the  level  of  the  lesion  we  are  likely  to  find  the 
reflexes  abolished.  We  commonly  find  also  anaesthesia  covering  the  body 
below  this  level  if  the  lesion  is  grave,  and  the  upper  limit  of  anaesthesia, 
with  the  zone  of  absent  reflexes  coinciding,  is  the  best  index  to  the  level 
of  the  spinal  lesion.  If  the  lesion  affects  one  lateral  half  of  the  cord  the 
above  principles  still  apply,  but  the  disturbance  of  sensation,  except  of 
the  sense  of  position,  is  found  on  the  side  opposite  to  that  of  the  lesion 
and  to  that  of  the  motor  symptoms — Brown-Sequard's  paralysis,  although 
even  in  this  form  tactile  sensation  is  often  preserved. 

The  level  thus  ascertained  marks  the  relative  position  of  the  lesion, 
but  its  actual  position  in  the  spinal  column  will  be  found  above  this,  gener- 
ally a  distance  of  about  three  spinal  segments.  A  narrow  zone  of  anaesthesia 
is  usually  present  in  Brown-Sequard's  paralysis  on  the  side  of  the  lesion, 
and  at  its  level  and  above  this  may  be  a  narrow  zone  of  hyperaesthesia. 
Such  an  anaesthetic  zone  occurring  independently  points  to  a  lesion  outside 
the  cord  substance  and  involving  spinal  roots  of  at  least  two  segments. 
Sensory  loss  from  injury  to  the  cord  proper  or  the  posterior  roots  is  dis- 
tributed in  horizontal  bands  about  the  trunk  and  longitudinal  bands  in  the 
limbs,  irrespective  of  the  distribution  of  the  nerves — segmental  anaesthesia. 

The  clinician  should  be  able  to  conclude  off-hand  from  atrophy  of  the 
shoulder,  or  loss  of  reflexes  in  that  region,  that  the  upper  cervical  region  is 
affected  when  the  symptoms  are  of  spinal  origin;  from  such  symptoms 
affecting  the  forearm  and  hand,  that  the  lesion  is  lower  down  in  the  cervical 
swelling;  from  loss  of  knee-jerk,  that  it  is  in  the  lumbar,  and  from  loss  of 
control  of  sphincters,  in  the  sacral  region;  but  for  finer  deductions  it  is 
well  to  record  the  findings  in  a  particular  case,  and  then  interpret  them 
by  reference  to  the  tables  and  diagrams  upon  pp.  312,  313,.  and  314. 

Combined  Degenerations. — "  Typical  cases"  are  as  narrow  summits 
in  the  great  ranges  of  disease.  From  each  summit  the  symptomatology 
and  pathology  form  a  downward  slope,  by  which  that  disease  merges  with 
one  or  more  of  its  neighbors.  Of  lateral  sclerosis  very  few  absolutely  pure 
cases  have  been  reported.  On  the  one  hand,  in  cases  that  seem  like  pure 
lateral  sclerosis,  there  is  nearly  always  insidious  degeneration  in  the  ventral 
gray  horns — chronic  poliomyelitis;  or  the  latter  disease  after  a  course  of 
years  may  take  on  spastic  symptoms  because  the  pyramidal  tracts  are 
invaded,  that  is,  degeneration  beginning  in  either  motor  neuron  tends 
to  progress  to  the  other. 

In  some  cases  the  affection  of  superior  and  inferior  motor  neurons 
is  simultaneous,  progressive  muscular  atrophy  and  spastic  paraplegia 
developing  pari  passu.  Such  cases  constitute  amyotrophic  lateral  sclerosis. 
In  them  the  bulbar  part  is  prominent  and  degeneration  may  extend  even 
to  the  cortex,  mapping  out  the  motor  zone,  for  amyotrophic  lateral  sclerosis 
is  a  disease  of  the  whole  motor  system. 


PLATE  VII. 


6" TO  l2^inTEKC05TAL 
nERVE5     suppu 
OBLIQUI  .TRAN5VER5U5 
i  RECTUS. 


GREAT  SPLAMCHniC  MERVE 
5nALL 


LEFT  PnEunOCASTRfC 

nERVE    SUPPLIES    PMARYnX. 
(ESOPHAGUS    » 
STOnACH . 


RIGHT 

HpnEunoGASTRic  n 

1SUPPLIES  PHARYMX, 
llZSOPHACUS  «STOnACH . 

SOLAR  PLEXU5 

SUPPLIES  ALL 
ABDOtllnAL  VISCERA  . 


SUP'nESEnTERIC 

PLEXUS  SUPPLIES  PANCREAS. 
-\  SMALL  iriTESTinE.   ILIO- 

COLon.ASCEnoino  s 

I  TRAnSVERSE  COLOM. 


5  LUHBAR  riERVE:5 
SUPPLY  QUADRATUS 

6  PSOAS. 


44  5"  SACRAL  n: 

LEVATOR  Ani 
SPHIMCTER  AMI 


COCCYGEAL  PLEXUS 


ILIO -IMGUIMALn.su 
ILIO  -HYPOGASTRIC  N. 
CEMITO -CRURAL   t^m.ti    CREHASTER. 


COCCYGEAL  MERVES   supply 
LEVATOR  AMI  4  5PHIMCTER  AMI 


PLEXUS  on  THE  SUPr 

HEHORRHOIDAL 

VESSELS    SUPPLIES 
RECTUM  i Anus. 


'IRECTAL  ^VESICAL 

■<  PLEXUSES       SUPPLY 
VRECTUn  t  BLADDEn  . 


Connection  between  sympathetic  nerves  supplying  viscera  and  spinal  nerves  supplying  muscles  of 

abdominal  walls. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  331 

On  the  other  hand  degeneration  in  the  lateral  columns  may  be  accom- 
panied by  dorsal  degeneration.  Such  implication  of  superior  motor  neurons 
with  inferior  sensory  neurons  in  combined  degeneration  suggests  a  local, 
extraneous  cause,  acting  upon  the  lateral  and  posterior  columns  simul- 
taneously. The  mechanism  for  this  could  be  the  marginal  system  of 
arteries  carrying  some  toxin  into  these  portions  of  the  white  matter,  and 
the  lesion  might  be  expected  to  spread  around  the  arterioles  from  the 
very  margin  of  the  cord.  These  conditions  are  clearly  present  in  some  cases 
of  ergotism,  pernicious  anaemia,  etc.  An  acute  diffuse  dorsolateral  degen- 
eration may  be  found  at  autopsy,  though  commonly  no  symptoms  have 
been  observed  in  life.  In  various  undetermined  toxaemias  (Putnam  and 
E.  W.  Taylor)  a  subacute  degeneration  is  established,  partly  diffuse,  but  also 
partly  systematic,  as  in  time  it  enters  the  course  of  ascending  and  descend- 
ing tracts.  This  subacute  combined  degeneration  is  clinically  distinct 
from  the  other  types  (Russell,  Batten  and  Collier).  Possibly  similar  in 
origin  but  appearing  as  a  pure  combined  system  disease  (Striimpell) ,  the 
chronic  form,  posterolateral  sclerosis,  has  been  recognized  longer.  It  is 
manifested  clinically  by  paraplegia  from  the  pyramidal  tract  lesion,  with 
ataxia  from  the  lesion  in  the  dorsal  columns — ataxic  paraplegia  of  Gowers 
— but  without  lightning  pains  or  other  sensory  phenomena  and  without  eye- 
symptoms,  because  the  sensory  root-zones  and  roots — including  the  optic 
nerves — are  spared.  For  this  last  reason,  too,  the  reflexes  are  preserved 
in  posterolateral  sclerosis;  by  the  degeneration  of  the  pyramidal  tracts 
they  are  usually  increased  and  the  legs  made  spastic.  At  a  late  stage  the 
root-zones  may  be  invaded  and  reflexes  impaired  until  the  case  appears  like 
one  of  simple  tabes  dorsalis,  only  an  autopsy  revealing  the  combined  lesion. 

A  combined  sclerosis  is  the  commonest  spinal  lesion  of  paresis. 

6.   The   Reflexes. 

Every  segment  of  the  spinal  cord  contains  not  only  centres  for  certain 
groups  of  muscles  but  also  for  reflex  movements.  The  reflex  starts  in  an 
impulse  arising  from  the  stimulation  of  a  sensory  nerve.  It  is  transmitted 
to  a  centre  in  the  cord  and  passes  by  way  of  the  processes  of  the  sensory 
cell-bodies  to  the  neurons  of  the  corresponding  motor  centre,  in  which  it 
originates  a  motor  impulse  which  in  turn  passes  by  way  of  the  motor  nerve 
to  the  muscle-fibres  supplied  by  the  nerve.  This  complete  path,  made  up 
of  centripetal  or  sensory  fibres  with  their  cell-bodies  and  correlated  cell- 
bodies  with  their  centrifugal  or  motor  fibres,  is  called  a  reflex  arc.  The 
sensory  impulse  may  be  transmitted  to  centres  at  higher  or  lower  levels 
and  excite  several  motor  impulses,  thus  producing  a  complicated  reflex  arc. 
The  cord  segments  are  connected  with  fibres  from  the  cerebrum  having 
the  function  of  inhibiting  the  reflex.  If  these  fibres  are  irritated  the  reflexes 
are  impaired  from  abnormal  inhibition;  if  they  are  destroyed  the  reflexes 
are  exaggerated.  If  the  arc  is  interrupted  either  in  its  afferent  or  efferent 
limb  or  in  the  centre  the  reflex  is  lost. 

Involuntary  contraction  of  muscles  aroused  by  a  sensory  impression 
upon  related  parts  is  a  reflex  in  the  ordinary  sense.  For  fine  deductions 
the   muscles   themselves   must   be   observed.      The   quadriceps   cruris,   for 


332  MEDICAL  DIAGNOSIS. 

example,  may  be  seen  to  contract  on  tapping  the  patellar  tendon,  even 
when  no  motion  of  the  leg  occurs,  and^nder  such  circumstances  the  "  knee- 
jerk"  cannot  be  said  to  be  abolished;  but  ordinarily  we  recognize  reflex 
response  in  muscles  by  a  characteristic  motion  imparted  to  a  member,  as 
the  kicking  movement  of  the  leg  which  is  regarded  as  a  measure  of  the 
knee-reflex. 

Absence  of  the  usual  motor  response,  of  the  knee-jerk  for  example, 
or  its  diminution  or  exaggeration,  are  the  matters  to  be  attended  to  in  the 
study  of  most  reflexes,  particularly  the  "tendon-reflexes."  This  is  true 
also  of  most  of  the  superficial — skin — reflexes,  though  in  certain  of  them 
the  character  of  the  motion  elicited  is  significant;  thus  with  the  plantar 
reflex,  flexion  of  the  toes  is  normal,  while  extension — Babinski  reflex — 
indicates  lesion  of  the  pyramidal  tract  of  the  corresponding  side,  extension 
of  the  toes  being  equivalent  to  exaggeration  of  other  reflexes.  In  a  third 
group,  the  so-called  periosteal  reflexes,  any  motion  of  the  member  estab- 
lishes the  presence  of  the  reflex,  as  in  the  case  of  the  scapulohumeral, 
the  motion  of  which  maj^  be  external  or  internal  rotation,  and  ad-  or  ab- 
duction of  the  upi^er  arm,  according  as  to  which  of  the  muscles  attached 
to  the  scapula  are  most  actively  excited  when  this  bone  is  jarred  by 
tapping  at  a  spot  where  it  is  bare  save  of  periosteum  and  skin. 

A  reflex  must  be  fairly  constant  and  discernible  in  the  normal  subject 
to  give  much  significance  to  its  alterations,  particularly  to  its  absence. 
Many  reflexes  are  of  minor  clinical  importance  because  they  are  present 
in  only  a  small  percentage  of  normal  subjects  and  then  are  not  pronounced, 
the  ulnar  for  instance.  Reflexes  of  the  lower  extremity  are  on  the  whole 
more  important  than  those  of  the  upper,  and  the  knee-jerk  is  preeminent 
in  this  respect. 

The  reflexes  of  the  upper  extremity  being  inconstant,  absence  of  any 
one  of  them  signifies  little;  exaggeration  of  one  has  a  certain  value;  and 
even  the  marked  presence  of  a  number  of  them  in  a  patient  has  something 
of  the  import  of  exaggeration  of  other  reflexes. 

Knee=jerk  or  Patellar  Tendon  Reflex. — To  elicit  the  knee-jerk  the 
leg  is  rendered  passive  by  crossing  the  knee  over  its  fellow,  or  by 
supporting  it  on  the  examiner's  forearm  passed  under  the  patient's  knee 
and  braced  by  the  hand  placed  upon  the  other  knee,  or  by  having 
the  patient  while  recumbent  draw  up  his  knee  into  an  easj^  position 
with  all  muscular  tension  on  his  part  withdrawn;  the  patellar  tendon  well 
below  the  knee-cap  is  then  struck  a  firm,  quick  blow  with  the  ulnar  edge 
of  the  hand  or  with  a  percussion  hammer. 

The  knee-jerk  should  never  be  declared  absent  until  Jendrassik's 
method  of  reinforcement  has  confirmed  the  result.  This  is  applied  by 
directing  the  patient  to  hook  his  hands  together  and  to  keep  them  so  while 
tugging  at  them  as  if  to  pull  them  apart.  It  is  customary  for  the  examiner 
to  count  "one,  two,  three"  after  instructing  the  patient  to  "pull  hard" 
at  "three,"    the  tap  on  the  tendon  being  made  at  about  "four." 

The  signs  +  for  increased  and  —  for  diminished  knee-jerks  are  com- 
monly employed;    and,  in  writing,  "  kj "  for  the  reflex  itself  is  allowable. 

The  knee-jerk  being  due  to  contraction  of  the  quadriceps  cruris 
muscle,    the    essential    phenomenon    may    be    induced    by    tapping    the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


333 


muscle  itself  just  above  the  patella,  especially  if  the  latter  is  pressed 
downward  by  a  finger  laid  along  the  upper  edge  of  the  bone  and  this 
finger  is  then  tapped   with  the  hammer. 


Fig.  133. — Method  of  testing  patellar  reflex. 


Fig.  134. — Achilles  tendon  reflex. 


Babinski    Reflex. — In  testing  for  the   Babinski  reflex  the  examiner 
supports  the  patient's  ankle  with  his  left  hand  and  strokes  the  sole  of  the 


Fig.  13.5. — Plantar  flexion. 


foot  with  any  object  which  makes  a  distinct  sensory  impression — a  some- 
what sharp  point  being  necessary  when  the  skin  is  thick — at  the  same  time 
noting  the  movement  of  the  toes,  which  in  all  normal  persons  past  the  age 


334  MEDICAL  DIAGNOSIS. 

of  infancy  is  plantar  flexion.  Extension  (dorsifiexion)  of  the  toes,  partic- 
ularly of  the  big  toe,  elicited  in  this  way  constitutes  the  Babinski  reflex, 
which  is  a  most   impoitant  sign  of  involvement  of  the  pyramidal  tracts. 


i-iG.  130. — BabiiisKi  reliex  (dorsiflexion  of  the  toes). 

Ankle  Clonus. — This  phenomenon  usually  accompanies  a  considera- 
bly increased  knee-jerk,  and  has  a  similar  significance.  To  test  for  it.  the 
v.-hole  leg  should  be  relaxed — best  by  having  the  patient  supine.     The 


Fig    (37. — Biceps  reflex. 


examiner's  left  hand  supports  the  leg,  and  his  right,  clasping  the 
patient's  foot,  presses  it  upward,  when,  if  clonus  is  present,  the  foot  is 
pushed  back  against  the  hand  in  a  series  of  jerks  which  are  due  to  clonic 
spasm  of  the  (soleus)  muscle. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


335 


Achilles  Jerk. — A  single  reflex-contraction  of  the  calf  muscle  may  be 
induced  by  tapping  the  tendon,  which  the  examiner  has  rendered  tense  by 
pressing  the  foot  upward.  This  reflex  is  called  the  Achilles  jerk  and  is  an 
index  of  the  condition  of  the  sciatic  nerve  and  corresponding  segments 
of  the  spinal  cord.  It  is  best  obtained  by  having  the  patient  kneel  upon  a 
chair  while  the  examiner  taps  the  Achilles  tendon. 

The  Abdominal  Reflex. — This  reflex,  quite  a  constant  one,  is  elicited 
by  stroking  the  side  of  the  abdomen.  The  ensuing  contraction  is  wide- 
spread over  tliis  region. 

The  Cremasteric  or  Inguinal  Reflex  consists  in  a  drawing-up  of  the 
scrotum  and  testicle  on  stroking  the  inside  of  the  thigh. 

The  Epigastric  Reflex. — On  stroking  along  the  costal  margin  the 
muscles  over  the  pit  of  the  stomach  contract. 


Fig.  138. — Triceps  reflex. 


Among  the  i-eflexes  of  the  upper  extremity,  the  Radial — ^a  periosteal 
reflex — is  elicited  by  tapping  above  the  styloid  process  of  the  radius,  and 
consists  mainly  in  flexion  at  the  elbow-joint.  The  nearly  identical  motion 
of  the  Biceps  Reflex  arises  when  the  tendon  of  this  muscle  is  tapped  at  the 
bend  of  the  elbow.  In  testing  the  last  two  reflexes  the  examiner  places 
his  forearm  under  that  of  the  patient,  in  order  to  relax  the  latter. 

To  elicit  the  Triceps  Reflex  the  patient's  upper  arm  is  given  a  fixed 
support  on  the  examiner's  wrist  or  on  a  chair-back,  when  tapping  above  the 
olecranon  causes  an  outward  jerk  of  the  forearm. 

Plantar  Reflex. — Produced  by  tickling  the  sole  of  the  foot.  It  consists, 
when  fully  developed,  of  sudden  withdrawal  of  the  foot  by  flexion  at  the 
hip  and  knee,  dorsal  flexion  of  the  ankle  and  plantar  flexion  of  the  toes. 
The  movement  in  undeveloped  cases  may  consist  of  sudden  plantar  flexion 
of  the  toes.  It  occurs  in  normal  conditions,  but  in  varying  degrees.  There 
are  those  who  have  the  power  to  voluntarily  prevent  it.  This  reflex  is 
exaggerated  in  neurasthenia,  hysteria  and  other  functional  diseases  of  the 
nervous   system,  and    may  be  associated   in   extreme   cases   with  general 


336  MEDICAL  DIAGNOSIS. 

convulsive  movements  or  may  be  crossed, — that  is,  it  may  occur  not  only 
on  the  side  tickled  but  also  upon  the  opposite  side.  It  is  also  increased, 
but  usually  to  a  moderate  extent  only,  in  organic  disease  of  the  central 
nervous  system.  It  is  as  a  rule  abolished  in  the  affected  side  in  hemiplegia 
and  invariably  absent  in  destructive  lesions  involving  the  sensory  nerves 
of  the  legs. 

Other  reflexes  of  minor  clinical  importance  are: 

The  Supra=orbital  Reflex. — Produced  by  a  sharp  tap  upon  the  trunk 
of  the  supra-orbital  nerve,  it  consists  of  slight,  momentary  contractions  of 
the  orbicularis  palpebrarum,  especially  in  its  external  half.  It  is  absent  in 
destructive  lesions  of  the  supra-orbital  nerve  and  in  peripheral  facial  palsy. 

The  Malar  Reflex. — Not  usually  present  in  normal  conditions,  but 
caused  in  recent  facial  paralysis  of  peripheral  origin  by  percussion  over 
the  malar  bone.  It  consists  of  contraction  of  the  elevator  of  the  angle  of 
•the  mouth  and  movements  of  the  ala  nasi. 


Fig.  139. — Paradoxical  reflex. 

The  Chin  Reflex. — This  phenomenon  is  ehcited  by  tapping  upon  a 
small  flat  object,  as  an  ivory  paper  cutter  or  a  tongue  depressor,  laid  upon 
the  lower  front  teeth,  or  the  finger  laid  upon  the  protuberance  of  the  chin 
when  the  mouth  is  open  and  the  jaw  relaxed  and  drooping.  The  response 
consists  in  a  sharp  upward  movement  of  the  jaw.  It  may  be  present  in 
nervous  conditions,  as  hysteria,  and  in  cachectic  states. 

The  Femoral  Reflex. — This  phenomenon  does  not  occur  in  health. 
It  is  produced  in  transverse  lesions  of  the  spinal  cord  above  the  level  of  the 
eighth  dorsal  segment  by  irritation  of  the  anterior  surface  of  the  upper 
part  of  the  thigh,  and  consists  in  plantar  flexion  of  the  toes  and  extension 
of  the  foot. 

Sinkler's  Toe  Reflex. — This  reflex  is  produced  by  sudden  forcible 
flexion  of  the  great  toe.  It  consists  in  forcible  flexion  of  the  knee  and  hip 
and  is  met  with  in  spastic  conditions  arising  in  spinal  disease,  as  spastic 
paraplegia. 

Qowers's  Front  Tap. — The  leg  being  slightly  flexed,  a  blow  is  struck 
upon  the  tibiahs  anticus  muscle.  Plantar  flexion  of  the  toes  occurs  in  a 
considerable  proportion  of  normal  persons,  many  neurasthenic  and  hysteri- 
cal individuals,  and  not  at  all  in  tabes. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  337 

Paradoxical  Reflex. — This  phenomenon  is  caused  by  sudden  short- 
ening of  the  tendon.  It  is  elicited  by  deep  pressure  upon  the  calf  muscles 
and  consists  in  extension — dorsifiexion — of  the  toes,  especially  the  great 
toe.  It  is  regarded  as  a  sign  of  irritation  or  early  organic  affection  of  the 
motor  pathway. 

Oppenheimer's  Reflex. — Dorsifiexion  of  the  toes  and  foot  upon 
forcibly  stroking  the  skin  along  the  inner  border  of  the  tibia. 

Pfliiger's  Laws. — 1.  The  reflex  occurs  upon  the  same  side  of  the  body 
as  that  to  which  the  irritant  is  applied  and  in  muscles  whose  motor  nerves 
arise  from  the  same  segments  of  the  cord. 

2.  If  the  reflex  occurs  on  the  opposite  side,  only  the  corresponding 
muscles  contract. 

3.  If  the  reflexes  are  unequal  on  the  two  sides,  the  stronger  are  on  the 
side  upon  which  the  irritation  has  been  applied. 


Fic;.  140.— Oppenheimer's  reflex. 

4.  When  the  reflex  extends  to  other  segments  the  direction  of  the 
extension  is  toward  the  medulla. 

5.  All  the  muscles  of  the  body  may  yield  reflexes. 

7.   Electrodiagnosis. 

For  diagnostic  purposes  the  galvanic  battery  is  more  important  than 
the  faradic;  but  each  gives  considerable  information  as  to  the  cause  and 
character  of  motor  paralysis  or  the  variety  of  muscular  atrophy  present, 
and  the  prognosis  in  paralysis  and  atrophy  of  certain  kinds. 

The  electrodes,  covered  with  absorbent  cotton  and  wetted,  are  placed 
upon  the  patient's  bare  skin,  one  at  some  "indifferent"  point,  as  the  back 
of  the  neck,  the  other  upon  the  part  to  be  examined — motor  point  of  the 
muscles  or  the  nerve-trunks.  With  a  faradic  current  thus  appUed,  on 
opening  the  circuit  a  quick  contraction  of  the  muscles  ensues  in  the  region 
of  the  distal  electrode,  whether  this  be  positive  (the  anode)  or  negative 
(the  cathode) ;  but  if  the  interruptions  are  rapidly  repeated  the  muscle  is 
thrown  into  a  tetanic  state.  If  these  muscles  be  the  seat  of  paralysis  from 
lesion  of  the  inferior  motor  neuron — poliomyelitis,  neuritis,  etc. — or  if 
they  be  atrophied,  their  response  to  the  faradic  current  is  diminished  in  a 
degree  which,  after  some  experience;  can  be  estimated  by  the  examiner. 
22 


338 


MEDICAL  DIAGNOSIS. 


Fig.  141. — Motor   points.     1,    frontalis;    2,    corrugator    pupercilli;    3 
nasal  muscles;    5,  levator  labii  superioris;    6,  zygornaticus  major 


orbicularis   palpebrarum;   4, 

,uo  ...c., aris  oris;    8,  lower  branch  of 

ferioris;    11,  depressor  anguli  oris;    12    platysnja; 


facial;  9,  depressor  labii  inferioris;  10,  levator  labii  infenons;  11,  depress9r  anguii  o"^'  i^/^J^'X  18 
13,  sternohyoid;  14,  omohyoid;  15,  sternothyroid;  16,  temporalis;  17.  .^"^1  "f  ve  "pper  ^Dra"^.'  if' 
facial  nerve,  middle  branch;  19,  facial  nerve,  lower  branch;  20,  occipitalis;  21,  retrahens  aurem,  22, 
facial  trunk;  23,  posterior  auricular  nerve;  24,  masseter;  25.  spinal  accessory  "f^ve,  ,^t).  sp'enms,  //, 
hypoglossal  nerve;    28,  sternocleidomastoid;    29,  trapezius;    30,  phrenic  nerve;    31,  Erb=.  point  (dertoia 


hypoglossal  nerve;    zs,  s^ernocleluuIIla^Lulu,    -c,   uii^jjc^iuo,    ^^•,  h"'— -;"—•-'.--■-.... -oo    ^irnumflpx 
biceps,  brachialis  anticus,  supinator  longus);  32,  anterior  thoracic  nerve  (pectoralis  major)     33   circumHex 

nerve.'Cdeltoid);    34,   long  thoracic  "--   ^f '-f.^-  --^-g^.-)-,  ^itis^muf  do^  ^'^-^a    ">^<'--  ^hdZinil 
(nervi  intercostales  abdominales);     37,   .serratus  magnus,     .i>s,   latissimus  uorsi, 
externus  (nervi  intercosta  es  abdominales);    40,  transversus  abdominis. 


39,  obliquus  abdominis 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


339 


This  diminution  of  faradic  contractility  serves  as  an  early  index  of  the 
extent  of  paralysis  and  atrophy  which  is  likely  to  appear  in  acute  anterior 


\  y~ 


31 

—  32 


Fig.  142. — Motor  points  1,  musculocutaneus;  2,  caput  interims  m.  tricipitis;  3,  n.  musculocu- 
taneus;  4,  biceps;  5,  medianus;  C,  brachialis  internus;  7,  n.  ulnaris;  8,  rami  n.  median!  pro  m.  pronatore 
radii  terete;  9,  paimaris  longus;  10,  radialis  internus;  11,  ulnaris  internus;  12,  flexor  digitorum  pro- 
fundus; 13,  flexor  digitorum  sublimis;  14,  flexor  digitorum  sublimis  (digitt.  11  et  III);  15,  n.  ulnaris; 
16,  flexor  digitorum  sublimis  (digitt.  indicis  et  minim.);  17,  flexor  pollicis  longus;  18,  medianus;  19, 
abductor  pollicis  brevis;  20,  rami  volar,  prof,  nervi  ulnaris;  21,  paimaris  brevis;  22,  abductor  digiti 
minimi;  23,  flexor  digiti  minimi;  24,  opponens  digiti  minimi;  25,  lumbricales  II,  HI  et  IV;  26,  opponens 
pollicis;  27,  flexor  pollicis  brevis;  28,  adductor  pollicis;  29,  lumbricalis  I;  30,  caput  externus  m.  tncipitis; 
31,  n.  radialis;  32,  brachialis  internus;  33,  supinator  longus;  34,  radialis  externus  longus;  35,  radialis 
externus  brevis;  36,  extensor  digitorum  communis;  37,  ulnaris  internus;  38,  extensor  digiti  minimi 
proprius;  39,  extensor  indicis  proprius;  40,  extensor  indicis  prop,  et  abductor  pollicis  longus-  41,  abduc- 
tor pollicis  longus;  42,  extensor  pollicis  brevis;  43,  extensor  pollicis  longus;  44,  flexor  pollicis  longus; 
45,  interosseus  dorsalis  I;  46,  abductor  digiti  minimi;  47,  interosseus  dorsalis  IV;  48,  mterosseus 
dorsalis   III;    49,  interosseus  dorsalis  II. 

poliomyelitis,  in  Bell's  palsy,  or  other  disease  inducing  rapid  degeneration 
of  muscles;  but  at  the  end  of  two  weeks  from  the  onset  in  these  affections 
there  is  commonly  no  response  whatever  to  faradism. 


340 


MEDICAL  DIAGNOSIS. 


On  the  other  hand,  if  the  galvanic  current  be  applied  as  described 
above  over  paralyzed  or  atrophied  muscles  the  contractility  is  found  to  be 
at  first  increased;  that  is,  galvanic  hyperexcitability  is  a  sign  of  muscle 


34 


19_ 


37 


Fig.  143. — Motor  points.  1,  anterior  crural  nerve;  2,  tensor  fasciae  latee;  3,  sartorius;  4,  obturator 
nerve;  5,  pectineus;  6,  quadriceps  (comnaon  point);  7,  rectus  femoris;  8,  adductor  longus;  9,  adductor 
magnus;  10,  gracilis;  11,  crureus;  12,  vastus  externus;  13,  vastus  internus;  14,  external  popliteal 
nerve;  1.5,  peroneus  longus;  16,  extensor  longus  digitorum;  17,  tibialis  anticus;  18,  peroneus  brevis; 
19,  extensor  hallucis  longus;  20,  extensor  brevis  digitorum;  21,  dorsal  interossei;  22,  gluteus  maximus; 
23,  adductor  magnus;  24,  sciatic  nerve;  25,  semitendinosus;  26,  gracilis;  27,  biceps  (long  head);  28, 
semimembranosus;  29,  biceps  (short  head);  30,  internal  popliteal  nerve;  31,  external  popliteal  nerve; 
32,  gastrocnemius  (outer  head);  33,  gastrocnemius  (inner  head);  34,  soleus;  35,  flexor  longus  digitorum; 
36,  flexor  longus  hallucis;    37,  posterior  tibial  nerve. 


degeneration.  Later  it  diminishes.  Contraction  of  the  muscles  under  the 
galvanic  current  is  only  momentary,  appearing  both  on  closing  and  on 
opening  the  circuit.  The  various  responses  of  the  normal  muscle  are  as 
follows:  To  the  negative  pole,  or  cathode,  the  first  or  most  active  response 
is  on  closing  the   jircuit,  which  is  expressed  thus,  C.C.C.     On  opening  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  341 

circuit  there  is  no  response,  C.O.C.  To  the  positive  pole,  or  anode,  a 
response  not  so  active  as  to  the  cathode  is  obtained  on  closing  the  circuit, 
A.C.C.,  and  occasionally  a  response  is  also  obtained  on  opening  the  circuit, 
especially  if  the  pole  is  held  on  the  trunk  of  a  motor  nerve,  A.O.C.  These 
two  responses  to  the  anode  may  be  about  equal,  but  usually  the  response 
at  closure  is  greater  than  at  opening,  and  neither  is  as  active  as  the  response 
to  the  closure  of  the  cathode.    Thus  the  normal  formula  stands  as  follows: 

C.C.C.  >  A.C.C.  >  or  =  A.O.C.  >  C.O.C. 

This  formula  represents  what  we  find  practically  at  the  bedside. 
There  are  some  distinctions  between  the  responses  to  nerve-tissue  on  the 
one  hand  and  muscle-tissue  on  the  other,  as  observed  in  laboratory  experi- 
ments on  animals;  but  these  need  not  detain  and  confuse  us  here. 

Reaction  of  Degeneration — R.Q. — When  a  muscle  is  degenerating — 
for  instance,  when  it  is  cut  off  from  its  nerve  supply  either  by  injury  or 
disease  (nerve  injuries,  neuritis,  acute  anterior  poliomyelitis) — the  reactions 
to  galvanism  are  altered.  The  anodal  closure  contraction  becomes  greater 
than  the  cathodal  closure  contraction,  A.C.C.  >  C.C.C,  although  both  are 
diminished  as  compared  with  those  of  the  normal  muscle.  At  the  same  time 
the  anodal  opening  contraction  (never  very  conspicuous)  disappears,  and  very 
rarely  the  cathodal  opening  contraction  is  seen.  Thus  the  typical  reaction 
of  degeneration  is  as  follows:  A.C.C.  >  C.C.C.  (C.O.C.  sometimes  seen,  A. 
O.C.  disappearing).  The  response  of  degenerating  muscle  is  sluggish,  not 
quick  and  active, 

8.  Trophic  Disturbances. 

In  a  broad  sense  all  disease  is  nutritional  disorder;  but  there  are  some 
diseases  which  directly  attack  the  nervous  structures  presiding  over  nutri- 
tion of  related  parts  of  the  body,  and  these  are  properly  "trophic  diseases." 
The  nutritional  disorder  may  be  the  principal  manifestation  of  the  disease, 
as  is  indeed  recognized  in  the  very  name  of  the  group  of  muscular  atrophies. 
Whether  or  not  there  be  separate  trophic  nerve-fibres,  we  know  that  for 
the  muscles  the  trophic  impulses  traverse  the  motor  nerves  chiefly.  If 
motor  palsy  is  accompanied  by  rapid  wasting,  the  lesion  is  probably  in  the 
gray  matter  (of  the  cord,  oblongata,  etc.)  or  in  the  peripheral  nerves, 
since  they,  comprising  the  lower  motor  neurons,  preside  over  nutrition 
most  directly.  But  slow  wasting  may  affect  parts  paralyzed  by  cerebral 
disease  (upper  motor  neurons),  the  affected  side  in  old  hemiplegia  being 
commonly  much  atrophied.  This  is  ascribed  to  involvement  of  trophic 
centres  in  the  cortex.  While  the  spastic  spinal  palsies  arise  from  disease 
of  superior  motor  neurons — pyramidal  tracts — they  often  manifest 
atrophy  which  may  be  similar  in  all  respects  to  that  of  chronic  poliomye- 
Htis — ordinary  progressive  muscular  atrophy.  In  such  cases  there  is  no 
physiological  paradox:  the  atrophy  is  referable  to  implication  of  the  gray 
matter  of  the  cord.  Primary  lateral  sclerosis  is  practically  always  accom- 
panied by  atrophy,  distributed  as  in  poliomyelitis,  which  implies  that  the 
two  motor  neurons— superior  and  inferior — are  perhaps  independently, 
though  simultaneously,  involved,  and  bulbar  palsy  is  frequently  included 
in  the  clinical  picture.     It  is  well,  therefore,  to  conceive  of  chronic  polio- 


342  MEDICAL  DIAGNOSIS. 

myelitis,  lateral  sclerosis,  amyotrophic  lateral  sclerosis  and  bulbar  palsy 
as  constituting  one  disease,  of  which  a  particular  symptom — atrophy, 
etc. — is  dominant  in  each  of  the  types  named. 

The  distribution  of  muscular  atrophy  has  considerable  significance, 
especially  the  region  of  the  body  in  which  it  first  appears.  Atrophy  begin- 
ning in  the  small  muscles  of  the  hand,  or  in  the  shoulder,  is  generally  pro- 
gressive— spinal — muscular  atrophy. 

In  the  "family  type"  of  spinal  atrophy  appearing  in  infancy,  the 
muscles  of  the  legs  and  back  are  the  first  to  show  wasting.  The  myopathies 
or  muscular  dystrophies  are  likely  to  appear  first  in  the  pelvic  girdle  (leg 
type),  in  the  shoulder  girdle  (arm  type),  or  in  the  face  (face  type).  When 
atrophy  occurs  in  the  foot  and  outer  lower  leg — peroneal  muscles — the 
so-called  primary  neuritic  atrophy  is  to  be  considered. 

The  cardinal  tests  of  spinal,  as  distinguished  from  idiomuscular,  atro- 
phies are  the  electrical  reaction  of  degeneration  and  fibrillary  twitching, 
both  present  in  the  former,  and  absent  in  the  latter  or  myopathies. 


Fig.  144. — l^ed-.^ore-J. — German    Hospital. 

The  muscles  above  or  below  a  diseased  joint  often  waste.  This  is 
called  "  arthritic  atrophy,"  and  is  explained  as  a  reflex  phenomenon  set 
up  by  irritation  of  sensory  nerves  supplying  the  joint. 

The  clinician  must  discriminate  between  the  atrophy  from  disuse  or 
from  joint  disease,  and  that  which  is  the  essential  manifestation  of 
certain  grave  nervous  diseases;  and  he  does  so  mainly  by  considering 
the  correlated  symptoms  and  signs. 

Certain  diseases  are  presumably,  though  not  manifestly,  trophic  in 
origin;  as  arthritis  deformans.  Others,  such  as  acromegaly,  myxoedema, 
and  adiposis  dolorosa,  result  from  disease  of  ductless  glands — pituitary 
body,  thyroid — through  the  medium  of  the  trophic  nervous  apparatus, 
which  is  affected  by  the  absence  or  derangement  of  the  secretions  of  these 
glands.  These  diseases — characterized  respectively  by  gross  enlargement 
of  hands,  feet,  and  face;  by  thickened,  doughy  skin;  by  great  masses  of 
painful  fat — illustrate  trophic  excess,  hypertrophy,  and  hyperplasia. 

Still  another  group  of  affections,  pathologically  obscure  and  clinically 
indefinite,  illustrate  trophic  disease  arising  through  the  medium  of  vaso- 
motor derangement.  These  comprise  angioneurotic  oedema,  acroparaes- 
thesia,  Raynaud's   disease,    erythromelalgia,   and   perhaps  other  diseases. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


343 


A  variety  of  local  affections  occur  however  as  incidents,  more  or  less 
important,  in  the  course  of  organic  nervous  diseases,  and  constitute  trophic 
manifestations  of  these  diseases,  just  as  paralysis  and  anaesthesia  constitute 


Fig.  145. — Ataxic  elbow-joint. — Young 


their  motor  and  sensory  manifestations.  These  trophic  disturbances  some- 
times resemble  independent  affections  and  the  nervous  diseases  underlying 
them  may  thus  be  overlooked,  for  instance,  bed-sores  in  emaciation  or 
sprains  in  Charcot  joints.     A  joint  affection,  especially  if  it  be  subacute  or 


Fig.  14f). — Pprforatinp:  ulcers  of  the  foot. — German  Hospital. 

chronic  and  confined  to  one  oi-  two  joints,  is  often  of  nervous  origin.  In 
acute  myehtis  inflammatory  arthropathies;  resembling  rheumatism,  may 
arise.  In  old  hemiplegia — on  the  paralyzed  side — and  in  various  chronic 
cord-diseases,  an  osteo-arthritis  is  not  uncommon.  The  classic  form  is 
the  Charcot  joint,  which  occurs   most  frequently  early  in  the  course  of 


344  MEDICAL  DIAGNOSIS. 

tabes  dorsalis.  The  arthropathy  of  syringomyelia  often  affects  the  spine, 
inducing  scohosis.  Painless  whitlows  of  fingers  or  toes  call  for  study  of 
sensation  in  these  parts,  for  if  they  betray  loss  of  temperature  and  pain 
sensibility,  we  are  dealing  with  "Morvan's  disease,"  a  trophic  manifesta- 
tion of  syringomyelia.  Painless  perforating  ulcer  of  an  extremity,  often 
on  the  ball  of  the  foot  or  great  toe,  belongs  commonly  to  tabes  dorsalis  or 
to  syringomyelia.  Bed-sores  form  usually  at  spots  injured,  especially  over 
the  sacrum  from  pressure  of  the  bed,  but  the  extent  of  the  ulceration  is 
ordinarily  out  of  proportion  to  the  apparent  cause.  Moreover,  sloughs  do 
form  without  external  cause,  from  purely  trophic  defect.  The  skin  shows 
changes  in  various  nervous  diseases,  as  do  the  nails,  hair  and  other 
structures  histologically  allied  to  the  skin.  ''  Glossy  skin," — shiny,  thin, 
dry  epidermis  on  the  extremities, — results  from  neuritis  of  somewhat  long 
duration.  The  vesicles  of  herpes  zoster  are  a  trophic  manifestation  of 
neuritis,  most  frequently  intercostal. 

9.   Pain   and   Temperature. 

In  ordinary  anaesthesia,  as  that  of  neuritis  or  of  tabes  dorsalis,  loss  of 
sensibility  to  pain,  and  to  heat  and  cold,  is  associated  with  the  loss  of 
touch  sense.  The  nerves  and  dorsal  roots,  the  seat  of  these  diseases,  con- 
tain the  fibres  for  all  forms  of  sensation. 

There  is  a  remarkable  condition,  however,  in  which  a  patient,  though 
feeling  himself  touched  by  an  object — touch  sensation  preserved — cannot 
tell  whether  it  is  hot  or  cold — temperature  sense  lost — or  whether  it  is 
sharp  or  dull — pain  sense  lost.  This  separate  sensory  loss  is  called  disso- 
ciated ancesthesia.  It  is  in  the  root-zone  that  the  pain  and  temperature 
fibres  part  company  with  all  others  to  enter  the  gray  matter  and  sweep 
across  by  way  of  the  commissure  to  the  opposite  margin  of  the  cord. 

In  the  neighborhood  of  the  central  canal — central  gray  matter — the 
pain  and  temperature  fibres  from  one  side  decussate  with  those  from 
the  opposite  side  in  a  narrow  space,  and  a  small  lesion  at  this  point, 
sparing  the  dorsal  columns,  may  cause  dissociate  anaesthesia.  The  lesion 
that  most  often  occoirs  here  is  a  peculiar  tumor  that  forms  by  prolifera- 
tion of  neuroglia  just  back  of  the  central  canal. 

When  proliferated  rapidly  neuroglia  forms  a  soft  mass.  In  the  brain 
where  its  commonest  seat  is  deep  in  the  cerebellum,  it  meets  equal  pres- 
sure on  all  sides  and  so  becomes  globular — glioma;  but  in  the  cord  the 
line  of  least  resistance  is  up  and  down,  and  the  gliomatous  tissue  forms  a 
rod  along  the  centre  of  the  cord.  Neuroglia  tumors  tend  to  break  down 
centrally.  Glioma  of  the  brain  is  thus  commonly  cystic,  and  gliosis  of  the 
cord  when  advanced  is  characterized  by  cavity  formation  within  it,  by 
which  the  cord  is  finally  converted  into  a  tube.  From  this  circumstance 
the  entire  disease-process  gets  its  name  syringomyelia. 

Dissociated  anaesthesia  may  result  from  tumor,  hemorrhage  in  the  cen- 
tral gray  matter,  but  it  is  so"  early  and  so  constant  in  gliomatosis  that  it 
is  commonly  spoken  of  as  syringomyelic  dissociation. 

As  the  neuroglia  mass  spreads  it  causes  various  symptoms,  most  com- 
monly those  of  progressive  muscular  atrophy  because  the  ventral  gray 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  345 

horns  are  slowly  invaded.  In  chronic  poliomyelitis  it  is  usually  the  hands 
and  arms  that  are  atrophied,  the  cervical  and  upper  thoracic  part  of 
the  cord  being  the  commonest  seat  of  the  gliosis.  The  pain  and  tem- 
perature fibres  from  each  root-zone,  having  reached  the  opposite  margin 
of  the  cord,  turn  upward  to  form  the  column  of  Gowers.  This  column 
is  bounded  in  front  by  the  motor  root-zone,  behind  by  an  imaginary 
line  passing  transversely  through  the  central  canal.  A  lesion  such  as 
tumor  severing  the  column  of  Gowers  will  cause  dissociated  anaesthesia 
below  it  on  the  opposite  side  of  the  body.  Lateral  trauma  of  the  spine 
is  likely  to  sever  this  column,  with  a  similar  result;  but  practically 
such  a  trauma  always  implicates  also  the  crossed  pyramidal  tract,  causing 
motor  paralysis  on  the  side  of  the  lesion.  The  combination  of  motor  paral- 
ysis on  one  side  of  the  body  and  sensory  paralysis  on  the  opposite  side, 
"  Brown-Sequard's  paralysis,"  is  pathognomonic  of  unilateral  cord  lesion. 
In  Brown-Sequard's  paralysis  touch  sense  is  usually  preserved  on  both 
sides  of  the  body,  the  dorsal  columns  of  the  cord  escaping. 

10.   Muscular  Sense. 

Normal  coordination  depends  upon  several  factors,  any  one  of  which 
being  defective,  incoordination  or  ataxia  may  result.  In  walking,  under 
normal  circumstances,  the  sensations  imparted  by  the  surface  control  to 
some  extent  the  movements,  and  the  absence  of  this  control,  as  in  the 
anaesthesia  of  tabes,  constitutes  an  element  of  ataxia.  Subconscious  sensa- 
tions from  the  joints,  muscles,  skin,  fasciae,  together  with  appreciations 
of  weight  and  balance,  enter  into  the  special  kind  of  perception  designated 
the  muscular  sense — ''sixth  sense"  of  Sir  Charles  Bell — and  defect  of  this 
sense  is  an  important  factor  in  most  forms  of  ataxia.  It  is  suppressed 
at  its  very  source  when  the  nerve-termini  in  joints  and  muscles  are  impli- 
cated in  a  peripheral  neuritis,  and  this  causes  so  marked  an  ataxia  that 
such  cases  have  been  designated  peripheral  pseudotabes.  A  part  of  the 
ataxia  in  such  cases  of  peripheral  neuritis  may  be  due  to  anaesthesia  of 
the  skin.  The  ataxia  of  true  tabes  has,  to  some  extent,  this  same  periph- 
eral origin,  since  neuritis  is  a  part  of  the  disease,  but  it  has  a  more 
important  spinal  origin.  In  the  cord  many  muscular-sense  axons  pass 
up  the  dorsal  columns  in  company  with  the  touch-sense  axons,  and  here 
they  are  implicated  in  tabetic  degeneration.  Ataxia,  by  loss  of  muscular 
sense  and  by  anaesthesia  combined,  is  a  constant  symptom  of  lesion  of 
the  dorsal  columns. 

Muscular  sense  is  represented  in  the  cerebral  cortex  posterior  to  the 
motor  area,  being  associated  with  touch  sense  here  as  in  the  cord.  These 
two  senses  are  involved  when  the  hand,  unaided,  recognizes  an  object  held 
in  it  (stereognosis) ;  they  are  especially  combined  for  this  purpose  in  the 
superior  parietal  lobule,  and  loss  of  this  perceptive  power — astereognosis — 
is  most  commonly  due  to  lesion  in  that  area. 

Muscular  sense  guides  the  cerebellum  in  its  chief  function,  the  mainte- 
nance of  equilibrium.  Fibres  delegated  to  this  function  from  the  root- 
zone  enter  the  base  of  the  dorsal  gray  horn  and  connect  with  the  cell- 
bodies  of  Clarke  and  Stilling  which  are  found  in  that  situation  throughout 


346  MEDICAL  DIAGNOSIS. 

the  cord  (Gordinier).  These  cell-bodies  are  the  beginning  of  superior 
muscular-sense  neurons;  their  axons  sweep  outward  to  the  margin  of  the 
cord  and  turn  upward  in  the  direct  cerebellar  tract,  the  terminus  of 
which  is  the  middle  lobe — vermis — of  the  cerebellum,  which  it  reaches 
by  way  of  the  inferior  cerebellar  peduncle — restiform  body.  Lesion  of 
this  neuron-system,  in  the  cord  or  in  the  cerebellum  (Barker),  causes  the 
defect  of  equilibration  called  cerebellar  ataxia. 

Assistance  in  coordination  is  derived  from  all  the  senses,  consciously, 
as  when  the  tabetic  watches  the  ground  in  walking,  and  unconsciously, 
through  impulses  collected  in  the  cerebellum  from  the  eye,  cutaneous  sen- 
sations, the  joint  and  muscle  surfaces  and  the  internal  ear.  Disturbance 
in  one  of  these  sensory  organs  may  cause  vertigo. 

The  internal  ear  is  virtually  two  organs,  having  distinct  functions, 
and  the  eighth  nerve  is  double  accordingly.  The  semicircular  canals  of  the 
vestibule  are  water-levels  telling  the  position  of  the  head,  as  muscular 
sense  does  that  of  the  limbs,  and  the  part  of  the  eighth  nerve  arising  thence 
called  the  vestibular  nerve  is  concerned  not  with  hearing  but  with  equili- 
bration. It  connects  with  its  superior  neurons  in  the  dorsomesal  nucleus 
to  pass  to  the  cerebellum. 

Lesion  of  any  part  of  the  vestibular  tract  from  the  internal  ear  to  the 
cerebellum  may  cause  vertigo,  as  in  Meniere's  disease. 

The  eighth  nerve's  division  into  two  js  clear  as  it  enters  the  pons,  the 
two  parts  being  separated  by  the  inferior  cerebellar  peduncle.  The  outer  or 
cochlear  division  is  the  true  nerve  of  hearing.  It  enters  the  ventrolateral 
nucleus  to  be  continued  by  fibres  that  cross  the  middle  line  of  the  pons, 
forming  the  trapezoid  body, — acoustic  decussation  (M.  Allen  Starr), — then 
pass  upward  in  the  lateral  fillet,  and  by  way  of  the  postgeminum  and  post- 
geniculum  reach   the  auditory  centre  in  the  first  temporal  convolution. 

The  Stigmata  of  Degeneration. 

Degeneration,  degeneracy,  deviation  are  terms  used  to  denote  in 
individuals  a  decline  from  the  average  normal  condition  in  physical  or 
moral  quahties.  This  decline  varies  in  degree  from  deviations  from  the 
normal  scarcely  to  be  recognized  upon  the  most  careful  study,  to  the  pos- 
session of  physical  and  moral  defects  which  render  the  subject  unfit  for 
the  ordinary  duties  and  responsibilities  of  life,  and  are  obvious  to  the  casual 
observer.  It  is  accompanied  by  physical,  physiological  and  neuropsychic 
anomalies  known  as  the  ''stigmata  of  degeneration."  An  undue  impor- 
tance has  doubtless  been  ascribed  to  these  anomalies  and  their  combina- 
tions, especially  to  those  of  minor  degree,  by  Lombroso  and  his  followers; 
nevertheless  their  consideration  is  of  practical  value  in  the  study  of  diseases 
of  the  nervous  system  and  has  an  important  bearing  upon  the  diagnosis 
and  prognosis  of  individual  cases  of  this  group  of  affections.  Every  sign 
of  deviation  from  the  average  normal  is  not  necessarily  a  stigma  of  degen- 
eration, and  Walton  has  suggested  that  it  is  desirable  "  to  name  the  phe- 
nomena signs  of  deviation,  and  call  their  possessors  deviates  or  a  deviate 
as  the  case  may  be,  limiting  the  term  degeneration  only  to  such  deviations 
as  obviously  imply  deterioration." 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


347 


Etiological  Classification. — Walton  has  grouped  the  causes  of  the 
so-called  stigmata  of  degeneration,  including  the  signs  of  deviation  only, 
as  follows: 

I.  The  potential  variations  from  the  average  normal  contained  in  the 
parent  germ,  including  the  results  (a)  of  atavism,  (b)  of  parental  similarity, 
and  (c)  of  selective  tendency  on  the  part  of  the  ancestry. 

II.  Intra-uterine  infection. 

III.  Mechanical  injury  during  intra-uterine  life. 

IV.  The  absence  or  peculiarity  in  the  germ  of  certain  elements,  or 
their  disappearance  or  anomalous  development,  without  traceable  inherited 
tendency  or  other  known  explanation. 

V.  Mechanical  influence  exerted  during  infancy. 

VI.  Deleterious  influences  and  habits  in  the  ancestry,  productive  of 
enfeeblement,  undersize,  and  lessened  resistance  in  the  progeny  but  not  alter- 
ing the  essential  potential  characteristics  transmitted  by  the  parent  germ. 

VII.  Absence  or  hypertrophy  of  certain  glands,  pituitary,  thyroid, 
which  have  a  nutritional  influence. 

VIII.  Arrest  of  development,  such  as  is  seen  in  harelip  and  similar 
defects. 

List  of  Stigmata. — The  following  list,  compiled  from  Dana,  Church 
and  Peterson,  Walton,  and  others,  includes  the  more  important  deviations 
and  stigmata.  Those  which  are  of  minor  significance,  either  alone  or  in 
association  with  others,  as  indicating  actual  degeneracy,  are  placed  in 
middle  single  columns;  those  generally  recognized  as  stigmata  of  degen- 
eration, in  double  columns  at  the  sides. 


Anatomical  Stigmata. 

Anomalies  of  the  Cranium. 


Cranial  asymmetry. 

Macrocephalus. 

Microcephalus. 

Platycephalus. 

Leptocephalus. 

Oxycephalus. 

Plagiocephalus. 

Scaphocephalus. 

Trigonocephalus. 

Short  parietal  arc. 

Short  frontal  arc. 

High  prominent  forehead. 

Anomalies  of  the  Face. 


Heavy  jaws. 
Lemurian  hypophysis. 
Orthognathism. 

Prognathism. 

Opisthognathism  or  retrognar- 
thism. 

Large  frontal   sinuses,   small 

Crania  progenia  (lower  teeth 

orbit. 
Great  or  unequal  prominence 
of  malar  bones. 

projecting    beyond    upper, 
and  inferior  maxillary  angle 
obtuse). 

Anomalies  of  the  Eye. 


Narrow  palpebral  fissure. 

Flecks  on  the  iris. 
Chromatic  asymmetry  of  the 

Microphthalmus. 

Albinism. 

iris. 

Congenital  cataracts. 

Pigmentary  retinitis. 

Muscular   insufficiency,  stra- 

Hypermetropia. 

bismus. 

Myopia. 

Astigmatism. 

348 


MEDICAL  DIAGNOSIS. 


Deformities  of  the  Palate. 


High  and  narrow. 
Torus  palatinus. 
Dome-shaped. 
Hip-roofed. 


Horseshoe. 
Gothic  arch. 
Flat-roofed. 
Asymmetrical. 


Dental  Anomalies. 


Badly  set   and 

badly 

nour- 

Small  or  peg-shaped  lateral 

ished. 

Double  rows. 
Adventitious  teeth. 
Double  crown. 
Macrodontism. 

incisors. 

Microdontism. 

Projecting  teeth. 

Badly  placed    c 

3r    misplaced 

Striated  transversely. 

teeth. 

Hutchinson's  teeth. 

Anomalies  of  the  Nose. 


Defective  development  of 
cartilage  and  tissue  of  alse. 


Deviation  of  nose. 


Absent  cartilages. 
Atresia  of  nasal  fossa. 
Defective    osseous    develop- 
ment. 


Anomalies  of  the  Tongue  and  Lips. 


Macroglossus. 
Microglossus. 
Bifidity  of  point. 
Harelip. 
Cleft  palate. 


Anomalies  of  the  Ear. 


Excessively  long. 

Excessively  prominent. 

Set  too  close  to  the  head. 

Set  too  far  back. 

Set  too  low. 

Absence  of  helix,  antihelix,  or 

Obliteration  of  markings. 

lobule. 

Absence  of  fissura  intertrag- 

Too  conchoidal  (antihelix, 

ica. 

Excessively  large  (absolutely 

crura,  etc. ,  too  little  marked 

or  relatively). 

and  helix  like  rim  of  funnel) . 

Too  small. 

Lack  of  uniformity  in  width. 

Asymmetry  of  the  two  ears, 

general    anomaly  of  left 

(Blainville  ear). 

Prominence  of  antihelix. 
Adherent  lobules. 

Anomalies  of  the  Limbs. 


Symphysodactyly  or  achisto- 
dactylus  (joining  of  fin- 
gers). 

Ectrodactyly  (fingers  want- 
ing). 


Left  arm  and  leg  longer  than 

right. 
Excessive  length  of  arms. 
Long  fingers. 
Polydactyly. 


Syndactyly  (web  fingers). 


Amelus   or    ecromelus    (limb 
wanting). 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

Anomalies  of  the  Limbs. 


349 


Phocomelus  (segment  of  limb 
wanting) . 


Oligomelus  (excessive  gracil- 

ity). 


Megalomelus. 
Megalodactyly, 


Oligodactyly. 


Anomalies  of  the  Trunk  and  General  Structure. 


Hernias,  when  congenital. 

Malformation  of  breasts  and 
thorax. 

Dwarfism. 

Gigantism. 

Infantilism. 

Masculinism  in  women. 

Spina  bifida. 

Femininism  in  men. 

Feebleness  of  construction. 

Lordosis. 

Scoliosis. 

Kyphosis  (Fere). 

Malformed  coccyx. 

Thoracic  asymmetry. 

Mammary   development   in 

Mammary  absence   or   redu- 

males. 

plication  in  females  (poly- 
mastia) . 

Anomalies  of  the  Genital  Organs. 


Small  or  deformed  genitalia. 

Hermaphrodism. 

Cryptorchismus. 

Hypospadias. 

Epispadias. 

Defect,    or  great   volume   of 
prepuce. 

Torsion  of  prepuce. 

Imperforate  meatus. 

Labia  too  large  or  too  small. 

Clitoris  large. 

Labia  minora  hypertrophied. 

Folds  between  labia  majora 
and  minora. 

Labia  minora  pigmented,  par- 
ticularly in  brunettes. 

Imperforate  vulva. 

Atresia  of  vagina. 

Double  vagina. 

Uterus  bicornis. 

Atrophic  uterus. 

Muscular  Anomalies. 


Dystrophies. 

Depression  above  glabella  due 
to  overaction  of  corrugators. 


Unequal  innervation  of  facial 
muscles  on  the  two  sides. 


Anomalies  of  the  Skin. 


Polysarcia. 

Hypertrichosis      (superfluous 

hair) . 

Premature  grayness. 

Precocious  and   abnormal 

hairy  development. 

Rudimentary  tail. 

Glabrous  chin  (no  beard). 

Vitiligo. 

Absence  of  nails  or  fetal  state 

Melanism  of  skin. 

of  nails. 

Pigmented  or  vascular  na'vi. 

Molluscum. 

Pigmented  spots. 

Ichthyosis. 

350 


MEDICAL  DIAGNOSIS. 


Physiological  Stigmata. 

Anomalies  of  Motor  Function. 


Lefthandedness. 
Retardation    of    learning    to 

walk  and  talk. 
Nystagmus  (congenital) . 


Tremors. 
Epilepsy. 

Tics. —  Facial    spasm,    habit 
chorea,  tic  convulsif. 


Anomalies  of  Sensory  Function. 


Deaf -mutism. 

Neuralgia. 

Migraine. 

Constitutional  headaches. 

Hyperaesthesia. 

Angesthesia. 

Bhndness. 

Daltonism    (color-blindness, 

achromatopsia). 
Hemeralopia     (night-blind- 

Nyctalopia (day-blindness) . 

ness)  . 

Concentric  limitation  of  visual 
field. 

Anomalies  of  Speech. 


Mutism. 


Stammering. 
Stuttering. 


Defective  speech. 


Anomalies  of  Genito-urinary  Function. 


Sexual  irritability. 

Sterility. 
Amenorrhoea. 


Impotence. 

Urinary  incontinence. 


Anomalies  of  Instinct  or  Appetite. 


Gluttony. 
Rumination. 


Merycism. 

Uncontrollable  appetites  (nar- 
cotics) . 


Retardation  of  Puberty. 


Deficient  Vital  Activity  of  Organic  Functions. 


Weak  heart. 

Low  arterial  tension. 

Coldness  of  extremities. 

Flushing  of  extremities. 

General  chills  and  flushes. 

Weak  digestion. 

Constipation. 


Psychic  and  Psychoneurotic  Stigmata. 


Dementia  praecox. 
Mania  depressive. 
Hysteria. 
Phobia. 
Invalid  habit. 
Feeble-mindedness . 

Moral  delinquency. 
Precocity. 

Paranoia. 


Eccentricity. 


Compulsive  insanity. 
Melancholia. 
Hypochondria. 
Psychopathic  endowment. 
Idiocy. 


Sexual  perversion. 
Over-development  of  certain 

aptitudes. 
Ideo-obsessive  constitution. 


EXAMINATION  OF  THE  EYE. 


351 


X. 

THE  EXAMINATION  OF  THE  EYE. 


General  Considerations. 

The  close  relationship  existing  between  the  eye  and  the  nervous 
system,  the  opportunities  furnished  by  the  fundus  of  the  eye  to  study 
changes  in  the  general  circulatory  system,  and  the  knowledge  that  disturb- 
ances of  ocular  function  are  not  infrequently  the  underlying  cause  of 
systemic  affections,  render  a  study  of  the  ocular  apparatus  of  extreme 
importance  in  the  diagnosis  of  general  disease. 

It  must  be  remembered  that,  while  the  eye  is  the  organ  of  sight,  with 
its  own  special  function,  it  is  also  a  part  of  the  general  organism,  is  influ- 
enced by  the  status  of  the  whole  body,  is  disturbed  with  the  disturbance 
of  other  structures,  and  exhibits  in  a  marked  degree  affections  of  other 
organs  by  which  its  function  is  interfered  with. 

The  importance  of  the  thorough  analysis  of  the  ocular  comphcations  in 
all  diseases,  particularly  in  affections  of  the  brain  and  spinal  cord,  is  well  rec- 
ognized. An  examination  of  this  character,  to  be  effective,  must  be  systema- 
tized in  order  to  determine  the  actual  conditions  underlying  an  affection  of 
which  the  eyes  furnish  the  chief  manifestation;  in  what  respect,  if  any,  the 
ocular  functions  are  abnormal;  and  finally,  the  true  inference  to  be  drawn 
from  these  disturbed  functions  in  the  diagnosis  of  systemic  affections. 

1.  Inspection:  The  position  of  the  eyeballs  in  relation  to  the  orbital 
bones  is  observed  to  determine  any  undue  prominence  or  recession  of  one 
or  of  both  eyes;  any  abnormality  of  the  eyelids  as  evidenced  by  tumors, 
general  swelling,  drooping,  inability  to  close  the  lids,  inverted  margins, 
size  of  the  commissure,  and  the  presence  of  crusts  or  secretions  on  the 
margins;  congestion  of  the  blood-vessels,  or  granulations  or  new  growths 
on  the  conjunctiva;  the  size,  response  to  light  stimuli,  and  equality  or 
inequality  of  the  pupils,  and  variations  in  the  color  of  the  irides;  deviation 
of  the  visual  axes,  or  involuntary 
movement  of  the  eyeballs;  the  sensi- 
bility of  the  cornea  or  its  loss  of 
transparency;  and  the  depth  of  the 
anterior  chamber  and  any  turbidity 
of  its  fluid  contents. 

The  anterior  segment  of  the 
eyeball  is  most  satisfactorily  studied 
by  oblique  illu7nination.  The  patient 
is  placed  about  two  feet  from  the 
source  of  illumination.  The  exam- 
iner focusses  the  light  upon  the 
cornea  with  a  convex  lens  of  2-inch  or  3-inch  focus  held  between  the  thumb 
and  forefinger  of  the  right  hand,  and  studies  the  illuminated  area  through 
another  lens  of  similar  strength  held  between  the  thumb  and  forefinger  of  the 


Fig.    147 


-Ob'ique   or    focal    illumination. - 
Hausell   and    Sweet. 


-From 


352 


MEDICAL  DIAGNOSIS. 


left  hand,  the  second  finger  raises  the  upper  hd,  and  the  little  finger  resting 
upon  the  forehead  steadies  the  hand.  The  distance  of  the  second  lens  from 
the  eye  is  varied  slightly  to  bring  into  focus  the  cornea,  iris,  and  crystalline 
lens.  Opacities  of  the  cornea  or  lens,  as  seen  by  oblique  illumination, 
appear  as  gray  or  white  spots  upon  the  black  background  of  the  pupil. 

2.  Vision:  Decrease  in  the  normal  acuteness  of  vision  of  each  eye 
as  measured  by  test  letters  for  near  and  far  is  to  be  noted;  the  history  of 
the  decline,  and  its  association  with  pain  or  inflammation  of  the  external 
structures;  any  departure  from  the  normal  field  of  vision  must  be  recorded; 
contraction  of  the  peripheral  limits  for  form  and  color,  areas  of  deficient  or 
lost  perception,  and  reversal  in  the  order  of  the  color  fields. 

3.  Ophthalmoscopic  Examination:  Two  methods  are  employed  in 
the  examination  of  the  deeper  structures  of  the  eye  by  the  ophthalmo- 
scope— the  Direct  Method,  which  gives  an  upright  image  of  the  eyeground, 

and  the  Indirect,  in  which  the  image 
is  inverted.  In  both  the  patient  is 
seated  in  a  darkened  room  with  his 
back  to  the  source  of  illumination, 
and  the  observer  is  to  the  side  to 
be  examined.  B}"  the  direct  method 
the  examiner  approaches  close  to  the 
side  of  the  patient's  head,  using  his 
eye  corresponding  to  the  eye  under 
examination,  and  reflects  the  light 
by  means  of  the  ophthalmoscopic 
mirror  into  the  eye.  The  rays  from 
the  fundus  are  reflected  back,  and, 
passing  through  the  opening  in  the 
mirror  enter  the  observer's  eye,  giv- 
ing an  upright  image  of  the  eyeground.  The  optic  nerve  is  best  seen 
when  the  patient  looks  at  a  distant  object  to  the  side  and  beyond  the 
observer's  head.  The  fovea!  region  is  brought  into  view  when  the  patient's 
gaze  is  directed  into  the  aperture  of  the  mirror.  By  the  indirect  method 
the  observer,  about  15  to  20  inches  in  front  and  to  the  side  of  the  patient, 
reflects  the  light  through  a  convex  lens  of  about  2-inch  focus  held  at 
its  focal  length  from  the  eye,  and  secures  an  aerial  image  focussed  by 
the  strong  glass.  In  case  the  details  of  the  fundus  are  not  at  first  plainly 
seen  the  object  lens  is  slightly  advanced  or  withdrawn  from  the  eye. 
Strain  on  the  examiner's  accommodation  is  reheved  by  a  +4  D.  lens 
rotated  before  the  sight-hole  of  the  ophthalmoscope. 

The  normal  eye  presents  many  variations  from  the  typically  pictured 
fundus,  and  extended  experience  is  necessary  to  distinguish  the  variations  in 
health  from  the  changes  wrought  by  disease.  The  color  of  the  fundus  reflex  is 
a  bright  pink  or  red,  due  to  the  reflected  light  from  the  choroidal  vessels  and 
the  pigment  of  the  retina  and  choroid.  In  the  negTO  the  reflex  is  grayish,  be- 
cause of  the  absorption  of  the  light  rays  by  the  abundant  pigment.  The  optic 
disk,  or  nerve  head,  lies  to  the  nasal  side  of  the  posterior  pole,  and  is  round  or 
oval,  with  clear  cut  edges,  often  fringed  with  choroidal  pigment.  The  nerve 
is  often  cupped  in  the  centre,  at  which  point  the  central  artery  and  vein 


Pig.  148. — Ophthalmoscopic  examination  by  direct 
method. — From  Hansell  and  Sweet. 


PLATE  VIII. 


[Varieties  of  the  Normal  Fundus.— After  Wurdemann  in  Posey  and  Spiller. 
A,  alblnotic   fundus;    albino  and   light  blonde   (after  Greef,  modified  by  Wiirdemann) .    B,  the 
tessellated  fundus;  brunette  (after  Greef,  modified  by  Wurdemann).    C,  the  negroid  fundus ;  negro 
(Wiirdemann).    D,  the  yellow  fundus ;  Chinese  (after  Oeller,  modified  by  Wurdemann.— DJ . 


EXAMINATION  OF  THE  EYE. 


353 


pass.  The  artery  and  vein  divide  into  two  main  branches,  and  these  sub- 
divide into  the  numerous  smaller  vessels.  The  fovea,  with  its  central 
yellow  spot,  is  the  most  sensitive  part  of  the  retina.  It  is  about  3  mm. 
to  the  temporal  side  of  the  nerve,  and  is  darker  than  the  rest -of  the  retina. 
In  this  region  no  blood-vessels  are  to  be  seen  by  the  ophthalmoscope. 

4.  Pain:  The  character  of  the  pain  should  be  known,  its  situation,  its 
dependence  on  the  use  of  the  eyes,  and  its  association  with  tenderness  in 
the  region  of  the  orbit,  particularly  at  the  points  of  exit  of  the  supra-orbital 
or  infra-orbital  nerves. 

5.  Headache  is  one  of  the  most  prominent  symptoms  of  eyestrain.  It 
is  dull  and  heavy,  usually  bilateral,  increased  by  application  to  close  work, 
riding  in  cars  and  shopping,  and  sometimes  accompanied  by  pain  in  the  eye- 
balls. It  is  to  be  distinguished  from  the  sharp  periodic  attacks  of  pain 
characteristic  of  neuralgia  of  the  first  and  second  divisions  of  the  5th  nerve. 

Affections  of  the  nasal  tissues,  as  deflections  of  the  septum  and 
purulent  collections  in  the  frontal  sinus,  cause  headache  which  resem- 
bles that  of  eyestrain.  The  diag- 
nosis of  nasal  and  sinus  headache 
is  made  by  its  longer  duration,  its 
association  with  manifest  symptoms 
of  nasal  trouble,  and  its  independ 
ence  of  use  of  the  eyes. 

Asthenopia  from  general 
muscle  weakness  is  present  during 
convalescence  from  acute  fevers  or 
prolonged  illnesses,  and  attempts  at 
reading  are  often  followed  by  head- 
ache, blurring  of  sight,  and  pain  in 

the  eyes  and  head.  DeSchweinitz  refers  to  a  peculiar  form  of  asthenopia  seen 
after  the  presbyopic  age,  most  frequently  in  women,  which  is  not  relieved 
by  glasses  or  treatment  of  muscular  anomalies.  These  patients  present 
the  ordinary  symptoms  of  neurasthenia,  doubtless  the  outcome  of  begin- 
ning arteriosclerosis,  and  proper  tests  usually  show  high  arterial  tension, 
which,  if  reduced  by  appropriate  dietetic  and  medicinal  measures,  will 
cause   a   disappearance  of  the  asthenopia. 

6.  Photophobia  is  a  symptom  of  affections  of  the  cornea  and  iris, 
of  a  few  diseases  of  the  retina,  and  in  many  cases  of  uncorrected  refractive 
errors  and  muscular  anomalies.  As  an  isolated  symptom  it  possesses 
little  importance  in  arriving  at  a  differential  diagnosis  of  ocular  affections. 

7.  Epiphora:  Increase  in  the  flow  of  tears  is  seen  in  exophthalmic 
goitre,  in  certain  affections  of  the  central  nervous  system  (locomotor 
ataxia),  and  in  obstruction  of  the  lachrymal  duct. 


Fig.  149. — Ophthalmoscopic  examination  by  indirect 
method. — From  Hansell  and  Sweet. 


The  Eyeball  and  Orbit. 

Protrusion  of  the  eyeball — exophthalmos,  proptosis — may  be  caused 
by  tumors,  aneurisms,  hemorrhage,  exostoses,  and  growths  or  inflamma- 
tions originating  in  or  extending  to  the  orbit  from  the  adjacent  sinuses; 
by  orbital  cellulitis  and  paralysis  of  the  ocular  muscles. 
23 


354  MEDICAL  DIAGNOSIS. 

Bilateral  exophthalmos,  varying  from  a  slight  prominence  of  the 
eyeballs  to  a  protrusion  that  prevents  the  closure  of  the  eyelids,  is  found 
in  exophthalmic  goitre.  Widening  of  the  palpebral  fissure  from  nervous 
affections,  with  undue  exposure  of  the  sclera,  will  give  the  impression 
of  exophthalmos. 

Proptosis  associated  with  deep-seated  pain  upon  attempts  to  move 
the  eyeball,  hmited  or  complete  immobility  of  the  globe,  and  swelling 
and  oedema  of  the  eyelids,  which  may  be  so  great  as  to  prevent  opening 
of  the  Uds,  is  found  in  orbital  celluhtis,  facial  erysipelas,  meningitis,  in 
general  septicaemia,  or,  in  less  degree,  after  scarlatina,  typhoid  fever,  and 
influenza.  Purulent  inflammation  of  the  adjacent  sinuses  may  lead  to 
the  same  symptoms. 

Sudden  exophthalmos  in  infants,  with  the  eyeballs  turned  down, 
points  to  the  possibility  of  the  existence  of  scurvy.  The  protrusion  may 
be  moderate  at  first  and  increase  during  24  hours  and  be  associated  at  its 
height  with  thickening  and  ecchymosis  of  the  upper  lid.  The  subperi- 
osteal hemorrhage  to  which  the  affection  is  due  may  affect  both  orbits, 
but  unequally.     The  eyeball  is  freely  movable. 

Pulsating  exophthalmos,  usually  unilateral,  most  frequently  follows 
traumatism,  and  is  found  in  arteriovenous  aneurism  of  the  internal  carotid 
and  cavernous  sinus  or  aneurism  of  the  ophthalmic  artery. 

Abscess  of  the  frontal  sinus  may  cause  displacement  of  the  eyeball 
downwards  and  outwards,  with  diplopia.  In  purulent  disease  of  the  frontal 
and  ethmoidal  sinuses  a  small  fluctuating  swelhng  may  appear  at  the 
upper  and  inner  angle  of  the  orbit,  which  breaks  and  discharges  pus. 
Gradual  displacement  of  the  eyeball  forward  may  be  the  result  of  an  orbital 
tumor  within  the  cone  of  muscles. 

Exophthalmic  Goitre. — One  of  the  earlier  signs  is  lagging  of  the  upper 
lid  when  the  eyes  are  slowly  rotated  downwards  (Graefe's  sign).  There  is 
also  imperfect  power  of  winking  (Stellwag's  sign);  retraction  of  the  upper 
lid  and  widening  of  the  palpebral  fissure  (Dalrymple's  sign),  and  imperfect 
power  of  convergence  of  the  eyes. 

Involuntary  resistance  to  eversion  of  the  upper  eyelids  is  believed 
by  Gifford  to  be  one  of  the  earhest  symptoms  of  Graves's  disease.  It  tends 
to  disappear  with  the  development  of  the  disease,  and  is  explained  by 
hyperexcitability  of  Miiller's  muscle  through  the  sympathetic.  Gifford 
also  attaches  importance  to  swelling  of  the  tissues  between  the  eyebrow 
and  eyelid  as  an  early  diagnostic  sign  of  the  disease. 

Retraction  of  Eyeball. — Enophthalmus,  or  sinking  of  the  eye  into 
the  orbit,  occurs  in  some  instances  in  extreme  emaciation  from  absorption 
of  orbital  fat,  in  paralysis  of  the  sympathetic,  in  facial  hemiatrophy,  and 
from  traumatism.  Since  the  amount  of  exposed  sclera  determines  the 
apparent  recession  of  the  globe,  the  examiner  may  be  misled  into  mistak- 
ing the  widened  commissure  of  tabes  or  other  nerve  disease  for  enophthal- 
mus. Traumatism  in  the  vicinity  of  the  orbit  is  sometimes  followed  by 
an  actual  enophthalmus,  which  may  be  immediate,  or  be  delayed  for  several 
weeks  or  months. 

Nystagmus  is  a  series  of  involuntary,  regular,  and  rapid  oscillations 
of  the  eyes.     These  movements  may  be  horizontal,  vertical,  or  rotary,  or 


EXAMINATION  OF  THE  EYE.  355 

a  combination  of  all  three.  Unilateral  nystagmus  is  rare.  The  lateral 
oscillation  is  the  most  common.  Congenital  nystagmus  i.-^  found  in  children 
with  congenital  cataract,  dense  central  corneal  opacity,  or  imperfectly 
developed  eyeballs,  and  in  albinism.  Miner's  nystagmus  is  an  acquired 
form,  which  is  probably  due  to  the  prolonged  upward  inclination  of  the 
eyes  in  semi-darkness.  Nystagmus  may  be  a  symptom  of  irritation  or 
diseases  of  the  inner  ear,  of  tumors  of  the  cerebellum,  multiple  sclerosis, 
hereditary  ataxia,  and  of  syringomyelia. 

In  multiple  sclerosis  and  in  hereditary  ataxia  the  nystagmus  occurs 
only  when  the  eyes  are  turned  in  the  direction  of  a  moving  object,  and 
particularly  as  the  eyes  reach  the  limit  of  their  rotation  in  the  lateral 
plane.     A  slight  nystagmus  is  occasionally  found  in  hysteria. 

Tension." — In  the  normal  eyeball  the  tension  of  the  globe,  as  measured 
by  the  pressure  of  the  two  index  fingers  upon  the  sclera  through  the  closed 
lid,  presents  a  uniform  resistance.  Increase  in  the  intra-ocular  tension 
occurs  in  acute  glaucoma,  in  some  forms  of  iridocyclitis,  and  occasionally 
after  traumatism.  Lowered  tension  may  result  from  degeneration  of  the 
ciliary  body  and  choroid,  in  rupture  of  the  globe,  detachment  of  the  retina 
and  after  operations. 

The  Eyelids. 

Marginal  Inflammation. — Red,  moderately  swollen  lid  margins,  asso- 
ciated with  heat,  burning  and  photophobia,  are  seen  in  persons  exposed  to 
cold  winds  and  dust,  in  children  affected  with  nasopharyngeal  inflammation 
following  measles,  and  as  a  result  of  the  strain  of  uncorrected  refractive 
errors.  In  severe  types  of  the  disease  the  lid  margins  are  covered  with 
hardened,  yellowish  crusts  which,  upon  removal,  expose  ulcers  extending 
deep  into  the  lid  border. 

Redness  and  itching  of  the  lid  margins  in  children  may  be  due  to 
the  presence  of  the  pediculus  pubis  in  the  eyelashes.  Close  examination 
will  show  the  eggs  upon  the  cilia,  and  the  parasite  partly  buried  in  the 
hair  follicle. 

Inversion  of  the  lashes  or  of  the  lid  border  is  most  commonly  caused 
by  chronic  inflammation  of  the  bulbar  conjunctiva.  The  irritation  of  the 
misplaced  cilia  ultimately  leads  to  inflammation  and  haziness  of  the 
cornea.  Eversion  of  the  lid  may  follow  burns  or  wounds,  with  subse- 
quent cicatricial  contraction  of  the  skin;  appears  as  a  senile  condition, 
from  loss  of  muscle  power;  or  accompanies  facial  palsy.  The  lower  lid 
is  most  frequently  affected. 

CEdema  of  the  lids  accompanies  severe  inflammation  of  the  conjunc- 
tiva, purulent  disease  of  the  eyeball,  orbit  or  frontal  or  ethmoidal  sinuses, 
and  general  affections  like  nephritis  and  gout. 

Localized  swelling  of  the  eyelids  and  conjunctiva,  with  or  without 
vascular  changes  of  the  eyeball,  is  seen  in  neurotic  oedema,  urticaria,  and 
disease  of  the  antrum,  or  may  be  due  to  errors  of  diet.  The  swelling  may 
be  sufficient  to  completely  close  the  eye,  and  is  accompanied  by  itching 
and  burning.     In  a  few  days  the  parts  return  to  the  normal. 

A  locahzed  painful  swelling  of  the  fid  and  discoloration  of  the  skin 
may  be  either  a  st3'-e  {hordeolum)  or  an  abscess  of  the  fid  (phlegmon).    The 


356  MEDICAL  DIAGNOSIS. 

pain  is  severe  and  is  frequently  accompanied  by  swelling  of  the  entire  lid 
and  oedema  of  the  conjunctiva.  Styes  are  situated  in  the  connective  tissue 
near  the  lid  margin  and  are  apt  to  recur  in  persons  with  deranged  bodily 
functions,  and  in  those  who  suffer  from  uncorrected  refractive  errors. 

Swelling  of  the  lid,  appearing  suddenly  after  injury,  and  increasing 
upon  blowing  the  nose,  the  soft  mass  crackhng  on  pressure,  is  caused  by 
the  presence  of  air  which  has  escaped  into  the  cellular  tissue  through  a 
fracture  of  the  orbital  wall  (emphysema). 

Inflammation  of  the  tarsus  (tarsitis),  usually  monocular,  may  be 
syphilitic,  gouty  or  tubercular.  The  Hd  is  swollen  and  drooping  and  can- 
not be  raised  by  the  levator  palpebrarum  muscle. 

Sebaceous  cysts  occur  both  on  the  eyelids  and  in  the  eyebrow.  An 
accumulation  of  secretion  in  the  sebaceous  glands  of  the  lids  appears  as 
small  yellowish  elevations  which  develop  about  the  age  of  puberty,  and  are 
due  to  improper  care  of  the  skin  or  to  gastro-intestinal  disorders.  Mol- 
luscum  contagiosum  is  a  disease  of  the  sebaceous  glands  which  occurs 
among  ill-nourished  children.  It  is  characterized  by  waxy-colored,  rounded 
papules,  the  size  of  a  pea. 

Erysipelas  attacks  the  lids  by  extension  from  the  adjoining  skin  of 
the  face.  The  typical  shiny,  dusky  swelling,  with  the  subsequent  develop- 
ment of  small  vesicles,  serves  to  distinguish  it  from  other  affections.  Severe 
attacks  may  affect  the  orbital  tissues  and  cause  optic  nerve  atrophy  and 
fatal  meningitis. 

Syphilis  may  appear  either  as  a  primary  sore,  or  as  a  secondary  disease, 
and  is  usually  located  at  the  Hd  border.  The  ulceration  and  induration 
present  the  typical  features  of  a  chancre.  It  may  be  mistaken  for  an 
epithelioma,  but  the  improvement  under  antisyphilitic  treatment  clears 
up  the  diagnosis. 

Herpes  Zoster. — Violent  paroxysmal  pain,  associated  with  a  vesicular 
eruption  on  the  skin  of  the  Hd,  forehead  and  occasionally  the  side  of  the 
nose,  is  indicative  of  herpes  zoster  ophthalmicus.  The  vesicles  vary  in  size, 
have  an  inflamed  base,  and  are  situated  over  the  region  supplied  by  the 
first  and  second  division  of  the  fifth  nerve.  Corneal  ulcers  and  iritis  show 
ocular  involvement.     Depressed  nutrition  is  a  common  cause. 

Xanthelasma. — YeUowish  irregular  shaped  patches  of  connective 
tissue,  located  in  the  upper  eyeHds  near  the  internal  canthus,  are  termed 
xanthelasma.  Rarely  they  form  on  the  lower  Hds.  The  growth  causes 
no  trouble,  and  is  probably  due  to  local  iU  nutrition. 

Chalazion. — A  smaU  round  elevation  of  either  the  upper  or  lower  Hd, 
of  slow  growth,  with  the  skin  freely  movable  over  the  hardened  tumor, 
and  a  purplish  discoloration  of  the  surface  of  the  conjunctiva  immediately 
beneath,  is  termed  a  chalazion.  It  is  due  to  inflammation  of  a  Meibomian 
gland,  with  retention  of  the  secretion.  Inflammation  of  the  Hd  margins 
and  the  strain  of  ametropia  may  be  causative  factors. 

Inflammation  of  the  Lachrymal  Sac. — A  small  tumor  near  the  inner 
surface  of  the  lower  Hd  over  the  lachrymal  sac,  which  disappears  upon  pres- 
sure, with  the  escape  of  a  viscid  mucus  through  the  puncta,  is  due  to 
catarrhal  inflammation  of  the  sac.  The  secretion  may  become  purulent, 
with  severe  pain,  and  intense  swelling  and  redness  of  the  skin  somewhat 


EXAMINATION  OF  THE  EYE.  357 

resembling  erysipelas.  In  both  the  chronic  and  acute  forms  the  tears 
flow  over  the  cheek.  A  swelling  at  the  upper  and  inner  angle  of  orbit, 
due  to  sinus  disease,  has  been  mistaken  for  lachrymal  abscess. 

Ptosis. — Drooping  of  the  eyelid,  partially  or  completely  covering  the 
cornea,  may  be  either  congenital,  or  due  to  injury  to  the  levator  muscle,  to 
thickening  of  the  tissues  of  the  lid,  or  to  paralysis  of  the  third  nerve.  A  form 
of  hysterical  ptosis  due  to  spasm  of  the  orbicularis  muscle  has  been  described. 

Lagophthalmos,  or  inability  to  close  the  eyelid,  may  be  congenital, 
but  is  usually  an  accompaniment  of  paralysis  of  the  facial  nerve.  Marked 
protrusion  of  the  eyeball,  mechanically  preventing  closure  of  the  lid,  is 
seen  in  orbital  tumors,  exophthalmic  goitre,  and  in  corneal  staphyloma. 

Blepharospasm,  or  an  involuntary  contraction  of  the  eyelids,  may 
vary  in  degree  from  a  slight  twitching  of  a  few  of  the  fibres  of  the  orbicu- 
laris to  a  tonic  spasm.  In  its  simplest  form  it  is  due  to  uncorrected  refrac- 
tive errors,  inflammation  of  the  lid  borders,  and  corneal  and  conjunctival 
irritation.  Obstinate  cases  of  cramp  of  the  orbicularis  arise  from  reflex 
irritation  of  the  fifth  nerve,  through  some  remote  cause  that  it  is  often 
difficult  to  determine.     It  is  occasionally  a  hysterical  manifestation. 

Conjunctiva  and  Sclera. 

The  white  of  the  conjunctiva  changes  to  a  dull  yellow  in  so-called  bilious- 
ness, and  to  a  pronounced  brownish-yellow  color  in  icterus.  In  anaemia, 
tuberculosis,  and  nephritis  the  conjunctiva  may  become  pearly  white. 

Inflammation. — The  normal  conjunctiva  is  coursed  by  a  few  small 
blood-vessels  which  arise  from  the  deep  furrow  where  the  membrane  is 
reflected  to  the  under  surface  of  the  lids.  Redness  is  the  result  of  a  marked 
increase  in  the  number  of  blood-vessels  from  inflammation  of  the  conjunc- 
tiva, or,  as  this  membrane  covering  the  eyeball  is  transparent,  to  con- 
gestion of  the  deep  sclera  beneath. 

Hyperemia  of  the  conjunctiva  is  seen  in  measles,  scarlet  fever,  hay 
fever,  influenza,  nasal  catarrh,  the  strain  of  uncorrected  refractive  errors 
and  from  exposure  to  wind,  dust,  and  bright  light  and  heat.  The  con- 
junctiva is  often  inflamed  in  facial  paralysis,  owing  to  the  inability  of  the 
lids  to  protect  the  globe  from  external  irritants.  The  presence  of  a  foreign 
bod}^  on  the  conjunctiva  or  cornea  causes  many  of  the  characteristic  symp- 
toms of  an  acute  catarrhal  conjunctivitis. 

The  ordinary  conjunctival  inflammations  are  unattended  with  severe 
pain,  but  are  accompanied  with  a  mucous  or  mucopurulent  discharge. 
In  inflammation  of  the  sclera,  the  affected  area  is  seen  to  be  beneath  the 
loose  conjunctiva,  while  in  disease  of  the  iris,  ciliary  body  or  cornea,  a 
ring  of  fine  straight  vessels  surrounds  the  corneal  border.  In  these  latter 
affections,  pain  is  often  quite  severe.  Since  the  conjunctiva  may  be  also 
inflamed  in  disease  of  these  deeper  structures,  a  diagnosis  cannot  be  made 
by  the  appearance  of  congestion  only. 

A  type  of  contagious  conjunctivitis  (acute  contagious  conjunctivitis) 
is  due  to  the  Koch-Weeks  bacillus  or  to  the  pneumococcus.  A  subacute 
form  of  conjunctival  inflammation,  which  may  occur  in  epidemic  form,  is 
caused  by  the  diplobacillus  of  Morax  and  Axenfeld.     Severe  inflamma- 


358  MEDICAL  DIAGNOSIS. 

tion,  with  swelling  of  lids,  infiltration  of  the  conjunctiva,  and  a  purulent 
discharge,  occurs  from  the  entrance  of  infection,  usually  the  gonococci, 
into  the  eyes  of  the  child  from  the  birth  canal  (ophthalmia  neonatorum). 
A  similar  form  of  inflammation  follows  the  entrance  of  gonorrhoea!  pus 
into  the  conjunctival  sac  of  the  adult  (gonorrhoeal  conjunctivitis). 

Diphtheria  of  the  conjunctiva  is  rare.  A  membrane  forms  on  the 
surface  of  the  conjunctiva,  presenting  the  same  characteristics  as  that 
found  in  the  throat.  A  pseudomembranous  conjunctivitis  may  be  due 
to  the  pneumococcus  or  to  streptococcus  infection,  and  to  some  of  the 
other  micro-organisms  found  in  the  ordinary  types  of  inflammation. 

Roughness  or  elevation  of  the  conjunctiva  of  the  hds  may  indicate 
trachoma  or  vernal  catarrh.  Distended  and  tortuous  vessels  in  the  con- 
junctiva may  be  due  to  constipation,  auto-intoxication,  chronic  alcoholism 
or  lithsemia. 

Single  or  multiple  blebs  appear  on  the  conjunctiva  in  badly  nourished 
children,  often  after  measles.  Eczema  of  the  nares  and  disease  of  the 
nasopharynx  are  usually  coexistent. 

Hemorrhage  beneath  the  conjunctiva  appears  in  injuries  of  the  head, 
and  also  in  severe  compression  of  the  abdomen.  It  is  not  uncommon  in 
whooping-cough,  after  severe  vomiting,  and  in  obstinate  constipation, 
the  straining  causing  a  rupture  of  one  of  the  conjunctival  vessels.  Spon- 
taneous hemorrhage  in  the  aged,  especially  if  recurrent,  should  direct 
attention  to  the  possibility  of  disease  of  the  blood-vessels  and  to  nephritis. 

Uric  acid  deposits  are  frequently  found  in  the  conjunctiva  of  the 
lids  of  gouty  individuals. 

Tumors  and  cysts  of  various  kinds  may  appear  in  the  conjunctiva  of 
the  eyeball.  Small,  yellowish  elevations  are  found  near  the  cornea,  usually 
at  the  inner  portion,  but  are  of  little  significance.  A  fleshy  fan-shaped 
growth  is  often  seen  in  persons  past  40  years  whose  eyes  have  been  sub- 
jected to  long  exposure  to  wind,  dust  or  sand.  The  usual  situation  is  over 
the  internal  rectus  muscle,  the  apex  often  extending  upon  the  cornea.  Most 
of  the  malignant  growths  appear  at  the  junction  of  the  sclera  and  cornea. 

Inflammation  of  the  sclera  is  found  in  association  with  the  rheu- 
matic and  gouty  diathesis,  in  scrofula,  intestinal  disorders  and  in  syphilis. 
In  the  superficial  form  of  inflammation  (episcleritis)  there  is  usually  a 
circumscribed  area  of  purpHsh  discoloration  beneath  the  conjunctiva, 
most  frequently  in  the  region  of  the  external  rectus  muscle,  and  slightly 
raised  above  the  healthy  sclera.  In  disease  of  the  true  sclera  (scleritis) 
the  inflammation  may  affect  the  entire  anterior  portion,  and  extend  to  the 
cornea,  iris,  and  ciliary  body.  Affections  of  sclera  are  distinguished  from 
conjunctivitis  by  the  engorgement  of  the  deeper  vessels,  the  purplish  color, 
the  severe  pain,  the  absence  of  discharge,  and  the  frequent  relapses. 

Cornea. 

Keratitis. — The  cornea  is  subject  to  both  ulcerative  and  non-ulcera- 
tive  affections. 

Ulcerative  Keratitis. — Loss  of  sensibility  of  the  cornea,  with 
subsequent  ulceration  and  destruction,  is  found  in  affections  of  the  trunk 


EXAMINATION  OF  THE  EYE.  359 

of  the  fifth  nerve  or  of  its  ganghon,  or  after  removal  of  the  latter  for 
trifacial  neuralgia.  The  corneal  affection  is  due  to  a  trophic  change  in 
the  membrane  and  to  the  irritation  of  foreign  substances,  which  are  not 
recognized  by  the  insensitive  cornea. 

A  severe  type  of  corneal  ulceration,  which  may  progress  to  perforation, 
is  found  in  association  with  herpes  of  the  region  about  the  eyes,  particularly 
of  the  lachrymal  branch  of  the  trifacial.  The  disease  is  preceded  by  severe 
burning  and  neuralgic  pain,  in  isolated  spots,  upon  which  are  developed 
the  characteristic  vesicles. 

Chronic  malarial  keratitis  attacks  the  superficial  layers  of  the  cornea, 
is  characterized  by  anaesthesia  of  the  cornea  and  tenderness  over  the  supra- 
corneal  notch.  The  ulcer  is  narrow,  with  offshoots  resembling  the  veins 
of  a  leaf  (dendritic  keratitis).  The  disease  is  rare,  however,  even  in 
malarious  districts. 

Small  blebs,  which  later  break  down  into  ulcers,  are  located  either  on 
the  cornea  or  at  the  junction  of  the  cornea  and  the  sclera  in  strumous 
children,  and  are  associated  with  inflammatory  diseases  of  the  nasal  pas- 
sages, often  following  the  exanthematous  fevers.  Eczema  about  the 
nares  is  usually  coexistent.  Abscess  and  ulceration  may  occur  during 
convalescence  from  measles,  smallpox,  scarlet  fever  and  other  toxic  diseases. 
Exophthalmic  goitre  may  give  rise  to  extensive  ulceration  owing  to  con- 
stant exposure  of  the  cornea  through  inability  to  close  the  lids  over  the 
globe.  An  extensive  ulceration  of  the  centre  of  the  cornea  may  follow  the 
exhaustion  of  a  prolonged  diarrhoea  or  dysentery  or  similar  debilitating 
illness  in  the  aged. 

Interstitial  Keratitis. — Inflammation  of  the  deeper  layers  of  the 
cornea,  without  ulceration,  is  frequently  seen  in  children,  between  5  and 
15  years  of  age,  who  have  inherited  syphilis,  and  also  in  tubercular,  scrofu- 
lous, and  other  poorly  nourished  individuals.  In  its  earliest  stage  the  con- 
gestion surrounding  the  cornea  is  of  the  deep  vessels,  there  is  dread  of 
light,  and  close  examination  shows  a  fine  dot-like  infiltration  of  the  inter- 
stitial layers  of  the  cornea,  which  later  coalesce  into  the  typical  bluish 
white  haziness.  The  affection  is  bilateral,  although  months  may  elapse 
before  the  second  eye  is  affected. 

Arcus  Senilis. — A  circle  of  fatty  degeneration  close  to  the  cornea, 
but  with  a  clear  ring  separating  it  from  the  junction  of  the  cornea  and 
sclera  is  present  in  the  eyes  of  persons  of  advanced  years.  It  possesses 
no  significance.  A  senile  atrophy  of  the  margin  of  the  cornea  has  been 
described  in  association  with  arcus  senilis. 

Partial  insensibility  of  the  cornea  is  seen  in  exophthalmic  goitre,  and 
its  presence  probably  explains  a  number  of  the  other  eye  symptoms. 

The   Iris  and  Pupil. 

Pigmentation. — Slight  variation  in  the  pigmentation  of  the  irides  is 
not  uncommon  in  health,  but  difference  in  color  is  rare,  except  in  disease. 
A  yellow  green  color  of  one  iris,  while  the  other  is  blue  or  brown,  is  an  early 
evidence  of  inflammation  of  the  iris  and  ciliary  body.  Retained  metallic 
foreign  bodies  often  cause  the  iris  to  assume  the  brownish  hue  to  which 


360  MEDICAL  DIAGNOSIS. 

the  term  siderosis  is  given.  Inflammation  of  the  iris  occurs  in  syphilis, 
rheumatism,  gout,  tuberculosis,  diabetes,  and  from  injuries,  primarily  in 
one  eye,  or  in  the  fellow  eye  from  sympathy.  Inflammation  is  accompanied 
by  irregularity  and  contraction  of  the  pupil,  injection  of  the  pericorneal  ves- 
sels, and  frontal  pains,  usually  worse  at  night.  SweUing  in  the  stroma  of  the 
iris  is  a  sign  of  tertiary  syphilis.     Sarcoma,  as  a  primary  disease,  is  rare. 

The  Pupil. — Variations  in  the  size  of  the  pupil  occur  under  the  influ- 
ence of  light,  and  in  convergence  and  accommodation.  The  average  size 
of  the  pupils,  in  diffuse  daylight,  with  the  eyes  fixed  on  a  distant  point, 
is  4  mm.  Careful  tests  of  changes  in  the  pupils  are  of  importance  in  the 
diagnosis  of  general  affections,  particularly  of  the  nervous  system. 

The  normal  reactions  are  as  follows: 

1.  Direct  Reaction. — If  one  eye  is  excluded,  and  the  patient  directed 
to  fix  a  distant  object,  the  pupil  of  the  exposed  eye,  when  covered  by  the 
hand  or  card,  will  dilate.  Upon  removal  of  the  cover  it  will  contract  to 
its  previous  size. 

2.  Indirect  Reaction  (Consensual  Reflex).— If  one  eye  is  shaded, 
the  other  pupil  will  dilate  equally  with  the  shaded  pupil,  to  again  contract 
when  the  shade  is  removed.  Normally  the  two  pupils  should  be  of  equal 
size,  whether  one  or  both  is  covered  or  uncovered. 

3.  Associated  Reaction  (Reflex  to  Accommodation  and  Con- 
vergence).— The  patient  is  directed  to  look  into  the  distance  and  then 
converge  the  eyes  on  a  point,  such  as  a  pencil,  held  about  5  inches  from  the 
eye.  The  pupils  contract  under  the  influence  of  the  convergence  and 
accommodation. 

4.  Sensory  Reaction  (Skin  Reflex). — Stimulation  of  the  sensory 
nerves  of  the  skin,  by  pinching  the  skin  of  the  neck,  or  by  the  passage  of 
a  faradic  brush  along  the  spine,  causes  slight  dilatation  of  the  pupils. 

5.  Orbicularis  Pupillary  Reaction  (Lid-closure  Reflex). — 
Contraction  of  the  pupils  occurs  upon  forcible  efforts  to  close -the  lids. 

6.  Drug  Reaction. — Dilatation  of  the  pupil  (mydriasis)  follows  the 
instillation  of  mydriatic  drugs,  and  contraction  of  the  pupil  (myosis)  the 
instillation  of  myotics. 

7.  Cerebral  Cortex  Pupillary  Reflex. — Haab  describes  a  reflex 
to  which  this  term  has  been  given.  He  found  that  if  a  patient  seated  in 
a  dark  room,  with  the  eyes  fixed  at  the  black  wall,  and  a  light  placed  to 
shine  laterally  into  the  eyes,  is  requested  to  direct  his  attention  to  the  light, 
without  changing  the  position  of  the  eyes,  the  pupils  will  contract.  Since 
the  accommodation  remains  suspended,  and  the  light  entering  the  eye  is 
unchanged,  the  contraction  of  the  pupil  is  in  some  manner  connected  with 
the  power  of  attention,  and  Haab,  therefore,  believes  the  test  should  be 
made  in  every  case  of  .nervous  disorder. 

Myotic  Pupillary  Tract. — Stimulation  of  the  centre  for  the  third 
nerve,  by  the  action  of  light  passing  along  the  optic  nerve  and  optic 
tracts,  causes  an  impulse  to  pass  to  the  lenticular  ganglion,  and  thence 
by  the  short  ciliary  nerves  to  the  sphincter  of  the  pupil,  which  contracts, 
lessening  the  size  of  the  pupil. 

Mydriatic  Pupillary  Tract. — The  dilator  muscle  of  the  iris  is 
innervated  by  the  sympathetic.     The  impulse  passes  from  the  medulla 


EXAMINATION  OF  THE  EYE,  361 

into  the  cord,  thence  through  the  first  three  dorsal  nerves  to  the  superior 
cervical  ganglion,  to  the  plexus  around  the  internal  carotid,  and  through 
the  long  ciliary  nerves  to  the  ciliary  muscle  and  iris.  Stimulation  of  the 
centres  of  this  tract  causes  dilatation  of  the  pupil. 

Abnormal  Pupillary  Reactions. — Failure  of  the  pupil  to  react,  either 
wholly  or  in  part,  is  due  to  a  lesion  in  the  iris,  in  some  part  of  the 
third  nerve,  in  the  centres  of  the  brain,  or  in  the  light-conducting  paths. 
Lesions  in  the  iris  may  be  swelling  or  atrophy,  or  old  or  recent  attach- 
ments from  inflammation.  Immobility  to  light  stimulus,  with  preser- 
vation of  the  reflex  to  accommodation,  is  one  of  the  important  abnormal 
pupillary  changes. 

Reflex  Immobile  Pupil  (Argyll-Robertson  Pupil).  —  Loss  of 
reaction  of  the  pupil  to  direct  light,  with  preservation  of  the  contraction 
of  the  iris  in  accommodation  and  convergence,  comprises  the  well-known 
Argyll-Robertson  pupil,  and  is  an  early  symptom  of  tabes.  Although  of 
great  diagnostic  value  when  present, — and  in  the  majority  of  cases  it 
exists  in  the  incipient  stages  of  the  disease,  —  there  are  rare  instances  in 
which  it  has  not  been  found,  even  when  all  other  symptoms  of  the  disease 
have  existed  for  years.  Associated  with  lost  light  reflex  is  frequently  noticed 
alteration  in  the  shape  of  the  pupil.  The  pupil  may  be  of  normal  size,  but 
more  often  myosis  is  found,  from  implication  of  the  cervical  portions  of 
the  cord  controlling  the  dilating  centres.  The  Argyll-Robertson  pupil- 
lary phenomenon  is  also  seen  in  paretic  dementia.  The  loss  of  the  light 
reflex  in  aortic  disease  is  due  to  the  general  syphilitic  infection. 

Dilatation  of  the  Pupil. — The  pupil  is  dilated  in  glaucoma,  in  optic 
atrophy,  in  diseases  of  the  orbit,  in  irritation  of  the  cervical  sympathetic, 
in  acute  mania,  m  cerebral  softening,  in  extensive  disease  or  injury  of  the 
cerebral  centres,  in  complete  paralysis  of  the  third  nerve,  in  paralysis  of 
the  sphincter  of  the  iris  by  a  blow  upon  the  eyeball,  in  strong  emotion, 
and  when  mydriatics  have  been  used.  In  neurasthenia  and  hysteria, 
mydriasis  is  often  present. 

Dilatation  of  the  pupil  may  be  caused  by  an  irritation  of  the  dilator 
pupillary  centre  or  tract  (irritative  mydriasis),  or  by  a  paralysis  of  the 
pupil-contracting  centre  or  fibres  (paralytic  mydriasis). 

Unilateral  mydriasis,  in  which  the  pupil  fails  to  react  to  direct  light 
but  contracts  consensually  with  its  fellow,  is  seen  in  complete  optic  atrophy, 
in  which  the  conductivity  of  the  one  optic  nerve  is  lost.  The  failure  of  one 
pupil  to  react  to  separate  stimulation  of  either  eye,  but  contracting  upon 
convergence,  while  the  other  pupil  reacts  to  light  stimulus  of  either  eye, 
is  seen  in  tabes  and  in  syphilis.  Sudden  unilateral  mydriasis  in  which  the 
instillation  of  a  drug  can  be  excluded  is  worthy  of  a  careful  study  as  a 
possible  early  symptom  of  latent  sclerosis  of  the  cord. 

Corte  claims  that  in  any  serious  diphtheritic  attack  failure  of  the 
pupils  to  react  to  light  indicates  a  fatal  termination. 

Complete  blindness  will  cause  bilateral  mydriasis  with  failure  of  the 
pupils  to  react  to  light  stimulus.  A  slight  contraction  of  the  pupils  has 
been  observed  in  the  blind,  who  are  entirely  devoid  of  light  perception, 
after  the  eyes  have  been  exposed  to  bright  daylight  for  several  minutes. 

In  mydriasis  from  drugs,  the  accommodation  is  temporarily  suspended. 


382  MEDICAL  DIAGNOSIS. 

Contraction  of  the  Pupil. — Abnormal  contraction  of  the  pupils  is 
due  either  to  irritation  of  the  pupil-contracting  centre  or  fibres,  or  to 
paralysis  of  the  sympathetic. 

In  disease  of  the  central  nervous  system,  the  myosis  may  be  due  to 
irritation  of  the  sphincter  nucleus;  but  should  mydriasis  follow  the  myosis, 
it  is  an  indication  of  the  spread  of  the  affection  and  destruction  of  the 
sphincter  centre. 

In  irritative  myosis  the  pupil  rarely  dilates  under  cover  or  in  a  bright 
light,  but  acts  normally  when  a  mydriatic  or  myotic  drug  is  instilled. 
In  the  paralytic  myosis  the  reaction  to  light  and  in  convergence  is  pre- 
served, but  the  pupils  dilate  imperfectly  when  shaded.  Mydriatics  act 
Imperfectly,  but  the  pupils  contract  further  to  myotics. 

In  old  age  the  pupils  are  usually  smaller  than  in  middle  life,  although 
perfectly  normal  in  reaction.  Inflammations  of  the  iris  are  always  asso- 
ciated with  small  pupils,  and  the  iris  is  likely  to  become  attached  to  the 
lens  capsule. 

Myosis  is  seen  in  the  early  stages  of  inflammation  of  the  brain  and 
meninges,  apoplexy,  abscess,  and  in  other  affections  which  indicate  irrita- 
tion of  the  part;  also  in  hysteria,  toxaemia,  and  in  epilepsy.  Paralytic 
myosis  occurs  in  tabes,  general  paralysis,  spinal  meningitis,  and  destructive 
lesions  of  the  cord. 

Unequal  pupils  (anisocoria)  may  point  to  purely  functional  affec- 
tions, such  as  hysteria  and  the  psychoses,  or  to  grave  organic  disease,  as 
paresis,  tabes,  etc.  The  pupillary  phenomena  must  be  studied  in  connec- 
tion with  other  symptoms  to  arrive  at  a  correct  diagnosis.  Inequality  of 
the  pupils,  although  the  reaction  to  light  remains,  is  present  in  many  cases 
of  exophthalmic  goitre.  Bichelonne  believes  that  unilateral  mydriasis  is 
an  important  sign  in  the  early  diagnosis  of  pulmonary  tuberculosis. 

Alternating  mydriasis,  in  which  the  dilatation  changes  from  one 
eye  to  the  other,  is  occasionally  present  in  general  paralysis  and  in  tabes, 
and  has  been  described  as  a  premonitory  symptom  of  insanity. 

Hippus. — An  alternate  contraction  and  dilatation  of  the  pupil,  occur- 
ring under  a  uniform  stimulus  of  Hght,  is  a  normal  phenomenon,  but  may 
be  excessive  in  hysteria,  epilepsy,  advanced  paralysis,  early  stages  of 
meningitis  and  mania,  and  in  phthisis. 

Hemiopic  Pupillary  Inaction. — The  Wernicke  pupil  is  described 
under  hemianopsia. 

Iritis. — Inflammation  of  the  iris  may  accompany  disease  of  or  trauma- 
tism to  other  ocular  structures,  or  be  due  to  constitutional  disorders.  The 
principal  signs  are  changes  in  the  color  of  the  iris,  injection  of  the  peri- 
corneal vessels,  myosis,  and  attachments  of  the  iris  to  the  lens  capsule.  The 
symptoms  are  severe  brow  pain,  worse  at  night,  and  slowly  faihng  vision. 

Syphilis  is  the  most  common  cause  of  iritis.  In  the  secondary  stage 
the  iritis  is  plastic,  and  in  the  tertiary  stage,  plastic  and  gummatous. 

The  iritis  of  rheumatism  is  usually  unilateral,  although  the  second  eye 
may  later  become  affected.  In  chronic  rheumatic  subjects  the  iritis  is  of  a 
severe  and  destructive  type.  The  attacks  usually  recur  during  a  relapse  of 
the  rheumatism,  or  they  may  be  the  only  evidence  of  the  rheumatic  poison. 
The  so-called  idiopathic  iritis,  in  which  syphihs,  gonorrhoea,  and  traumatism 


EXAMINATION  OF  THE  EYE.  363 

can  be  positively  excluded,  is  probably  due  to  the  so-called  gouty  or  rheu- 
matic diathesis.  In  these  cases  the  pain  is  usually  of  greater  severity,  the 
disease  more  slowly  amenable  to  treatment,  and  the  relapses  frequent. 

In  severe  inflammations  of  the  iris,  the  ciliary  body  is  involved,  and 
the  disease  is  referred  to  as  iridocyclitis.  Uveitis,  or  inflammation  of 
the  iris,  ciliary  body,  and  choroid,  occurs  in  rheumatism  and  gout,  dia- 
betes, influenza,  anaemia,  syphilis,  tuberculosis,  and  the  specific  fevers. 
The  disease,  which  is  probably  the  manifestation  of  some  toxic  process,  is 
characterized  by  moderately  deep  anterior  chamber,  hazy  cornea  and  aque- 
ous, pupil  not  contracted,  occasionally  a  slight  increase  in  the  tension  of 
the  eyeball,  and  the  deposit  in  triangular  form  of  small  dots  on  the  pos- 
terior surface  of  the  cornea. 

Iritis  is  often  seen  during  the  late  stages  of  gonorrhoea,  usually  affects 
both  eyes,  and  recurs  with  relapses  of  gonorrhoea  and  with  the  appearance 
of  the  gleety  discharge. 

Although  tubercle,  particularly  in  the  miliary  form,  is  occasionally 
found  in  the  iris  and  choroid,  it  is  of  little  value  in  general  diagnosis,  since 
the  deposits  in  the  choroid  are  seen  at  a  time  when  the  disease  has  shown 
itself  in  other  regions  so  plainly  that  the  diagnosis  is  easy. 

Ocular  Muscles. 

Mobility  of  the  Eyes. — Under  normal  conditions,  the  eyeballs  move 
in  perfect  accord  in  all  directions,  with  no  manifest  lagging  movement  in 
either  eye  in  any  of  the  several  rotations.  In  equilibrium  of  the 
ocular  muscles,  every  movement  of  one  eye  is  accompanied  by  simultaneous 
and  equal  movement  of  the  other,  the  image  of  the  object  upon  which 
the  eyes  are  fixed  is  formed  on  the  fovea  of  each  eye,  and  the  effort  required 
on  the  part  of  any  one  muscle  or  group  of  muscles  in  sustaining  binocular 
single  vision  is  equal  in  the  two  eyes. 

Disturbance  of  equilibrium  may  be  arranged  in  two  groups: 

1.  Organic  anomalies,  in  which  there  is  double  vision  in  attempts  to 
rotate  the  eyes  in  the  direction  of  the  affected  or  paralyzed  muscle  or 
group  of  muscles. 

2.  Functional  anomalies,  in  which  there  are: 

(a)  An  actual  deviation  of  the  visual  line  of  one  eye  from  that  of  the 
other,  persisting  in  all  movements  of  the  two  eyes. 

(b)  A  tendency  to  deviation,  which  is  overcome  by  increased  or  de- 
creased innervation  to  the  muscle  or  group  of  muscles  affected. 

Organic  Anomalies  (Ocular  Palsies). — Since  binocular  single  vision 
can  only  be  maintained  if  the  image  of  the  object  falls  upon  the  macula 
of  each  eye  or  upon  corresponding  points  of  each  retina,  any  disturbance 
of  the  motor  apparatus  by  palsy  of  one  or  more  of  the  ocular  muscles  results 
in  an  impression  of  the  object  upon  non-corresponding  points  of  each  retina. 
Two  images  are,  therefore,  transmitted  to  the  brain,  and  double  vision,  or 
diplopia,  results.  The  symptoms  of  ocular  palsies  are:  (1)  diplopia; 
(2)  limitation  of  movement  of  one  or  both  eyes  in  the  direction  of  the 
paralyzed  muscle;  (8)  actual  deviation;  (4)  false  projection;  (5)  vertigo; 
and  (6)  abnormal  position  of  the  head. 


364  MEDICAL  DIAGNOSIS. 

Diagnosis  of  Ocular  Palsies. — Paralysis  of  an  ocular  muscle  is 
to  be  suspected  if  the  patient  complains  of  seeing  double  or  tilts  the  head 
to  prevent  diplopia,  and  complains  of  vertigo  in  attempts  to  fix  an  object 
in  that  portion  of  the  field  in  which  double  vision  exists.  If  the  paralysis 
is  complete,  the  eye  with  the  affected  muscle  fails  to  rotate  past  the  median 
line  when  the  object  fixed  passes  to  the  side  to  which  the  affected  muscle 
ordinarily  rotates  the  eye,  and  in  fixation  with  the  affected  eye,  the  devia- 
tion of  the  sound  eye  (secondary  deviation)  is  greater  than  is  the  deviation 
of  the  squinting  eye  when  the  sound  eye  fixes  (primary  deviation). 

Diplopia. — In  partial  paralysis  the  limitation  of  rotation  may  be  so 
slight  as  to  escape  observation.  It  becomes  manifest,  however,  even  in 
slight  degrees,  upon  the  tests  for  diplopia.  The  patient,  seated  in  a  dark- 
ened room,  with  the  head  fixed  in  one  position,  is  directed  to  follow  with 
the  eyes  a  lighted  candle  held  at  a  distance  of  about  10  feet,  and  moved 
in  all  portions  within  the  field  of  vision.  If  a  piece  of  colored  glass  is  held 
before  one  eye,  the  images  of  the  two  eyes  are  in  this  way  differentiated. 
By  this  test  the  behavior  of  the  two  images  in  their  relative  height  and 
distance  from  each  other,  and  their  separation  and  approximation,  as  the 
light  is  carried  up  and  down,  to  the  right  and  to  the  left  of  the  patient, 
determines  which  of  the  muscles  is  palsied.  Special  skill  and  training 
are  essential  in  the  diagnosis  of  the  more  complex  forms  of  palsies,  and  it 
is  unnecessary  in  this  connection  to  enter  fully  into  details,  but  the  fol- 
lowing points  will  serve  to  indicate  roughly  the  character  of  the  affection: 

1.  Double  images  are  seen  only  when  the  eyes  are  turned  in  the  direc- 
tion in  which  the  paralyzed  muscle  or  muscles  normally  rotate  the  eye;  in 
all  other  directions  there  is  single  vision. 

2.  The  image  of  the  eye  with  the  paralyzed  muscle  (false  image) 
separates  from  the  image  of  the  sound  eye  (true  image)  as  the  object  is 
carried  into  the  field  governed  by  the  muscle  affected;  that  is,  the  distance 
between  the  double  images  increases  as  the  object  fixed  upon  is  moved 
in  the  direction  toward  which  the  paralyzed  muscle  should  rotate  the  eye. 

If  the  false  image  is  on  the  same  side  as  the  affected  eye  the  diplopia 
is  homonymous;  if  the  false  image  is  projected  to  the  side  of  the  sound 
eye  the  diplopia  is  crossed,  or  heteronymous. 

Homonymous  diplopia,  with  images  in  the  same  horizontal  plane,  indi- 
cates paralysis  of  an  external  rectus,  right  externus  if  the  images  separate 
as  the  object  fixed  is  carried  to  the  right,  and  left  externus  if  they  separate 
as  the  object  fixed  is  carried  to  the  left. 

Crossed  diplopia  in  the  horizontal  plane  indicates  paralysis  of  an 
internus,  right  internus  if  the  double  images  separate  in  looking  to  the  left, 
and  the  left  internus  if  they  separate  in  looking  to  the  right. 

Vertical  diplopia  in  upper  field  (that  is,  one  image  higher  than  the 
other)  indicates  a  paralysis  of  the  superior  rectus  or  inferior  oblique:  if 
diplopia  increases  in  looking  up  and  to  the  right,  and  image  of  right  eye  is 
higher,  paralysis  of  right  superior  rectus;  if  lower,  left  inferior  oblique. 
Increase  in  diplopia  in  looking  up  and  to  the  left,  with  image  of  right  eye 
higher,  paralysis  of  right  inferior  oblique;    if  lower,  left  superior  rectus. 

Vertical  diplopia  in  lower  field  shows  a  paralysis  of  the  inferior  rectus 
or  superior  oblique.     Increase  in  the  diplopia  in  looking  down  and  to  the 


EXAMINATION  OF  THE  EYE.  365 

right,  with  image  of  right  eye  lower,  indicates  paralysis  of  right  inferior 
rectus;  if  higher,  left  superior  oblique.  Diplopia  increasing  down  and  to 
the  left,  with  image  of  right  eye  higher,  shows  paralysis  of  right  superior 
oblique,  if  lower,  left  inferior  rectus. 

Special  Palsies. — Paralysis  of  the  Sixth  Nerve. — The  long  course 
of  the  sixth  nerve  at  the  base  of  the  brain  renders  it  particularly  liable 
to  pressure  from  inflammatory  exudation,  hemorrhage,  and  fracture.  It 
is  the  most  frequent  of  the  ocular  palsies,  and  it  is  indicated  by  conver- 
gence of  the  affected  eye,  homonymous  diplopia,  and  inability  of  the  eye  to 
rotate  outwards  past  the  median  line. 

Paralysis  of  the  third  nerve  is  shown  by  ptosis,  the  pupil  moder- 
ately dilated  and  unresponsive,  the  power  of  accommodation  abohshed, 
and  crossed  diplopia,  with  the  eyeball  turned  outward  and  slightly  down- 
ward from  the  action  of  the  external  rectus  and  superior  oblique.  In  cyclo- 
plegia  only  that  portion  of  the  nerve  controlling  the  ciliary  muscle  is 
affected.  There  may  or  may  not  be  associated  paralysis  of  the  sphincter 
of  the  pupil   (iridoplegia). 

Paralysis  of  the  fourth  nerve,  which  controls  the  superior  oblique, 
is  less  frequent.  There  is  vertical  diplopia  in  the  lower  field,  the  image 
of  the  affected  eye  is  the  lower,  and  the  distance  between  the  images 
increases  as  the  eye  is  rotated  downwards  and  inwards. 

Ophthalmoplegia  externa  is  the  term  employed  to  designate  paraly- 
sis of  all  the  external  ocular  muscles.  The  affected  eye  is  incapable  of  move- 
ment, and  the  lid  droops  and  cannot  be  voluntarily  raised.  Paralysis  of 
the  iris  and  ciliary  muscle  is  known  as  ophthalmoplegia  interna. 

Conjugate  Palsy. — In  this  rare  affection  the  individual  muscles  of 
each  eye  possess  their  normal  power  to  turn  the  globe  in  any  desired  posi- 
tion, but  there  is  inability  to  rotate  the  two  eyes  in  associated  action. 
It  may  affect  convergence,  so  that  the  eyeballs  cannot  be  converged, 
although  individually  capable  of  internal  rotation;  or  it  is  shown  in  loss 
of  associated  lateral  or  vertical  movements.  In  all  cases  the  lesion  is 
central,  and  involves  the  centres  for  conjugate  movement,  although  spas- 
modic conjugate  deviation  is  seen  in  hysteria. 

Causes  of  Ocular  Palsies, — The  seat  of  the  lesion  in  paralysis  of 
the  ocular  muscles  may  be  intracranial,  orbital,  or  peripheral:  it  may  include 
meningitis,  tumors,  hemorrhage,  gumma,  or  vascular  changes  in  the  brain; 
orbital  cellulitis,  traumatism,  and  inflammation  of  the  nerve  in  the  muscle. 
The  constitutional  causes  are  syphilis,  tuberculosis,  diabetes,  nephritis, 
influenza,  tabes,  rheumatism,  and  general  paralysis  of  the  insane,  and 
toxic  agents. 

At  least  one-half  of  the  ocular  palsies  are  considered  to  be  due  directly 
to  syphihtic  gummatous  deposits,  syphilitic  periostitis  in  the  orbit  or 
along  the  base,  or  to  degeneration  in  or  close  to  the  nuclei  of  the  nerves. 
These  are  exclusive  of  the  indirect  syphilitic  affections,  as  manifested  in 
tabes,  general  paresis,  and  diseases  of  the  blood-vessels.  Nuclear  and  periph- 
eral palsies  may  be  caused  by  rheumatism,  diabetes,  tonsillitis,  influenza, 
ptomaine  poisoning,  and  by  lead,  alcohol,  tobacco,  and  other  toxic 
agents.  In  that  variety  of  ptomaine  poisoning  known  as  botulismus, 
nuclear  palsies  are  frequent.    Basal  palsies  are  seen  in  hemorrhage,  menin- 


366  MEDICAL  DIAGNOSIS. 

gitis,  especially  tubercular,  abscess,  and  cavernous  sinus  disease.  The 
paralyses  associated  with  diabetes  occur  only  in  diabetes  mellitus,  develop 
suddenly,  but  usually  are  of  short  duration  and  most  frequently  affect 
the  sixth  nerve.  Neuralgia  of  the  region  about  the  eye  is  often  associated 
with  the  paralysis,  so  that  pain  in  this  situation  in  saccharine  diabetes 
should  direct  attention  to  a  possible  disturbance  of  the  motor  apparatus 
on  the  same  side. 

Ophthalmoplegia  interna,  or  paralysis  of  the  ciliary  muscle  and 
the  sphincter  of  the  pupil,  is  more  frequently  unilateral  than  bilateral, 
and  is  seen  in  syphilis,  tabes,  and  intracranial  disease.  Either  the  sphincter 
or  the  ciliary  muscle  may  be  first  affected,  and  later  the  external  ocular 
muscles  become  implicated.  It  is  also  found  after  diphtheria.  The  lesion 
is  probably  nuclear. 

Paralysis  op  the  accommodation,  destroying  the  power  of  reading, 
is  seen  in  about  5  per  cent,  of  cases  of  diphtheria,  usually  affects  both  eyes, 
and  only  rarely  is  associated  with  palsy  of  the  iris.  Occasionally  paraly- 
sis of  the  external  rectus  is  associated  with  the  loss  of  accommodation. 
The  same  palsies  are  also  seen  in  severe  cases  of  influenza,  in  multiple 
sclerosis,  and  in  ptomaine  poisoning. 

Intermittent  palsy  of  one  or  more  muscles  is  frequently  one  of  the 
early  symptoms  of  tabes.  One  eye  is  generally  affected,  and  the  paralysis 
disappears  in  a  few  weeks  to  again  recur.  The  same  is  found  in  syphilis, 
but  the  paralysis  affects  more  than  one  muscle.  The  external  rectus  is 
probably  the  most  frequently  involved,  and  next  the  muscles  supplied  by 
the  third  nerve,  either  as  a  group  or  individually,  while  the  parts  supplied 
by  the  fourth  nerve  are  rarely  affected. 

Palsies  of  some  of  the  ocular  muscles,  most  frequently  those 
supplied  by  the  third  nerve,  are  present  in  "ophthalmoplegic  migraine" 
and  follow  the  subsidence  of  pain.  The  attacks  are  usually  recurrent, 
the  palsy  occurring  on  the  same  side  as  the  pain.  The  disease  is  rare, 
and  should  be  differentiated  from  brain  tumor. 

Functional  Anomalies. — Both  of  the  functional  defects,  the  tendency  to 
deviation  (heterophoria)  and  the  actual  turning  of  one  visual  line  from  that 
of  its  fellow  (heterotropia,  or  functional  squint),  are  due  in  many  instances  to 
errors  of  refraction,  and  to  disturbance  of  the  relation  between  convergence 
and  accommodation.     There  is  no  paralysis  and  no  double  vision. 

Latent  Deviations  (Heterophoria,  Insufficiency  of  the  Ocular 
Muscles).- — If  there  is  a  lack  of  equilibrium  in  the  action  of  the  muscles  of 
the  two  eyes  in  binocular  vision,  so  that  fixation  of  the  eyes  is  only  main- 
tained through  an  excessive  amount  of  nerve  force  expended  in  helping 
the  weak  muscle  or  set  of  muscles,  there  follows  a  train  of  symptoms 
which  is  usually  included  under  the  term  muscular  asthenopia.  There  is 
more  or  less  constant  dull  headache,  which  may  be  general  or  localized 
in  the  frontal  or  occipital  region,  blurred  vision,  inability  to  use  the  eyes  at 
near  work,  and  photophobia.  Sometimes  there  may  be  vertigo  and  nausea, 
confusion  of  ideas,  insomnia,  and  a  feeling  of  physical  exhaustion  while 
in  a  moving  crowd,  in  attendance  at  the  theatre,  or  after  riding  in  the  cars. 
Heterophoria  is  a  most  active  causative  factor  in  many  of  the  reflex  nervous 
disorders.     Pelief  in  many  cases  has  undoubtedly  followed  the  correction  of 


EXAMINATION  OF  THE  EYE.  367 

the  defects,  but  does  not  justify  the  extravagant  claims  made  that  epilepsy, 
chorea,  melancholia,  dyspepsia,  and  other  affections  are  not  only  primarily 
due  to  heterophoria,  but  are  cured  after  correction  of  the  muscle  anomaly. 

Forms  of  Deviation. — The  tendency  of  the  visual  lines  to  deviate 
from  the  normal  parallehsm  is  divided  into  esophoria,  a  tendency  of  the 
visual  lines  to  turn  inward;  exophoria,  a  tendency  of  the  visual  lines  to 
turn  outward;  and  hyperphoria,  a  tendency  of  one  visual  line  to  deviate 
above  that  of  its  fellow.  The  inward  tendency  of  the  visual  lines  is  of 
relatively  less  importance  as  a  cause  of  reflex  symptoms  than  is  hyper- 
phoria or  exophoria. 

To  determine  the  existence  of  the  muscle  anomaly,  the  latent  defect 
is  made  manifest  by  means  of  a  prism  of  sufficient  strength  to  cause  di- 
plopia, or  by  the  use  of  a  piece  of  cobalt  glass  or  a  rod  of  glass  held  before 
the  eye.  The  line  of  light  made  by  the  rod  is  so  dissimilar  from  the  image  of 
the  other  eye  that  the  fusion  impulse  is  abolished,  and  the  eyes  take  the 
position  of  greatest  rest.  The  prism  that  fuses  the  double  images  made  by 
the  prism  or  brings  the  line  of  light  into  the  flame  seen  by  the  other  eye  is 
the  measure  of  the  defect.     Correction  of  the  refraction  is  essential  to  a  cure. 

Manifest  Deviations  (Concomitant  Squint,  Heterotropia). — In 
this  affection  there  is  an  actual  deviation  of  one  visual  hne  from  that  of 
the  other,  but  the  squinting  eye  is  able  to  follow  the  movements  of  the 
fixing  eye  in  all  directions;  there  is  no  acknowledged  diplopia,  and  the 
deviation  is  transferred  from  one  eye  to  the  other,  and  remains  of  the  same 
degree  upon  alternately  covering  one  eye  and  then  the  other.  The  absence 
of  double  vision,  and  the  fact  that  the  power  of  rotation  of  the  eye  is  not 
limited,  serve  to  distinguish  the  functional  from  the  paralytic  squint. 

Functional  squint  may  be  either  convergent,  divergent,  or  vertical. 
The  three  principal  causes  of  the  strabismus  are  a  disturbance  in  the  normal 
relation  between  convergence  and  accommodation,  brought  into  existence 
by  errors  of  refraction;  a  weakness  of  opposing  muscles,  either  through 
structural  changes  or  disturbed  innervation;  and  unequal  vision  of  the  two 
eyes,  so  that  the  normal  desire  for  fusion  is  abolished.  The  strabismus 
may  be  monolateral,  when  one  eye  always  fixes  and  the  other  always  squints; 
or  alternating,  when  either  eye  may  be  used  for  fixation,  since  the  visual 
acuity  is  about  the  same  in  each.  Squint  is  an  affection  of  early  child- 
hood, often  disappearing  if  proper  treatment  is  instituted  at  this  time. 

Vision. 

AFFECTIONS  OF  VISION. 

Imperfect  vision  is  due  to  errors  of  refraction;  to  opacities  of  the 
cornea,  crystalHne  lens,  or  vitreous;  to  disease  of  the  retina,  choroid,  optic 
nerve,  or  central  nervous  system;    or  to  functional  neuroses. 

Central  vision  is  tested  by  means  of  letters  corresponding  in  size  to 
a  fixed  standard.  The  patient,  seated  20  feet  from  the  test  card,  and  one 
eye  covered,  is  asked  to  read  the  smallest  line  of  letters  that  can  be  de- 
ciphered. If  the  vision  thus  estimated  does  not  conform  to  the  standard, 
the  various  errors  of  refraction  should  be  excluded  before  concluding  that 
the  reduced  vision  is  the  result  of  disease.    The  effect  of  faulty  vision  upon 


368 


MEDICAL  DIAGNOSIS. 


the  health  of  patients  is  oftentimes  overlooked.  In  a  person  given  to  any 
manner  of  indoor  vocation,  whose  nervous  system  is  at  all  delicately 
balanced,  an  uncorrected  eye-strain  may  give  rise  to  headache,  drowsiness, 
transient  vertigo,  and  sometimes  to  nausea,  irritability  of  temper,  and 
insomnia.  These  symptoms  are  probably  more  often  found  when  vision  is 
in  excess  of  the  normal  standard,  hence  the  state  of  the  refraction  must  be 
learned  in  order  to  determine  the  extent  to  which  the  accommodative 
strain  is  responsible  for  the  reflex  manifestation. 

Peripheral  Vision. — In  testing  the  perception  of  the  outlying  por- 
tions of  the  visual  field,  the  examination  is  made  of  each  eye  separately, 
the  oculist  employing  an  instrument  known  as  a  perimeter,  which  consists 
of  an  arc  of  a  circle,  of  about  12  inches  radius.  The  eye  to  be  examined  is 
at  the  centre  of  the  circle,  and  fixed  steadfastly  upon  a  white  spot  upon 


Fig.  150. — Diagram  of  perimetric  charts  of  visual  fields  for  white  (form  field). 

the  arc.  A  white  object  5  to  10  mm.  in  size  is  slowly  moved  along  the  arc, 
from  its  extremity  towards  the  fixed  spot,  until  it  comes  within  the  patient's 
range  of  vision,  and  the  point  recorded  at  which  the  object  is  first  seen. 
The  arc  is  moved  to  another  position  and  this  is  continued  until  the  whole 
circle  has  been  tested.  The  record  of  the  usual  points  so  taken  is  recorded, 
as  in  Fig.  150.  As  will  be  seen,  the  outlines  of  the  visual  field  are  far  from 
symmetrical.  Its  greatest  extent  is  on  the  temporal  side,  usually  about 
90°,  on  the  nasal  side  55°,  above  50°,  below  65°.  The  perimeter  is  not 
absolutely  necessary  to  make  out  gross  lesions  such  as  hemianopsia  or 
extensive  contraction  of  the  field,  since  the  finger  carried  from  point  to 
point,  as  the  patient  gazes  into  the  examiner's  eye,  will  indicate  marked 
departure  from  the  normal  limits.  Accurate  examination  requires  the 
services  of  the  ophthalmologist. 

Gradual  failure  of  vision  apart  from  refractive  errors  is  seen  in  disease 
of  the  cornea,  in  cataract,  non-inflammatory  glaucoma,  atrophy  of  the  optic 
nerve,  and  various  forms  of  intra-ocular  disease.    Rapid  loss  of  sight  occurs 


EXAMINATION  OF  THE  EYE. 


369 


in  acute  glaucoma,  retinal  hemorrhages,  embolism  or  thrombus  of  the 
central  retinal  vessels,  oedema  of  the  retina,  cerebral  effusions,  metastatic 
disease  of  the  eye,  ptomaine  poisoning,  and  after  quinine,  wood  alcohol, 
and  other  toxic  agents.  In  every  instance  of  decrease  in  the  normal  acuity 
of  vision,  the  oculist  should  be  immediately  consulted. 

Cataract  affects  vision  in  proportion  to  the  degree  and  situation  of 
the  opacity.  It  appears  as  a  congenital  or  senile  condition,  in  connection 
with  disease  of  the  eyes,  in  diabetes,  in  traumatism,  and  with  many  con- 
stitutional disorders  that  influence  the  nourishment  of  the  lens  through  the 
nutrient  vessels  of  the  choroid  and  ciliary  body.  Cataract  has  been  mistaken 
for  non-inflammatory  glaucoma,  owing  to  the  greenish  reflex  of  the  lens  in 
the  latter  disease.     The  diagnosis  is  readily  made  with  the  ophthalmoscope. 

Second  Sight. — The  ability  of  persons  past  middle  life  to  lay  aside 
their  usual  convex  reading  glasses  and  read  the  finest  print  (so-called  second 
sight)  indicates  swelling  of  the  lens,  and  is  one  of  the  first  signs  of  cataract. 
Glycosuria  is  a  frequent  cause  of  cataract,  and  acquired  myopia  after  40 
years  of  age,  even  with  clear  crystalline  lens,  should  direct  attention  to 
the  possible  existence  of  diabetes. 

Acute  Glaucoma. — Recurring  attacks  of  blurred  vision,  the  obscura- 
tion lasting  from  a  few  minutes  to  an  hour  or  more^  when  associated  with 
halos  about  the  light  (iridescent  vision),  should  direct  attention  in  persons 
past  middle  life  to  the  possibility  of  an  oncoming  attack  of  acute  glaucoma. 
The  "glaucomatous  attack"  usually  occurs  at  night,  is  characterized  by 
severe  pain  in  the  head,  nausea  and  vomiting,  and  rapid  loss  of  sight. 
The  eyeball  is  intensely  congested,  the  pupil  dilated,  the  cornea  anaesthetic 
and  steamy,  and  the  globe  of  stony  hardness.  The  affection  should  not  be 
mistaken  for  a  ''  cold  in  the 
eye,"  iritis,  or  neuralgia.  The 
rheumatic  and  gouty  diathesis 
is  a  possible  causative  factor. 

Alterations  in  the  Visual 
Field. — Changes  in  the  visual 
field,  as  evidenced  by  irregular 
or  concentric  narrowing  of  the 
normal  limits  for  form  and 
color,  the  presence  of  central 
or  peripheral  areas  of  lost  per- 
ception (scotoma),  or  transpo- 
sitions of  the  order  of  colors, 
is  seen  in  disease  of  the  retina, 
optic  nerve,  and  central  ner- 
vous system,  or  may  be  present 
in  purely  functional  neuroses. 

Amblyopia  and  amaurosis 
designate  defective  vision  due 
either  to  functional  disturbance 

or  to  actual  disease  of  the  visual  apparatus,  without  gross  ophthalmoscopic 
changes,  although  the  latter  restriction  is  not  always  adhered  to.  The 
affection  of  the  sight  may  be  limited  to  central  vision,  include  the  whole 

24 


GREEN 

Rtn 

BLUl 


Fig.  151. — Diagram  of  form  and  co'or  fields  of  right  eye. 


370  MEDICAL  DIAGNOSIS. 

or  only  part  of  the  visual  field,  or  be  only  for  form  or  for  color.  A  number 
of  congenital  forms  of  amblyopia  are  recognized — for  form,  as  in  the  poor 
vision  of  squint,  or  for  color,  as  in  color-blindness.  Partial  or  complete  loss 
of  sight  may  be  due  to  irritations  affecting  the  fifth  nerve,  severe  injuries  of 
the  head,  autointoxication,  the  nephritis  of  the  eruptive  fevers,  diabetes,  ma- 
laria, rheumatism,  action  of  certain  drugs,  and  to  hysterical  manifestations. 

Sudden  transient  failure  of  vision  may  mean  merely  the  tempo- 
rary giving  out  of  eyes  already  weakened  by  general  affections  or  too 
persistent  use. 

In  the  so-called  "visual  aura"  of  migraine,  there  is  a  decided  blurring 
of  the  visual  field,  which  has  been  designated  as  amblyopia,  but  is  transi- 
tory, and  is  to  be  distinguished  from  the  permanent  functional  impairment 
of  sight  included  in  the  term. 

Dercum  regards  a  slight  degree  of  amblyopia,  with  or  without  a  dimi- 
nution of  the  color  sense,  as  an  early  and  invaluable  symptom  of  paresis, 
which  may  even  antedate  distinct  and  demonstrable  anomalies  of  the 
pupils  or  changes  in  the  eye-grounds. 

Transient  blindness,  persisting  for  a  few  minutes  to  several  hours  or 
days,  may  be  due  to  spasm  of  the  retinal  arteries.  The  diminution  in  the 
calibre  of  the  vessels  has  been  observed  in  epilepsy,  migraine,  cold  stage 
of  malarial  fever,  and  in  some  toxic  conditions. 

In  ursemia,  particularly  in  the  nephritis  of  scarlet  fever  and  of  preg- 
nancy, the  sudden  loss  of  sight  may  be  associated  with  convulsions,  coma, 
and  other  cerebral  symptoms.  Although  the  blindness  may  be  complete^ 
the  reactions  of  the  pupils  are  usually  preserved. 

Amblyopia  from  Loss  of  Blood.- — Amblyopia,  with  subsequent 
complete  atrophy  of  the  optic  nerve,  may  follow  profuse  spontaneous 
hemorrhages  from  the  stomach,  intestines,  uterus,  or  nasal  cavity.  The 
loss. of  sight  may  not  appear  for  a  week  or  more  after  the  bleeding,  being 
due,  as  shown  by  Holden,  to  degeneration  of  the  ganglionic  cells  of  the 
retina  from  impaired  nutrition. 

Methyl-alcohol  Amblyopia. — Rapid  loss  of  sight  may  follow  the 
drinking  of  wood  alcohol  in  its  crude  or  purified  state,  or  when  employed 
as  an  adulterant  in  the  manufacture  of  Jamaica  ginger,  impure  whiskey, 
cheap  essences,  bay  rum,  and  other  alcoholic  beverages.  The  eye  symptoms 
are  often  associated  with  vomiting  and  purging,  severe  headache,  and  intense 
weakness.  The  vision  may  improve  for  a  few  hours  or  days  to  again  relapse, 
often  ending  in  complete  blindness. 

Quinine  Amblyopia. — Total  blindness  may  follow  the  taking  of 
quinine  in  large  quantities,  the  amount  of  the  drug  required  varying  in 
different  individuals.  The  pupils  are  dilated  and  unresponsive,  the  optic 
disks  pale,  and  the  retinal  circulation  seriously  restricted.  Central  vision 
is  usually  restored  but  the  peripheral  limits  of  the  field  remain  contracted. 

Central  Amblyopia  (Retrobulbar  Neuritis). — The  orbital  portion 
of  the  optic  nerve  is  subject  to  interstitial  inflammation  in  either  an  acute 
or  chronic  form.  In  both,  the  disease  affects  those  portions  of  the  nerve 
that  supply  the  macular  region.  The  early  symptoms  are  dimness  of  vision, 
without  marked  ophthalmoscopic  changes,  and  a  weakness  or  loss  of  color 
perception  in  the  central  visual  field. 


EXAMINATION  OF  THE  EYE.  371 

In  retrobulbar  inflammations,  as  pointed  out  by  Gowers,  the  visual 
acuity  is  less  in  very  bright  light,  and  exposure  to  excessive  hght  may 
lead  to  deterioration  of  vision  that  may  last  for  some  time.  This  is  due 
to  the  slowness  with  which  the  ill-nourished  axis-cylinders  are  regenerated. 
The  same  author  also  shows  the  close  relationship  between  retrobulbar 
disease  and  affections  of  the  seventh  nerve,  since  paralysis  of  the  facial 
nerve  may  precede  the  optic-nerve  inflammation. 

In  acute  retrobulbar  neuritis  there  is  rapid  failure  of  vision  with  central 
or  paracentral  scotoma,  which  is  usually  followed  by  recovery  of  vision, 
although  the  optic  disk  still  shows  pallor.  The  affection  may,  however, 
rapidly  progress  until  the  entire  nerve  is  implicated,  and  vision  is  nearly 
if  not  completely  lost.  The  disease  may  arise  during  the  course  of  rheu- 
matism, gout,  diabetes,  smallpox,  and  other  general  affections,  in  which 
the  blood  carries  the  toxsemic  substance;  or  may  follow  orbital  or  sinus 
disease,  menstrual  suppression,  alcohol  or  lead  intoxication;  and  occasion- 
ally is  found  in  insular  sclerosis  and  myelitis. 

In  chronic  retrobulbar  neuritis  there  exists  with  dimness  of  vision  a 
small  central  color  scotoma,  particularly  for  red  and  green,  the  horizontal 
oval  area  in  the  visual  field  extending  from  the  fixing  point  to  the  blind 
spot.  The  affection  is  found  principally  in  persons  using  large  quantities 
of  tobacco,  especially  when  combined  with  the  use  of  alcohol.  It  is  most 
frequently  noted  between  40  and  50  years  of  age,  and  has  also  been  found 
in  alcoholics  who  are  not  users  of  tobacco,  and  from  the  toxaemia  of  lead, 
cannabis  indica,  stramonium,  chloral,  carbon  bisulphide,  iodoform,  etc. 
The  disturbance  of  vision  is  greater  for  near  objects,  and  is  more  marked 
in  bright  light. 

A  form  of  retrobulbar  neuritis  similar  to  that  of  toxic  origin  appears 
as  an  hereditary  affection,  and  is  referred  to  as  hereditary  optic  neuritis. 
It  affects  several  members  of  a  family,  especially  the  males,  and  has  been 
traced  through  several  generations.  The  exciting  cause  is  exposure  to 
cold,  syphilis,  excessive  venery,  and  the  heavy  consumption  of  tobacco. 

Hemianopsia  (hemianopia)  is  a  loss  of  one-half  of  the  visual  field 
of  one  or  both  eyes,  due  to  a  lesion  in  the  optic  chiasm,  along  the  optic 
tracts,  or  in  the  visual  centres  in  the  occipital  lobe.  It  does  not  include 
defects  in  the  field  caused  by  disease  within  the  eyeball.  The  line  divid- 
ing the  seeing  from  the  blind  field  is  horizontal  or  vertical,  or  nearly  so, 
and  may  cut  exactly  through  the  fixing  point,  or  circumscribe  this  point 
by  a  small  zone  of  preserved  vision. 

The  dividing  line  may  have  an  oblique  direction,  but  this  is  extremely 
rare,  or  only  a  sector,  commonly  a  quadrant,  of  the  field  may  be  wanting. 

Hemianopsia  is  classified  according  to  the  relative  position  of  the 
blind  portions  of  the  two  fields.  It  is  homonymous  if  there  is  loss  in  the 
corresponding  halves  of  each  field;  bitemporal  if  both  temporal  fields  are 
blind,  and  binasal  when  the  nasal  halves  are  lost.  When  the  dividing  line 
between  the  lost  and  preserved  field  is  vertical,  the  defect  is  known  as 
vertical  hemianopsia,  and  when  the  dividing  line  is  horizontal,  the  hemi- 
anopsia is  horizontal  or  altitudinal. 

Homonymous  hemianopsia  is  the  commonest  form,  and  reveals  itself 
as  a  defect  in  the  right  or  left  half  of  each  visual  field.     For  instance,  in 


372 


MEDICAL  DIAGNOSIS. 


Fig.  152  the  left  half  of  each  field  is  wanting,  showing  loss  of  function  in  the 
right  half  of  each  retina.  If  the  right  half  of  each  field  is  lost  the  condition 
is  right  lateral  hemianopsia;  in  loss  of  the  left  half  of  each  field,  left  lateral 
hemianopsia.  The  seat  of  the  lesion  in  homonymous  lateral  hemianopsia 
is  in  any  part  of  the  visual  tract  between  the  chiasm  and  the  occipital  lobe. 
BiTEMPOEAL  HEMIANOPSIA  is  a  Comparatively  rare  phenomenon,  but 
one  of  great  diagnostic  moment  when  found.  It  manifests  itself  as  a 
blindness  of  the  outer,  or  temporal,  halves  of  the  visual  fields,  indicat- 
ing suspended  function  of  the  nasal  portions  of  each  retina.  It  is  caused 
by  a  lesion  which  destroys  the  function  of  the  crossed  fibres  without 
affecting  the  uncrossed  fascicuh.  This  may  be  a  tumor,  fracture,  exos- 
tosis, aneurism,  or  disease  of  the  blood-vessels.     Loss  of  the  two  temporal 


Fig.  152. — Diagram  of  perimetric  charts  of  right  lateral  hemianopsia.  The  dark  areas  show  loss 
of  the  nasal  half  of  left  and  temporal  half  of  right  fields,  with  contraction  of  the  preserved  fields.  The 
dividing  line  passes  aroiind  fixing  point. 


fields  is  seen  in  acromegaly,  although  it  is  not  a  constant  symptom,  since 
the  type  of  hemianopsia  will  depend  upon  the  direction  the  pressure  is 
exerted  upon  the  chiasm  and  tracts. 

BiNASAL  HEMIANOPSIA,  in  which  both  the  nasal  fields  are  lost,  is  rare. 
If  it  is  true  that  the  crossed  and  uncrossed  fibres  of  the  optic  nerve  are 
mingled  at  the  outer  half  of  the  chiasm,  then  a  lesion  of  this  structure 
cannot  cause  binasal  hemianopsia.  Shoemaker  believes  that  this  defect 
in  the  fields  is  due  to  an  inflammation  of  the  optic  nerves. 

Both  upper  or  both  lower  fields  may  be  wanting.  In  this  condition,  the 
lesion  is,  as  a  rule,  at  the  chiasm,  encroaching  on  it  from  above  or  below. 

If  the  blind  halves  of  the  field  have  lost  not  only  perception  of  form 
and  light,  but  also  of  color,  the  defect  is  absolute;  if  only  recognition  of 
color  is  lost,  the  hemianopsia  is  relative. 

Hemianopsia  as  a  Diagnostic  Symptom. — In  lateral  hemianopsia 
the  intracranial  lesion  is  on  the  opposite  side  from  the  dark  fields.  If 
unassociated  with  motor  or  sensory  symptoms,  the  lesion  is  confined  to 


EXAMINATION  OF  THE  EYE.  373 

the  cuneus,  or  the  immediately  surrounding  gray  matter;  a  lesion  in  one 
nerve  tract,  or  in  the  primary  optic  centres,  with  symptoms  of  basal  disease, 
would  cause  changes  in  the  pupil,  and  possibly  some  affection  of  the  nerve 
head  could  be  recognized.  Hemiplegia  and  hemianaesthesia  are  often  present 
with  lateral  hemianopsia,  indicating  organic  disease  of  the  brain,  the  lesion 
being  situated  in  the  internal  capsule.  If  right  hemiplegia  and  aphasia 
are  associated  with  lateral  hemianopsia,  an  extensive  lesion  probably 
exists  of  the  area  supphed  by  the  middle  cerebral  artery.  A  lesion  of  the 
posterior  gray  matter  of  the  optic  thalamus  could  produce  lateral  hemi- 
anopsia, with  hemianaesthesia  and  ataxia  of  one  side  of  body.  A  cortical 
lesion  is  usually  associated  with  concentric  contraction  of  the  preserved 
fields,  or  is  found  in  cases  in  which  the  light  sense  is  preserved,  but  the 
color  or  form  sense  is  abolished. 

Hemianopic  Pupillary-inaction  Sign. — This  is  an  important  local- 
izing sign  in  hemianopsia,  and  consists  in  carefully  noting  if  the  pupil  reacts 
to  a  beam  of  light  thrown  upon  the  non-functionating  half  of  the  retina. 
It  is  an  extremely  delicate  test  to  make,  owing  to  the  difficulty  of  restrict- 
ing the  beam  of  light  so  that  it  shall  illuminate  the  non-acting  half  of  the 
retina  without  allowing  any  light  to  fall  upon  the  seeing  half.  If  the  pupil 
reacts  when  the  light  is  thrown  upon  either  the  blind  or  the  seeing  half  of 
the  retina,  the  lesion  is  back  of  the  primary  optic  centres;  but  if  there  is 
no  reaction  when  the  light  falls  upon  the  blind  side,  but  the  pupil  reacts 
when  the  light  falls  upon  the  functionating  side,  the  lesion  is  in  front  of 
the  primary  optic  centres,  and  in  that  position  has  affected  the  motor  arc 
of  the  pupil.  The  test  should  always  be  made  in  a  well-darkened  room, 
with  barely  sufficient  light  to  conduct  the  examination,  and  should  be 
confirmed  by  a  second  observer  before  basing  a  diagnosis  on  its  apparent 
presence.  When  present  it  is  a  valuable  sign,  but  its  absence  is  not  decisive, 
owing  to  the  difficulty  of  making  the  test. 

Hysterical  Amaurosis. — The  diagnosis  of  visual  defects  due  to 
hysteria  is  sometimes  difficult,  although  healthy  eye-grounds  and  pupils 
normally  reacting  to  light  would  point  strongly  to  hysteria.  Cases  of 
hysteric  blindness  have  been  reported,  however,  in  which  light  failed  to 
have  any  action  on  the  pupil. 

If  unilateral  blindness  arises  suddenly,  following  fright,  emotional 
excitement,  slight  injury,  or  menstrual  pain,  hysteria  may  be  suspected. 
While  the  defect  may  be  bilateral,  it  is  more  often  unilateral.  It  is  not 
uncommon  to  find,  associated  with  the  ocular  symptoms,  other  disturbances 
of  sensation,  such  as  hemianaesthesia  of  the  skin,  cornea,  or  conjunctiva. 
If  the  amaurosis  is  restricted  to  one  eye,  under  some  conditions  it  may  be 
transferred  to  the  other  temporarily;  and,  again,  the  unilateral  character 
of  the  affection  may  entirely  disappear  in  binocular  fixation,  as  proved 
by  the  diplopia  if  a  prism  of  sufficient  strength  to  prevent  normal  fusion 
is  placed  before  one  eye. 

Not  only  may  the  vision  be  reduced  in  hysteria,  but  changes  in  the 
peripheral  field  are  common.  The  contraction  in  the  field  is  usually  equal 
in  the  different  meridians,  and  is  often  of  the  tubular  type,  in  which  the 
limits  of  contraction  remain  the  same,  no  matter  what  distance  the  test 
object  is  removed  from  the  eye.     The  field  for  colors  likewise  shows  con- 


374  MEDICAL  DIAGNOSIS. 

centric  contraction,  or  the  limits  of  one  color  may  overlap  that  of  another, 
or  there  may  be  a  complete  reversal  of  the  colors. 

Optic  Neuritis. — Inflammation  may  affect  the  optic  nerves  at  their 
intra-ocular  portions  (papillitis)  or  in  their  course  in  the  orbit  (retro- 
bulbar neuritis).  Under  the  term  hypercemia  of  the  nerve  head  is  included 
a  type  of  optic-nerve  irritation  in  which  the  disks  become  of  dull  red  color, 
the  surface  and  margins  veiled,  and  the  lymph  sheaths  of  the  vessels 
prominent.  It  is  seen  in  refractive  error,  particularly  hyperopia  and  hyper- 
opic  astigmatism,  after  long-continued  exposure  to  intense  light  or  heat, 
in  some  types  of  inflammation  of  the  uveal  tract,  in  orbital  and  sinus  disease, 
in  chronic  insanity,  and  from  toxic  agents. 

Papillitis. — Optic  neuritis  may  be  manifest  as  a  true  inflammation 
of  the  nerve  tissue,  a  swelling  of  the  intra-ocular  ending  of  the  optic  nerve, 
or  as  a  descending  neuritis.  The  changes  in  the  optic-nerve  head  may 
range  from  a  decided  redness,  moderate  swelling,  and  blurring  of  the  margins, 
to  an  intense  rounded  protrusion  of  the  disk  from  inflammatory  exudation, 
reddish  gray  in  color  and  sloping  down  into  the  surrounding  retina,  the 
retinal  arteries  shrunken,  and  the  veins  full  and  tortuous  and  covered  in 
by  infiltration  or  ending  in  numerous  hemorrhages.  Upon  subsidence  of 
the  inflammation  the  nerve  head  becomes  grayish  white  in  color,  the  oedema 
subsides,  and  the  extent  to  which  the  pressure  has  affected  the  nerve- 
fibres  is  shown  by  the  degree  of  optic  atrophy  that  follows. 

A  moderate  degree  of  papillitis,  associated  with  hemorrhages  through- 
out the  retina,  few  changes  in  the  vessels,  and  spots  of  fatty  degeneration 
of  the  retinal  elements,  is  described  as  neuroretinitis,  and  is  the  type  most 
frequently  found  in  association  with  renal  disease.  The  intense  swelling  of 
the  papilla,  with  exudation  and  tortuosity  of  the  veins,  is  termed  choked  disk 
or  papillcedema,  and  is  the  usual  type  found  in  certain  forms  of  brain  tumor. 

The  neuritis  may  be  due  to  affections  of  the  orbit,  such  as  fracture, 
orbital  tumors,  purulent  cellulitis,  and  sinus  disease.  Intracranial  causes 
are  tumors,  meningitis,  gumma,  abscesses,  and  aneurisms.  The  situation 
of  the  intracranial  portion  of  the  optic  nerve  tracts  at  the  base  of  the 
brain  renders  them  particularly  liable  to  implication  in  inflammations  of 
the  basal  portion  of  the  meninges  and  to  the  pressure  of  tumors,  abscesses, 
or  aneurisms.  In  children,  tubercular  meningitis  is  usually  accompanied 
by  swelling  of  the  optic  disk.  The  absence  of  affections  of  the  optic  nerve 
does  not  preclude  the  presence  of  a  new  growth  in  the  brain,  although  when 
the  base,  and  particularly  the  cerebellum,  is  the  seat  of  a  neoplasm,  swelling 
of  the  optic  disk  is  almost  always  present.  Double  optic  neuritis  of  high 
degree,  rapidly  progressive,  and  accompanied  by  marked  exudation  in 
the  nerve  and  surrounding  retina,  usually  indicates  a  tumor  of  the  cere- 
bellum, while  one  of  slower  growth,  less  intense,  and  either  unilateral  or 
considerably  greater  on  one  side  than  on  the  other,  is  seen  in  neoplasms  of 
the  cerebrum.  The  "stellate  figure"  in  the  macula,  which  is  seen  in  a  large 
proportion  of  the  cases  of  renal  retinitis,  is  not  uncommon  in  the  intense 
papillitis  of  brain  tumor.  Tumors  or  abscesses  of  the  frontal  region  rarely 
cause  optic  neuritis,  although  swelling  of  the  optic  disk  may  occur. 

Apart  from  the  intracranial  causes,  papillitis  may  occur  from  general 
infections.     These  are  in  the  nature  of  a  toxin,  occurring  in  such  diseases 


EXAMINATION  OF  THE  EYE.  375 

as  influenza,  syphilis,  malaria,  rheumatism,  erysipelas,  and  many  of 
the  exanthematous  and  continued  fevers.  Lead  and  alcohol  may  also 
cause  inflammation  of  the  optic  nerve,  and  the  same  process  is  seen  in 
anaemia,  loss  of  blood,  sunstroke,  and  after  violent  exertion.  Syphilis 
may  cause  a  primary  neuritis  or  act  secondarily  through  gumma  of  the 
brain  or  meninges. 

Unilateral  optic  neuritis  may  be  due  to  orbital  or  sinus  disease,  and  in 
rare  instances  to  cerebral  tumor,  in  which  the  neuritis  occurs  on  the  side 
of  the  neoplasm.  The  inflammation  of  the  retina  and  optic  nerve  of  nephri- 
tis and  certain  constitutional  disorders  is  often  unilateral,  but  with  the 
progress  of  the  systemic  disease  the  inflammation  attacks  the  other  eye. 

Perfect  central  vision  is  usually  unimpaired  even  in  intense  papillitis 
during  the  acute  stage,  and  if  defects  in  vision  occur  they  partake  of  the 
nature  of  sector-like  defects  in  the  visual  field. 

Retrobulbar  neuritis  has  been  considered  under  Amblyopia. 

Optic-nerve  Atrophy. — Degeneration  and  atrophy  of  the  optic  nerves 
may  be  primary,  when  there  has  been  no  previous  inflammation  or 
swelling  of  the  papilla,  or  secondary,  if  preceded  by  previous  optic  neuritis. 
In  both  forms  there  are  changes  in  the  color  of  the  disk,  varying  from  a 
gray  to  grayish  white,  with  the  edges  usually  clear  and  distinct  in  the 
primary  forms,  but  veiled  in  the  secondary. 

Primary  atrophy  is  more  frequently  associated  with  spinal  disease, 
particularly  locomotor  ataxia,  in  which  it  usually  appears  before  the  ataxic 
symptoms.  It  is  also  found  in  insular  sclerosis,  paralysis  of  the  insane, 
and  occasionally  in  lateral  sclerosis.  It  may  occur  as  a  result  of  excessive 
hemorrhage  from  the  stomach,  uterus,  or  intestines,  in  the  toxaemia  of 
fevers,  alcohol  or  lead  poisoning,  in  chronic  malaria,  syphihs,  and  dia- 
betes, in  fractures  of  the  base,  and  in  deformities  of  the  skull.  Hered- 
itary optic-nerve  atrophy  is  not  uncommon,  the  atrophy  appearing  in 
early  adult  life. 

Secondary  or  Consecutive  Atrophy. — The  contracted  retinal  arteries, 
the  dilated  and  tortuous  veins,  and  the  veiling  of  the  surface  and  edges 
of  the  optic  nerve  point  to  a  previous  papillitis.  Extensive  retinal  and 
choroidal  disease  also  results  in  atrophy  of  the  nerve,  as  will  pressure 
upon  the  nerve-fibres  by  an  aneurism,  tumor,  or  exostosis. 

Retinitis. — The  retina  is  implicated  in  disease  affecting  the  intra- 
ocular end  of  the  optic  nerve,  and  also  from  extension  of  disease  from  the 
ciliary  body  and  choroid.  The  inflammation  is  associated  with  oedema 
and  exudation,  hemorrhages  either  in  the  fibre  layer  or  deeper,  small- 
cell  infiltration,  and  tortuosity  of  the  retinal  vessels,  with  changes  in 
their  calibre. 

Retinal  Hemorrhage. — Extravasation  of  blood  into  the  retina  may 
occur  independently  of  any  inflammation  of  the  retina.  It  is  usually 
the  evidence  of  extensive  vascular  disease,  organic  heart  affections,  or 
suppressed  menstruation.  It  may  occur  in  scurvy,  purpura,  marked  anaemia, 
diabetes,  and  particularly  in  the  type  of  neuroretinitis  associated  with 
nephritis.  Retinitis  with  hemorrhages  resembling  those  seen  in  renal 
disease  are  often  present  in  simple  anaemia  and  chlorosis.  The  position 
and  extent  of  the  hemorrhage  determines  the  effect  on  vision. 


376  MEDICAL  DIAGNOSIS. 

Arteriosclerosis. — A  study  of  the  changes  in  the  retinal  blood- 
vessels is  of  extreme  importance  as  bearing  on  the  early  diagnosis  of  vari- 
ous phases  of  general  arteriosclerosis.  The  early  alterations  in  the  retinal 
circulation  which  should  direct  attention  to  general  symptoms  indicative 
of  beginning  sclerotic  changes  are  tortuosity  of  one  or  more  of  the  smaller 
arteries,  the  evidence  of  undue  pressure  of  an  artery  at  its  point  of  crossing 
of  a  retinal  vein,  and  an  increase  of  the  light  reflex  of  the  arteries.  At  first 
the  vein  is  simply  displaced  in  the  direction  of  the  arterial  circulation,  and 
its  flow  slightly  obstructed;  later  the  venous  current  is  markedly  impeded, 
and  the  vein  greatly  narrowed  where  the  arterial  pressure  is  exerted,  and 
is  distended  on  the  peripheral  side.  These  changes  are  rarely  accompanied 
by  sufficient  fibrous  thickening  to  cause  white  lines  of  perivascular  inflam- 
mation along  the  vessel.  As  the  vessel  walls  lose  their  elasticity,  the  im- 
pediment to  the  flow  of  blood  results  in  tortuous  vessels,  the  escape  of 
fluid  into  the  surrounding  tissues,  and  retinal  oedema.  These  conditions 
are  not  due  to  old  age  only,  but  to  actual  sclerosis  of  the  vessels  from  disease. 

The  importance  of  early  recognition  of  these  ocular  changes  lies  in 
their  association  with  similar  disease  of  the  brain  and  kidney.  There  is  no 
difficulty  in  determining  by  the  ophthalmoscope  the  evidence  in  the  eye- 
ground  of  well-advanced  types  of  arteriosclerosis^  but  it  is  important  that 
recognition  of  these  signs  should  be  made  before  the  disease  has  reached  a 
point  where  treatment  is  ineffectual.  De  Schweinitz  called  especial  atten- 
tion to  the  value  of  early  recognition  of  the  signs,  even  though  they  be 
only  suggestive,  of  angiosclerosis  of  the  retinal  vessels  in  persons  who  have 
reached  the  age  at  which  vessel  degeneration  may  begin  to  appear,  and 
who  consult  the  ophthalmologist  for  a  change  of  reading  glasses.  These 
signs  are  "  a  corkscrew  appearance  of  individual  vessels,  a  slight  thicken- 
ing of  the  perivascular  lymph  sheaths,  a  beginning  brick-dust  appearance 
of  the  optic  nerve-head,  and  a  flattening  of  a  vein  against  an  artery  or  a 
bending  in  a  curve  of  the  vein  overlying  the  artery."  With  these  retinal 
conditions  present  the  physician  should  carefully  examine  the  cardio- 
vascular system,  and  accurately  test  the  arterial  tension  by  approved 
means,  and,  should  the  tests  confirm  the  retinal  findings,  institute  appro- 
priate treatment,  which  may  save  not  only  lesions  of  the  eyes  but  of  other 
structures,  notably  the  brain,  which,  if  they  occur,  may  prove  fatal. 

Obstruction  of  the  Retinal  Vessels. — An  embolism  may  lodge  in  the 
central  retinal  artery  or  in  one  of  its  branches.  Sudden  blindness 
follows  complete  obstruction  of  the  central  vessel,  whereas  in  plugging  of 
one  of  the  smaller  vessels  the  blind  area  will  correspond  to  the  section  of 
the  retina  supphed  by  the  vessel  affected.  The  fundus  picture  in  embohsm 
of  the  central  artery  shows  a  palhd  disk,  a  grayish  white  cedema  of  the 
retina,  and  the  appearance  of  a  central  red  spot  in  the  fovea.  The  affection 
presents  the  same  general  symptoms  and  changes  in  the  eye-ground  as  in 
thrombus.  Both  occur  in  endarteritis,  heart  disease,  and  changes  in  the 
composition  of  the  blood. 


PLATE  IX. 


V 


[Changes  in  Arteriosclerosis.— After  De  Schweinitz. 

A,  Normal  fundus.  B  to  F,  successive  changes  occurring  in  arteriosclerosis,  including  pallid  arteries 
(B),  later  assuming  a  silver-wire  appearance  (C);  indented  veins  (B,  C),  afterward  showing  ampullifonn 
enlargements  (D,  E)  ;  corkscrew  capillaries  (C,  D) ;  corkscrew  arteries  and  veins  (D,  E)  ;  perivasculitis 
(C,  D);  sclerosis  of  vessels  (F);  oedema  of  disk  (B,  C,  D,  E),  hemorrhages(C,  F).— D.] 


PLATE  X. 


[Changes  in  Retinal  Vessels.— After  \Yurdemann  in  Posey  and  t^pille^. 
A,  Embolism  central  artery;  partial,  affecting  only  inferior  branch  (Haab).  B,  Embolism  central 
artery  total  within  nerve;  a  cilio-retinal  vessel  supplies  a  small  area  of  retina  m  which  function  is 
preserved  (Wiirdemann).  C,  Thrombosis  of  central  vessels  from  mumps  (^^urdemann).  D,  bame  case 
six  months  later,  showing  sclerosis  and  atrophy  (Wiirdemann).  E,  Hemorrhages  trom  retmal  vessels 
(Magnus).    F,  Perivasculitis  luetica  (Magnus).— D.] 


PLATE  XL 


[Inflammations  of  the  Retina.— After  Wiirdemann  in  Posey  and  Spiller. 

A,  CEdema  in  pernicious  ansemia  (Oliver).  B,  Leiuwmic  retinitis  (Oliver).  C,  Albuminuric  ret- 
initis and  neuritis  of  pregnancy  (Wiirdemann).  D,  Albuminuric  retinitis  in  the  negro  (\\  virdemnnn). 
E,  Syphilitic  retinitis  (Haab).  F,  Atrophy  of  retina,  chorioid,  and  nerve  following  chorio-retnutis 
luetica)   (Oeller.— D.] 


EXAMINATION  BY  X-RAYS.  377 


XI. 
THE  EXAMINATION  BY  X-RAYS. 

The  Rontgen  ray  with  present-day  technic,  in  the  hands  of  one 
skilled  in  its  employment,  brings  to  the  general  practitioner  an  agent  of 
very  positive  worth. 

In  surgery  its  employment  for  diagnostic  purposes  is  well  recognized. 
To  the  ophthalmologist  its  service  in  localizing  foreign  bodies  in  the  eye 
marks  one  of  the  distinct  advances  in  that  specialty.  With  an  efficient 
equipment,  and  one  skilled  in  the  use  of  it,  the  Rontgen  rays  play  a  very 
important  part  in  the  diagnosis  of  general  medicine.  Not  that  they  alone 
should  be  expected  to  declare  what  the  obscure  disease  of  head,  chest,  or 
abdomen  is,  but,  in  conjunction  with  the  history  of  the  case,  its  physical 
signs  and  symptoms,  and  such  other  technic  as  is  in  current  use,  the 
X-rays  prove  a  very  useful  adjunct  in  corroborating,  modifying,  or 
controlling  knowledge  gained  in  the  more  usual  ways. 

Apparatus  and  Technic. — In  the  development  of  the  Rontgen  rays 
the  chief  things  necessary  are  a  source  of  electricity,  an  apparatus  for 
transforming  the  electric  current,  an  X-ray  tube,  a  fluoroscope,  and  radio- 
graphic plates. 

Source  of  Electricity. — The  electric  current  may  be  that  of  the 
street,  of  the  storage  battery,  or  of  the  static  machine.  The  street  current 
(of  100  or  more  volts)  is,  perhaps,  the  most  satisfactory  supply  for  those 
who  can  obtain  it.  The  static  machine  is  subject  to  changes  of  weather 
and  is  costly,  but  it  is  often  the  only  means  of  delivering  an  electric  current 
sufficient  to  produce  the  Rontgen  rays.  With  the  static  machine  a  coil  is 
not  necessary.  The  storage  battery  is  also  costly,  heavy,  requires  frequent 
recharging,  and  is  employed  principally  because  of  its  portability. 

Tube. — The  tube  consists  of  a  glass  bulb,  from  4  to  8  inches  in  diam- 
eter, and  so  exhausted  of  air  as  to  make  it  nearly  a  vacuum.  Within  this 
bulb  and  near  its  centre  is  a  platinum  plate,  known  as  the  anode,  and  at 
a  fixed  distance  and  angle  another  aluminum  plate,  known  as  the  cathode. 
The  poles  are  connected  outside  the  bulb  with  the  terminals,  and  the  cur- 
rent passes  within  the  tube  from  the  cathode  to  the  anode,  and  in  doing  so 
generates  the  Rontgen  rays.  Attached  externally  to  the  best  tubes  now 
in  use  is  a  smaller  glass  bulb,  which  serves  as  a  "safety  valve"  to  the  larger 
bulb.  It  contains  certain  chemicals,  which,  acted  upon  by  the  current, 
reduce  the  vacuum  of  the  larger  bulb,  and  so  preserve  it  from  puncture 
and  fit  it  for  use.  The  glass  of  the  bulb  should  be  of  the  clearest  quality, 
free  from  lead,  and  as  thin  as  can  be  emploj^ed  with  safety.  The  tubes 
highly  exhausted  are  known  as  "high"  or  hard  tubes,  and  are  the  tubes 
required  where  the  greatest  penetration  is  necessary.  The  tubes  of  lesser 
vacuum  are  known  as  "soft"  tubes,  and  are  commonly  used  for  purposes 
of  treatment.  Age  and  usage  vary  the  vacuum  and  make  the  life  of  a 
tube  an  uncertainty.  Tubes  are  easily  broken,  punctured,  and  softened, 
so  that  they  are  always  an  item  of  expense  to  the  skiagrapher. 


378  MEDICAL  DIAGNOSIS. 

Coil. — The  coil  consists  of  three  principal  parts:  1.  The  interrupter 
which  makes  and  breaks  the  current,  and  so  increases  the  electromotive 
force  of  the  current.  2.  The  condenser,  designed  to  eliminate  self-induced 
currents.  3.  The  coil  itself.  The  coil  consists  of  the  primary,  through 
which  the  interrupted  current  passes,  and  the  secondary,  which  delivers 
the  induced  current  through  the  terminals  to  the  tube.  In  the  use  of  the 
street  current  and  the  current  from  the  storage  battery  the  coil  is  essential 
for  the  production  of  the  X-rays. 

The  Fluoroscope. — The  fluoroscope  consists  of  a  screen,  upon  which 
are  deposited  crystals  of  calcium  tungstate  or  barium  platinocyanide. 
The  screen  is  surrounded  on  one  side  by  a  hood. 

Fluoroscopic  examinations  can  be  quickly  made,  they  are  inexpensive, 
moving  organs  can  be  watched,  and,  for  certain  parts  of  the  body,  they 
give  the  most  satisfactory  information.  But  constant  use  of  the  fluoroscope 
has  been  found  dangerous,  and  there  is  less  detail  than  in  the  skiagraphic 
plate.  Furthermore,  no  record  remains  of  what  was  studied  except  in  the 
observer's  mind. 

Plates. — The  plates  prepared  by  different  manufacturers  are  similar 
to  those  employed  by  the  photographer,  in  fact,  for  some  forms  of  X-ray 
work,  ordinary  photographers'  plates  may  be  used.  The  plate  shows  more 
detail  than  the  fluoroscope,  furnishes  a  permanent  record,  and  can  be 
studied  and  compared  with  plates  made  subsequently. 

The  Rontgen  rays  can  be  developed  regardless  of  daylight  or  dark- 
ness, but  a  darkened  room  gives  the  operator  the  best  opportunity  of 
controlling  his  apparatus  and  for  the  use  of  the  fluoroscope.  When  a 
tube  is  giving  satisfactory  results  it  emits  a  peculiar  greenish  fluorescence, 
so  that  when  the  hand  is  held  between  it  and  the  fluoroscope  its  bony 
structures  are  clearly  seen  and  outlined.  In  making  radiographic  pictures 
the  tube  is  placed  at  a  definite  distance  from  the  part,  with  the  plate  on 
the  opposite  side.  The  current  is  turned  on  to  produce  the  rays,  and  after 
a  proper  exposure  the  structures  of  the  part  are  pictured  upon  the  sensitive 
plate.  Every  operator  learns  to  know  his  current,  coil,  and  tubes,  and 
how  they  are  best  used,  and  the  length  of  time  required  to  make  a  picture. 
The  rays,  too  frequently  used  or  employed  for  too  great  a  length  of  time, 
are  likely  to  excite  a  dermatitis,  deep  burns  that  require  months  to  heal, 
destruction  of  hair,  withering  of  fingers  and  nails,  possible  injury  to  the 
sexual  functions,  and  interference  with  the  process  of  metabolism.  The 
tube  should  be  enclosed  in  a  heavy  glass  shield,  and  the  operator  protected 
behind  a  leaden  screen.  The  fluoroscope  must  he  einployed  loith  great  caution. 
The  handle  should  be  protected  with  a  leaden  cover,  and  the  observations 
made  as  rapidly  as  possible.  The  well-being  of  both  the  patient  and  the 
operator  is  to  be  kept  constantly  in  mind. 

The  Head. — Perhaps  the  most  difficult  field  of  all  in  the  use  of  the 
X-rays  is  that  of  the  head.  The  tissues  of  the  head  offer  much  resistance 
to  the  transmission  of  the  rays,  and  cause  shadows  of  varying  intensities, 
since  the  bony  walls  are  irregular,  interrupted  by  numerous  sutures,  fur- 
rowed by  grooves  and  sinuses,  containing  air  spaces,  and  because  the  brain 
structures  are  convoluted  and  freely  bathed  with  blood.  "When  a  good 
picture  is  obtained,  the  shadows  of  the  normal  structures  make  the  outline 


EXAMINATION  BY  X-RAYS.  379 

of  any  pathological  condition  difficult  to  procure  and  difficult  to  interpret. 
It  requires  the  best  of  technic  to  produce  a  satisfactory  picture,  and  a 
wide  experience  to  interpret  a  good  picture.  It  is  possible,  especially 
when  the  skull  is  thin,  to  derive  definite  information  as  to  the  size  and  posi- 
tion of  dense,  sharply  outlined,  coarse  lesions,  as  sarcomata,  fibromata, 
cysts,  abscesses,  tuberculous  nodules,  and  rarely  of  blood-clots.  The  find- 
ings here  are  not  as  certain  as  elsewhere,  but  the  diagnostician,  who  wishes 
to  exhaust  every  means,  will  certainly  not  reject  the  information  brought 
to  him  by  this  agency.  In  the  hands  of  expert  operators  positive  infor- 
mation is  often  added  to  that  obtained  by  other  means  of  diagnosis,  and 
not  infrequently  negative  findings  are  of  great  value.  To  know,  for  in- 
stance, that  a  good  skiagraph  shows  no  shadow  in  a  region  where  the  physi- 
cal signs  suggest  a  tumor,  would  probably  make  the  average  physician 
hesitate  to  employ  surgical  intervention;  while,  in  an  equally  good  picture, 
a  clearly  outlined  growth  in  some  region  producing  few  physical  signs 
might,  if  known  at  an  early  period,  be  the  means  of  saving  life. 

The  Neck. — The  presence  of  an  aneurism,  or  a  tumor,  and  its  extent 
can  often  be  determined.  Expansile  pulsation  would  suggest  an  aneurism 
with  thin  walls,  and  a  dense,  dark  shadow  having  a  heaving  impulse 
synchronous  with  the  cardiac  beat  would  be  suggestive  of  a  tumor  attached 
to  one  of  the  larger  vessels. 

The  Thorax. — The  chest  is  the  region  in  which  the  X-rays  are  of 
great  use  to  the  internist,  and  the  fluoroscope  often  yields  data  of  diagnostic 
value.  The  lung  tissue  offers  little  resistance  to  the  passage  of  the  rays, 
and,  consequently,  the  shadows  of  the  sternum,  ribs,  clavicle,  scapulse,  and 
spinal  column  are  clearly  seen,  and  the  position  of  the  heart,  the  arch  of 
the  aorta  and  diaphragm  recognized  without  difficulty.  A  further  advan- 
tage of  the  fluoroscope  is  that  these  organs  can  be  observed  in  motion, 
in  both  the  state  of  health  and  disease. 

Upon  the  screen  of  the  fluoroscope,  the  normal  lung  appears  trans- 
lucent, the  bony  parts  dark,  and  the  heart  and  diaphragm  exhibit  charac- 
teristic movements.  It  is,  therefore,  evident  with  these  conditions  that 
positive  information  can  be  gained  with  the  fluoroscope.  Through  this 
instrument  the  diaphragm  in  health  is  seen  as  a  dome-shaped  shadow  at 
the  level  of  the  fourth  rib  on  the  right  side,  and  of  the  fourth  interspace 
on  the  left,  which  in  health  makes  an  excursion  between  1.5  and  1.7  cm., 
and  in  full  inspiration  between  6.8  and  7.1  cm.  The  average  excursus  in 
quiet  breathing  is  estimated  at  1.25  cm.  In  tall  subjects  it  is  greater,  and 
in  small,  deep-chested  persons  somewhat  less.  This  knowledge  of  the 
action  of  the  diaphragm  is  of  great  moment,  for  in  nearly  every  morbid 
condition  of  lung  or  pleural  cavity  there  is  an  attending  change  in  the 
action  of  the  diaphragm.  Consequently,  every  operator  should  familiarize 
himself  with  the  appearance  of  the  normal  chest,  the  position  and  move- 
ment of  the  normal  heart,  and  particularly  the  position  and  excursions  of 
the  normal  diaphragm. 

Phthisis. — In  general  it  may  be  said  that  a  darkening  of  the  fluoro- 
scopic pictures  of  the  apices  suggests  phthisis.  Sometimes  there  may  be 
only  a  diminution  of  the  clearness  of  the  lung,  and  the  outline  of  clavicle 
and  ribs  is  less  distinct  than  on  the  sound  side.     The  movements  of  the 


380 


MEDICAL  DIAGNOSIS. 


diaphragm  may  be  restricted  on  the  affected  side,  and  occasionally  the 
heart  is  drawn  towards  it.  The  limits  of  the  excursion  of  the  diaphragm 
should  be  traced  upon  the  skin  with  pencil,  and  the  difference,  if  any, 
noted  in  this  way.    The  extent  of  the  darkened  area  and  its  outline  should 


Fig.  153. — Case  of  acute  miliary  tuberculosis  in  girl  of  twelve  years.     (A.  W.  George,  M.D.) — Rotch. 


Fig.  154. — Enlarged  bronchial  glands  in  a  girl  of  twelve  years.  Notice  dark  shadows  situated  along 
right  border  of  heart  extending  up  into  apex.  Seen  in  all  normal  chests,  but  to  less  extent  than  these. 
Lungs  and  pleurae  otherwise  normal.     (A.  W.  George,  M.D.) — Rotch. 

be  likewise  indicated  upon  the  chest  wall,  or  tracing  paper,  so  that  it  may 
be  compared  with  the  condition  later.  An  X-ray  plate  made  in  this  state 
often  shows  a  "mottling"  of  the  part,  or  it  ma}^  indicate  general  apical 
consolidation.  If  there  be  enlarged  bronchial  glands  they  also  may  cause 
circumscribed  shadows.     In  the  early  stages,   with  an  irregular  rise  of 


EXAMINATION  BY  X-RAYS. 


381 


Fig.  155. — Case  of  plastic  pleurisy  in  girl  six  years  of  age.     Shadow  extending  over  entire  left  chest  except- 
ing in  central  part.     Shadow  not  changed  with  position.     (A.  W.  George,  M.D.; — Rotch. 


Fig.   156. — Left-sided  pleural  effusion  with  displacement  of  heart  to  the  right.      (Mange.s.) — Jefferson 

Hospital. 


382  MEDICAL  DIAGNOSIS. 

evening  temperature,  with  slight  digestive  symptoms,  with  or  rarely  with- 
out cough,  before  the  sputum  gives  a  positive  report,  and  when  indefinite 
physical  signs  exist,  the  Rontgen  rays  may  afford  diagnostic  criteria  as 
to  the  nature  of  the  disorder.  The  progress  of  the  pathological  process 
can  also  be  studied.  Cavity  formation  presents  a  clear  space  in  the  picture 
of  the  affected  lung.  If  there  are  thickened  walls,  they  frequently  cast  a 
dark  shadow,  and  fluid,  offering  resistance  to  the  rays,  can  be  seen  and 
outlined  in  the  broken-down  area.  Comparative  studies  of  skiagraphs 
made  on  repeated  examinations  afford  valuable  information  in  some  cases. 
The  report  of  the  Rontgen  rays  should  never  be  considered  apart  from  the 
knowledge  gained  by  other  clinical  investigations  and  the  history  of  the 
case,  but,  combined  with  these,  it  rounds  out  and  completes  the  case 
record,  and  gives  the  practitioner  an  opportunity  to  see  with  his  own  eyes 
what  is  transpiring  before  him.  In  emphysema  the  lung  is  brighter  than 
normal,  as  seen  through  the  screen.  This  obtains  throughout  the  whole 
structure  involved.  Thickening  of  the  pleura  may  present  shadows,  and, 
not  infrequently,  pleural  fibrosis  is  responsible  for  displacement  of  organs, 
and  shows  a  picture  which  indicates  these  changes. 

Pneumonia. — Usually  the  physical  signs  of  pneumonia,  with  its  his- 
tory, are  so  characteristic  that  an  appeal  to  the  X-rays  is  not  necessary. 
The  fluoroscope  may  be  of  aid  in  the  diagnosis  of  central  pneumonia,  and 
the  picture  will  localize  the  darkened,  restricted  area  in  the  central  part 
of.  the  lung  with  a  clear  space  above  and  below  it.  In  certain  obscure 
cases  where  the  physical  signs  are  less  marked  than  usual,  and  in  the  aged, 
the  rays  may  be  of  great  service. 

Pleurisy  with  Effusion. — Referring  alwaj^s  to  the  history  and  physi- 
cal signs,  the  rays  in  this  disease  may  give  much  additional  information. 
In  a  pleural  effusion  of  any  extent  the  movements  of  the  diaphragm  are 
restricted  or  arrested.  The  lung  above  is  more  dense  than  on  the  sound 
side.  The  heart  is  displaced.  The  line  of  the  ribs  is  distorted,  and  the 
dark  shadow  of  the  effusion  joins  that  of  the  diaphragm.  If  the  pleurisy  is 
attended  by  phthisis,  the  apex  will  show  an  area  reduced  in  clearness. 
In  old  pleurisy  with  adhesions,  the  heart  is  often  displaced  toward  the 
affected  side,  the  ribs  are  drawn  nearer  together,  and  the  excursion  of  the 
diaphragm  is  markedly  restricted.  Empyema. — In  empyema  the  outline  of 
the  involved  area  is  seen  as  a  very  dense  shadow.  The  very  heavy  shadows 
of  the  thickened  walls  can  occasionally  be  distinguished  from  the  opacity 
caused  by  the  fluid.  The  movements  of  the  diaphragm  are  interfered  with, 
and  the  adjacent  viscera  are  dislocated.  In  chronic  empyema  adhesions  may 
displace  surrounding  organs  towards  the  diseased  side.  In  pneumopyothorax 
and  pneumohydrothorax  there  is  a  clear  space  between  the  fluid  and  the 
lung  above.  The  dark  shadow  of  the  fluid  shifts  with  the  change  of  the 
patient's  position.     It  sometimes  can  be  seen  to  pulsate  with  the  heart. 

Emphysema. — In  this  condition,  wdth  more  air  in  the  lung  tissue  than 
normally,  it  is  evident  that  the  extent  of  the  lung  will  be  increased.  The 
picture  is  clearer  than  that  of  the  normal  lung.  The  diaphragm  is  lower, 
and  its  excursion  restricted.  If  the  left  side  is  involved,  the  outline  of  the 
heart  is  sharper  than  normal,  lower  down  in  the  chest,  and  more  vertical 
than  in  health. 


EXAMINATION  BY  X-RAYS. 


383 


Fig.  157. — Tack  in   the  right  bronchus.     Operation,  recovery  (case  of  Dr.  Gibbon).     (Manges.) — Jefferson 

Hospital. 


Fig.  158. — Aneurism  involving  the  arch  of  the  aorta.    (Manges.) — Jefferson  Hospital. 


384  MEDICAL  DIAGNOSIS. 

Bronchitis.  —  In  the  average  case  of  bronchitis  the  fluoroscopic 
and  radiographic  examinations  are  unnecessary.  The  action  of  the  dia- 
phragm may  be  restricted  when  the  bronchial  tubes  contain  much  secretion, 
and  after  coughing,  when  the  bronchi  have  been  freed  from  mucus,  the 
movements  of  the  diaphragm  approach  the  normal.  Occasionally  the 
outline  of  the  ribs  appears  less  distinct  than  in  health.  The  symptoms  of  a 
rapidly  developing  bronchitis  or  pneumonia,  especially  in  young  children 
in  whom  a  history  cannot  be  obtained,  may  depend  upon  a  foreign  body 
lodged  in  the  trachea  or  in  the  bronchial  tubes,  and  in  such  case  the  ad- 
vantage of  the  X-ray  examination  is  obvious.  Negative  findings  in  some 
cases  of  severe  bronchitis  may  be  of  diagnostic  importance. 

The  Heart. — By  means  of  the  fluoroscope  the  position,  size,  and 
action  of  the  heart  are  readily  seen  because  this  organ  casts  a  very  dark 
shadow  upon  the  screen,  and  if  the  heart  is  hypertrophied  or  dilated,  its 
extent  beyond  the  normal  boundaries  is  seen  at  a  glance.  Irregularity  and 
extent  of  contraction  of  the  ventricles  has  been  observed.  If  there  are 
pleuritic  or  diaphragmatic  adhesions,  the  displacement  of  the  heart  and  its 
tugging  upon  these  structures  may  be  observed.  Displacement  from  new 
growths  or  pleural  effusion  is  likewise  recognized.  The  radiograph  is  of 
much  less  value  than  the  fluoroscope  in  the  study  of  this  particular  organ. 

The  Aorta,  and  Aneurisms. — The  course  of  the  aorta  can  be  seen 
arising  in  the  normal  chest,  slightly  to  the  right  and  above  the  heart,  and 
then  running  to  the  left  of  the  spinal  column  and  downward  until  it  is  lost 
in  the  shadow  of  the  heart.  A  small  aneurism  in  the  ascending  arch  wiU 
be  seen  as  a  shadow  extending  to  the  right  of  the  sternum,  while  a  smaU 
aneurism  of  the  transverse  or  descending  portion  of  the  arch  casts  a  shadow 
greater  than  the  normal  shadow  on  the  left  side  of  the  sternum.  A  large 
Aneurism  produces  a  shadow  both  to  the  right  and  to  the  left  of  the  sternum, 
and  shows  distinct  pulsation.  Here,  as  everywhere,  the  findings  of  the  X-rays 
must  be  taken  in  conjunction  with  the  history  and  signs  and  symptoms. 

New  Growths. — A  new  growth  of  considerable  size  is  almost  certain 
to  be  seen  and  localized  by  the  aid  of  the  fluoroscope  and  sensitive  plate. 
In  an  afebrile  case  with  the  signs  of  pulmonary  solidification,  with  cough 
and  blood-tinged  expectoration,  a  dark  area  in  the  picture  of  the  lung 
structure  is  almost  certain  to  be  a  new  growth.  Changes  in  its  position 
and  growth,  and  its  relation  to  the  surrounding  viscera,  can  be  noted  from 
week  to  week,  and  a  prognosis  indicated.  In  doubtful  cases  the  value  of  a 
negative  fluoroscopic  examination  is  self-evident.  In  diseases  of  the  chest 
the  X-ray  examination  is  an  agent  that  brings  positive  service  to  those 
who  employ  it  intelligently. 

The  Abdomen. — The  CEsophagus. — The  course  and  condition  of  the 
oesophagus  can  be  ascertained  by  means  of  the  Rontgen  rays.  The  shadow 
caused  by  a  rubber-coated  wire  when  inserted  into  the  oesophagus  will 
indicate  the  direction  of  the  organ.  The  X-rays  can  localize  a  stricture 
when  a  bulbar  bougie  is  inserted  to  the  level  of  the  obstruction,  and 
diverticula  can  be  outlined  by  lowering  a  thin  rubber  tube  filled  with  shot 
or  mercury  into  it,  or  by  having  the  patient  swallow  a  suspension  of  bis- 
muth subnitrate.  New  growths  in  the  oesophagus  are  difficult  to  see, 
because  of  the  density  of  the  shadows  cast  by  the  sternum  and  spinal  column. 


EXAMINATION  BY  X-RAYS. 


385 


The  Stomach. — By  distending  the  stomach  with  air  or  gas,  the  light- 
ened space  gives  a  fair  idea  of  the  position  and  size  of  this  organ.  Bismuth 
suhnitrate  in  the  amount  of  an  ounce  or  more,  taken  in  a  bowl  of  milk, 
will  cast  a  dark  shadow  upon  the  plate,  which  more  distinctly  shows  the 
outline  of  the  viscus.  If  there  is  a  stricture  at  the  pylorus,  celluloid  cap- 
sules of  bismuth  will  lie  in  the  stomach  for  a  period  of  time,  and  then  be 
expelled  by  vomiting.     A  large  carcinomatous  mass  involving  the  stomach 


Vir,. 


l.jO. — "Hour-glass"  deformity  of  the  stomach;    diagnosis  confirmed  at  operation  (case  of  Dr.  Gibbon). 
(MangesJ — Jeffer.;on  Hospital. 


wall  will  usually  make  its  impress  upon  the  sensitive  plate  and  confirm 
the  other  means  of  diagnosis.  A  change  in  the  shape  and  size  of  the  stomach, 
as  in  the  ''hour-glass  stomach,"  has  been  likewise  studied  with  bismuth. 
Stomach  peristalsis  can  also  be  studied  with  the  X-rays. 

The  Intestinal  Tract. — Because  of  the  lack  of  contrast  in  the 
density  of  the  shadows,  the  amount  of  information  gained  b}^  the  X-ray 
examination  of  these  structures  is  often  disappointing.  New  growths  may 
cast  shadows  here  as  they  do  everywhere,  but  their  actual  relation  to  the 
section  of  the  bowel  from  which  they  spring  can  only,  as  a  rule,  be  roughly 
25 


386  MEDICAL  DIAGNOSIS. 

estimated.  Injection  of  bismuth  subnitrate  into  the  colon  serves  to  out- 
Hne  that  part  of  the  canal.  It  is  well  to  remember  that  acute  abdominal 
symptoms  may  be  excited  by  a  foreign  body,  which  has  been  swallowed^ 
and  in  such  cases  the  X-ray  picture  may  clear  up  the  diagnosis. 

The  Liver. — In  children  and  in  thin  subjects  the  left  lobe  of  the  liver 
can  usually  be  outlined.  Marked  displacement  or  enlargement  of  the  liver 
often  shows  in  a  satisfactory  radiograph.  A  distended  gall-bladder,  espe- 
cially if  it  be  filled  with  gall-stones,  is  likely  to  give  a  picture  of  some  real 
worth.    Carcinomatous  masses  cause  characteristic  irregular,  dense  shadows. 

The  Spleen. — If  the  stomach  is  distended  by  air  or  gas,  so  as  to 
increase  the  contrast,  the  shadow  of  the  spleen  can  quite  commonly  be  seen 
with  the  fluoroscope,  and  its  size,  position,  and  movement  on  deep  inspi- 
ration observed.  If  it  should  be  a  wandering  spleen,  the  absence  of  this 
shadow  in  the  normal  position  would  be  a  confirming  figure  in  that  diagnosis. 

The  Kidneys. — With  good  technic  it  is  at  times  possible  to  get  an 
outline  of  these  structures,  to  know  if  they  are  in  their  normal  positions 
(particularly  on  the  left  side),  to  know  if  they  are  swollen,  or  if  the  shadow 
is  enlarged  by  perinephritic  abscess,  and  particularly  if  it  is  possible  to 
determine  v/hether  there  be  a  stone  in  the  organ.  Stone  in  the  bladder  and 
stone  in  the  ureters  concern  the  surgeon  more,  as  a  rule,  than  the  general 
practitioner;  and  yet,  with  an  obscure  history  and  physical  signs,  the 
general  practitioner  is  the  first  one  called  in  to  make  a  diagnosis,  and  he 
fails  to  do  himself  justice  if  he  neglects  to  procure  a  good  radiograph  plate. 

The  Extremities. — Hardened  arteries,  when  palpable,  are  readily 
recognized,  but  in  the  deeper  structures  this  is  impossible,  and  a  good 
X-ray  plate  will  often  exhibit  this  condition  in  the  femoral,  the  popliteal, 
and  the  dorsalis  pedis,  as  it  will  in  the  bronchial  arteries.  The  shape  and 
density  of  the  bones  and  the  size  of  calcareous  deposits  in  muscles  and 
tendons  as  their  coverings  are  determined  satisfactorily  in  a  limited  group 
of  diseases. 

The  Joints. — In  swollen  and  stiffened  joints  it  is  often  important, 
both  in  determining  the  treatment  and  the  prognosis,-  to  know  whether 
injury  to  the  bony  structures  exists,  or  whether  there  be  exostosis,  or 
simply  an  inflammatory  condition  of  the  soft  parts.  A  good  view  with  the 
fluoroscope,  or,  better  yet,  a  satisfactory  radiograph  picture,  will  deter- 
mine this  question.  Calcified  joints  or  deposits  of  any  density  will  give  a 
dark  shadow. 

New  Growths. — The  position,  shape,  and  size  of  tumors  such  as 
sarcomata  and  fibromata  can  be  pictured,  and,  not  infrequently,  the 
differential  diagnosis  between  these  and  an  aneurism  made. 

Orthodiagraphy. — Moritz  has  devised  a  method  of  X-ray  examina- 
tion of  the  heart,  which  eliminates  certain  errors  of  the  ordinary  exami- 
nation by  a  device  which  makes  use  only  of  the  central  rays  from  the 
ordinary  Crookes'  tubes,  that  is,  those  which  fall  perpendicularly  upon  the 
plate  or  fluoroscopic  screen.  By  an  orderly  progressive  movement  of  the 
special  tube  along  the  periphery  of  the  heart's  shadow,  and  marking  upon 
the  screen  or  the  chest  of  the  patient  successive  points  at  its  border,  and 
joining  these  points  by  lines,  a  fairly  accurate  outline  of  the  heart  may 
be    obtained.     The   results   of   this   method,  as  worked  out   by  several 


r 


EXAMINATION  BY  X-RAYS 


387 


• 


Fig.  160. — Intestinal   obstruction   due  to  peritoneal   adhesions.     Diaainosis  confirmed  at  operation  (case 
of  Dr.  Loux).     (Manges.) — Jefferson  Hospital. 


Fig.  161. — Calculus  in  the  left  renal  pelvis.     (Manges.) — Jefferson  Hospital 


388  MEDICAL  DIAGNOSIS. 

observers,  confirm  certain  facts  that  have  been  determined  by  the  methods 
of  physical  diagnosis,  and  have  long  been  known.  Among  these  the 
following  are  important: 

(a)  In  the  adult  under  normal  circumstances  the  liver  and  diaphragm, 
upon  change  from  the  recumbent  to  the  erect  posture,  assume  a  lower 
level,  and  corresponding  with  this  change  the  heart  assumes  a  somewhat 
more  vertical  position,  its  apex  being  lower  and  its  transverse  diameter 
decreased. 

(b)  In  the  aged  the  diaphragm  likewise  occupies  a  lower  position,  but, 
owing  to  the  relaxation  of  the  ligamentous  attachments  of  the  great  vessels, 
the  heart  sinks  as  a  whole  so  that  its  position  remains  more  transverse. 

(c)  In  females  the  average  position  of  the  heart  is  about  an  interspace 
higher  than  in  males. 

(d)  In  acute  and  chronic  pulmonary  emphysema  the  position  of  the 
diaphragm,  and  consequently  that  of  the  heart,  is  much  lower  than  under 
normal  circumstances,,  and  for  that  reason  the  upper  border  of  cardiac 
dulness  is,  notwithstanding  the  increase  in  size  of  the  right  ventricle, 
considerably  lowered. 

(e)  Under  pathological  conditions  the  cardiac  impulse  does  not,  in 
all  cases,  correctly  indicate  either  the  extreme  left  border  of  the  heart 
or  its  lower  border.  The  apex  may  be  covered  by  the  border  of  the  lung 
on  the  one  hand,  and  the  movement  of  the  chest  wall  may,  on  the  other, 
extend  beyond  the  actual  border  of  the  heart.  As  shown  by  the  X-ray 
shadow  the  lower  border  may,  in  some  cases,  extend  below  the  region  of 
the  impulse. 

Stereoskiagraphy. — The  application  of  the  principles  of  stereoscopy 
to  skiagraphy,  first  employed  by  Elihu  Thompson,  is  of  service  in  the 
locaHzation  of  foreign  bodies,  tumors,  and  various  lesions  of  the  skeleton. 
Several  special  instruments  for  making  skiagraphs  and  different  methods  for 
viewing  stereoskiagrams  (Wheatstone,  Brewster)  have  been  devised.  "In 
the  study  of  normal  and  morbid  conditions  I  invariably  resort  to  the  em- 
ployment of  stereoskiagraphy  at  the  Philadelphia  Hospital"  (Kassabian). 


PART   III. 

OF  SYMPTOMS  AND   SIGNS. 


I. 

GENERAL  CONSIDERATIONS. 

Symptoms  and  Signs. — The  clinical  phenomena  of  disease  are  divided 
into  two  general  groups:  (a)  subjective,  those  obtained  by  inquiry,  and 
(b)  objective,  those  learned  by  observation.  The  former  are  known  as 
SYMPTOMS,  the  latter  as  signs.  These  may  be  general,  as  fever,  debility, 
or  emaciation,  or  local,  as  pain,  dyspnoea,  or  dulness  upon  percussion. 
The  dividing  line  between  symptoms  and  signs  is  not  well  defined.  Pain 
and  nausea  are  symptoms  of  which  nothing  can  be  learned  by  observa- 
tion alone;  an  endocardial  murmur  or  pleural  friction  rub,  signs  concern- 
ing which  the  patient  can  give  no  personal  account;  while  retching,  cough, 
and  palpitation  partake  at  once  of  the  nature  of  both  signs  and  symptoms 
and  may  be  referred  to  the  one  or  other  group  of  clinical  phenomena  accord- 
ing to  the  point  of  view  from  which  they  are  regarded.  Symptomatology 
is  .that  department  of  medical  science  which  has  for  its  object  the  consider- 
ation of  the  symptoms  of  disease;  semeiology  {(rri/isiov,  a  sign),  that 
which  has  for  its  object  the  consideration  of  the  signs  of  disease.  Just  as 
symptoms  and  signs  are  not  always  to  be  closely  distinguished,  so  the 
scope  and  subject  matter  of  these  sub-sciences  of  medicine  largely  overlap, 
and  symptomatology  and  semeiology  are  frequently  used  interchangeably. 
Pure  symptoms  are  limited  in  number  as  compared  with  signs,  and,  since 
they  are  wholly  subjective  and  our  knowledge  of  them  is  based  upon  the 
statements  of  the  patient,  who  may,  according  to  his  temperament  or  for 
purposes  of  his  own,  either  unintentionally  or  wilfully  misrepresent  them, 
they  are  of  far  less  value  in  diagnosis  than  signs.  Symptoms,  which  have 
their  origin  in  the  deranged  sensations  of  the  patient,  stand  in  contrast  to 
signs,  which  are  dependent  upon  changes  in  organs  or  tissues.  For  this 
reason  qualifying  adjectives  are  sometimes  employed,  and  we  speak  of 
rational  symptoms  and  physical  signs.  It  is  customary,  however,  to 
apply  the  word  symptom  to  many  of  the  objective  phenomena  of  disease. 

Syndrome  is  a  term  used  to  designate  a  set  of  concomitant  symptoms, 
especially  the  concurrence  of  a  group  of  symptoms  not  indicating  a  disease 
with  well-determined  anatomical  lesions,  as  for  example  fever,  seasickness, 
and  astasia-abasia;    a  symptom-complex;    a  symptom-group. 

Diseases  upon  one  basis  of  classification  are  divided  into  constitutional 
or  general,  namely,  those  in  which  the  organism  as  a  whole  reacts  to  the 
pathogenic  influence;  and  local  or  organic,  in  which  the  lesions  involve 
primarily  or  chiefly  a  viscus  or  an  anatomical  tract.     General  symptoms 

3S9 


390  MEDICAL  DIAGNOSIS. 

fire  often  the  expression  of  a  local  disease  and  local  symptoms  the  expression 
of  a  general  disease;  thus  emaciation,  pallor,  and  a  profound  cachexia 
attend  the  progress  of  carcinoma  of  the  stomach,  while  tenderness  in  the 
right  iliac  fossa,  diarrhoea,  and  tympany  are  symptoms  of  enteric  fever. 


II. 

APPEARANCE;    TEMPERAMENT  AND   DIATHESIS;    FACIES; 

FORM    AND    NUTRITION. 

APPEARANCE. 

The  general  appearance  of  the  patient  when  first  seen  forms  the  ground- 
work for  the  study  of  his  present  condition — the  status  prcesens.  Whatever 
knowledge  may  be  subsequently  obtained  of  the  facts  in  the  case,  the 
general  appearance  constitutes  the  point  of  departure  for  the  direct  diag- 
nosis. In  the  successful  clinician  the  habit  of  observing  and  noting  its 
various  details  with  great  rapidity  is  cultivated  in  a  high  degree.  The 
facial  expression,  state  of  nutrition,  movements  and  attitude,  mode  of 
speech,  and  mental  condition  are  at  once  observed.  An  opinion  is  formed 
as  to  what  manner  of  man  the  patient  is.  Information  as  to  his  social 
position,  occupation,  and  habits  may  be  learned  from  his  dress:  Is  he  neat 
or  slovenly?  Are  his  clothes  buttoned  awry?  Is  his  collar  loose  to  make 
room  for  swollen  glands  or  a  goitre?  Do  his  trousers  show  the  white  stains 
of  diabetic  urine?  Has  he  the  tabetic  or  steppage  gait  or  the  festination 
of  paralysis  agitans?  Has  he  the  flushed  face  with  dilated  venules  and  the 
trembling  tongue  of  the  alcoholic,  or  the  enlarged  girth  and  the  waistband 
lengthened  with  a  loop  of  string,  of  hepatic  cirrhosis  with  ascites?  The 
hands  tell  a  story  of  their  own.  We  note  at  a  glance  that  they  are  white 
and  soft  and  the  finger-nails  are  clean,  as  occurs  mostly,  but  not  always, 
with  men  of  leisure  and  professional  men;  that  they  are  large  and  callous, 
as  in  those  who  follow  the  sea;  coarse,  sunburnt,  and  freckled,  as  in  the 
farmer;  or  that  they  bear  the  oil  and  grime  of  the  mechanic  who  has  hurried 
from  his  work.  The  trembling  hand  of  alcoholism,  the  pill-rolling  move- 
ments of  paralysis  agitans,  the  nodules  and  tophi  of  gout,  the  deformities 
and  relaxed  ligaments  of  arthritis  deformans,  and  the  spade-like  hands  of 
myxoedema  tell  their  own  tale. 

The  diagnosis  may  sometimes  be  made  at  a  glance.  The  flushed  face, 
hurried  breathing,  unilateral  movement  of  the  chest,  and  rusty  sputum  of 
pneumonia  scarcely  demand  the  additional  data  of  chill,  crepitant  rale, 
and  percussion  dulness;  nor  the  intense  headache,  opisthotonos,  vomiting, 
herpes,  and  petechise  the  history  of  sudden  onset  or  the  epidemic  prevalence 
of  cerebrospinal  fever;  while  the  paroxysm  of  whooping-cough  is  in  itself 
diagnostic.  The  diagnosis  thus  made  cannot,  however,  be  called  intuitive. 
In  truth  there  is  no  such  thing  as  an  intuitive  diagnosis.  Before  a  conclu- 
sion is  reached,  however  brief  the  time,  the  clinician,  usually  without  being 
aware  of  his  mental  processes,  has  been  weighing  and  sifting  the  symptoms 


SYMPTOMS  AND  SIGNS:  TEMPERAMENT— DIATHESIS.    391 

and  assigning  to  each  its  proper  value  and  importance.  Such  a  diagnosis 
must  in  all  cases  be  personally  regarded  as  provisional  and  not  announced, 
however  tempting  the  circumstances,  until  sufficient  facts  for  its  full  sup- 
port have  been  obtained.  There  are  pitfalls  in  the  way  of  him  who  makes 
"what  in  the  language  of  the  ward  classes  is  called  a  "snap  diagnosis." 
It  is  never  complete;  the  pneumonia  may  be  complicated  with  pericarditis. 
Such  a  diagnosis  is  sometimes  altogether  false;  there  are  cases  of  enteric 
fever  in  neurotic  individuals  in  early  life  that  closely  simulate  the  symp- 
tom-complex of  meningitis — the  so-called  cerebrospinal  form  of  enteric 
fever — and  a  child  long  convalescent  from  whooping-cough  may  under 
emotional  excitement  or  when  suffering  from  an  attack  of  subacute 
laryngitis  have  paroxysms  of  cough  with  whooping. 

TEMPERAMENT  AND   DIATHESIS. 

Under  the  teaching  of  the  French  school  great  importance  was  at  one 
time  attached  to  temperament  or  diathesis  as  a  condition  of  the  hereditary 
constitution  manifested  in  the  general  appearance  of  the  patient.  Less 
attention  is  paid  to  this  subject  now  than  formerly,  but  no  very  close 
observation  is  required  to  establish  the  fact  that  many  individuals  have  in 
common  peculiarities  of  physical  and  mental  organization  very  different 
from  those  of  others  and  that  corresponding  differences  in  general  health 
and  tendency  to  disease  occur.  Disregarding  misleading  refinements  and 
combinations  the  following  principal  forms  may  be  described: 

The  sanguine,  sometimes  called  the  Arthritic  or  Gouty  Tempera- 
ment.-^The  characteristics  of  this  condition  are  well-developed  bones  and 
muscles,  a  fine  skin,  good  hair,  fair  complexion,  good  nutrition,  a  general 
appearance  of  health  and  energy.  The  physiological  processes  are  active, 
the  digestion  excellent,  the  bowels  regular,  the  respiratory  excursus  large, 
the  action  of  the  heart  regular,  the  pulse  full  and  strong.  In  disposition 
persons  of  this  temperament  are  cheerful  and  hopeful,  hence  the  adjective 
"sanguine"  often  applied  to  them.  Mentally  they  are  active  but  of  delib- 
erate judgment  and  they  do  a  large  part  of  the  world's  work.  They  are 
especially  liable  to  bronchitis  and  other  catarrhal  affections  and  to  arterio- 
sclerosis, and  in  advancing  life  prone  to  sclerotic  changes  in  the  valves  of 
the  heart,  aneurism,  angina  pectoris,  or  apoplexy. 

The  nervous  diathesis  shows  itself  commonly  in  slender  or  under- 
sized individuals  who  are  often  poor  and  irregular  eaters,  not  well  nourished. 
Such  persons  are  alert  and  active  but  often  incapable  of  sustained  effort. 
The  physiological  processes  are  not  always  well  performed.  They  often 
possess  high  intellectual  ability  and  are  subject  to  intense  emotions.  They 
are  predisposed  to  derangements  of  the  digestive  apparatus  and  to  head- 
ache from  slight  causes.  They  take  things  to  heart,  as  the  phrase  goes, 
and  are  liable  to  break  down  under  stress  of  work  and  worry.  Neuras- 
thenia, hysteria,  migraine,  and  other  functional  diseases  of  the  nervous 
isystem  and  insanity  are  common. 

The  Bilious  Diathesis. — The  complexion  is  dark,  the  hair  dark 
brown  or  black,  often  coarse  and  oily,  the  skin  shows  a  tendency  to  local 
pigmentation  which  varies  in  intensity,  especially  about  the  eyes  and  brow. 


392  MEDICAL  DIAGNOSIS. 

The  appetite  is  irregular,  often  poor,  fats  and  sugars  are  digested  with 
difficulty,  and  the  bowels  are  sluggish.  The  nutrition  is  not  good,  though 
women  of  this  temperament  often  grow  stout  in  middle  life.  They  are 
subject  to  attacks  of  that  form  of  gastrohepatic  catarrh  popularly 
described  as  biliousness  and  are  often  at  such  times  faintly  jaundiced. 
Nausea  and  headache  are  common.     Such  persons  often  lack  energy. 

The  Lymphatic  Diathesis. — The  muscles  are  soft  and  flabby,  there 
is  very  often  a  slight  excess  of  subcutaneous  fat.  The  skin  is  pallid,  the 
physiological  processes  are  sluggishly  performed.  Mentally  such  persons  are 
dull  and  unresponsive.  They  are  subject  to  enlargements  of  the  subcuta- 
neous lymph-nodes  and  are  liable  to  chlorosis  and  other  forms  of  ansemia. 

The  Strumous  Diathesis. — The  word  struma,  meaning  scrofula  or 
glandular  tuberculosis,  though  still  applied  in  another  sense  to  goitrous 
swellings,  has  lost  its  significance  in  medicine  and  has  almost  disappeared 
from  the  modern  literature.  The  term  strumous  diathesis  has,  however, 
a  very  definite  significance  and  is  applied  to  a  bodily  constitution  unfor- 
tunately too  common.  The  bony  framework  departs  widely  from  the 
normal  type.  The  chest  is  small  and  flat,  the  shafts  of  the  long  bones 
slender,  their  epiphyses  enlarged  and  thickened.  The  musculature  is 
undeveloped  and  soft.  The  appearance  is  characteristic,  the  head  is  large, 
the  cranial  bosses  prominent,  the  forehead  broad  and  protuberant,  the 
lips  full,  the  nose  short  and  broad,  its  alse  thickened,  the  lower  jaw  small, 
the  teeth  carious,  the  complexion  commonly  fair,  the  hair  fine  and  the  eye- 
lashes long.  The  nutrition  is  poor  and  the  general  appearance  of  such 
individuals  delicate  and  frail.  The  cervical  lymphatics  are  often  enlarged. 
Such  persons  are  subject  to  tuberculosis  of  the  glands,  bones,  and  lungs 
and  miliary  tuberculosis,  and  usually  die  at  an  early  age.  They  are  fre- 
quently the  offspring  of  tuberculous  parents.  Whether  the  constitutional 
peculiarities  which  go  to  make  up  the  so-called  strumous  diathesis  are  to 
be  ascribed  to  profound  derangements  of  nutrition,  transmitted  from 
tuberculous  parents,  or  to  a  latent  tuberculosis  acquired  in  the  earliest 
period  of  life  cannot  always  be  determined. 

Cachexia  is  a  term  used  to  describe  the  ravages  of  certain  chronic 
wasting  diseases,  especially  untreated  malaria,  the  graver  forms  of  syphilis, 
and  carcinoma,  particularly  when  it  involves  the  digestive  organs.  The 
cachexisB  present  a  combination  of  profound  ansemia,  extreme  emaciation 
and  debility,  and  a  diffuse,  faint,  muddy  pigmentation  of  the  skin. 

Dyscrasia  is  a  depraved  state  of  the  system,  especially  of  the  blood, 
due  to  constitutional  disease.  In  the  words  of  Bristowe  it  is  a  general 
deterioration  of  health  and  functional  disturbance  caused  by  the  deflec- 
tion of  nutrition.  We  speak  of  a  tuberculous,  malarial,  syphilitic,  or 
cancerous  dyscrasia. 

FACIES. 

The  appearance  of  the  face  is  often  of  diagnostic  importance.  It 
frequently  indicates  the  subjective  sensations  and  not  rarely  the  psychical 
condition.  To  say  that  a  patient's  expression  is  that  of  suffering,  acute 
pain,  anxiety,  overwhelming  illness,  or  that  it  is  excited,  dull  or,  stupid,  is 
intelligible  without  further  comment.     The  face  is  an  index  of  the  physio- 


SYMPTOMS  AND  SIGNS:    FACIES. 


393 


logical  age  of  the  patient.  The  gray  hair,  wrinkled  brow,  arcus  senilis,  and 
hanging  folds  of  skin  about  the  neck  are  very  suggestive.  They  enable  the 
clinician  to  compare  the  apparent  age  of  the  patient  with  his  actual  age  as 
measured  by  years.  The  facies  of  fever  patients  is  often  characteristic. 
In  the  stage  of  excitement  there  is  an  intensification,  in  that  of  depression 
a  blurring  of  expression,  accompanied  by  a  peculiar  moist  appearance  of 
the  eye,  a  feverish  flush  and  often  a  very  slight  turgescence  of  the  skin 
of  which  I  shall  speak  more  fully  in  a  later  paragraph.  Equally  character- 
istic is  the  facies  of  dyspnoea.  Here  also  puffing  or  turgescence  is  present, 
sometimes  marked,  and  there  is  cyanosis,  and  with  these  symptoms  dilated 
nostrils,  an  open  mouth,  and  hurried  breathing.  The  flushed  face  and 
bright  eyes  that  follow  too  much  wine,  and  the  bloated  countenance  with 
its  blurred  lines,  dilated  venules,  thickened  nose,  acne,  and  trembling  tongue 
of  some  forms  of  chronic  alcoholism  are  sadly  familiar.  The  characteristic 
change  of  the  countenance  seen  in  those  about  to  die,  especially  in  patients 

suffering  from  ileus,  peritonitis,      ^ ......„„.,...„„„..,  : 

cholera,  and  similar  diseases,  is  ;««"•'=•'>■ 
described  as  the  facies  Hip- 
pocRATiCA.  The  changes  are 
largely  due  to  a  diminution  in 
the  contents  of  the  blood-  and 
lymph- vessels  and  muscular  re- 
laxation. The  skin  falls  back 
upon  the  bones,  the  lines  of 
expression  are  more  sharply  de- 
fined than  normally,  the  nose 
is  sharp  and  pinched,  the  eyes 
sunken,  the  temples  hollow. 
With  the  pallor  there  is  some  de- 
gree of  cyanosis  which  gives  the 
skin  a  leaden  or  faintly  livid  hue.   The  surface  is  cool  and  bathed  with  sweat. 

The  appearance  of  the  face  in  the  following  conditions  is  suggestive 
if  not  always  characteristic: 

Enteric  Fever. — In  well-developed  cases  the  face  is  dull,  expression- 
less, pallid,  with  a  faint,  dusky  flush  over  the  cheek  bones,  often  slightly 
drawn.  The  eyelids  are  half  closed,  the  lips  pallid  and  separated,  in  neg- 
lected cases  sordes  may  be  seen  upon  the  teeth.  Such  also  is  the  facies  of 
patients  profoundly  septic.  It  occurs  in  the  so-called  "typhoid  state" 
and  is  seen  in  puerperal  septicaemia,  malignant  endocarditis,  infection  after 
surgical  operations,  and  the  like. 

Acute  Peritonitis. — The  expression  is  one  of  intense  suffering, 
the  face  is  pale  and  drawn,  sometimes  the  upper  lip  is  contracted  so  as  to 
show  the  teeth. 

Pneumonia. — A  circumscribed  flush  of  one  or  both  cheeks  may  be 
seen;  it  may  be  bright  or  dusky.  When  one  cheek  only  is  flushed  it  is  usu- 
ally that  upon  the  side  of  the  pulmonary  lesion.  With  this  appearance  in. 
grave  cases  are  associated  the  facial  changes  peculiar  to  dyspnoea.  A 
similar  appearance  accompanies  the  symptomatic  fever  of  phthisis — hectic 
fever.    The  flushing  is,  however,  brighter  and  not  so  distinctly  circumscribed. 


Fig.  162. — Cerebrospinal  fever,  fourth  day  of  attack. 
Fever  facies;  patch  of  herpes;  retraction  of  head. — Munic- 
ipal Hospital,  Royer. 


394 


MEDICAL  DIAGNOSIS. 


It  is  in  strong  contrast  with  the  pallor  of  the  brow  and  neck.  The  strik- 
ing appearance  of  such  patients  is  intensified  by  expanding  nostrils,  hurried 
-    -  breathing,  bright  moist  eyes,  and  an 

intense,  often  eager,  expression. 

Tetanus. — The  facial  peculiarity 
is  startling.  Under  the  action  of  the 
toxin  of  the  disease  all  the  muscles 
of  expression  are  thrown  into  tonic 
spasm  more  or  less  intense  at  the 
same  time,  whereas  under  ordinary 
circumstances  the  varying  moods 
are  expressed  by  the  contraction 
now  of  one  set  of  muscles,  now  of 
another.  The  lips  are  parted  and 
the  corners  of  the  mouth  drawn  up 
as  in  laughter  or  grinning,  while  other 
parts  of  the  face  and  especially  the 
brow  are  contracted  and  throwa 
into  folds  as  though  in  grief  or 
anger  —  risus  sardoxicus  of  the 
older   writers. 

The  Exanthemata — The  appear- 
ance of  the  face  in  the  eruptive  infec- 
tious diseases  is  usually  diagnostic. 
The  diffuse  uniform  rash,  often  in 
strong  contrast  with  the  white  border 
around  the  mouth,  and  the  slightly  tumid  skin  of  scarlet  fever,  the  turgid 
skin,  coarse  measly  rash  with  its  crescentiform  arrangement  and  coryza  in 
measles,  the  pock  in  different  stages 
of  development  T\dth  its  umbilicated 
vesicles  or  hideous  pustules  and 
crusts  and  swollen  and  disfigured  fea- 
tures in  the  variolous  diseases,  and 
the  pellucid  hemispherical  vesicles 
or  crusts  without  areolae,  scattered 
singly  or  in  groups  about  the  brow  or 
mouth  in  varicella,  are  characteristic. 
Mumps.— The  deformity,  alike 
when  it  involves  one  or  both  sides, 
is  characteristic.  The  swelling  is  at 
first  limited  to  the  region  of  the 
parotid  gland,  behind  the  jaw  and 
below  the  ear,  but  the  surrounding 
oedema  sometimes  assumes  remark- 
able proportions.  The  lobule  of 
the  ear  stands  out  at  right  angles 
to  the  side  of  the  head.  When 
the  swelling  advances  upon  the  cheeks,  the  corners  of  the  mouth  are 
slightly  drawn  up.     The  parotid  bubo  which  occurs  in  some  cases  of  enteric 


Fig.  163. — Parotid  bubo  complicating  enteric  fever. 
— Jefferson  Hospital. 


Fk; 


1C4. — Oedema    in    acute    nephritis 
Hospital. 


-Jefferson 


SYMPTOMS  AND  SIGNS:   FACIES. 


395 


Fig.  165. — Facies  in  a  case  of  adenoid  vegetations 
of  the  nasopharynx. — Merrick. 


fever,  pneumonia,  septicaemia,  and  other  grave  infections  superadds 
to  the  facies  of  those  conditions  a  deformity  somewhat  like  that  of 
mumps.     The  overlying  skin  is  usually  of  a  dusky  red  color. 

Renal  Disease. — The  striking 
appearance  of  the  patient  in  some 
forms  of  acute  nephritis  and  very 
commonly  in  chronic  parenchyma- 
tous nephritis  is  of  diagnostic  impor- 
tance. It  is  characterized  by  intense 
waxy  pallor,  marked  oedema  of  the 
35^elids,  and  general  puffiness  of  the 
face  by  which  the  lines  of  expression 
are  to  some  extent  impaired. 

Hepatic  Disease.  —  In  chronic 
diseases  of  the  liver  and  especially 
in  cirrhosis  and  gall-stone  disease  the 
facies  is  peculiar.  The  features  are 
as  a  rule  sharp,  the  face  thin,  con- 
junctivae muddy,  venules  dilated, 
lips  red,  and  skin  slightly  jaundiced 
or  subicteroid — facies  hepatica  of 
the  older  writers. 

Malaria. — The  pallor,  sallow- 
ness,  and  muddy  conjunctivae  which 

are  so  commonly  seen  in  intensely  malarious   districts   are  not  without 

considerable    value    in    the    diagnosis    of    the    cachexia    of    this    disease. 

Syphilis. — The  face   may  show  characteristic  eruptions   at   different 

stages  of  the  disease.    The  coppery  fiat  papule  or  papulosquamous  syphilide 

upon  the  temples  and  forehead — 
CORONA  VENERIS — is  commou.  The 
face  of  the  patient  under  treatment 
may  show  not  the  eruption  of  the 
disease  but  the  drug  exanthem 
produced  by  the  iodides.  Babies 
suffering  from  inherited  syphilis  are 
usually  pale,  weazened,  and  wrin- 
kled. They  look  curiously  like 
miniature  old  men.  They  have 
snuffles  and  superficial  excoriations 
about  the  angles  of  the  nose  and 
corners  of  the   mouth. 

Rickets. — The  frontal  and  pari- 
etal eminences  are  exaggerated 
and  the  top  of  the  skull  flattened, 
so  that  the  head  assumes  an  appear- 
ance of  squareness  and  is  some- 
times spoken  of  as  box-shaped. 
Hydrocephalus. — The  head  is  characterized  by  its  spherical  shape, 
great  size,  and  protruding  eyeballs,  the  result  of  depression  of  the  orbital 


-Exophtlialmic  goitre. — Jefferson 
Hospital. 


396 


MEDICAL  DIAGNOSIS. 


Fig.  167. — Leprosy. 


plate  of  the  frontal  bone.  The  exophthalmus  is  sometimes  so  marked 
that  the  eyelids  cannot  be  closed.    The  size  of  the  head  is  often  enormous, 

its  diameter  may  reach  20  to  25  cm. 
in  a  child  a  few  years  old.  The  face 
on  the  contrary  appears  very  small, 
its  expression  vacant  and  fatuous. 
The  cranial  bones  are  separated 
and  exceedingly  thin.  The  hair  is 
scanty  and  the  veins  may  be  seen 
beneath  the  skin. 

Hypertrophy  of  the  Tonsils 
and  of  the  Adenoid  Tissue  of  the 
Pharnyx. — As  a  result  of  habitual 
mouth-breathing  the  expression  of 
the  countenance  gradually  under- 
goes characteristic  changes,  the  face 
becomes  apathetic  and  vacant,  the 
nostrils  are  narrow,  the  lips  thick, 
and  there  is  projection  of  the  upper 
jaw  and  lip. 

Myxoedema. — The  face  is 
"moon-shaped,"  swollen  and  flattened,  the  nose  broad,  the  mouth 
coarse  and  large,  the  lines  of  expression  obliterated.  The  skin  is  yellow, 
waxy,  dry,  and  scaly,  the  hair  thin  and  scanty,  the  cheeks  and  nose  flushed. 

Cretinism.- — The  face  is  large, 
the  lips  thick,  the  tongue  large  and 
protruded,  the  mouth  open  and  drool- 
ing, the  nose  flattened,  the  skin  pallid 
and  waxy,  the  expression  idiotic. 

Acromegaly. — The  bony  hyper- 
trophy is  especially  manifested  in 
the  supra-orbital  arches,  the  malar 
bones,  and  in  the  projecting  lower 
jaw.  The  forehead  is  receding,  the 
nose  is  increased  in  size,  its  alas  dis- 
tended, the  eyelids  enlarged  and 
thickened.  The  cartilages  of  the  ear 
are  also  enlarged  so  that  very  often 
the  ears  stand  out  conspicuously 
from   the   head. 

Exophthalmic  Goitre.  —  The 
protrusion  of  the  eyeballs,  some- 
times so  marked  that  the  patient 
can  no  longer  close  his  eyes,  pro- 
duces a  remarkable  change  in  the 
expression.     In    its    lighter    grades 

the  air  is  that  of  surprise,  but  when  the  exophthalmus  is  marked  the 
patient  has  a  frightened  or  astonished  look  which  is  intensified  by  the 
characteristic   tremor.     The   enlargement    of  the    thyroid    body   as    well 


\      / 

j 
i 

1__ 

Fig.  168. — Facial  paralysis  following  cerebrospinal 
fever. — Jefferson  Hospital. 


SYMPTOMS  AND  SIGNS:   FACIES. 


397 


Hemiatrophia  facialis. — After  Hirt. 


as  the    visible    pulsation    and    venous    distention    add    to    the    peculiar 
expression  of  the  countenance  in  this  disease. 

Leprosy. — The  development  of  leprous  nodules  upon  the  face  and 
the  thickening  of  the  skin  give  rise  to  remarkable  deformities.  The  chin, 
lips,  nose,  eyelids,  and  ears  undergo 
peculiar  and  characteristic  changes, 
in  consequence  of  which  the  face 
assumes  the  appearance  of  a  hideous 
expressionless  mask.  Baldness,  loss 
of  the  eyebrows,  lashes,  and  beard, 
and  ulceration  also  occur.  The  dis- 
figurement suggests  the  conventional 
face  of  the  satyr  or  the  lion  and  is 
often   spoken   of   as   leonine — facies 

LEONIXA. 

Nervous  and  Mental  Disease. — 

In  functional  nervous  diseases  there 
are  frequently  changes  in  the  coun- 
tenance more  easily  recognized  than 
described.  The  pallid,  slightly  drawn 
face  of  the  neurasthenic  with  its  habitual  air  of  depression  is  faixdliar 
to  the  practitioner.  These  traits,  somewhat  intensified,  are  common  in 
women  broken  down  by  frequent  child-bearing  and  in  those  who  suffer 
from  disease  of  the  pelvic  organs — facies  uterina.     In  hysteria  the  face 

usually  remains  free  from  the  motor 
disturbances  so  common  elsewhere,  par- 
ticularly in  the  lower  extremities.  There 
is  neither  spasm,  paralysis,  nor  other  con- 
stant characteristic  save  that  it  reflects, 
often  intensely,  the  varying  uncontrolled 
emotions  of  the  patient.  Equally  without 
cause  laughter  succeeds  tears  or  vivacity 
is  followed  by  an  air  of  sullen  and  dogged 
indifference.  Central  or  peripheral  dis- 
ease of  the  nervous  system  may  manifest 
itself  in  spasmodic  twitching  of  the  facial 
muscles.  ]\Iimetic  spasm  or  convulsive 
tic  consists  of  clonic  contractions  of  the 
muscles  supplied  by  the  facial  nerve. 
They  are  usually  limited  to  the  region 
about  the  eye  or  above  the  corner  of  the 
mouth.  Sometimes  they  involve  the 
greater  part  of  one  or  both  sides  of  the 
face.  Similar  contractions  of  the  mus- 
cles of  expression  occur  in  children  and 
are  known  as  habit  spasm.  In  peripheral  facial  palsy  the  affected  side  is 
smooth  and  motionless,  the  wrinkles  of  the  forehead  and  the  labionasal 
fold  disappear,  the  corner  of  the  mouth  is  lowered  and  frequently  drools, 
and  the  mouth  itself  is  slightly  drawn  toward  the  sound  side.    The  eyelids 


Pig.  170. — Paranoia,  homicidal  type. — Chase. 


398  MEDICAL  DIAGNOSIS. 

are  motionless  and  can  only  be  partly  closed.  The  tears  fall  over  the 
cheeks.  The  contrast  mth  the  opposite  side  is  intensified  upon  efforts  to 
sniile  or  close  the  eye.  When  the  paralj^sis  is  due  to  central  causes  the 
lower  segment  of  the  face  is  chiefly  involved.  In  old  cases,  after  contract- 
ure has  taken  place  the  mouth  is  drawn  toward  the  affected  side. 

In  organic  disease  tremor  and  paralysis  are  significant.  Tremor  of 
the  lips  and  tongue  occurs  in  chronic  alcoholism.  Fibrillary  tremor  is  fre- 
quently associated  with  progressive  palsy.  In  bulbar  paralysis  the  lips 
are  thin,  compressed,  and  tremulous,  the  tongue  is  wasted  and  protruded 
with  difficulty,  and  there  is  dribbling  of  saliva.  In  paralysis  agitans  the 
appearance  of  the  countenance  is  very  strikingly  changed.  The  face  has 
a  curious  stiff,  expressionless  immobility  which  has  given  rise  to  the  name 
Parkinson's  mask.  There  is  often  druling  from  the  partially  closed  mouth 
and  the  lips  and  tongue  frequently  share  in  the  general  tremor.  In  general 
paresis  local  twitchings  of  the  face,  irregularity  of  the  pupils,  and  slight 
tremulousness  of  the  lips  are  suggestive.  The  rare  disease  facial  hemi- 
atrophy is  a  trophic  neurosis  affecting  one  side  of  the  face,  commonly  the 
left.  The  soft  tissues  and  bones  are  alike  involved  in  the  atrophic  process, 
wliich  is  sharply  limited  at  the  mesial  line.  The  eye  is  sunken  and  the 
corresponding  half  of  the  tongue  and  soft  palate  may  be  implicated. 

The  facies  in  disease  of  the  mind  is  often  characteristic.  The  depres- 
sion of  melancholia,  the  agitation  and  eagerness  of  acute  mania,  the  alert 
slyness  of  chronic  mania,  the  irregular  contractions  of  the  facial  muscles  in 
paresis,  the  fixed  expression  in  paranoia  with  homicidal  tendencies,  the 
fatuous  face  of  the  imbecile,  are  well  known  to  every  student  of  psychiatry. 

FORM  AND  NUTRITION  OF  THE  BODY. 

These  are  important  factors  in  the  problem  of  diagnosis.  The  normal 
of  different  individuals  varies  within  wide  limits.  It  is  scarcely  necessary 
to  say  that  persons  may  be  tall  or  short,  stout  or  slight,  fat  or  lean,  mthout 
manifesting,  even  in  wide  ranges  of  difference  in  these  respects,  either  the 
predisposition  to  or  the  sj^mptoms  of  disease.  Health  consists  in  the  ability 
of  the  individual  organism  to  maintain  its  normal  activities  in  the  environ- 
ment in  which  it  happens  to  be  placed.  The  somewhat  pallid,  hollow- 
chested  and  slender  book-keeper  often  has  good  health  and  length  of  daj's 
while  the  clear-eyed,  bright-skinned,  deep-chested,  well-developed  athlete 
not  infrequently  breaks  down'  in  early  middle  life.  Variations  in  these 
respects  give  rise  to  predisposition  or  constitute  the  indications  of  disease 
when  they  become  excessive.  We  say  that  a  man  has  a  splendid  or  powerful 
physical  development  when  the  measurements  of  his  body  transcend  the 
average,  but  the  health  of  another  who  does  not  reach  the  average  may 
be  equally  good.  Not  only  anatomical  structure  but  also  physiological 
function  are  to  be  considered.  Subtle  hereditary  tendencies,  the  value  of 
which  we  cannot  always  estimate,  and  the  shifting  balance  between  the 
powers  of  the  organism  and  the  work  which  it  is  called  upon  to  do  engage 
our  attention.  To  say  that  the  physical  organization  is  feeble,  dehcate, 
slender,  robust,  or  muscular  needs  no  further  explanation.  The  condition 
of  nutrition  shows  itself  furthermore  in  the  development  and  tonicity  of 


SYMPTOMS  AND  SIGNS:   FORM  AND  NUTRITION.         399 

the  muscles  and  especially  in  their  relation  to  the  amount  of  subcutaneous 
fat — panniculus  adiposus.  On  the  one  hand  a  moderate  amount  of  sub- 
cutaneous fat  is  not  incompatible  with  excellent  health,  an  excess  is  alike 
inconvenient  and  dangerous,  and  obesity  constitutes  a  positive  disease. 
On  the  other  hand  a  spare  man  may  be  equally  healthy,  while  rapid  loss 
of  fat  is  a  suspicious  symptom  and  emaciation  an  alarming  sign  of  disease. 
In  estimating  the  value  of  these  conditions  the  hereditary  tendencies,  the 
occupation,  the  age,  and  the  sex  of  the  patient  must  receive  due  consideration. 
In  young  infants  the  panniculus  is  well  developed.  In  infancy  it  often 
dmndles,  only  to  increase  again  as  puberty  approaches.  At  this  period  it 
not  infrequently  again  becomes  excessive.  In  advanced  life  the  fat  com- 
monly diminishes  and  the  aged  as  a  rule  are  spare.  The  panniculus  is  usually 
greater  in  women  than  in  men  and  very  often  increases  after  the  menopause. 
In  most  chronic  diseases  the  nutrition  is  impaired  because  either  sufficient 
nourishment  is  not  taken  on  account  of  loss  of  appetite,  or  that  which  is 
taken  is  not  assimilated.  A  high  degree  of  emaciation  attends  diseases  of 
the  digestive  organs  and  chronic  febrile  diseases,  for  example,  carcinoma, 
especially  carcinoma  of  the  oesophagus  or  pylorus,  enterocolitis  with  exces- 
sive diarrhoea,  some  forms  of  diabetes  mellitus,  phthisis,  and  enteric  fever 
with  repeated  relapses.    Wasting  of  fat  is  accompanied  by  wasting  of  muscle. 

Weight. — The  weight  of  the  body  and  the  amount  of  subcutaneous 
fat  may  be  approximately  estimated  by  inspection,  but  this  method  is 
uncertain  and  practically  valueless  in  determining  the  progress  of  gain  or 
loss.  Accurate  data  can  only  be  obtained  by  the  use  of  scales  at  regular 
intervals  and  the  preservation  of  the  records  for  comparison.  Small  plat- 
form scales  provided  \\dth  a  device  for  ascertaining  the  height  of  the  patient 
are  indispensable  in  the  consulting  room  of  the  medical  clinician  engaged 
in  the  treatment  of  chronic  cases.  The  autoinatic  weighing  machines  found 
in  public  places  in  the  cities  are  unreliable.  Allowance  must  be  made  for 
the  clothing  and  its  variations  in  the  different  seasons,  and  when  practica- 
ble the  weight  should  be  obtained  shortly  after  the  voidance  of  urine  and 
an  action  of  the  bowels,  and  before  a  meal.  Errors  of  two  or  three  pounds 
may  thus  be  eliminated,  though  for  practical  purposes  in  the  long  run  slight 
fluctuations  in  the  weight  may  be  disregarded  in  the  course  of  chronic 
disease.  Many  healthy  individuals  show  an  annual  oscillation  of  several 
pounds  in  net  weight,  allowance  being  made  for  clothing,  the  minimum 
being  reached  in  the  spring  or  early  summer,  the  maximum  in  the  autumn 
or  beginning  of  the  winter.  The  body  weight  should  be  taken  according  to 
the  requirements  of  individual  cases  at  regular  intervals  of  a  week  or 
longer.     Daily  observations  are  unnecessary. 

The  relation  of  the  average  body  weight  to  the  age  and  height  of 
healthy  individuals  is  set  forth  in  the  following  tables: 

Average  Weight  of  Healthy  Adult  Males. — Hutchinson. 

4  ft.  6  in.  to  5  ft.  0  in 92.26  lbs. 

5  ft.  0  in.  to  5  ft.  1  in 115.52  lbs. 

5  ft.  2  in.  to  5  ft.  .3  in 127.86  lbs. 

5  ft.  4  in.  to  5  ft.  5  in 1.39.17  lbs. 

5  ft.  6  in.  to  5  ft.  7  in 144.29  lbs. 

5  ft.  8  in.  to  5  ft.  9  in 157.76  lbs. 

5  ft.  10  in.  to  5  ft.  11  in 170.86  lbs. 

5  ft.  11  in.  to  6  ft.  0  in 177.25  lbs. 


400  MEDICAL  DIAGNOSIS. 

Infants,  whether  nursed  or  artificially  fed,  should  be  weighed  at  regular 
intervals  of  some  days  or  a  week.  Important  information  is  thus  obtained 
not  only  as  to  the  appropriateness  of  the  food  in  kind  and  quantity  but 
also  as  to  the  presence  of  assimilative  disorders.  The  average  normal 
weight  of  the  newborn  is,  according  to  Uffelmann,  in  girls  3000  grammes, 
in  boys  3500.  During  the  first  three  or  four  days  of  life  there  is  a  decrease 
of  from  220  to  300  grammes.  After  this  there  is  in  healthy  children  a 
progressive  increase. 

Average  Daily  Increase  in  Weight  During  the  First  Year  of  Life. — Gerhardt. 

1st    month 25  grammes. 

2nd  month 23  grammes. 

3rd  month 22  grammes. 

4th  month 20  grammes. 

5th  month 18  grammes. 

6th  month 17  grammes. 

7th  month 15  grammes. 

8th  month 13  grammes. 

9th  month 12  grammes. 

10th  month 10  grammes. 

11th  month 8  grammes. 

12th  month 6  grammes. 

The  weight  index  is  the  ratio  of  the  weight  of  a  given  infant  to  the 
weight  of  the  average  normal  infant  of  the  same  age. 

Useful  figures  to  remember  are  that  the  initial  weight  is  doubled  at 
5  months  and  trebled  at  15  months;  also  that  the  weight  at  one  year  is 
doubled  at  7  years  and  that  this  weight  is  again  doubled  at  14  years  (Rotch). 

In  infants  and  young  children  misleading  inferences  may  be  drawn 
from  a  consideration  of  the  weight  alone.  There  are  some  who  are  fat  and 
flabby  and  not  healthy.  Such  children  are  pallid,  they  lose  and  gain  weight 
rapidly  and  have  but  little  resisting  power  to  disease.  Then  there  are  many 
who  are  bright  and  rosy,  whose  flesh  is  firm  and  solid,  whose  nutrition  is 
good,  who  gain  in  weight  normally  and  are  not  liable  to  the  wasting  diseases. 

In  the  following  table  the  comparative  average  weight  of  the  sexes 
is  shown.  It  will  be  observed  that  from  birth  until  the  sixth  year  the 
average  weight  in  the  two  sexes  is  nearly  the  same.  From  this  period  for 
some  years  the  weight  of  the  female  is  considerably  less  than  that  of  the 
male.  About  the  age  of  puberty  the  difference  becomes  less  marked,  though 
the  weight  of  the  female  is  decidedly  below  that  of  the  male. 

Average  Normal  Weight  in  the  Two  Sexes  at  Different  Periods  of  Life — Quetelet. 

Males.  Females. 

New-born 3.1  kgs.  6.82  lbs.  3.0  kgs.  6.60  lbs. 

1st  year 9.6  kgs.  19.80  lbs.  8.6  kgs.  18.92  lbs. 

2nd  year 11.0  kgs.  24.20  lbs.  11.0  kgs.  24.20  lbs. 

3rd  year 12.5  kgs.  27.50  lbs.  12.4  kgs.  27.28  lbs. 

4th  year 14.0  kgs.  30.80  lbs.  13.9  kgs.  30.58  lbs. 

5th  year 15.4  kgs.  33.88  lbs.  15.3  kgs.  33.66  lbs. 

6th  year 17.8  kgs.  39.16  lbs.  16.7  kgs.  36.74  lbs. 

7th  year 19.7  kgs.  43.34  lbs.  17.8  kgs.  39.16  lbs. 

8th  year 21.6  kgs.  47.52  lbs.  19.0  kgs.  41.80  lbs. 

9th  year 23.5  kgs.  51.70  lbs.  21.0  kgs.  46.20  lbs. 

10th  year 25.2  kgs.  55.44  lbs.  23.1  kgs.  50.82  lbs. 

11th  year 27.0  kgs.  59.40  lbs.  25.5  kgs.  56.10  lbs. 

13th  year 33.1  kgs.  72.82  lbs.  32.5  kgs.  71.50  lbs. 


SYMPTOMS  AND  SIGNS:    FORM  AND  NUTRITION.         401 

Males.  Females. 

15th  year 41.2  kgs.  90.64  lbs.  40.0  kgs.  88.00  lbs. 

17th  year 49.7  kgs.  109.34  lbs.  46.8  kgs.  102.96  lbs. 

19th  year 57.6  kgs.  126.72  lbs.  52.1  kgs.  114.62  lbs. 

20th  year 59.5  kgs.  130.90  lbs.  53.2  kgs.  117.04  lbs. 

25th  year 66.2  kgs.  145.64  lbs.  54.8  kgs.  120.56  lbs. 

30th  year 66.1  kgs.  145.42  lbs.  55.3  kgs.  121.66  lbs. 

60th  year 61.9  kgs.  136.18  lbs.  54.3  kgs.  119.46  lbs. 

70th  year 59.5  kgs.  130.90  lbs.  51.5  kgs.  113.30  lbs. 

In  cases  of  tardy  or  interrupted  convalescence  from  an  acute  disease 
systematic  observations  of  the  weight  of  the  patient  at  intervals  of  a  week 
are  of  great  use.  A  sudden  arrest  or  decrease  in  weight  may  mark  the 
development  of  a  tuberculous  process.  Loss  of  weight  is  of  great  impor- 
tance in  the  diagnosis  of  early  phthisis.  An  arrest  of  the  loss,  still  more 
a  gain  in  body  weight,  must  in  most  cases  of  this  disease  be  regarded  as 
favorable.  There  are,  however,  exceptional  cases  in  which  after  a  consider- 
able steady  gain  in  weight  the  tuberculous  process  suddenly  makes  grave 
or  even  fatal  progress. 

The  weight  is  not  in  all  cases  merely  an  indication  of  the  general 
nutrition  and  amount  of  fat.  It  is  sometimes  made  up  in  considerable  part 
of  dropsical  effusions,  as  in  advanced  disease  of  the  mitral  valve  with  rup- 
ture of  compensation,  of  accumulations  in  the  serous  sacs,  as  in  massive 
serofibrinous  pleurisy  or  the  ascites  of  cirrhosis  of  the  liver,  of  the  contents 
of  cysts,  as  in  enormous  monolocular  disease  of  the  ovary,  or  of  new  growths 
of  large  size,  as  in  the  splenic  tumor  in  leukaemia  or  sarcoma  of  the  kidney 
in  young  children.  In  a  dropsical  patient  the  successful  use  of  salines  or 
diuretics  may  be  followed  coincidently  with  the  subsidence  of  the  ana- 
sarca by  a  reduction  in  weight  amounting  to  many  pounds  in  a  few  days. 
The  tendency  to  accumulate  excessive  fat  at  middle  life,  especially  in  women 
after  the  menopause,  must  be  regarded  as  pathological,  and  obesity,  as 
has  been  said,  constitutes  a  positive  disease.  The  gain  in  weight  occurs 
at  the  time  of  beginning  decrease  of  muscular  power,  at  the  period  of  physio- 
logical involution.  The  individual  must  carry  about  a  growing  mass  of 
inert  fat  with  lessening  ability  on  the  part  of  the  skeletal  muscles  to  bear 
it  and  of  the  heart  to  carry  on  the  circulation,  and  the  disproportion 
between  the  burden  and  the  ability  to  bear  it  increases  with  advancing 
years.  Visceral  fat  accumulations  occur,  also  fatty  changes  in  the  myo- 
cardium and  vessels.  Obese  persons  in  early  middle  life  bear  the  acute 
infections  and  especially  enteric  fever  badly.  Very  often  the  fat  accumu- 
lations are  largely  local,  as  in  the  mammae,  abdomen,  and  hips  in  women, 
or  in  the  abdomen,  abdominal  walls,  and  omentum  in  men  of  sedentary 
life  and  given  to  the  pleasures  of  the  table. 


26 


402 


MEDICAL  DIAGNOSIS. 


III. 

BONES;    JOINTS;    MUSCULATURE;  POSTURE,    ATTITUDE,   AND 
GAIT;    POSTURE    AND    MOVEMENTS    OF    INFANTS. 

BONES. 

The  skeleton  determines  the  stature  and  frame  of  the  individual.  As 
has  been  already  pointed  out  the  normal  limits  of  variation  in  the  meas- 
urements of  the  bony  framework  are  very  wide.  Excess  in  either  direc- 
tion, as  in  gigantism  or  dwarfism,  is  pathological  and  has  been  ascribed  to 
derangements  of  the  functions  of  the  pituitary  body. 

Average  Height  in  Males  and  Females  at  Different  Periods  of  Life. — Quetelet. 

New-born 50.0 

1st  year 69.8 

2nd  year 79.1 

3rd  year 86.4 

4th  year 92.7 

5th  vear 98.7 

6th  year 104.6 

7th  year 110.4 

8th  year 116.2 

9th  year 121.8 

10th  year 127.3 

15th  year 151.3 

20th  year 167.0 

25th  year 168.2 

30th  year 168.6 

40th  year 168.6 

60th  year 167.6 

70th  year 166.0 

There  is  a  constant  relationship  in  healthy  persons  between  the  mus- 
cular development  and  the  size  and  strength  of  the  bones.  In  puny  individ- 
uals with  small  and  flabby  muscles  the  skeleton  is  usually  more  or  less 
under-developed.  In  this  nutritional  relationship  between  the  muscles 
and  the  bones  the  muscles  constitute  the  controlling  factor.  In  a  similar 
manner  the  bony  walls  of  the  cranium  and  thorax  undergo  changes  corre- 
sponding to  changes  in  the  viscera  which  they  contain. 

Thorax. — In  bed-ridden  individuals  and  those  suffering  from  wasting, 
diseases  the  involution  of  the  lungs  from  diminished  functional  activity  or 
their  diminution  in  size  from  pathological  changes  causes  alterations  in 
the  shape  and  contour  of  the  thorax,  which  tends  to  assume  permanently 
the  EXPIRATORY  FORM;  while  an  active  life  in  the  open  air  by  increasing 
the  volume  of  the  lungs  modifies  the  chest,  which  under  these  circumstances 
tends  to  assume  permanently  the  inspir.-vtory  form.  Analogous  changes 
in  the  chest  result  from  lesions  which  increase  the  volume  of  the  thoracic 
viscera,  as  in  pulmonary  emphysema  and  great  cardiac  enlargement. 
The  point  for  the  student  to  bear  in  mind  is  that  many  general  and  local 
changes  in  the  form  of  the  chest  are  primarily  due  to  visceral  disease  and 
not  to  disease  of  the  bones.     Some  of  these  are  more  marked  when  the 


Males. 

Females. 

cm. 

20.00 

in. 

49.4 

cm. 

19.76 

in 

cm. 

27.92 

m. 

69.0 

cm. 

27.60 

in 

cm. 

31.64 

m. 

78.1 

cm. 

31.24 

in 

cm. 

34.56 

in. 

85.4 

cm. 

34.16 

in 

cm. 

37.08 

in. 

91.5 

cm. 

36.60 

in 

cm. 

39.48 

m. 

97.4 

cm. 

38.96 

m 

cm. 

41.84 

in. 

103.1 

cm. 

41.24 

m 

cm. 

44.16 

m. 

108.7 

cm. 

43.48 

in 

cm. 

46.48 

m. 

114.2 

cm. 

45.68 

in 

cm. 

48.72 

m. 

119.6 

cm. 

47.84 

m 

cm. 

50.92 

m. 

124.9 

cm. 

49.96 

in 

cm. 

60.52 

in. 

148.8 

cm. 

59.52 

m 

cm. 

66.80 

m. 

157.8 

cm. 

63.12 

m 

cm. 

67.28 

m. 

157.4 

cm. 

62.96 

m 

cm. 

67.44 

in. 

158.0 

cm. 

63.20 

m 

cm. 

67.44 

m. 

158.0 

cm. 

63.20 

m 

cm. 

67.04 

m. 

157.1 

cm. 

62.84 

m 

cm. 

66.40 

m. 

155.6 

cm. 

62.24 

in 

SYMPTOMS  AND  SIGNS:   JOINTS.  403 

visceral  disease  takes  place  early  in  life,  as  in  precordial  prominence  and  the 
development  of  Harrison's  furrows,  others  late  in  life,  as  in  fibroid  phthisis 
and  emphysema.  There  are,  however,  exceptions  to  this  general  state- 
ment, an  example  of  which  is  to  be  found  in  the  changes  of  the  shape  of  the 
chest  which  result  from  disease  of  the  spine,  as  kyphosis. 

Cranium. — The  skull  may  be  abnormal  in  size  and  shape  either  as 
the  result  of  arrest  of  development  of  the  brain  with  or  without  malfor- 
mation, or  as  the  result  of  pathological  increase  in  the  size  of  the  brain. 
The  short  diameters  and  peculiar  shape  of  the  head  of  the  microcephalic 
idiot  and  the  globe-like  cranium  of  chronic  hydrocephalus  developing  at 
birth  or  in  early  infancy  with  its  wide  sutures,  open  fontanelles,  and  card- 
like thinness  of  the  bones,  are  examples  of  the  influence  exerted  by  changes 
in  the  soft  parts  upon  the  bony  walls  containing  them. 

Skeletal  Changes. — The  bones  themselves  undergo  pathological 
changes.  These  changes  may  be  general  or  local.  In  acromegaly  there 
is  hypertrophy  of  the  bones  of  the  hands,  feet,  and  face,  especially  the 
inferior  maxilla.  The  clavicles,  sternum,  and  in  some  instances  the  long 
bones  of  the  extremities  also  participate  in  the  over-growth.  In  ostitis 
DEFORMANS  Or  Paget's  DISEASE  there  is  thickening  of  the  bones  of  the 
skull  and  changes  in  those,  of  the  face,  the  outline  of  which  becomes  tri- 
angular with  the  apex  at  the  chin;  the  long  bones  are  involved  and  become 
deformed.  In  rickets,  a  disease  of  childhood,  the  head  is  large  and  square, 
the  forehead  prominent,  the  anterior  fontanelle  open,  the  epiphyses  of 
the  long  bones  are  enlarged,  nodules  develop  at  the  junction  of  the  ribs 
with  their  cartilages.  Changes  in  the  shape  of  the  chest  and  protrusion 
of  the  sternum  cause  the  deformity  known  as  chicken  or  pigeon  breast. 
The  spine  is  curved,  the  clavicle  bent,  the  pelvis  deformed,  and  the  long 
bones  of  the  lower  extremities  show  deformity.  Rachitic  children  are  often 
bow-legged;  those  who  reach  maturity  are  under-sized.  Osteomalacia  is 
characterized  by  resorption  of  the  lime  salts.  The  bending  of  the  softened 
bones  under  the  action  of  gravity  and  muscular  tension  gives  rise  to 
extraordinary  deformities.  These  affect  the  spine,  thorax,  pelvis,  and  long 
bones.  In  some  instances  the  superficial  bones  crepitate  upon  pressure 
and  can  be  indented  by  the  finger.  They  are  readily  fractured  and  this 
accident  may  follow  a  trifling  fall  or  blow  or,  in  the  case  of  the  femur  or 
humerus,  result  from  the  muscular  force  exerted  in  turning  in  bed.  Pul- 
monary osteo-arthropathy — osteo-arthropathie  hypertrophiante 
pneumonique  of  Marie — a  condition  encountered  in  certain  chronic  dis- 
eases of  the  lungs  and  pleura,  is  characterized  by  bulbous  enlargement  of 
the  terminal  phalanges  of  the  fingers  and  toes  and  of  the  distal  epiphyses 
of  the  bones  of  the  upper  and  lower  extremities.  The  finger-nails  are 
hypertrophied  and  strongly  incurved.  The  bones  of  the  head  and  face  are 
not  affected. 

JOINTS. 

There  are  affections  of  the  joints  which  lie  on  the  border  line  between 
surgery  and  medicine.  To  the  former  belong  traumatic  and  operative 
conditions;  to  the  latter  lesions  arising  in  consequence  of  various  consti- 
tmional  affections.     Commonly  the  question  of  diagnosis  first  rests  with 


404  MEDICAL  DIAGNOSIS. 

the  medical  clinician.  Those  joint  affections  which  properly  come  within 
the  scope  of  internal  medicine  may  be  comprehensively  described  as  the 
MEDICAL  ARTHROPATHIES.  The  large  and  small  joints  may  be  affected. 
The  chief  symptoms  are  pain,  especially  upon  movement,  impairment  of 
function,  and  the  signs  of  inflammation  or  disorganization,  namely,  changes 
in  color,  size,  and  shape.  The  requisites  to  the  proper  examination  of  a 
diseased  joint  are  a  knowledge  of  the  local  anatomy  and  pathology  and  of 
the  constitutional  diseases  in  which  joint  affections  occur. 

Pain. — Pain  is  an  important  symptom.  It  may  be  spontaneous.  More 
commonly  it  is  caused  by  movement.  Pain  upon  pressure  occurs  in  acute 
forms  of  arthritis  and  is  often  intense.  Pain  is  commonly  referred  to  the 
affected  joint,  sometimes  to  a  distant  part,  as  the  pain  in  the  knee  in  hip- 
joint  disease.  In  con3equence  of  the  freer  movement  permitted  by  mus- 
cular relaxation  during  sleep  the  pain  is  worse  at  night.  There  may  be 
insomnia,  or  sleep  may  from  time  to  time  be  broken  by  sudden  agonizing 
pain.  This  is  especially  the  case  in  tuberculous  joint-disease.  The  patient 
very  often  awakes  with  a  sharp  cry  of  pain.  The  pain  in  myalgia  and 
various  forms  of  neuritis  is  frequently  attributed  to  diseases  of  the  joint; 
upon  movement  the  pain  is  found  not  to  involve  the  joint,  but  other  struct- 
ures, and  the  joint  is  neither  tender  nor  swollen.  In  chronic  joint  affections 
movement  is  sometimes  attended  by  a  sensation  of  grating  or  crepitus,  or 
there  may  be  a  catching  sensation  attended  with  crackling  sometimes 
audible  at  a  distance. 

Color. — The  color  of  the  joint  in  acute  inflammation  is  pinkish  or  red; 
when  intense  it  is  cyanotic  or  dusky.  When  there  is  marked  periarticular 
oedema  the  overlying  skin  is  pale. 

Changes  in  Size. — In  acute  inflammation  the  joints  are  usually 
enlarged.  This  enlargement  is  attended  with  alteration  in  the  contour. 
These  changes  are  due  to  effusion,  which  may  be  articular  or  periarticular. 
The  former  may  be  serous,  purulent,  or  hemorrhagic.  The  latter  may 
be  oedematous  or  exudative.  These  conditions  are  often  combined.  In 
chronic  arthritis  there  is  infiltration  of  the  tissues  entering  into  the  for- 
mation of  the  joint.  Enlargement  due  to  effusion  within  the  joint  may 
be  recognized  by  palpation,  especially  in  large  joints.  In  the  knee  the 
patefla  floats.  Rounded  local  swellings  fluctuating  upon  palpation  may 
indicate  the  distention  of  the  synovial  sac.  Enlargement  may  be  due 
to  changes  in  the  ends  of  the  bones. 

Irregular  diminution  in  the  size  may  occur  in  chronic  disease  of  the 
joints,  as  rheumatoid  arthritis  or  other  diseases  characterized  by  resorp- 
tion or  retrogressive  processes.  Not  only  the  tissues  of  the  joint  but  the 
periarticular  structures  undergo  atrophy  and  subluxations  occur,  or  there 
may  be  diminution  in  the  soft  parts  with  thickening  of  the  bones.  All 
these  processes  are  associated  with  changes  in  contour. 

The  posture  is  of  importance.  In  forms  of  acute  arthritis,  flexion  or 
semi-flexion  and  immobility  are  present — the  attitude  of  least  tension  and 
therefore  of  least  pain.  The  mobility  of  the  joint  is  determined  by  passive 
movement.  Fixation  may  be  voluntary  because  it  relieves  pain.  It  may 
result  from  muscular  spasm  or  large  effusion.  Sudden  locking  of  a  joint, 
especially  the  knee,   may  be  due  to  floating  cartilages  or  "joint  mice" 


SYMPTOMS  AND  SIGNS:   JOINTS. 


405 


becoming  arrested  between  the  anterior  surface  of  the  bones  and  the  cap- 
sular Hgament.  In  late  cases  the  immobility  is  due  to  ankylosis,  which  may 
be  adhesive,  fibrous,  or  bony.  Movement  may  be  limited  or  prevented  by 
the  development  of  osteophytes  in  the  region  of  the  joints.  Crepitus  may 
be  detected  upon  palpation. 

Any  of  the  joints  may  be  involved  in  general  diseases.  The  knee, 
hip,  and  shoulder  are  especially  important,  because  of  the  frequency  with 
which  they  are  implicated,  the  disabling  results,  and  the  tendency  to 
disorganization   and   ankylosis. 

The  medical  arthropathies  are  inflammatory  or  infective,  degenera- 
tive, and  neuropathic. 

Primary  Arthritis. — Simple  acute  synovitis  with  effusion  is  very 
common  especially  in  adolescents  and  young  adults.     It  most  frequently 


Fig.  171. — Tophaceous  deposits  in  gout. 


involves  the  knee-joint.  Traumatism  and  sudden  chilling  are  causes.  Some 
of  the  cases  appear  to  be  monarticular  rheumatism  with  trifling  fever. 
There  is  marked  tendency  to  recurrence  and  chronicity. 

Rheumatic  Fever. — The  affected  joints  are  swollen,  hot,  usually 
slightly  reddened,  and  painful  upon  motion.  The  amount  of  swelling  is 
variable.  The  intra-articular  effusion  is  usually  slight  or  moderate,  the 
periarticular  oedema  being  commonly  marked.  When  the  wrists  and 
ankles  are  implicated  there  is  marked  swelling  of  the  hands  and  feet.  The 
joint  effusion  of  rheumatic  fever  is  fugacious.  The  tendency  to  rapidly  sub- 
side in  one  joint  and  develop  in  others  is  characteristic.  The  process  is 
rarely  limited  to  a  single  joint.  Any  joints  may  be  affected,  but  the  knees, 
ankles,  and  wrists  are  especially  liable  to  the  rheumatic  inflammation. 

Chronic  Rheumatism. — This  term  is  applied  to  a  chronic  condition 
in  which  the  joints  are  painful,  stiff,  moderately  swollen,  and  but  slightly 
deformed.  It  is  common  in  individuals  who  have  been  much  exposed  to 
the  vicissitudes  of  the  weather  or  have  lived  in  damp  places.  Its  etiological 
affinity  to  rheumatic  fever  may  well  be  questioned.  Some  of  the  cases 
described  under  this  term  are  undoubtedly  subacute  forms  of  rheumatoid. 


406  MEDICAL  DIAGNOSIS. 

arthritis.  In  others  the  process  is  gouty.  Cases  of  adhesive  chronic  ar- 
thritis have  been  described  under  the  term  chronic  rheumatism.  Very 
fat  persons  with  small  bones  at  or  beyond  middle  life  often  suffer  from 
painful  knees.  There  is  nothing  to  indicate  gouty  or  rheumatic  disease 
and  no  sign  of  actual  inflammation.  The  pain  is  brought  on  by  standing 
or  walking  and  is  often  intense^  There  may  be  tenderness.  The  condition 
is  mechanical,  the  bearing  surface  being  inadequate  to  the  weight  of  the 
body.     Other  articulations  are  not  involved. 

Qout. — This  form  of  arthritis  is  due  to  the  precipitation  of  salts  of 
uric  acid  in  the  joint  structures.  The  metatarsophalangeal  joint  of  the 
great  toe  is  first  and  most  commonly  affected,  but  other  joints  and  espe- 
cially the  knee  and  ankle  are  occasionally  involved.  There  is  rapid  swell- 
ing with  heat,  tension,  and  a  bluish-red  glistening  skin. 

Arthritis  Deformans. — Implication  of  the  joints  is  usually  symmetri- 
cal though  monarticular  forms  occur.  First  one  or  two  joints  only  are 
involved.     Gradually   others   are    implicated   and   cases   occur  in    which 


Fig.  172. — Heberden's  nodes  (page  909). 

all  the  joints  suffer.  Attacks  of  acute  inflammation  are  succeeded  by 
periods  of  quiescence,  but  after  each  attack  the  evidences  of  disintegra- 
tion are  more  pronounced.  The  ligaments  of  the  small  joints,  especially 
of  the  hands,  are  relaxed  and  the  bones  of  the  phalanges  under  the  action, 
of  gravity  very  often  form  an  obtuse  angle  with  the  metacarpal  bones 
toward  the  ulnar  side.  Atrophic  changes  in  the  muscles  and  other 
structures  relating  to  the  affected  joints  occur  in  extreme  cases. 
All  the  articulations  may  become  ankylosed  and  the  patient  bed- 
ridden and  almost  completely  helpless.  There  are  partial  or  mon- 
articular forms  which  occur  in  old  persons.  The  spine  may  be 
involved — spondylitis  deformans — with  pain,  anaesthesia,  and  muscular 
atrophy.  In  other  cases  the  spine  is  involved  together  with  the  shoul- 
der- and  hip-joints  and  nervous  symptoms  are  less  prominent.  Kyphosis 
and  fixation  occur. 

Infective  Arthritis.  —  Inflammatory  joint  affections  frequently 
develop  during  convalescence  from  the  acute  infectious  diseases.  One 
or  more  joints,  show  signs  of  inflammation.  This  form  of  arthritis 
is  frequent  after  scarlet  fever  and  sometimes  occurs  in  cerebrospinal 
meningitis,     the    variolous    diseases,     dengue,    and    enteric     fever.      An 


SYMPTOMS  AND  SIGNS:   JOINTS. 


407 


Fig.  173. — Arthritis  deformans. — Jefferson  Hospital. 


acute  arthritis  going  on  to  suppuration  with  disorganization  of  the  joint 
occurs  in  septic  conditions.  The  joint  affection  which  accompanies 
•osteomyehtis  is  attended  with  high 
fever  and  constitutional  disturbances. 
Gonorrhoea!  Arthritis.  —  Fre- 
quently one  joint  only  is  involved, 
sometimes  several.  The  knee,  wrist, 
and  ankle  frequently  suffer.  Teno- 
synovitis may  occur.  Fever  is 
moderate  or  absent,  or  there  is 
great  pain  on  movement,  and  the 
joint  affection  is  frequently  per- 
sistent   and    disabling. 

Arthritis  in  Hemorrhagic  Dis= 
eases. — Acute  arthritis,  more  or  less 
intense  and  suggestive  of  the  joint 
affection  of  rheumatic  fever,  occurs 
in  forms  of  purpura  and  in  haemo- 
philia. It  is  the  larger  joints  that 
are  chiefly  affected.  Intra-articular  hemorrhage  may  occur.  Arthritis 
is    an    occasional    complication    of    scurvy. 

Tuberculous  Arthritis. — Tuber- 
culous joint  disease  is  common.  It 
is  often  secondary  to  tuberculosis  of 
the  bones.  It  was  formerly  known 
as  white  swelling — tumor  albus.  The 
process  is  comj)aratively  subacute 
but  tends  to  permanent  disorgani- 
zation. Tuberculous  joints  are 
usually  swollen.  In  the  course  of 
the  disease  chronic  inflammatory 
infiltration  takes  place  into  the  cap- 
sule, ligaments,  and  periarticular 
connective  tissue.  Caseation  and 
softening  result  in  abscess  formation 
and  burrowing  along  the  lines  of 
least  resistance.  Tortuous  fistulous 
passages  occur.  The  hip,  elbow, 
knee,  and  wrist  are  frequently 
affected.  There  may  be  evidences 
of  tuberculosis  in  the  lungs  or  else- 
where. More  commonly  the  process 
is  limited  to  the  affected  joint  and 
adjacent  structures. 

Syphilis. — The  acute  joint  affec- 
tion of  new-born  infants  sometimes 
regarded  as  rheumatic  is  mostly  syphilitic.  It  is  a  form  of  primary  exuda- 
tive arthritis  with  fibrous  thickening  of  the  capsule.  Gummatous  inflam- 
mation in  the  neighboring  tissues  may  involve  a  joint  by  extension.     In 


Fig.  174. — Arthritis  deformans  with  extreme  ulnar 
deformity. — Jefferson  Hospital. 


408 


MEDICAL  DIAGNOSIS. 


acquired  syphilis  subacute  synovitis  occasionally  occurs  during  the  period 
of  eruption.  The  sternoclavicular  joint  shows  a  peculiar  liability.  In 
late  syphilis,  forms  of  chronic  arthritis,  the  result  of  gummatous  infiltration 

of  the  tissues  forming  the  joint,  occur. 
Actinomycosis. — The  joints  are 
sometimes  involved  by  metastasis. 
In  other  cases  they  are  invaded  by 
extension,  as  when  the  disease  reaches 
the  articulations  of  the  cervical  verte- 
brae or  when  prevertebral  actino- 
mycosis attacks  the  spine  or  the 
disease  extends  from  the  thorax  to 
the  sternoclavicular  joints  or  from 
the  abdomen  to  the  hip-joints. 

Neuropathic  Joint  Affections. — 
Hysteria  especially  may  simulate  dis- 
ease of  the  joints.  The  impairment 
of  function  is  caused  by  contracture 
of  muscles.  Pain  is  more  diffuse  and 
spontaneous  than  in  actual  arthritis. 
The  patient  avoids  movement  and 
does  not  cooperate  in  the  examination. 
The  signs  of  effusion,  inflammation, 
and  erosion  are  lacking.  These  are  the  cases  in  which  spontaneous  cures 
sometimes  occur  under  profound  mental  suggestion.  In  some  instances, 
from  prolonged  disuse,  infiltration,  and  thickening  of  the  periarticular 
tissues,  false  ankylosis  and  atrophy  of  the  associated  muscles  occur.  It 
is  important  to  bear  in  mind  that  hysterical  symptoms  may  be  superadded 
to  those  of  actual  joint  disease.  The  differential  diagnosis  between 
traumatic  joint  disease  and  a  hysterical  joint  in  traumatic  hysteria  is 
occasionally  attended  with  difficulty.     Vasomotor  changes  with  swelling, 


Fig.    175. — Gonorrhceal  arthriti 
Hospital. 


-Pennsylvania 


Fig.  176. — Ataxic  knee-joint. — Young. 

tension,  and  redness  sometimes  occur  and  the  surface  temperature  may 
be  two  or  three  degrees  higher  than  that  in  the  axilla.  These  symp- 
toms are  not  associated  with  fever  or  the  evidences  of  constitutional 
disturbance  and  are  commonly  transitory  and  recurrent. 


SYMPTOMS  AND  SIGNS:   MUSCULATURE.  409-. 

More  important  are  the  changes  that  take  place  in  connection  with 
certain  diseases  of  the  nervous  system — Charcot's  joints,  tabetic 
JOINTS — particularly  locomotor  ataxia,  syringomyelia,  less  frequently  in 
anterior  poliomyelitis  and  other  diseases  of  the  spinal  cord.  The  joint 
affection  in  tabes  is  much  more  common  in  the  joints  of  the  lower  extrem- 
ities, especially  the  knee,  less  frequent  in  the  hip  and  ankle;  that  of 
syringomyelia  is  by  far  more  common  in  the  upper  extremities.  The 
derangements  are  primarily  trophoneurotic.  The  process  is  frequently 
monarticular.  The  pathological  and  clinical  changes  correspond  to  those 
of  the  milder  and  graver  forms  of  rheumatoid  arthritis.  In  the  more 
severe  forms  they  differ  in  suddenness  of  onset,  intra-articular  effusion,, 
and  a  rapid,  disintegrating  course  without  pain.  Subluxations  and 
luxations  take  place.  When  the  tarsal  articulations  are  implicated 
flat-foot  occurs  with  characteristic  deformities — the  tabetic  foot. 

MUSCULATURE. 

Diagnostic  criteria  of  importance  are  obtained  by  an  examination  of 
the  condition  of  the  muscles.  Wide  variations  in  the  bulk  and  tonicity 
of  the  general  musculature  is  encountered  within  the  limits  of  health. 
These  variations  depend  largely  upon  the  hereditary  constitution,  occu- 
pation, and  bodily  activities  of  the  individual  and  are  not  of  diag- 
nostic significance.  Trophic  derangements  result  in  hypertrophy  and 
atrophy. 

Hypertrophy. — True  hypertrophy,  that  is  to  say,  increased  volume 
with  increase  of  power,  is  exceedingly  rare.  It  occurs  in  Thomsen's  disease. 
Congenital  hypertrophia  musculorum  vera  has  been  described.  Patho- 
logical increase  in  the  muscles  is  almost  always  a  pseudohypertrophy. 
The  abnormal  volume  is  not  due  to  an  increase  in  the  contractile  tissue 
but  to  a  proliferation  of  the  connective  tissue  and  fat.  This  muscular 
dystrophy  occurs  in  its  most  pronounced  form  in  the  so-called  pseudo- 
hypertrophic muscular  paralysis  of  childhood,  and  very  rarely  in  some 
of  the  affected  muscles  in  certain  cases  of  chronic  progressive  muscular 
atrophy. 

Atrophy. — Atrophy  of  the  muscles  may  be  simple  or  inactivity  atrophy 
— the  atrophy  of  disuse.  The  affected  muscles  are  diminished  in  size,  soft, 
and  flaccid;  there  is  loss  of  the  contractile  substance;  the  interstitial  con- 
nective tissue  is  not  increased.  This  form  of  atrophy  occurs  in  certain 
forms  of  paralysis,  and  supervenes  upon  mechanical  fixation  of  a  limb  or 
the  prolonged  immobility  resulting  from  joint  pain  or  ankylosis.  Com- 
plete loss  of  movement  usually  gives  rise  to  a  high  grade  of  simple  atrophy. 
Atrophy  from  disuse  rarely  attains  the  degree  often  seen  in  the  degenera- 
tive atrophies.  In  simple  atrophy  there  is  general  diminution  in  the  volume 
of  the  affected  limb,  while  in  the  degenerative  atrophies  single  muscles  or 
groups  of  muscles  are  exclusively  or  chiefly  involved.  The  electrical  re- 
actions in  simple  atrophy  are  quantitatively  and  not  qualitatively  changed. 
The  nutritional  muscular  atrophy  which  occurs  in  starvation,  in  the  course 
of  acute  infections,  and  in  the  chronic  wasting  diseases  must  be  regarded 
as  a  diffuse  form  of  simple  atrophy. 


410 


MEDICAL  DIAGNOSIS. 


Myoidema. — This  phenomenon  consists  in  a  sudden  contraction  of 
muscular  fibres  when  smartly  tapped  with  the  finger  or  hammer,  with 
transitory  humping  at  the  point  of  impact.  It  is  manifested  in  muscles 
that  are  undergoing  rapid  wasting,  especially  in  phthisis,  and  is  as  a  rule 
best  developed  in  the  muscles  of  the  chest. 

Degenerative  Atrophy. — The  degenerative  muscular  atrophies,  which 
are    characterized   not   only   by   loss    of    contractile    substance   but   also 


Fig.  177. — Pseudohypertrophic  muscular  paralysis.      Brothers,  eight  and  ten  years  old. 
lordosis ;    b,  showing  atrophy  of  back  and  enlarged  calves. — Rotch. 


a,  showing  the 


by  an  overgrowth  of  the  interstitial  connective  tissue,  may  be  referred  to 
two  groups:  (a)  the  progressive  muscular  atrophies,  and  (b)  the  atrophic 
paralyses. 

The  progressive  muscular  atrophies  may  be  divided  into  myopathic, 
peripheral,  and  central  or  nuclear  according  to  the  seat  of  the  essential 
pathological  process,  which  may  primarily  involve  the  muscles,  or  result 
from  an  acute  or  chronic  peripheral  neuritis,  or  from  degenerative  changes 
in  the  ganglion  cells  of  the  anterior  horns  of  the  cord,  or  the  motor 
nuclei  of  the  brain.  There  is  progressive  atrophy  of  individual  muscles 
and  muscle  groups;  diffuse  atrophy  of  an  entire  limb  occurs  only  in 
advanced  stages;  the  strength  of  the  muscles  is  diminished  in  proportion 
to  the  diminution  of  their  volume.    In  this  respect  the  progressive  muscular 


SYMPTOMS  AND  SIGNS:   MUSCULATURE. 


411 


atrophies  are  in  contrast  with  the  secondary  degenerative  atrophies  which 
follow  the  atrophic  paralyses.  In  the  latter  the  paralysis  comes  first,  the 
atrophy  afterwards.  The  discrimination  between  myopathic,  neural,  and 
nuclear  muscular  atrophies  rests  upon  the  fact  that  in  the  different  forms 
particular  groups  of  muscles  are  affected.  In  the  myopathic  forms  of 
degenerative  atrophy— the  muscular  dystrophies— the  following  principal 
types   occur:      1.  Pseudohypertrophic   muscular  atrophy   of   childhood — 


Fig.  178.- 


-a,  infantile  atrophy  from  improper  feeding  (female  ten  miontlis  old);    6,  recovery  after  three 
months. — Rotch. 


the  so-called  pseudohypertrophic  muscular  paralysis.  2.  The  juvenile 
type  of  Erb — dystrophia  musculorum  progressiva;  the  atrophy  begins  in 
the  shoulder  girdle  and  is  not  preceded  by  pseudohypertrophy.  3.  The 
juvenile  type  of  Leyden-Mobius;  the  atrophy  begins  in  the  lower  extrem- 
ities. This  form  is  closely  allied  to  the  progressive  pseudohypertrophy  of 
childhood.     4.  The  infantile  type  of  Duchenne — the  facio-scapulo-humeral 


Fig.  179. — General  atrophy  of  the  muscles  in  a  case  of  cerebrospinal  fever;   fifty-fifth  day  of  illness. — Royer. 

type  of  Landouzy-Dejerine.  This  form  begins  j.n  the  face.  The  loss  of 
power  in  the  muscles  of  expression  gives  rise  to  the  characteristic  facies 
MYOPATHICA.  The  eyes  can  no  longer  be  completely  closed,  the  cheeks  are 
sunken,  the  lips  thickened  and  everted,  speech  is  impaired,  and  the  ordinaiy 
changes  in  the  countenance  in  laughter  and  crying  are  not  seen.  The 
myopathic  atrophies  are  commonly  hereditary  and  almost  always  show 
themselves  in  early  life.  Neural  atrophy  begins  commonly  in  the  under 
extremities  in  the  distribution  of  the  peroneal  nerve — the  peroneal  type 
of  Charcot  and  Marie — and  may  lead  to  the  development  of  club-foot, 
usually  pes  equinus  or  pes  equinovarus.     It  differs  from  other    forms  of 


412  MEDICAL  DIAGNOSIS. 

myopathic  atrophy  in  the  frequent  occurrence  of  derangements  of  sensation^ 
pain,  and  fibrillary  contractions  and  in  the  occasional  presence  of  the  reaction 
of  degeneration.  In  many  cases  of  peripheral  neuritis  the  affected  muscles 
undergo  degenerative  atrophy.  Spinal  or  nuclear  atrophy  usually  first 
shows  itself  in  the  intrinsic  muscles  of  the  hand  and  by  extension  early 
involves  the  tongue,  lips,  palate,  pharynx,  and  larynx,  giving  rise  to  the 
picture  of  bulbar  paralysis.  Fibrillary  contractions  of  the  muscles  are 
common  and  reactions  of  degeneration  occur.  The  disease  develops  almost 
exclusively  in  adult  life  and  is  not  hereditary. 

The  Atrophic  Paralyses. — The  muscles  undergo  secondary  degenera- 
tive atrophy.  The  lesion  which  interferes  with  the  transmission  of  motor 
impulses  at  the  same  time  interrupts  trophic  influences  to  the  muscle. 
The  paralysis  shows  itself  first  and  is  followed  by  atrophy,  which  in  the 
course  of  some  weeks  becomes  marked  and  often  reaches  a  very  high  grade. 
The  reactions  are  those  of  degeneration.  In  this  form  of  degenerative 
atrophy  fibrillary  contractions  are  frequently  present. 

THE   POSTURE,   ATTITUDE,   AND   GAIT. 

Posture. 

Patients  who  are  very  ill  of  an  acute  disease  or  in  the  advanced  stages 
of  chronic  disease  are  usually  seen  in  bed;  those  suffering  from  trifling 
affections  or  in  whom  the  symptoms  of  grave  disease  are  not  yet  urgent 
or  disabling  continue  to  be  about,  but  this  is  not  always  the  case.  Whether, 
on  the  one  hand,  a  patient  remains  up  and  about,  endeavoring  to  attend 
to  his  ordinary  duties  while  suffering  from  serious  symptoms  or,  on  the 
other  hand,  betakes  himself  to  bed  upon  the  occurrence  of  trifling  symp- 
toms is  often  a  matter  of  temperament.  It  is  not  uncommon  for  a  patient 
suffering  from  enteric  fever  to  come  to  the  consultation  room  or  dispensary 
in  the  second  week  of  the  attack  with  a  temperature  of  104°  F.  (40°  C.)  and 
a  well-developed  rose  rash — walking  typhoid.  Patients  who  realize  their 
condition  very  often  feel  compefled  by  circumstances  to  continue  the 
discharge  of  a  daily  duty  or  are  buoyed  up  by  the  hope  of  speedy  improve- 
ment, and  again  there  are  acute  diseases  which  run  a  favorable  course  which 
begin  with  urgent  and  distressing  symptoms.  The  physician  usually 
finds  those  patients  in  bed  who  have  high  fever,  prostration,  or  a  general 
sense  of  serious  illness,  and  those  who  suffer  from  dyspnoea,  pain,  vertigo, 
and  other  symptoms  intensified  by  movement  or  exertion.  In  meningitis, 
peritonitis,  rheumatic  fever,  pericarditis,  typical  croupous  pneumonia,  and 
in  well-developed  cases  of  the  acute  exanthemata  it  is  impossible  for  the 
patient  to  be  out  of  bed.  It  is  to  be  noted,  however,  that  upon  the  appear- 
ance of  the  eruption  in  the  variolous  diseases  the  symptoms  of  onset  often 
undergo  such  an  amelioration  that  the  patient  regards  himself  as  conva- 
lescent and  insists  upon  getting  out  of  bed. 

Decubitus  is  the  posture  of  the  patient  in  bed.  It  is  of  diagnostic 
importance.  It  is  in  moderate  illness,  as  in  health,  easy  and  unconstrained. 
The  patient  arranges  the  bed-clothes,  changes  his  position  when  it  has 
become    uncomfortable,    lies    naturally    upon    his    back— active    dorsai^ 


SYMPTOMS  AND  SIGNS:    POSTURE.  413 

DECUBITUS — or  turns  upon  the  side — active  lateral  decubitus.  The 
posture  of  weak,  helpless,  or  unconscious  individuals  in  bed  is  wholly  dif- 
ferent. The  muscles  play  little  part  in  maintaining  the  position. 
The  relaxed  body  yields  to  the  law  of  gravity  and  sinks  toward  the 
foot  of  the  bed,  where  it  remains.  The  patient,  even  when  his  breathing 
is  hindered  and  his  position  is  uncomfortable,  is  unable  to  change  it.  The 
attendants  must  again  and  again  lift  him  upon  the  pillows.  The  condition 
is  wholly  passive — passive  dorsal  decubitus.  In  rare  instances  the 
patient  in  this  state  lies  upon  the  side — passive  lateral  decubitus. 

Forced  or  imperative  attitudes  are  very  characteristic  of  certain 
diseases.     The  following  are  the  most  important: 

The  Dorsal  Posture. — In  acute  peritonitis,  whether  general  or  local, 
the  patient  lies  upon  the  back  with  the  thighs  flexed  upon  the  abdomen 
and  the  legs  upon  the  thighs.  Movement  is  avoided  and  the  patient  shrinks 
from  pressure  upon  the  abdomen. 

The  Reclining  Dorsal  or  the  Sitting  Posture. — In  diseases  attended 
with  difficult  respiration,  especially  certain  diseases  of  the  respiratory 
and  circulatory  organs  and  the  kidneys,  the  patients  are  forced  to  assume 
a  semi-upright  posture  on  the  bed-rest  or  propped  up  with  pillows,  or  to 
sit  upright.  Attempts  to  lie  flat  in  bed  increase  the  difficulty  of  respiration. 
The  sitting  position  relieves  it  by  favoring  the  action  of  the  accessory 
respiratory  muscles,  especially  when  the  arms  are  used  to  elevate  and  fix 
the  shoulders.  In  the  case  of  peritoneal  effusions  the  respiratory  move- 
ment of  the  diaphragm  is  less  interfered  with  in  the  sitting  posture  unless 
the  effusion  be  very  large,  in  which  case  the  abdomen  is  somewhat  com- 
pressed by  the  thighs.  This  attitude,  furthermore,  favors  the  return  of  the 
venous  blood  from  the  brain.  For  this  reason  high  grades  of  dyspnoea 
are  described  under  the  term  orthopncea.  When  the  difficulty  of  respira- 
tion is  extreme  the  patients  can  no  longer  remain  in  bed  but  are  obliged  to 
sit  upright,  fixing  the  shoulders  by  placing  the  hands  upon  the  side  of  the 
chair  or  its  arms  in  order  to  facilitate  the  use  of  the  accessory  muscles  and 
to  relieve  the  abdomen  from  the  pressure  of  the  thighs.  The  distress  is 
also  to  some  extent  relieved  by  the  gravitation  of  venous  blood  and  the 
fluid  of  general  dropsical  effusions  to  the  lower  extremities.  Orthopncea 
is  present  during  the  paroxysms  of  asthma,  in  extreme  cases  of  valvular 
■disease  of  the  heart  with  ruptured  compensation,  in  large  pleural  and  peri- 
'Cardial  effusions,  in  massive  peritoneal  effusions,  and  in  general  anasarca, 
which  may  be  cardiac  or  renal  but  is  very  often  cardiorenal.  It  occurs 
also  in  advanced  pulmonary  emphysema  and  in  obstructive  diseases  of 
the  larynx,  as  croup  and  diphtheria.  Except  in  extreme  cases  it  is  usually 
paroxysmal,  the  attack  being  brought  on  by  movement,  coughing,  conver- 
sation, or  other  exertion. 

Lateral  Postures. — Patients  suffering  with  unilateral  disease  of  the 
thoracic  organs  very  often  lie  upon  the  affected  side.  This  is  especially 
the  case  in  large  pneumonic  exudates,  pleural  and  pericardial  effusions,  and 
other  conditions  which  greatly  diminish  the  respiratory  surface  of  the 
affected  lung.  In  this  posture  the  respiratory  excursus  of  the  sound  side 
is  not  hampered  by  the  weight  of  the  diseased  organs.  In  painful  condi- 
tions, however,  the  patients  sometimes  lie  upon  the  sound  side.     In  acute 


414  MEDICAL  DIAGNOSIS. 

fibrinous  pleurisy  the  pain  of  which  is  greatly  intensified  by  breathing^ 
the  lateral  decubitus  upon  the  affected  side  is  assumed  by  preference  because 
the  weight  of  the  body  somewhat  diminishes  the  respiratory  excursus  of 
that  side  of  the  chest.  Patients  suffering  from  heart  disease  and  many 
individuals  in  good  health  lie  more  comfortably  upon  one  side  than  upon 
the  other;  sometimes  the  right  side  is  preferred,  sometimes  the  left.  In 
cardiac  hypertrophy  the  patients  usually  lie  more  comfortably  upon  the 
left  side,  and  in  large  aneurisms  of  the  aorta,  upon  the  affected  side.  Pa- 
tients suffering  from  harassing  cough  in  the  dorsal  position  are  sometimes 
relieved  by  turning  upon  one  side.  This  happens  in  certain  cases  of  uni- 
lateral pulmonary  cavity  and  the  relief  is  obtained  by  turning  upon  the 
affected  side.  The  explanation  of  this  phenomenon  is  purely  physical; 
while  the  patient  lies  upon  his  back  or  upon  the  sound  side  the  secretion 
formed  in  the  cavity  escapes  into  the  bronchus  little  by  little,  causing 
irritation  which  manifests  itself  by  cough,  while,  on  the  other  hand,  if  he 
continues  to  lie  upon  the  affected  side  it  collects  without  producing  reflex 
cough  until  the  cavity  overflows.  The  lateral  decubitus  with  the  thighs, 
and  legs  flexed  upon  the  abdomen  and  the  spine  and  neck  strongly  arched 
forward  is  usually  assumed  during  the  pains  of  parturition  and  is  common 
in  hepatic  and  intestinal  colic.  In  acute  cerebrospinal  meningitis  the 
patient  frequently  lies  upon  the  side  with  the  thighs  and  legs  strongly 
flexed  and  the  spine  extended  in  the  position  of  opisthotonos.  In  some 
cases  the  lower  extremities  are  extended — complete  opisthotonos. 

The  ventral  posture  is  sometimes  assumed  in  cases  of  abdominal  pain,, 
as  colic,  gastralgia,  or  enteralgia.  The  patient  lies  prone  upon  the  bed 
with  his  face  buried  in  the  pillow.  Tenderness  upon  abdominal  pressure, 
as  in  peritonitis,  renders  this  attitude  impossible.  It  sometimes  affords 
relief  to  the  pain  of  abdominal  aneurism  and  in  certain  cases  of  caries  of 
the  spine.  In  most  cases  of  gastric  ulcer  this  posture -is  avoided  on  account 
of  the  epigastric  tenderness  upon  pressure.  In  some  cases  of  this  disease, 
however,  the  pain  is  relieved  by  the  ventral  decubitus,  probably  because 
the  ulcer  is  so  situated  as  to  escape  in  this  position  the  pressure  of  the 
contents  of  the  stomach.  Patients  suffering  from  headache  very  often 
assume  this  posture. 

Restlessness  in  bed  is  a  very  common  symptom.  The  patient  is  unable 
to  maintain  the  same  position  for  any  length  of  time;  he  tosses  about, 
turns  from  side  to  side,  fusses  at  the  bed-clothes,  and  his  hands  and  feet 
are  in  constant  motion.  Restlessness  may  be  the  manifestation  of  nervous 
irritability  or  of  pain.  It  is  common  in  affections  attended  with  burning 
and  itching  of  the  skin,  as  scarlet  fever  and  urticaria.  It  occurs  also  in 
some  cases  of  shock  and  accompanies  profuse  hemorrhage,  in  which  case 
it  is  attended  with  pallor,  urgent  thirst,  and  rapid,  small  pulse.  In  truth 
the  association  of  restlessness  with  these  symptoms,  occurring  suddenly 
without  visible  bleeding,  warrants  a  provisional  diagnosis  of  internal 
hemorrhage.  The  term  jactitation  is  used  to  designate  a  high  degree  of 
restlessness.  The  patient  tosses  about  violently;  the  constant  efforts  of 
the  attendants  are  necessary  to  keep  him  in  bed.  Jactitation  occurs  in 
maniacal  delirium,  in  cases  of  violent  chorea,  in  which  it  is  accompanied 
by  constant  twitching  of  the  muscles,  as  a  temporary  manifestation  in 


SYMPTOMS  AND  SIGNS:   ATTITUDE. 


415 


some  forms  of  hysteria,  and  in  a  high  degree  during  the  stage  of  clonic 
convulsions  in  epilepsy. 

Opisthotonos,  predominating  tonic  contraction  of  the  spinal  muscles, 
so  that  the  body  rests  upon  the  head  and  heels;  emprosthotonos,  or 
bending  forward  of  the  trunk;  pleurothotonos,  arched  lateral  posture; 


--^ 


r 


^>iliWlirm.ftite. 


Fig.  180. — Opisthotonos  in  a  case  of  epidemic  cerebrospinal  meningitis. — Royer. 


Fig.    181. — Pleurotliotonos    in   a   case    of   epidemic    cerebrospinal    meningitis. — lloyer. 

and  ORTHOTONOS;  in  which  the  trunk  and  neck  are  rigidly  extended  in  a 
straight  line,  are  all  symptoms  that  occur  in  tetanus  and  in  some  cases  of 
meningitis  and  strychnine  poisoning. 


Attitude. 

The  attitude  and  movements  of  patients  who  are  able  to  be  about 
frequently  convey  important  information  in  regard  to  their  condition. 
The  young  and  the  strong  carry  themselves  erect  and  walk  briskly  and 
firmly;  the  aged  and  feeble  and  those  mentally  depressed  are  bowed  and 
move  slowly  and  with  effort.  The  convalescent  from  a  prostrating  disease 
is  at  first  weak  and  shaky;  he  can  scarcely  stand;  an  hour  in  the  arm-chair 
fatigues  him.     In  a  little  time  he  makes  the  journey  around  his  room  with 


416  MEDICAL'  DIAGNOSIS. 

slow  and  uncertain  gait,  and  is  soon  obliged  to  rest.  With  returning 
strength  comes  the  erect  carriage  and  firmer  step.  Modifications  of  atti- 
tude and  gait  constitute  characteristic  symptoms  in  many  diseases.  In 
general  they  are  due  to  skeletal  defects,  as  in  caries  of  the  spine,  hip-joint 
disease,  or  ankylosis  of  the  knee;  derangements  of  the  muscular  power  or 
function,  as  in  pseudohypertrophic  muscular  paralysis,  chorea,  and  the 
shaking  palsies;  derangements  of  the  balance  between  antagonistic  muscle 
groups,  as  in  forms  of  spinal  curvature  and  club-foot;  derangements  of 
coordination,  as  in  cerebellar  disease  and  tabes;  forms  of  paralysis,  as  in 
hemiplegia,  anterior  poliomyelitis;  and  contractures,  as  in  the  cross-legged 
progression  of  children  suffering  from  spastic  paraplegia. 

Station  is  technically  the  ability  to  maintain  the  erect  position  while 
standing.  It  depends  largely  upon  muscular  and  visual  coordination. 
Within  limits  it  is  better  the  wider  the  base  of  support,  hence  the  test  should 
be  made  with  the  feet  parallel  and  the  heels  and  toes  touching,  first  with  the 
eyes  open,  later  with  them  closed.  Hinsdale  found  in  normal  individuals 
of  both  sexes  the  average  oscillation  in  the  above  position,  as  determined 
by  an  instrument  devised  for  the  purpose,  to  be  about  an  inch  in  a  forward 
and  backward  line  and  three-quarters  of  an  inch  laterally.  The  oscilla- 
tion in  children  is  greater  than  that  in  adults.  Upon  closing  the  eyes  it  is 
increased  about  50  per  cent.  In  diseases  characterized  by  impairment  of 
the  power  of  coordination,  as  tabes  and  lesions  of  the  cerebellum,  station 
is  greatly  impaired  and  the  patient  may  be  wholly  unable,  under  the  condi- 
tions of  the  test  and  with  closed  eyes,  to  keep  his  balance — Romberg's 
SYMPTOM.  During  paroxysms  of  Meniere's  disease — aural  vertigo — the 
power  of  standing  in  the  erect  posture  is  wholly  lost.  Astasia  is  a  term 
employed  to  designate  inability  to  stand,  abasia  the  inability  to  walk,  in 
the  absence  of  paralysis.  Astasia-abasia  is  a  syndrome  of  hysteria  in 
which  the  patient  is  unable  to  stand  or  walk  but  can  usually  creep  about 
like  a  child,  upon  the  hands  and  knees. 

The  following  peculiarities  of  attitude  are  to  be  noted: 
In  HEMIPLEGIA  and  paralysis  of  one  leg  the  patient  supports  himself 
almost  entirely  upon  the  sound  leg.  In  chronic  sciatica  the  patient  spares 
the  affected  limb  both  in  walking  and  standing  by  fixation  of  the  hip-joint, 
and  in  doing  so  develops  a  scoliosis,  the  spinal  column  showing  a  double 
curvature,  the  lower  convex,  the  upper,  which  is  compensatory,  concave 
toward  the  affected  side,  the  general  inclination  of  the  body  being 
toward  the  sound  side.  In  paralysis  agitans  the  attitude  is  characteris- 
tic. The  head  and  upper  part  of  the  body  are  inclined  forward,  the  elbows 
and  knees  being  slightly  flexed.  The  striking  appearance  of  the  patient  is 
heightened  by  the  expressionless  countenance,  the  tremor,  and  the  move- 
ments of  the  fingers  and  hands.  In  pseudohypertrophic  paralysis  the 
patient  stands  with  his  feet  separated,  the  belly  protruding,  and  the 
shoulders  thrown  back  as  the  result  of  marked  lordosis.  In  the  sitting 
posture  the  curvature  of  the  spine  is  corrected. 


SYMPTOMS  AND  SIGNS:   GAIT.  417 


Gait. 


In  a  number  of  diseases,  especially  those  affecting  the  nervous  system, 
the  gait  is  much  modified  and  its  peculiarities  often  justify  conclusions 
regarding  both  functional  derangements  and  anatomical  lesions.  The 
following  symptomatic  gaits  are  frequently  observed: 

The  Paraplegic  Gait.— In  paresis  of  the  lower  extremities  the  gait 
is  feeble  and  uncertain.  Both  feet  are  slowly  advanced  and  dragged 
upon  the  floor.  The  patient  stumbles  over  trifling  inequalities  and  eleva- 
tions of  the  surface.  The  loss  of  power  is  frequently  more  marked  on  one 
side  than  on  the  other.  Crutches  become  necessary  and  at  length  the  loss 
of  power  is  complete.    This  gait  is  seen  in  chronic  myelitis. 

The  Hemiplegic  Gait. — When  the  hemiplegic  has  sufficiently  recov- 
ered to  walk,  the  gait  is  characteristic.  The  sound  limb  is  advanced, 
the  paralyzed  limb  dragged  after  it.  In  other  cases  the  step  of  the  para- 
lyzed limb  is  accomplished  by  lifting  the  pelvis  and  a  movement  of  cir- 
cumduction. When  contractures  have  taken  place  the  affected  arm  is 
rigid,  strongly  flexed  at  the  elbow  and  wrist  and  carried  across  the  body, 
and  the  fingers  and  thumb  are  flexed  upon  the  palm. 

The  Spastic  Gait.  —  In  spastic  paresis  of  the  lower  extremities 
such  as  occurs  in  forms  of  spinal  paralysis  there  is  peculiar  stiffness  of  the 
legs,  which  are  scarcely  bent  at  the  hip-  and  knee-joints,  while  the  thighs 
interfere  with  each  other  by  reason  of  the  contraction  of  the  adductors. 
The  contraction  of  the  gastrocnemii  produces  pes  equinus.  The  patient 
walks  with  two  canes  and  in  stepping  leans  upon  one,  lifting  the  pelvis  of 
the  opposite  side  as  he  steps,  and  dragging  the  foot  in  circumduction. 
In  some  cases  the  contact  of  the  foot  with  the  floor  produces  ankle  clonus 
which  adds  to  the  peculiarity  of  the  gait.  A  modification  of  the  spastic 
gait,  sometimes  seen  in  children,  is  known  as  cross-legged  progression. 
In  consequence  of  the  contraction  of  the  adductors  and  calf  muscles  there 
is  close  circumduction  of  the  knees,  and  in  stepping  the  legs  are  crossed 
and  the  advancing  foot  brought  down  not  only  in  front  of  but  to  the  out- 
side of  its  fellow. 

The  Steppage  Gait.  —  In  some  cases  of  peripheral  neuritis  the 
paralysis  of  the  extensors  of  the  feet  causes  a  peculiar  modification  in 
progression.  In  stepping  forward  the  knee  is  strongly  flexed  and  the  foot 
sharply  advanced  in  order  that  the  dragging  toes  may  be  lifted  from  the 
ground;  the  heel  is  brought  down  first  and  the  appearance  is  that  of  a 
person  stepping  over  obstructions. 

The  waddling  gait  occurs  in  pseudohypertrophic  muscular  paralysis 
and  is  not  less  characteristic  than  the  attitude  in  this  disease.  In  con- 
sequence of  the  lordosis  the  shoulders  are  thrust  back  and  the  belly 
forward,  the  legs  are  separated,  the  feet  raised  slowly  with  the  toes  drop- 
ping, the  centre  of  gravity  being  alternately  shifted  over  the  foot  upon 
which  the  patient  throws  his  weight.  The  manner  in  which  the  child,  after 
lying  down  upon  the  floor,  gets  up  is  especially  characteristic.  He  rolls 
over  upon  the  abdomen,  gets  upon  all  fours,  and  first  extends  the  arms, 
then  the  legs.  The  hands  are  next  drawn  toward  the  legs  until  he  can 
grasp  one  knee  with  the  corresponding  hand.  He  pushes  himself  up  until 
27 


418  MEDICAL  DIAGNOSIS. 

the  other  knee  can  be  grasped  and  assumes  the  erect  posture  by  gradually- 
raising  the  point  of  support  of  the  hand  upon  the  thigh.  Late  in  the  disease, 
when  the  atrophy  involves  the  muscles  of  the  upper  extremities,  it  becomes 
impossible  to  rise. 

The  ataxic  gait  is  that  of  incoordination  of  the  lower  extremities. 
It  is  observed  in  its  most  typical  form  in  tabes  dorsalis.  In  stepping  the 
foot  is  raised  higher  than  usual  with  a  jerk  and  rapidly  advanced  with 
an  awkward  and  irregular  movement,  the  toes  slightly  drooping.  It  is 
then  brought  down  with  an  abrupt  stamp  upon  the  heel  or  the  entire  sole. 
Progression  is  irregular  and  it  is  impossible  for  the  patient  to  walk  with, 
one  foot  before  the  other,  as  in  following  a  crack  upon  the  floor  or  a  chalked 
line.  He  walks  with  a  swaying  motion.  The  legs  are  separated  in  order  to 
increase  the  base  of  support,  which  is  further  enlarged  as  the  disease  makes 
progress  by  the  use  first  of  one  cane,  later  of  two.  In  advanced  cases  walk- 
ing becomes  impossible  without  the  aid  of  one  or  even  two  attendants. 
Finally,  the  power  of  locomotion  is  entirely  lost.  These  symptoms  of  im- 
paired coordination  are  greatly  increased  upon  closing  the  eyes.  Patients 
who  can  go  about  fairly  well  in  daylight  cannot  walk  at  all  in  the  dark. 

The  gait  of  sciatica  derives  its  characteristics  from  muscular  fixation 
of  the  hip-joint  voluntarily  brought  about  to  diminish  pain. 

The  Gait  in  Chorea. — In  severe  chorea  the  irregular  muscular  con- 
tractions interfere  greatly  with  ordinary  movements.  The  gait  of  the 
patient  is  often  hopping  or  sliding,  sometimes  it  resembles  the  movements 
of  skating.     In  the  worst  cases  walking  becomes  impossible. 

The  reeling  or  staggering  gait  is  a  form  of  the  ataxic  gait.  It 
occurs  in  conditions  attended  with  marked  disturbance  of  coordination,, 
such  as  drunkenness,  cerebellar  disease,  lesions  of  the  labyrinth,  and  some 
forms  of  paralysis  of  the  muscles  of  the  eye. 

The  Festinating  Gait. — This  modification  of  walking  occurs  in. 
paralysis  agitans  and  is  not  less  characteristic  than  the  attitude  in  that 
disease.  The  patient  bends  forward,  the  elbows  are  slightly  abducted 
and  flexed,  the  knees  are  also  flexed,  and  the  patient  walks  with  the  appear- 
ance of  haste,  as  though  to  overtake  his  advancing  centre  of  gravity. 
He  cannot  halt  at  once.  The  peculiarity  of  the  gait  is  largely  due  to  stiff- 
ness and  weakness  of  the  muscles.  The  gait  is  sometimes  described  as 
propulsive.  A  similar  gait  and  inability  to  stop  immediately  sometime® 
shows  itself  in  exhausted  pedestrians.     Retropulsion  may  occur. 

Posture  and   Movements  of  Infants. 

The  position  and  movements  of  infants  are  of  diagnostic  impor- 
tance. The  healthy  baby  uses  its  muscles  and  joints.  Its  postures  are 
active,  its  movements  constant,  and  a  source  of  evident  pleasure.  It 
loves  to  be  fondled  and  played  with.  How  different  the  baby  who  is  really 
ill!  Its  postures  are  passive.  Its  head  drops  and  rolls  from  side  to  side 
with  the  motion  of  the  pillow  upon  which  it  rests.  Its  limbs  dangle  help- 
lessly, and  voluntary  movements  are  slight  and  infrequent.  In  many 
febrile  diseases  there  is  cerebral  irritation,  shown  by  the  drawn  face  and 
head  pressure  deep  into  the  pillow.     In  severe  rickets  there  is  tenderness 


SYMPTOMS  AND  SIGNS:   TEMPERATURE.  419 

of  the  muscles  and  bones,  motion  is  painful  and  therefore  avoided;  in 
infantile  scurvy  a  similar  condition  exists,  and  in  well-developed  cases  the 
attitude  is  almost  diagnostic,  the  child  lying  upon  its  back  with  the  thighs 
and  legs  strongly  flexed,  shunning  all  movements  and  screaming  with 
fear  if  it  is  approached.  In  cerebrospinal  fever  and  other  forms  of  menin- 
gitis there  is  painful  retraction  of  the  muscles  of  the  back  of  the  neck — 
opisthotonos. 


IV. 

TEMPERATURE;    FEVER;    HYPOTHERMIA;    SIGNIFICANCE    OF 

ABNORMAL    TEMPERATURES. 

TEMPERATURE. 

Variations  in  the  temperature  of  the  body  constitute  symptoms  of 
great  importance  both  in  acute  and  in  chronic  disease.  From  the  earliest 
times  practitioners  estimated  the  heat  of  the  body  by  the  hand  and  thus 
sought  to  determine  the  presence  or  absence  of  fever.  The  introduction 
of  the  clinical  thermometer  into  medical  practice  marked  an  important 
advance  in  modern  medicine.     (See  Part  II,  Clinical  Thermometry.) 

Heat  Mechanism. — The  temperature  of  homothermous  or  warm- 
blooded animals  is  constant  within  narrow  limits  and  is  not  materially 
influenced  by  changes  in  the  temperature  of  the  medium  in  which  the 
organism  lives.  In  the  human  being  the  amount  of  heat  produced  and 
dissipated  at  different  parts  of  the  body  varies.  The  equilibrium  of  tem- 
perature is  maintained  in  part  by  direct  conduction  but  chiefly  by  the 
circulating  blood  and  lymph.  The  internal  parts  of  the  body  have  never- 
theless a  higher  temperature  than  the  external  and  some  internal  organs 
are  warmer  than  others.  The  heat  production  is  greater  in  organs  when 
they  are  active  than  when  they  are  at  rest,  and  the  temperature  varies  in 
different  regions  of  the  surface  of  the  body.  The  heat  mechanism  is  made 
up  of  two  factors:  (a)  heat  production  or  thermogenesis,  and  (b)  heat  dis- 
sipation or  thermolysis.  Under  normal  conditions  these  two  functions  so 
nearly  balance  that  the  mean  bodily  temperature  is  maintained  within 
very  narrow  limits.  The  regulating  mechanism  is  expressed  by  the  term 
thermotaxis.  It  is  obvious  that  thermotaxis  may  be  deranged  by  altera- 
tions in  either  thermogenesis  or  thermolysis. 

Thermogenesis  accompanies  oxidation.  Hence  almost  every  struc- 
ture of  the  body  may  be  regarded  as  the  source  of  heat.  In  this  respect 
the  skeletal  muscles  and  the  glands  play  the  chief  part.  The  general  ther- 
mogenic centres  have  been  shown  to  be  in  the  spinal  cord.  Thermogenic 
centres  probably  exist  in  the  caudate  nuclei,  pons,  and  medulla  oblongata; 
excitation  of  these  regions  is  followed  by  a  rise  in  heat  production — punc- 
ture pyrexia.  They  are  therefore  known  as  thermo-accelerator  centres.  Irri- 
tation of  the  region  of  the  sulcus  cruciatus  and  at  the  junction  of  the  supra- 
Sylvian  and  post-Sylvian  fissures  in  the  dog  is  followed  by  a  decrease  in  heat 
production.     These  centres  are  therefore  known  as  thermo-inhibitory. 


420  MEDICAL  DIAGNOSIS. 

Thekmolysis  or  heat  dissipation  is  the  result  of  radiation  and  conduc- 
tion from  the  surface,  of  the  evaporation  of  water  from  the  lungs  and  skin, 
and  of  the  warming  of  the  food,  drink,  and  inspired  air. 

Thekmotaxis  or  heat  regulation  is  brought  about  by  reciprocal 
changes  in  heat  production  and  heat  dissipation  through  the  action  of 
cutaneous  impulses  and  of  variations  in  the  temperature  of  the  blood  upon 
the  thermogenic  and  thermolytic  centres.  Thus  in  an  animal  exposed  to 
moderate  cold,  heat  dissipation  is  increased,  but  cutaneous  impulses  are 
generated  which  excite  the  thermogenic  centres  and  heat  production  also 
is  increased,  whereas  an  increase  of  the  temperature  of  the  blood  increases 
the  activity  of  the  thermolytic  process.  In  either  case  the  temperature  of 
the  body  is  maintained.  Under  abnormal  conditions  this  reciprocal  influ- 
ence is  deranged. 

Abnormal  thermotaxis  is  a  term  used  to  designate  the  regulation  of 
the  heat  mechanism  under  pathological  conditions  in  which  the  body 
temperature  is  maintained  at  a  range  higher  or  lower  than  that  of  health. 

Under  ordinary  circumstances  the  presence  or  absence  of  hyperther- 
mia may  be  determined  by  the  hand,  but  this  mode  of  observation  yields 
no  accurate  data  either  for  comparison  or  record.  An  impression  as  to 
the  surface  temperature  is  thus  obtained  but  this  does  not  always  corre- 
spond with  the  internal  temperature  of  the  body.  During  a  chill  the  tem- 
perature of  the  skin,  in  consequence  of  the  contraction  of  the  arterioles,  is 
in  most  instances  greatly  reduced,  while  the  internal  temperature,  as  deter- 
mined by  the  thermometer,  is  high.  On  the  other  hand,  when  the  skin  is 
active  and  perspiring  and  evaporation  is  prevented  by  the  bed-clothing,  the 
surface  may  feel  hot  to  the  hand  while  the  internal  temperature  remains 
normal.  The  normal  axillary  temperature  ranges  about  98.6°  F. — 37°  C. 
It  undergoes  diurnal  oscillations  of  a  degree  to  a  degree  and  a  half,  falling 
to  97.5°-98°  F.  in  the  early  hours  of  the  morning  and  rising  to  99°-99.3°  F. 
toward  evening.  It  is  very  probable  that  this  physiological  oscillation 
is  dependent  upon  the  alternations  of  sleep  and  waking.  Observations 
upon  men  who  have  habitually  slept  during  the  day  and  watched  during 
the  night  have  shown  an  inversion  of  the  curve.  A  slight  physiological 
rise  takes  place  during  gastric  digestion.  Violent  physical  exercise  is  fre- 
quently followed  by  a  temporary  rise  of  two  or  three  degrees;  this  fact 
may,  in  part  at  least,  explain  the  elevation  of  temperature  sometimes 
observed  after  a  violent  general  convulsion  and  w^hich  is  very  common  in 
the  status  epilepticus.  In  children  and  adolescents  the  range  is  somewhat 
higher  than  in  adults  and  also  less  stable,  that  is  to  say,  the  diurnal  phys- 
iological oscillations  are  slightly  greater  and  the  sensitiveness  of  the  tem- 
perature to  pathogenic  influences  more  marked. 

Kieffer  states  that  careful  observation  has  shown  that  permanent 
increase  of  external  heat  in  the  tropics  is  followed  by  a  rise  of  bodily 
temperature  of  .05°  F.  for  every  degree  of  external  heat  above  the 
mean  annual  norm  and  that  as  a  direct  consequence  the  respiratory 
function  is  diminished,  the  pulse-frequency  shghtly  decreased,  the  diges- 
tion, appetite,  and  assimilation  unfavorably  affected,  the  functional  activ- 
ity of  the  skin  greatly  increased,  and  the  nervous  system  distinctly 
depressed. 


SYMPTOMS  AND  SIGNS:    FEVER.  421 

In  aged  persons  the  diurnal  temperature  range  in  health  is  slightly 
lower. and  may  fall  to  97°  F.  (36.1°  C).  In  very  aged  persons,  on  the  other 
hand,  the  range  may  be  as  high  as  in  children. 

The  action  of  prolonged  or  intense  heat  and  cold  upon  the  temperature 
must  be  regarded  as  pathological. 

Abnormal  Temperature. — Variations  in  the  body  temperature  may  be 
plus  to  progressively  higher  ranges,  designated  subfebrile  and  febrile,  the 
latter  comprising  (a)  slight  fever,  (b)  moderate  fever,  (c)  high  fever,  (d) 
hyperpyrexia;  or  minus — subnormal  temperature  and  the  temperature  of 
collapse. 

The  term  pyrexia  is  used  to  designate  conditions  characterized  by 
elevation  of  temperature;  hyperpyrexia,  those  marked  by  excessively  high 
temperature;  and  apyrexia,  the  absence  of  fever.  Hypothermia  is  the 
term  applied  to  conditions  in  which  the  temperature  is  subnormal. 

FEVER. 

Elevation  of  temperature  alone  does  not  constitute  fever.  Extreme 
transient  rises  of  104°  F.  (40°  C.)  have  been  observed  after  violent,  pro- 
longed gymnastic  exercises,  and  much  higher  temperatures  in  hysteria, 
in  neither  case  associated  with  the  other  symptoms  which  enter  into  the 
modern  conception  of  fever.  These  symptoms  are,  in  addition  to  eleva- 
tion of  temperature,  subjective  sensations  of  illness,  cerebral  phenomena, 
weakness,  loss  of  appetite,  thirst,  increased  frequency  of  pulse  and  respi- 
ration, altered  urine,  and  derangements  in  nutrition  which  cause  wasting 
of  the  body.  It  is  furthermore  essential  to  our  conception  of  fever  and 
necessary  to  the  complete  manifestation  of  the  symptom-complex  that 
the  process  should  occupy  a  certain  time.  There  are,  however,  febrile 
periods  of  minimal  duration,  as  for  example  in  the  course  of  the  ague 
paroxysm,  in  which  most  of  the  objective  symptoms  occur  or  in  which,  if 
the  paroxysm  is  repeated  for  some  time  at  quotidian  or  tertian  intervals, 
all  of  them,  including  wasting  of  the  body,  are  manifest.  On  the  other  hand, 
the  acute  febrile  infectious  diseases  usually  run  a  self-limited  course,  meas- 
ured by  days  or  weeks;  again,  in  certain  of  the  chronic  infections,  as  forms 
of  tuberculosis,  there  may  be  fever  every  day  for  months.  Nor  are  these 
symptoms  altogether  dependent  upon  or  caused  by  the  elevation  of  tem- 
perature, as  is  shown  by  the  fact  that  artificial  over-heating  of  the  body 
produces  certain  of  them  but  not  all,  that  in  different  diseases  their  in- 
tensity by  no  means  corresponds  to  the  degree  of  the  temperature,  and 
that  marked  falls  of  temperature  can  occur  either  spontaneously  or  as  the 
result  of  antipyretic  treatment  without  a  corresponding  amelioration  in 
other  respects.  Elevation  of  temperature  is  nevertheless  a  constant  and 
essential  element  in  the  condition  known  as  fever  and  in  certain  cases 
dominates  the  clinical  picture.  In  a  majority  of  instances,  however,  the 
associated  conditions  constitute  a  much  more  important  measure  of  the 
gravity  of  the  case  than  the  range  of  temperature. 

Causes  of  Fever. — It  is  evident  that  the  causes  of  fever  act  through 
the  nervous  system  and  thus  produce  derangements  of  the  heat-regulating 
function.    At  the  same  time  they  also  produce  derangements  of  the  normal 


422  MEDICAL  DIAGNOSIS. 

tissue  changes  with  increased  oxidation  and  heat  production.  They  con- 
sist of  soluble  toxic  substances  circulating  in  the  blood  and  are,  (a)  the 
result  of  infection  by  micro-organisms,  which  may  be  general  or  local,  or 
(b)  the  result  of  intoxication,  which  may  arise  within  the  body  itself  from 
faulty  metabolism  or  be  introduced  from  without,  as  in  food  poisoning. 
In  cases  of  infection  with  profound  nutritive  disturbances  toxins  derived 
from  both  these  sources  are  present.  In  either  event,  whether  the  fever- 
producing  agent  be  a  toxin  produced  by  the  growth  and  development  of 
micro-organisms  or  an  albumose,  ferment,  or  ptomaine  produced  by  faulty 
cell  metamorphosis  within  the  organs  or  tissues  themselves,  the  condition 
constitutes  a  toxaemia, 

Sapreemia  is  an  infection  of  the  blood  by  putrefactive  products. 

It  is  probable  that  in  the  rare  cases  of  fever  attributed  to  intense 
emotion,  as  fright,  or  to  violent  pain  or  peripheral  irritation,  the  rise  of 
temperature  is  caused  by  the  sudden  derangement  of  physiological  processes, 
with  the  production  of  toxins,  rather  than  by  direct  action  upon  the  heat- 
regulating  processes,  and  that  in  many,  though  not  all,  of  the  cases  of  cere- 
bral disease  accompanied  by  fever,  as  thrombosis,  hemorrhage,  and  tumor, 
the  elevation  of  temperature  is  due  to  local  infection  rather  than  to  imphca- 
tion  of  the  heat  centres,  while  the  symptom-complex  and  the  condition  of 
the  blood  in  sunstroke  render  it  highly  probable  that  the  elevation  of  tem- 
perature is  due  not  so  much  to  the  direct  effect  of  heat  upon  the  nervous 
system  as  to  toxic  substances  generated  by  the  action  of  heat  upon  the 
tissues  of  the  body  and  especially  upon  the  muscles.  It  is  thus  seen  that 
many  different  pathogenic  principles  developed  within  the  body  or  intro- 
duced from  without  are  directly  or  indirectly  capable  of  producing  the 
reaction  which  we  designate  by  the  term  fever. 

Symptoms  of  Fever. — These  substances  not  only  cause  elevation  of 
temperature  and  more  or  less  marked  disturbances  of  nutrition  but  they 
also  produce  subjective  sensations  of  illness  and  cerebral  symptoms,  such 
as  headache,  somnolence,  stupor,  and,  in  grave  cases,  coma  and  delirium, 
which  may  be  mild  and  wandering  or  active  and  maniacal.  Among  the 
effects  produced  upon  the  nervous  system  must  be  included  the  profound 
sensation  of  weakness  often  present  in  the  early  stages  of  febrile  diseases 
and  which  bears  no  direct  relation  to  the  inability  to  take  food  or  to  the 
wasting  of  the  tissues  of  the  body  which  occurs  later.  They  produce  de- 
rangements of  the  normal  secretions,  which  are  manifested  on  the  part  of 
the  skin  by  dryness  and  heat  or,  in  some  cases,  and  especially  at  the  time  of 
defervescence,  by  profuse,  even  colliquative  sweating,  on  the  part  of  the 
gastro-intestinal  tract  by  thirst,  loss  of  appetite,  dry,  furred  tongue,  im- 
paired digestion,  and  constipation,  and  on  the  part  of  the  urinary  appa- 
ratus by  scanty,  high-colored  urine  of  increased  specific  gravit3^ 

Pulse  in  Fever. — Derangement  of  the  pulse-frequency  is  a  constant 
phenomenon  of  fever.  To  what  extent  it  is  due  to  elevation  of  the  tem- 
perature and  to  what  extent  to  the  action  of  fever-producing  toxins  upon 
the  nervous  systejn  cannot  be  determined.  In  almost  all  cases  of  fever 
there  is  an  acceleration  of  the  pulse-rate,  the  frequency  of  which  usually 
corresponds  to  the  intensity  of  the  fever.  Liebermeister  found  that  for 
ever}^  degree  centigrade  (1.8°  F.)  of  elevation  of  temperature  above  the 


SYMPTOMS  AND  SIGNS:   FEVER.  423 

normal  there  is  an  increase  of  eight  beats  of  the  pulse.  This  parallelism 
between  the  temperature  and  pulse  may  be  regarded  as  relatively  favor- 
able, whereas  a  greatly  increased  pulse-frequency  indicates  serious  cardiac 
or  vasomotor  disturbance  and  is  of  unfavorable  prognostic  significance. 
A  pulse-rate  of  140-160  in  the  adult  while  resting  quietly  in  bed  is  in  itself 
a  very  serious  symptom.  The  pulse-frequency  in  children  suffering  from 
febrile  diseases  is  relatively  high.  In  phthisis  with  moderate  fever  or  even 
in  the  absence  of  fever  there  is  commonly  a  quickened  pulse.  There  are 
cases  in  which,  notwithstanding  marked  elevation  of  temperature,  the  pulse- 
rate  remains  low.  This  departure  from  the  ordinary  parallelism  is  of 
diagnostic  importance.  High  temperatures  with  slow  pulse  are  observed 
in  cases  of  cerebral  disease  in  which  there  is  pressure  at  the  base,  as  tuber- 
culous meningitis,  in  yellow  fever,  and  in  febrile  diseases  in  individuals 
suffering  from  cardiac  lesions  attended  by  diminished  pulse-frequency,  as 
sclerosis  of  the  coronary  arteries  and  myocarditis.  It  is  to  some  extent 
characteristic  of  enteric  fever  that  the  pulse-frequency  is  moderate  as 
compared  with  the  elevation  of  temperature,  and  this  want  of  correspond- 
ence is  of  importance  in  the  differential  diagnosis  between  enteric  fever 
and  acute  miliary  tuberculosis  or  septicaemia,  in  both  of  which  the  pulse- 
rate  is  high. 

Respiration  in  Fever.  —  Increased  frequency  of  respiration  occurs  in 
almost  all  cases  of  fever.  That  this  phenomenon  is  in  part  due  to  the 
stimulating  effect  of  the  heated  blood  upon  the  respiratory  centre  has  been 
shown  experimentally;  exposure  to  artificial  heat  increases  the  frequency 
of  breathing.  That  it  is  also  in  part  due  to  the  direct  action  of  the  fever- 
producing  toxins  upon  the  respiratory  centre  is  rendered  probable  by  the 
fact  that  the  acceleration  of  breathing  bears  no  direct  ratio  to  the  elevation 
of  temperature  but  varies  greatly  at  the  same  temperature  in  different  dis- 
eases. It  is  a  matter  of  experience  that  cases  of  febrile  disease  in  which,  in 
the  absence  of  complications  on  the  part  of  the  respiratory  organs,  the  res- 
piration frequency  is  greatly  increased  are  almost  always  of  grave  import. 

Emaciation. — Wasting  accompanies  fever.  Even  in  febrile  attacks  of 
moderate  duration  the  loss  of  flesh  may  be  marked;  in  prolonged  fevers 
emaciation  may  be  extreme.  The  blood  undergoes  analogous  changes, 
the  patient  becomes  anaemic,  and  the  loss  of  flesh  at  the  close  of  a  prolonged 
fever  is  not  more  striking  than  the  pallor,  A  decrease  in  the  number  of  the 
erythrocytes  accompanies  all  cases  of  pyrexia,  but  requires  some  time  to 
become  manifest.    There  is  progressive  loss  of  the  albumins  of  the  plasma. 

Pyrexia  a  Symptom. — The  clinical  significance  of  fever  would  be  much 
less  important  were  it  not  for  the  fact  that  the  febrile  movement,  in  its 
mode  of  onset,  intensity,  course,  and  decline,  bears  a  relation  to  the  partic- 
ular morbid  condition  in  which  it  occurs,  frequently  definite  and  always 
suggestive. 

Until  recently  much  stress  was  laid  upon  the  distinction  between  symp- 
tomatic fever  and  essential  or  idiopathic  fever.  The  former  was  regarded 
as  a  manifestation  of  some  local  malady,  the  latter  as  constituting  the 
actual  disease.  The  stimulus  given  to  the  study  of  causes  by  the  science 
of  bacteriology  has  shown  that  this  distinction  is  more  apparent  than  real 
and  that  in  the  light  of  modern  pathology  pyrexia  is  always  a  symptom. 


424  MEDICAL  DIAGNOSIS. 

Idiopathic  Fever. — Nevertheless  there  is  a  group  of  acute  infectious 
diseases  in  which  fever  is  not  only  constantly  present  but  also  the  most 
conspicuous  symptom,  and  in  which  the  morbid  process  is  literally  coex- 
tensive with  the  febrile  movement,  which  is  self-limited,  the  illness  begin- 
ning with  the  rise  of  temperature  and  the  convalescence  setting  in  with 
defervescence.  This  group  constitutes  the  idiopathic  fevers  or,  more 
sim.ply,  the  fevers. 

Varieties. — Subdivisions,  arranged  according  to  the  course  of  the 
febrile  movement,  are  (a)  the  continued  fevers,  as  influenza  and  enteric 
fever,  and  (b)  the  periodical  (malarial)  fevers,  as  intermittent,  remittent, 
and  pernicious  fever.  In  some  of  the  continued  fevers  other  symptoms, 
as  eruptions,  are  no  less  constant  or  characteristic  than  the  course  of  the 
fever, — a  fact  which  led  to  the  establishment  of  a  further  subdivision 
upon  an  entirely  different  basis  of  classification,  which  comprises  the 
EXANTHEMATA  OR  THE  ERUPTIVE  FEVERS.  Furthermore,  in  certain  of  the 
diseases  which  are  regarded  as  continued  fevers,  a  characteristic  periodicity 
occurs,  or  the  course  of  the  disease  is  interrupted  by  periods  of  apyrexia  of 
considerable  duration,  an  example  of  which  is  relapsing  fever,  whereas  in 
the  periodical  fevers,  strictly  so-called,  namely,  the  malarial  infections, 
there  are  certain  cases  in  which  the  febrile  movement  lacks  distinct  peri- 
odicity—continued malarial  fever — or  is  absent  altogether — malarial 
infection  without  fever.  On  the  other  hand  there  is  a  large  group  of  diseases 
that  has  nothing  to  do  with  malaria  in  which  the  occurrence  of  febrile 
paroxysms,  separated  by  very  definite  periods  of  apyrexia,  in  other  words, 
distinct  periodicity,  is  characteristic — for  example,  the  hectic  fever  of 
pulmonary  tuberculosis,  hepatic  fever,  urethral  fever,  and  the  fever  in  some 
cases  of  mahgnant  endocarditis.  Finally,  there  are  local  and  general  in- 
fections in  which  the  symptom  fever  is  inconstant  and  irregular.  For  these 
and  other  reasons,  the  principal  of  which  is  that  fever  is  always  sympto- 
matic and  never  of  itself  an  actual  disease,  the  distinction  between  symp- 
tomatic fever  and  essential  or  idiopathic  fever  has  been  abandoned — a  long 
step  in  the  direction  of  a  scientific  or  etiological  basis  for  the  classification 
of  diseases.  Terms  and  phrases  that  have  long  lost  their  original  significance 
remain  to  encumber  the  literature  and  embarrass  the  study  of  medicine 
and  the  period  is  remote  when  we  shall  cease  to  speak  of  scarlet  fever  or 
yellow  fever. 

Type  in  Fever. — Type  is  a  term  loosely  used  to  indicate  the  intensity 
of  fever.  Thus  we  speak  of  fever  of  mild  type  or  fever  of  grave  type.  It  is 
applied  more  accurately  to  the  course  or  range  of  the  temperature  as  de- 
picted upon  cHnical  charts.  There  are  three  principal  types  of  fever:  (a) 
the  CONTINUED,  in  which  the  limits  of  the  diurnal  range  do  not  usually 
exceed  1.8°  F.  (1°  C),  the  fall  occurring  in  the  morning,  the  rise  in  the 
evening.  This  is  about  the  measure  of  the  diurnal  oscillation  in  health. 
There  is,  therefore,  a  parallelism  between  the  temperature  of  health  and 
fever  of  the  continued  type,  the  latter  being  elevated  two  or  more  degrees 
above  the  former  and  fluctuating  in  harmony  with  it.  Since  the  tempera- 
ture range  upon  the  chart  is  represented  not  by  a  straight  but  by  a  curved 
line  showing  the  diurnal  oscillations  it  is  better  to  describe  this  as  the 
SUBCONTINUOUS  type.    Fever  of  this  type  is  characteristic  of  the  fastigium 


SYMPTOMS  AND  SIGNS;   FEVER. 


425 


of  uncomplicated  enteric  fever,  (b)  The  remittent  type,  characterized  by- 
falls  of  several  degrees  in  the  temperature,  which  does  not,  however,  reach 
the  normal.  The  remissions  may  take  place  at  any  hour  of  the  day  and  are 
often  accompanied  by  free  sweating.  They  are  followed  in  the  course  of  a 
few  hours  by  exacerbations  of  greater  or  less  extent.  There  is  no  parallelism 
between  fever  of  this  type  and  the  normal  temperature  range.  This  is  the 
type  seen  in  some  forms  of  estivo-autumnal  malaria  and  in  septic  condi- 
tions,    (c)  The  INTERMITTENT  type,  characterized  by  a  fall  of  temperature 


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Fig.  182. — Fever  of  remittent  type:  lysis  in  enteric       Fig.  183. — Intermittent  malar 
fever.  single  tertian  infection.   Man 


al  fever,  tertian  tjrpe; 
,  aged  thirty-three. 


from  febrile  ranges  to  the  normal  or  below  it,  a  period  of  apyrexia  of  vari- 
able duration,  and  the  recurrence  of  fever.  The  febrile  paroxysms  are  of 
short  duration  as  compared  with  the  intermission  and  commonly  liegin 
with  a  chill  and  terminate  in  profuse  sweating.  During  the  intermission 
the  patient  usually  feels  fairly  comfortable  or  quite  well.  Fever  of  this 
type  occurs  in  malaria.  The  repetition  of  the  paroxysms  may  extend 
over  a  considerable  time.  Intermittent  fever  in  which  the  paroxysm  recurs 
daily  is  known  as  quotidian;  when  the  paroxysm  recurs  upon  the  third 
day,  including  the  day  of  onset,  it  is  tertian;  when  it  recurs  upon  the  fourth 
day,  quartan.  The  paroxysms  may  occur  at  any  period  of  the  day  and 
usually  at  the  same  hour.  In  malaria  they  ordinarily  recur  in  the  fore- 
noon, in  hectic  fever  in  the  afternoon,    (d)  The  inverse  type.    The  tern- 


426 


MEDICAL  DIAGNOSIS. 


perature  in  fever  of  the  continued  type  and  in  many  cases  of  the  remit- 
tent type  undergoes  diurnal  oscillations  of  wider  excursus  than  those  of 
health  but  corresponding  to  them  in  time.  That  is,  the  remission  occurs 
in  the  early  morning  hours,  the  exacerbation  toward  evening.  In  excep- 
tional cases  the  remission  takes  place  in  the  evening  and  the  exacerbation 
in  the  morning — inverse  type.  Fever  of  this  type  occasionally  occurs  in 
tuberculosis  and  in  rare  instances  in  enteric  fever. 


^ 

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Fig.  184. — Intermittent  malarial  fever,  quotidian  type; 
double  tertian  infection.    Man,  aged  twenty-nine. 


Fig.  185. — Temperature  of  inverse  type. 


Atypical  Fever. — In  many  febrile  diseases  the  temperature  range  is 
altogether  irregular.  This  is  especially  the  case  in  diseases  in  which  the 
symptoms  in  general  are  irregular  or  atypical,  as  diphtheria  and  the  va- 
rious septic  infections. 

The  Type  of  Fever  in  Particular  Diseases. — Many  of  the  febrile  infec- 
tions have  a  characteristic  temperature  range.  The  febrile  movement  in 
uncompHcated  cases  on  the  one  hand  is  self-limited  and  on  the  other  under- 
goes definite  modifications  at  different  stages  in  the  course  of  the  affection 
and  upon  the  occurrence  of  special  manifestations,  as  the  appearance  of  an 
eruption.  In  a  more  narrow  sense  the  temperature  range  in  such  diseases 
is  said  to  be  typical  or  to  conform  to  type.  It  is  to  be  borne  in  mind, 
however,  that  marked  departures  from  type  may  occur  in  consequence  of 
variations  in  the  intensity  of  the  infection,  pecuHarities  on  the  part  of  the 


SYMPTOMS  AND  SIGNS:   FEVER. 


427 


individual,  the  occurrence  of  complications,  and  from  the  action  of  drugs. 
The  type  of  fever,  both  as  regards  the  daily  range  and  the  temperature 
curve  throughout  the  course  of  the  attack,  constitutes  a  valuable  aid  to  diag- 
nosis, and  is  always  to  be  taken  into  consideration.  It  is  rarely  possible, 
however,  to  make  a  diagnosis  from  the  temperature  alone,  nor  is  it  desirable. 
In  connection  with  the  temperature  we  must  consider  the  other  symptoms 
and  signs,  the  surrounding  circumstances,   and  the   previous  treatment. 

In  well-developed  cases,  unmodified  by 
complication  or  treatment,  the  temperature 
curve  may  be  said  to  be  characteristic  in 
the  following  diseases:  tertian  and  quartan 
malaria,  enteric  fever,  typhus  fever,  relaps- 
ing fever,  and  croupous  pneumonia.  It  con- 
forms in  a  general  way  to  type,  but  less 
closely,  in  scarlatina,  measles,  erysipelas,  and 
the  variolous  diseases.  It  is  variable  and 
atypical  in  cerebrospinal  fever,  rheumatic 
fever,  endocarditis,  and  the  septic  infections. 

Stages. — The  course  of  the  attack  may 
be  divided  into  (a)  the  stage  of  prodromes, 
(b)  the  onset  or  stage  of  invasion,  (c)  the 
fastigium,  and  (d)  the  defervescence  or  stage 
of  decline.  In  typical  cases  of  the  different 
febrile  diseases  each  of  these  periods  has  a 
definite  duration  and  a  characteristic  curve 
upon  the  temperature  chart. 

(a)  The  Stage  of  Prodromes.  —  This  pe- 
riod is  usually  marked  by  vague  feelings  of 
discomfort,  lassitude,  pain  in  the  back,  un- 
sound sleep,  and  feverishness,  the  tempera- 
ture reaching  subfebrile  or  even  mild  febrile 
elevations  in  the  later  part  of  the  day.  These 
symptoms  are  often  absent.  Prodromes  usu- 
ally occur  in  diseases  of  gradual  develop- 
ment.    They  are  common  in  enteric  fever. 

(b)  The  Onset  or  Stage  of  Invasion. — The  rise  of  temperature  may  be 
gradual  or  abrupt.  When  gradual  the  evening  exacerbations  exceed  the 
morning  remissions  in  such  a  way  that  the  temperature  rises  progressively 
to  the  fastigium  or  acme.  Under  these  circumstances  the  stage  of  invasion 
may  occupy  a  period  of  several  days,  as  in  enteric  fever.  When  abrupt  the 
acme  is  reached  at  once  or  in  the  course  of  a  few  hours,  as  in  scarlet  fever, 
influenza,  or  croupous  pneumonia.  The  onset  is  very  often  attended  by 
chilliness  or  a  chill.  This  symptom  may  vary  in  intensity  from  transient 
sensations  of  cold,  with  shivering,  pallor,  and  slight  cyanosis  of  the  lips  and 
finger-tips,  to  a  severe  and  prolonged  chill  or  rigor,  with  violent  shaking  or 
tremor  of  the  whole  body,  chattering  teeth,  cold  extremities,  and  marked 
cyanosis.  The  temperature  of  the  surface  of  the  body  is  much  reduced  and 
the  patient  experiences  a  sensation  of  extreme  cold,  whereas  the  internal 
temperature,  taken  in  the  rectum,  is  high,  104°-107°  F.  (40°-42°  C).    The 


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Fig.  186. — Fever  of  irregular  pe- 
riodicity. 


428 


MEDICAL  DIAGNOSIS. 


violence  of  the  chill  commonly  corresponds  with  the  abruptness  of  the  onset. 
The  insidious  and  gradual  invasion  of  enteric  fever  is  not  often  attended  by 
chills.  The  abrupt  onset  of  croupous  pneumonia  very  frequently  manifests 
itself  by  a  prolonged  chill  of  great  severity,  occurring  without  warning  in 
a  condition  of  apparent  health.  The  chill  which  ushers  in  the  febrile  par- 
oxysm or  ague  fit  of  malaria  is  intense  and  prolonged,  and  the  congestive 
chill  of  the  algid  variety  of  pernicious  estivo-autumnal  malaria  may  termi- 
nate in  death.  Chills  occurring  later  in  the  attack  may  mark  the  develop- 
ment of  an  intercurrent  disease,  as  croupous  pneumonia  in  the  course  of 
enteric  fever.  The  chills  of  malignant  endocarditis  cannot  be  distinguished 
from  the  ague  paroxysm,  the  resemblance  to  which  is  frequently  heightened 
by  a  regular  periodicity.  Ague-like  chills  occur  in  some  cases  of  phthisis 
and  are  common  in  local  suppurations  with  pent-up  pus,  cholelithiasis,  and 
septic  and  other  conditions  attended  by  fever  of  intermittent  type. 


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1 

Fig.  187. — ^Temperature  curve  in  enteric  fever,  with  recrudescence  and  relapse. 

The  perturbation  of  the  nervous  system,  which  is  manifested  in  the 
adult  as  a  chill,  may  show  itself  in  the  child  as  a  convulsion,  sudden  stupor, 
or  very  rarely  as  an  outbreak  of  delirium.  In  the  adult  the  onset  of  an 
acute  febrile  infection  may  be  marked  by  sudden  maniacal  delirium  and 
patients  developing  pneumonia  or  enteric  fever  have  in  some  instances 
been  regarded  as  insane  and  committed  to  an  asylum. 

The  chill  which  attends  the  general  or  local  infections  and  which  is  of 
varying  intensity  must  be  distinguished  from  the  so-called  nervous  chill 
which  sometimes  occurs  in  persons  of  neurotic  constitution  under  condi- 
tions of  excitement,  intense  pain,  moderate  shock,  or  great  fatigue.  Under 
such  circumstances  there  may  be  trembling  and  agitation,  but  the  pulse 
remains  good,  the  normal  color  is  preserved,  and  the  thermometer  does  not 
show  a  rise  in  temperature. 

(c)  The  Fastigium  or  Acme. — Fastigium  is  literally  the  summit  or 
ridge  of  a  building.  The  temperature  range  in  the  continued  fevers  shows 
diurnal  remissions  and  exacerbations  corresponding  to  those  of  health,  but 
somewhat  greater.     The  elevation  above  the  normal  differs  in  different 


SYMPTOMS  AND  SIGNS:    FEVER. 


429 


diseases  and  in  different  cases  of  the  same  disease.  In  croupous  pneumonia 
and  in  typhus  and  relapsing  fevers  the  elevation  is  high.  In  many  cases  of 
enteric  fever  it  is  moderate.  A  parallelism  with  the  temperature  of  health 
is  to  some  extent  maintained  in  the  continued  fevers.  This  parallelism 
may,  however,  be  interrupted  by  accidents,  as  hemorrhage  or  perforation 
in  enteric  fever,  complications,  as  empyema  in  pneumonia,  the  occurrence 
of  pseudocrises,  the  action  of  antipyretic  drugs,  or  the  external  applica- 
tion of  cold  by  means  of  baths  or  otherwise.     In  the  periodical  fevers  the 


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r-42» 


Fig.  188. — Croupous  pneumonia  in  a  child  three     Fig.  189. — Pneumonia.    Early  defervescence;  inter- 
years  old.    Defervescence  by  crisis  on  the  evening  rupted  crisis. 
of  the  sixth  day. 


diurnal  range  is  much  greater  than  in  health.  The  term  acme  is  used  to 
indicate  the  summit  of  the  range  when  the  febrile  movement  is  transient, 
as  in  influenza  or  the  ague  paroxysm. 

An  abundant  hemorrhage  from  any  surface,  especially  intestinal  hem- 
orrhage in  enteric  fever,  causes  an  abrupt  fall  of  the  temperature  to  normal 
or  below  it.  The  shock  of  perforation  is  likewise  accompanied  by  a  fall  of 
several  degrees. 

A  normal  temperature  in  the  course  of  fever  may  thus  assume  the 
significance  of  an  abnormal  temperature. 

In  abortive  cases  of  enteric  fever,  especially  in  children,  the  defer- 
vescence is  often  critical.  Intercurrent  diseases  and  complications  may 
cause  a  rise  above  the  range  of  the  fastigium. 


430 


MEDICAL  DIAGNOSIS. 


c. 

1-42  = 


(d)  The  Defervescence  or  Stage  of  Decline. — The  fall  of  temperature 
may  be  abrupt,  or  gradual.  The  former  is  known  as  crisis  or  critical  defer- 
vescence,  the  latter  as  lysis.  The  abrupt  fall  in  crisis  amounts  to  several 
degrees  in  the  course  of  a  few  hours.  The  temperature  usually  reaches 
subnormal  ranges  from  which  it  reacts  gradually.  The  fall  may  be  broken 
by  a  slight  rise — interru-pted  crisis.  It  is  often  attended  by  critical  dis- 
charges, such  as  copious  perspiration,  passage  of  a  large  quantity  of  urine, 
or  large  liquid  stools.  Not  infrequently  it  occurs  during,  or  is  followed  by, 
a  deep  and  prolonged  sleep  from  which  the  patient  awakes  refreshed  but 

weak  and  exhausted.  There  is  a  corre- 
sponding fall  in  the  pulse  and  respiration 
frequency.  The  gradual  fall  in  lysis  takes 
place  by  progressive  increase  in  the  morn- 
ing remissions  and  decrease  in  the  evening 
exacerbations  until  normal  or  subnormal 
ranges  are  attained.  This  process  fre- 
quently extends  over  several  days,  as  in 
enteric  fever.  The  term  rapid  lysis  is  ap- 
plied to  a  gradual  defervescence  of  shorter 
duration.  Febrile  diseases  of  sudden  onset, 
such  as  croupous  pneumonia,  for  instance, 
not  infrequently  terminate  by  crisis,  while 
those  of  gradual  invasion  commonly  ter- 
minate in  lysis. 

Persistence  of  fever  beyond  the  normal 
period  in  a  self-limited  disease  is  due  usu- 
ally to  a  complication;  sometimes  to  re- 
lapse. The  febrile  course  of  measles  is  fre- 
quently prolonged  by  bronchopneumonia; 
of  scarlet  fever  by  middle-ear  disease, 
endo-  or  pericarditis,  pleurisy,  or  nephritis; 
of  enteric  fever  by  phlebitis,  abscess  forma- 
tion, cholecystitis,  necrosis  of  cartilage  or 
bone,  some  form  of  secondary  infection,  or 
by  relapse.  Cases  of  enteric  fever  extend- 
ing to  the  fifth  week  or  longer,  in  which 
no  complication  can  be  discovered,  are 
mostly   instances   of   intercurrent  relapse. 

The  Temperature  during  Convalescence. — In  the  early  days  of  con- 
valescence from  acute  febrile  disease  the  temperature  range  is  frequently 
subnormal.  It  is  also  labile,  that  is  to  say,  very  readily  disturbed  by 
trifling  influences,  such  as  constipation,  the  return  to  sohd  food,  mental 
excitement,  or  over-exertion.  A  transient  rise  of  temperature  produced  by 
any  of  these  causes  is  known  as  a  recrudescence. 

Relapse. — A  recurrence  of  fever,  together  with  the  characteristic 
symptoms  of  the  primary  attack,  due  to  reinfection.  Instances  of  two  or 
more  relapses — midtiple  relapse — are  of  occasional  occurrence.  That  form 
of  relapse  which  begins  before  the  defervescence  from  the  primary  attack 
is  completed  is  known  as  intercurrent  relapse. 


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Fig.  190. — Scarlet   fever:    deferves- 
cence by  lysis.  Boy,  aged  twelve. 


SYMPTOMS  AND  SIGNS:   FEVER. 


431 


Bed  Fever. — Patients  who  have  passed  through  febrile  diseases  some- 
times develop  during  convalescence  a  moderate  febrile  movement,  the 
evening  exacerbations  ranging  as  high  as  100°  or  101°  F.  This  fever  tends 
to  run  on  indefinitely  but  may  quickly  disappear  if  the  patient  is  allowed 
to  sit  up.  A  diagnosis  of  bed  fever  should  never  be  made  until  other  fever- 
producing  conditions  are  excluded. 

Paroxysmal  Fever. — The  fever  recurs  at  intervals.  The  temperature 
is  high  and  the  accompanying  symptoms  usually  severe.  The  febrile  move- 
ment is  of  short  duration  and  commonly  preceded  by  a  chill  and  followed 
by  profuse  sweating. 


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Periodical  Fever. — The  periodicity  may  be  regular  or  irregular. 
Intermittent  and  remittent  fevers  are  periodical.  Tertian  and  quartan 
malaria  constitute  the  very  type  of  the  regularly  recurring  periodical 
fevers.  The  periodicity  of  the  estivo-autumnal  fevers  is  not  so  well  de- 
fined; the  type  is  blurred  and  in  some  cases  wholl}^  obliterated.  We 
observe  forms  of  continued  malarial  fever  due  to  estivo-autumnal  infection. 

Other  febrile  diseases  are  characterized  by  periodicity — a  matter  of 
great  practical  importance  in  diagnosis. 

Paroxysmal  fever,  often  of  regular  periodicity,  may  occur  in  the 
following  conditions:  (a)  Abscess  formation  and  other  suppurative  proc- 
esses, as  empyema.  In  cerebral  abscess  the  temperature  may  be  continu- 
ously normal  or  subnormal.     Evacuation  of  pus  and  free  drainage  is  fol- 


432 


MEDICAL  DIAGNOSIS. 


lowed  by  disappearance  of  fever,  (b)  Pyaemia  and  septicaemia,  (c)  Malig- 
nant endocarditis,  (d)  Suppurative  and' infectious  processes  in  the  liver 
and  bile-passages — hepatic  fever.  Under  this  heading  are  abscess  of  the 
hver,  diffuse  cholangitis,  cholecystitis,  inflammation  of  the  hepatic,  cystic, 
and  common  ducts,  gall-stone  disease,  especially  impacted  gall-stones,  and 
hypertrophic  cirrhosis,  (e)  Infections  of  the  genito-urinary  tract,  as  cysti- 
tis and  pyelitis,  prostatic  abscess,  and  after  the  passage  of  the  catheter  or 
sound — catheter  fever,  urinary  fever,  (f)  Tuberculosis.  Paroxysmal  fever 
is  present  in  the  acute  mihary  form,    the  early  stages  of  many  cases  and 


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Fig.  192. — Urethral  fever.   Man,  aged  sixty-four. 


Fig.  193. — Cerebral  hemorrhage.   Hyperpyrexia. 
Pre-agonistic  rise  of  temperature. 


the  later  stages — after  cavity  formation — of  almost  all  cases  of  pulmonary 
phthisis,  and  very  often  in  acute  tuberculous  processes  involving  the  bones, 
joints,  and  glands.  Sometimes  in  the  last  few  days  of  consumption  the 
fever  wholly  ceases,  (g)  Hodgkin's  disease  and  leukaemia.  Periods  of 
fever  may  be  separated  by  prolonged  periods  of  apyrexia.  (h)  Syphilis. 
The  initial  fever  may  come  on  within  four  or  six  weeks  after  infection  and 
persist  for  several  weeks.  Paroxysmal  "fever  in  some  instances  accom- 
panies the  development  of  gummata  and  other  lesions  of  the  tertiary 
period,  (i)  Rapidly  growing  malignant  neoplasms,  (j)  Very  rarely  in 
morphinism,  the  febrile  paroxysm  being  preceded  by  a  chill  and  followed 
by  copious  sweating.  If  the  minimal  temperatures  fall  to  or  below  the 
normal  the  fever  is  intermittent  in  type;   if  they  fail  to  reach  the  normal 


SYMPTOMS  AND  SIGNS:  HYPOTHERMIA.  433 

it  is  of  remittent  type.  In  the  course  of  any  of  the  foregoing  diseases  the 
fever  may  change  from  one  to  the  other  of  these  types  and  frequently 
it  becomes  irregular  and  wholly  atypical.  In  the  course  of  defervescence  by 
lysis  as  the  fever  gradually  falls  to  normal  it  passes  from  the  subcontinu- 
ous  type  of  the  fastigium  first  to  the  remittent  type,  then  to  intermittent. 

The  febrile  paroxysms,  in  some  cases  of  pyaemia,  malignant  endo- 
carditis, and  tuberculosis,  and  of  disease  of  the  liver  and  bile-passages,  are 
ushered  in  by  rigor  and  terminate  by  sweating,  and  recur  with  such  regu- 
larity that  they  closely  resemble  the  ague  paroxysms  of  malaria.  Errors 
of  diagnosis  are  common,  but  readily  avoide4  by  close  observation,  exam- 
ination of  the  blood,  and  the  therapeutic  test  of  quinine. 

Hyperpyrexia. — Excessively  high  temperatures  are  occasionally  ob- 
served. The  thermometer  may  register  105.8°  F.  (41°  C.)  and  higher  in 
injuries  involving  the  cervical  portion  of  the  spinal  cord,  and  in  tetanus, 
rheumatic  fever,  scarlet  fever,  enteric  fever,  yellow  fever,  and  sunstroke. 
Very  high  temperatures  occur  in  croupous  pneumonia,  the  paroxysms  of 
malarial  fever,  relapsing  fever,  and  erysipelas.  A  marked  rise  may  occur 
in  the  acute  infections  just  before  death — pre-agonistic  rise.  Excessive 
temperature  when  transient  is  not  necessarily  of  grave  prognostic  import; 
if  continued  for  some  hours  it  is  apt  to  be  followed  by  death.  Da  Costa 
has  recorded  a  temperature  of  110°  F.  (43.3°  C.)  in  a  case  of  cerebral  rheu- 
matism, Jacobi  has  seen  in  scarlet  fever  107.6°  F.  (42°  C),  Sahli  113°  F. 
(45°  C.)  in  enteric  fever,  Richet  107°  F.  (41.7°  C.)  in  sunstroke,  with  re- 
covery. The  literature  contains  many  instances  of  recovery  after  such 
temperatures.  There  are  well  authenticated  cases  of  even  higher  temper- 
atures with  recovery.  The  most  remarkable  is  that  of  Teale,  reported  to 
the  London  Clinical  Society  in  1875.  A  lady  fell  from  her  horse  and  sus- 
tained serious  spinal  injuries.  For  sixty  days  she  had  frequent  rises  of 
temperature  to  111.2°  F.  (44°  C.)  and  higher  but  eventually  recovered. 
Bryant,  Guy's  Hospital  Reports,  1894,  has  recorded  the  facts  of  one  hun- 
dred cases  of  hyperpyrexia,  several  of  which,  however,  are  not  above 
suspicion.  Many  of  the  cases  of  excessively  high  temperature  have  oc- 
curred in  hysterical  persons  and  several  of  the  most  remarkable  instances 
on  record  are  obviously  the  result  of  deception. 

HYPOTHERMIA. 

Subnormal  Temperature. — Hypothermia  may  be  present  under  the 
following  conditions: 

(a)  The  intense  action  of  external  cold.  A  transient  body  tempera- 
ture of  86°  F.   (30°  C.)   may  occur,  yet  recovery  take  place. 

(b)  After  a  pronounced  crisis  at  the  close  of  an  acute  infectious  dis- 
ease, as  pneumonia.  Postcritical  falls  to  95°  F.  (35°  C.)  or  even  to  93.2°  F. 
(34°  C.)  have  been  observed. 

(c)  In  shock  and  collapse.  The  fall  of  temperature  is  associated  with 
signs  of  failure  of-  the  circulation,  frequent,  small,  or  imperceptible  pulse, 
colliquative  sweating,  great  relaxation,  and  extreme  pallor.  The  mind, 
except  in  the  presence  of  cerebral  lesions,  usually  remains  clear.  The  con- 
dition may  be  transient  or  it  may  be  the  immediate  forerunner  of  death. 

28 


434 


MEDICAL  DIAGNOSIS. 


Subnormal  temperature  may  be  the  result  of  internal  or  external  hemor- 
rhage, traumatism,  surgical  operation,  prolonged  anaesthesia,  the  apoplectic 
insult  in  cerebral  hemorrhage,  embolism  or  thrombosis,  the  sudden  rupture 
of  a  hollow  viscus  with  the  discharge  of  its  contents  into  the  peritoneum, 
or  finally  the  action  of  intense  pain  or  a  sudden,  overwhelming,  depressing; 
emotion  in  a  neurotic  individual.  When  reaction  takes  place  the  tempera- 
ture rises  very  often  to  febrile  ranges,  either  as  the  result  of  infection  or,  in  the 
case  of  cerebral  or  spinal  lesions,  from  irritation  of  the  tissues  which  constitute 


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Fig.   194. — Pneumonia.     Death  in  collapse   after 

crisis. 


Fig.  195. 


—Enteric  fever;  subnormal  temperature 
due  to  repeated  hemorrhage. 


the  heat  centres.  In  lesions  of  the  cerebrospinal  axis  the  reactive  fever  is 
frequently  due  to  inflammatory  reaction  in  the  neighborhood  of  the  lesion, 

(d)  In  various  conditions  attended  by  greatly  diminished  tissue 
change  or  profound  disturbance  of  the  heat  mechanism,  as  in  the  coma 
attending  acute  poisoning  from  alcohol,  illuminating  gas,  carbohc  acid,  and 
other  toxic  agents,  starvation,  carcinoma  of  the  oesophagus,  other  internal 
cancers,  abscess  of  the  brain,  myxoedema,  sclerema  neonatorum,  and  in  some 
forms  of  mental  disease,  as  melancholia.  Subnormal  temperature  ranges 
are  also  occasionally  observed  in  profound  anaemia,  the  terminal  stages  of 
tuberculous  processes,  especially  tuberculous  peritonitis,  and  in  diabetes. 

The  Action  of  Drugs  upon  the  Temperature.— Antipyretic  drugs^ 
most  of  which  are  synthetic  products  of  coal-tar,  while  capable  of  produc- 


SYMPTOMS  AND  SIGNS:   ABNORMAL  TEMPERATURES.    435 


ing  marked  effects  upon  febrile  temperatures,  have  little  influence  upon  the 
body  temperature  in  health.  Their  free  use  in  fever  is  followed  by  a  tend- 
ency to  collapse,  and  the  resulting  fall  of  temperature  is  of  short  duration. 
External  Antipyretics. — Cold  baths  or  gradually  cooled  baths,  spong- 
ing, packs,  ice-bags,  circulating  coils  for  the  application  of  iced  water,  and 
cold  enemata  reduce  the  febrile  temperature  not  only  without  the  pertur- 
bating  effects  of  drugs  but,  if  rightly  employed,  with  a  favorable  influence 
upon  the  general  condition  of  the  patient.    • 

Trifling  rises  of  temperature  follow  the  administration  of  full  doses 
of  atropine,  cocaine,  strychnine,  caffeine,  and  certain  other  drugs,  while 
correspondingly  sHght  faljs  occur  after  morphine,  quinine,  alcohol,  and  the 
general  anaesthetics. 

THE  SIGNIFICANCE  OF  ABNORMAL 
TEMPERATURES. 

To  recapitulate:  A  rise  of  temperature,  if  moderate,  may  be  physio- 
logical—digestion, violent  muscular  effort.  Such  rises  are  commonly  tran- 
sient. If  the  rise  be  accompanied  by  other 
symptoms  of  fever  it  may  indicate  (a)  an 
infection,  either  general  or  local;  (b)  an  in- 
toxication, which  may  arise  within  the  body 
from  faulty  metabolism  or  be  introduced 
from  outside  the  body,  as  in  the  case  of  food 
or  drink;  (c)  a  lesion  involving  the  heat- 
regulating  mechanism  of  the  nervous  system. 

As  a  rule  there  are  associated  symp- 
toms which  render  practicable  the  differen- 
tial diagnosis  of  these  conditions. 

A  fall  of  temperature  may  indicate 
blood  loss,  which  may  be  internal  and  con- 
cealed, as  in  a  small  rupture  of  the  wall  of 
the  heart  not  presently  fatal;  a  similar  leak- 
age from  an  aneurism;  collapse,  as  in  apo- 
plexy; excessive  radiation,  as  in  exposure; 
diminished  metabolism,  as  in  convalescence, 
starvation,  forms  of  poisoning,  and  certain 
nutritional  and  nervous  diseases.  The  fall 
may  be  transient  or  sustained. 

Whether  the  temperature  be  higher  or 
lower  than  the  normal  it  serves  to  exclude 
maUngering  and,  as  a  rule,  hysteria.  It  is 
important  to  bear  in  mind  that  remarkable 
departures  from  the  normal  temperature  are 
observed  in  some  cases  of  hysteria,  and  that 
the  clever  malingerer  often  plays  tricks  with 
the  thermometer  that   are   as   difficult  of  detection  as  they  are  puzzling. 

The  Prognostic  Significance  of  Abnormal  Temperature. — The  height 
of  the  temperature  is  important,  since  the  danger  increases  with  the  inten- 


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Fig.  19G. — Ischiorectal  abscess. 
Fever  immediately  relieved  by  in- 
cision and  drainage. 


436  MEDICAL  DIAGNOSIS. 

sity  of  the  fever.  A  rise  of  7.2°  F.  (4°  C.)  or  9°  F.  (5°  C.)  is  of  itself  ominous. 
If  sustained  for  some  hours  death  almost  always  follows,  though  remark- 
able exceptions  to  this  rule  have  been  observed.  Abrupt  rises  from  the 
range  of  health,  such  as  are  seen  in  malaria  or  relapsing  fever,  are  less 
dangerous  than  sudden  rises  above  the  fastigium  in  the  course  of  enteric 
or  other  continued  fever. 

Variations  from  type  in  the  temperature  curve  modify  the  prognosis 
unfavorably.  The  irregular  pneumonias  of  moderate  temperature,  102°  F. 
(38.8°  C.)  are  attended  by  greater  danger  to  life  than  the  typical  forms 
with  intense  fever,  104°  F.  (40°  C.)  or  higher. 

The  temperature  in  childhood  is  less  stable  than  in  adult  life.  It  is 
elevated  by  slight  causes,  and  reacts  more  readily  to  antipyretic  treatment. 
Forms  of  ephemeral  fever  are  more  common  than  in  later  life.  High  tem- 
peratures are  less  dangerous. 


V. 

RESPIRATION;  MODIFIED  RESPIRATORY  MOVEMENTS;  COUGH 

AND  ALLIED  PHENOMENA;    SIGNIFICANCE  OF  COUGH  IN 

DIAGNOSIS;    EXPECTORATION. 

RESPIRATION. 

The  normal  respiration-frequency  in  the  adult  is  from  16  to  24  in  the 
minute.  The  average  pulse-frequency  varies  between  64  and  96.  The 
normal  pulse-respiration  frequency  is  therefore  1  to  4-4.5.  In  early  life 
the  respiration  is  more  rapid,  the  average  being  in  the  new-born  44;  in  the 
fifth  year  26.  Posture  exerts  a  marked  influence.  In  normal  adults  the 
average  frequency  while  recumbent  is  14,  while  sitting  20,  and  in  the  erect 
posture  22.  These  differences  are  exaggerated  in  those  who  are  enfeebled 
by  disease.  The  respiration  is  shghtly  less  frequent  in  the  morning  than  at 
night,  and  about  one-fourth  less  during  sleep.  It  is  more  rapid  after  eating 
and  especially  after  a  hearty  meal,  a  fact  which  finds  its  explanation  in 
the  more  limited  excursus  of  the  diaphragm  when  the  stomach  is  full. 
The  rate  is  very  httle  influenced  by  the  external  temperature.  It  is  modi- 
fied by  the  internal  temperature  and  much  increased  in  fever.  It  increases 
with  muscular  activity.  The  respiration  frequency  may  be  modified  within 
Hmits  by  an  effort  of  the  will  and  is  profoundly  affected  by  the  emotions. 
CHnically  the  rate  is  often  quickened  by  the  knowledge  on  the  part  of  the 
patient  that  his  breaths  are  being  counted.  It  is  therefore  important,  if 
possible,  to  count  without  his  being  aware  of  it,  for  instance,  when  you 
appear  to  be  counting  the  pulse.  Failures  of  observation  may  be  controlled 
by  counting  for  one  or  more  entire  minutes.  The  rate  and  depth  of  the 
respirations  bear  an  inverse  relation  to  each  other:  the  greater  the  fre- 
quency the  less  the  depth,  or  the  slower  they  are,  the  deeper.  General 
abnormal  conditions  and  local  diseases,  especially  those  which  involve  the 
organs  of  respiration,  modify  both  the  frequency  and  extent  of  the  respira- 
tory movements. 


SYMPTOMS  AND  SIGNS:    RESPIRATION.  437 

Tidal  Air. — This  term  is  used  to  designate  the  inflow  and  outflow  of 
air  during  quiet  respiration.  It  amounts  to  about  500  cubic  centimetres — 
30  cubic  inches.  Complemental  air  is  the  volume  that  can  be  inspired 
after  the  completion  of  an  ordinary  inspiration;  reserve  or  supplemental 
AIR,  the  volume  that  can  be  expelled  after  an  ordinary  expiration;  resid- 
ual air,  the  volume  remaining  in  the  lungs  after  the  most  forcible  expira- 
tion; stationary  air,  the  volume  remaining  in  the  lungs  after  an  ordinary 
expiration  and  equal  to  the  reserve  air  plus  the  residual  air.  Vital  ca- 
pacity is  the  volume  of  air  that  can  be  expired  after  the  fullest  inspiration. 
The  average  is  about  3400  cubic  centimetres  for  men  and  2500  cubic  centi- 
metres for  women.  Lung  capacity  is  the  total  quantity  of  air  in  the  lungs 
after  full  inspiration,  and  is  equal  to  the  vital  capacity  plus  the  residual  air. 

Vital  Capacity. — The  measurement  of  the  vital  capacity  is  determined 
by  various  modifications  of  the  spirometer  devised  by  Hutchinson.  It  is 
affected  by  age,  sex,  stature,  posture,  occupation,  and  disease.  It  increases 
with  age,  the  maximum  being  attained  at  about  the  thirty-fifth  year.  It 
is  greater  in  men  than  in  women  of  the  same  height  in  the  ratio  of  10  to 
7.5.  It  increases  in  proportion  to  the  stature  up  to  the  twenty-fifth  year, 
and  Arnold  found  that,  in  the  adult,  for  each  centimetre  of  increase  or 
decrease  of  height  beyond  a  mean  standard  there  is  a  corresponding  rise  or 
fall  in  the  vital  capacity  of  60  cubic  centimetres  for  men  and  40  for  women. 
The  ratio  as  modified  by  posture,  is  0,96  in  the  prone,  1.11  in  the  sitting 
or  erect,  and  1.13  in  the  standing  position.  The  vital  capacity  is  greater  in 
those  leading  an  active  than  in  those  who  lead  a  sedentary  life.  It  is 
obvious  that  improper  clothing  and  tight  lacing  and  all  pathological  condi- 
tions which  interfere  with  the  full  and  free  expansion  of  the  chest,  whether 
general,  as  in  wasting  diseases  of  every  kind,  or  local,  as  in  thoracic  or 
abdominal  diseases,  must  diminish  the  vital  capacity;  nor  is  it  to  be  over- 
looked that  pregnancy  or  a  sedentary  life  not  in  itself  incompatible  with 
excellent  health  may  exert  a  similar  influence.  The  spirometer,  partly  for 
these  reasons,  partly  by  reason  of  its  inconvenience  of  application  and  un- 
certainty as  an  instrument  of  precision,  and,  finally,  because  there  are  other 
methods  far  more  available  and  accurate,  has  fallen  wholly  into  disuse  in 
ordinary  clinical  work. 

Peculiarities  in  the  respiratory  phenomena  are  expressed  by  the  fol- 
lowing terms: 

Eupncea  is  a  condition  of  normal  respiration  observed  during  bodily 
and  mental  quiet.  Apncea  is  a  temporary  suspension  of  the  respiratory 
movements.  Hyperpncea  is  a  term  used  to  designate  increased  respiratory 
activity.  Heat-dyspncea  and  polypncea  are  forms  of  hyperpncea  due  to 
direct  excitation  of  the  respiratory  centres,  as  the  result  of  an  increase  in 
the  temperature  of  the  blood  or  of  reflex  excitation  of  the  cutaneous  nerves 
by  external  heat.  Dyspncea  is  difficult  or  labored  breathing;  the  respir- 
atory frequency  is  often  less  than  normal  but  may  be  increased.  As- 
phyxia or  suffocation  is  the  term  used  to  express  the  condition  caused 
by  deprivation  of  air.  The  respirations  are  at  first  increased  in  frequency 
and  depth,  then  a  period  of  increasing  dyspnoea  follows,  with  violent  spas- 
modic expirations  and  convulsions.  The  final  condition  is  that  of  collapse, 
which  is  ushered  in  by  progressive  slowness  and  shallowness  of  the  respi- 


438  MEDICAL  DIAGNOSIS. 

rations,  dilatation  of  the  pupils,  disappearance  of  the  motor  reflexes,  loss  of 
consciousness,  convulsive  twitching,  and  relaxation  of  the  sphincters.  The 
heart  commonly  continues  to  beat  for  some  minutes  after  the  cessation  of 
breathing,  so  that  by  means  of  artificial  respiration  the  patient  may  be 
restored  to  life.  After  death  the  blood  is  dark,  the  veins  and  lungs 
engorged,  and  the  arteries  empty. 

Type  in  Respiration. — The  filling  of  the  lungs  with  air  is  brought  to  pass 
in  part  by  the  outward  and  upward  movement  of  the  ribs  and  sternum  and 
in  part  by  the  contraction  of  the  diaphragm.  Either  of  these  factors  may 
predominate;  hence  a  costal  type  of  respiration  and  a  diaphragmatic  or 
abdominal  type.  In  women  the  costal  type  is  more  pronounced;  in  men  the 
abdominal.    In  the  new-born  the  type  is  abdominal,  in  older  children  costal. 

The  type  undergoes  modifications  in  consequence  of  various  patho- 
logical conditions  which  affect  the  costal  or  abdominal  respiration. 

Limitation  of  costal  respiratory  movements  is  caused  by  intratho- 
racic disease  or  by  changes  in  the  wall  of  the  thorax.  Dense  pleural  thick- 
ening, pulmonary  consolidation,  loss  of  pulmonary  elasticity,  effusions, 
large  aneurisms,  and  tumors  of  every  kind  limit  the  respiratory  excursus 
in  the  region  involved.  If  one-sided,  as  is  mostly  the  case,  the  unaffected 
lung  takes  upon  itself  additional  work, — vicarious  respiration, — and  the 
increased  respiratory  movement  of  the  sound  side  is  in  strong  contrast  to 
the  restricted  movement  of  the  affected  side.  Calcification  of  the  costal 
cartilages  and  the  ankylosis  of  the  costosternal  articulations,  which  takes 
place  in  arthritis  deformans  and  emphysema,  interfere  with  the  move- 
ments of  the  ribs  and  may  convert  the  costal  type  of  respiration  in  the 
female  or  the  costo-abdominal  in  the  male  into  the  purely  abdominal  type. 

Limitation  of  abdominal  respiration  may  arise  as  the  result  of  mechan- 
ical interference  with  movements  of  the  diaphragm,  paralysis  of  the  dia- 
phragm itself  through  flattening  of  its  vault  by  the  presence  of  pleural 
effusions,  or  in  emphysema,  and  instinctively  to  avoid  pain.  The  costal 
type  may  therefore  be  intensified  and  the  diaphragmatic  diminished  in 
the  following  conditions:  mechanically  in  all  forms  of  marked  distention 
of  the  ^.'r-r'omen,  as  advanced  pregnancy,  tympany,  tumors,  and  ascites; 
acute  inflammations  of  the  serous  membranes  in  relation  with  the  dia- 
phragm, as  pleurisy,  pericarditis,  and  peritonitis — the  limitation  of  move- 
ment being  in  part  the  result  of  pain,  in  part  the  result  of  paresis  of  the 
musculature  of  the  diaphragm;  paralytic  states  involving  the  diaphragm, 
as  multiple  neuritis  or  progressive  muscular  atrophy. 

MODIFIED  RESPIRATORY  MOVEMENTS. 

Derangements  of  the  Frequency  and  Rhythm  of  the  Respiration. — 
(a)  Diminution  in  the  Respiration  Frequency — Oligopnoea. — This  symptom 
is  common  in  stuporous  conditions  and  in  coma.  It  occurs  in  severe 
brain  disorders,  as  hemorrhage,  tumors,  meningitis,  in  uraemia,  diabetic 
coma,  intense  infections,  and  many  forms  of  narcotic  poisoning.  As  disso- 
lution approaches  the  respiration  dechnes  in  frequency.  In  all  of  these 
conditions  the  rhythm  of  the  respiration  may  be  deranged.  The  changes 
are  due  to  altered  function  of  the  respiratory  centre. 


SYMPTOMS  AND  SIGNS:   RESPIRATORY  MOVEMENTS.     439 

(b)  Increased  Frequency — Polypnoea. — This  results  from  increased  de- 
mands upon  the  respiratory  function  and  constitutes  an  important  element 
in  the  symptom-complex  dyspnoea.  It  occurs  also  as  a  nervous  symptom 
in  hysteria  and  certain  forms  of  cerebral  disease. 

(c)  Characteristic  Derangements. — 1.  Meningeal  Respiration. — This 
form  of  breathing,  as  its  name  indicates,  is  common  in  meningitis,  but  may 
occur  in  other  affections  of  the  brain  and  in  severe  general  infections  and 
toxic  conditions.  It  is  characterized  by  pauses  in  breathing,  which  last 
from  a  few  seconds  to  half  a  minute  or  longer  and  recur  at  regular  or  irreg- 
ular periods.     It  is  of  unfavorable  prognostic  import. 

2.  Cheyne-Stokes  Respiration. — There  are  similar  pauses  in  this 
form  of  breathing.  They  do  not,  however,  occur  as  mere  interruptions  of 
respiration  but  are  preceded  by  a  gradual  diminution  in  the  depth  and 
frequency  of  the  respiratory  acts  until  breathing  wholly  ceases.  After  a 
pause  of  several  or  many  seconds  the  breathing  is  re-established.  It  is  at 
first  shallow  and  slow,  but  progressively  increases  and  becomes  by  degrees 
more  rapid,  deeper,  and  sometimes  "urgent,  until  a  maximum  is  attained. 


Fig.  197. — Cheyne-Stokes  respiration — pneumatography. 

Then  follows  another  gradual  decrease,  to  be  again  followed  in  time  by 
total  arrest  of  respiratory  movement.  Cheyne-Stokes  respiration  is  char- 
acterized by  an  exquisite  periodicity.  It  is  encountered  in  grave  general 
conditions  due  to  affections  of  the  brain,  heart,  or  respiratory  organs,  espe- 
cially in  individuals  who  have  marked  arteriosclerosis.  It  occurs  also 
in  uraemia  and  usually  but  by  no  means  invariably  in  unconsciousness. 
This  form  of  breathing  may  arise  while  consciousness  is  retained,  and  espe- 
cially is  this  the  case  in  chronic  affections  of  the  circulatory  and  respiratory 
organs.  Under  some  circumstances  consciousness  is  partially  or  wholly 
lost  during  the  respiratory  pauses  and  regained  in  the  intervals  of  breath- 
ing. During  the  pauses  there  is  sometimes  a  marked  slowing  of  the  pulse, 
with  altered  tension,  and  contraction  of  the  pupils,  but  these  phenomena 
bear  no  constant  relation  to  the  respiratory  changes.  During  the  accel- 
eration in  breathing  which  follows  the  pause  the  patients  in  some  instances 
experience  a  desire  for  air  and  in  other  instances  the  sensation  of  having 
been  roused  from  sleep.  Cyanosis  may  occur  during  the  pause.  In  certain 
cases  Cheyne-Stokes  respiration  occurs  only  in  sleep.  Full  doses  of  mor- 
phine are  followed  by  an  intensification  of  the  phenomena,  and  Cheyne- 
Stokes  respiration  may  first  appear  in  the  sleej)  which  follows  the  admin- 


440  MEDICAL  DIAGNOSIS. 

istration  of  this  drug.  The  prognosis  of  the  underlying  condition  is  always 
grave,  and  this  form  of  respiration  is  seen  in  profound  illness  from  which, 
exceptionally,  the  patient  rallies  in  a  short  time  or,  and  this  is  the  general 
rule,  presently  dies.  In  some  cases  of  cardiac  or  renal  disease,  however, 
Cheyne-Stokes  respiration  recurs  from  time  to  time  for  months. 

3.  Jerking  Respiration. — The  act  may  be  spasmodic.  Usually  it  is 
the  inspiration  that  is  jerking,  less  commonly  the  expiration,  rarely  both. 
Jerking  inspiration  is  seen  in  sobbing,  hysteria,  hydrophobia,  sometimes, 
in  asthma;  jerking  expiration,  in  acutely  painful  respiration,  such  as 
occurs  in  pleurisy,  especially  diaphragmatic,  in  pleurodynia,  or  in  the  case 
of  a  broken  rib.  Jerking  respiration  is  more  apt  to  occur  when  the  breath- 
ing is  of  the  costal  type  than  when  it  is  abdominal. 

Dyspnoea. — This  term  includes  a  variety  of  respiratory  derangements 
which,  much  as  they  may  differ  among  themselves  in  detail,  have  one 
thing  in  common,  namely,  difficulty  in  breathing.  The  clinical  conception, 
whatever  the  cause  or  whatever  the  derangement,  rests  upon  inadequate 
oxygenation  of  the  blood.  Dyspnoea  may  arise  from  a  deficiency  of  oxygen 
or  from  an  excess  of  carbon  dioxide  in  the  blood.  Cardiac  and  hemorrhagic 
dyspnoeas  are  due  chiefly  to  a  deficient  supply  of  oxygen.  In  cardiac  dys- 
pnoea the  poor  supply  of  blood  to  the  tissues  results  from  the  enfeebled  action 
of  the  heart.  In  hemorrhagic  dyspnoea  there  is  enfeebled  action  of  the 
heart  on  the  one  hand  and  a  diminished  quantity  of  blood  on  the  other. 
All  conditions  which  lessen  the  force  of  the  circulation  or  the  quantity  of 
haemoglobin  tend  to  cause  dyspnoea;  hence  individuals  who  suffer  from  car- 
diac lesions  or  forms  of  anaemia,  or  who  are  enfeebled  by  disease,  experience 
difficulty  in  respiration  after  slight  exertion.  Conditions  which  interfere 
with  the  interchange  of  oxygen  and  carbon  dioxide  in  the  lungs,  such  as 
bronchitis  of  the  smaller  tubes,  forms  of  pneumonia,  emphysema,  extensive 
pulmonary  tuberculosis,  laryngeal  obstruction,  abdominal  tumors,  and 
large  ascites,  tend  to  the  production  of  dyspnoea,  especially  upon  exertion. 

The  respiration  may  be  more  or  less  frequent  than  normal.  Two  prin- 
cipal forms  may  be  distinguished,  namely,  that  in  which  the  breathing  is 
rapid  and  shallow  and  that  in  which  it  is  slow  and  deep.  In  the  former  the 
ratio  between  inspiration  and  expiration  is  not  usually  much  deranged; 
difficulty  in  breathing  attends  both  acts  and  the  condition  is  spoken  of  as. 
mixed  dyspnoea.  In  the  latter  the  ratio  is  disordered,  sometimes  the  inspi- 
ration, sometimes  the  expiration  being  more  prolonged.  To  the  one  is 
applied  the  term  inspiratory  dyspnoea;  to  the  other  expiratory  dyspnoea. 
The  first  is  characterized  by  inspiratory,  the  second  by  expiratory  stridor. 
In  all  forms  of  dyspnoea  certain  muscles  which  ordinarily  are  little  or  not 
at  all  used  in  respiration  and  have  other  functions  are  brought  into  play.. 
They  are  the  auxiliary  muscles  of  respiration.  Among  them  are  the 
scaleni,  trapezii,  levatores  scapulae,  the  sternocleidomastoid,  sterno-  and 
thyrohyoid  muscles,  and  the  pectorales.  The  action  of  these  muscles  is 
more  powerfully  exerted  in  the  6rect  or  sitting  posture — orthopnoea — the 
position  usually  assumed  in  inspiratory  dyspnoea.  In  expiratory  dyspnoea 
the  abdominal  muscles  are  used  as  auxiliary  muscles. 

In  dyspnoea  of  high  grade  the  muscles  of  facial  expression  are  also 
brought  into  play,  with  the  effect  of  dilating  the  nostrils  and  separating 


SYMPTOMS  AND  SIGNS:    RESPIRATORY  MOVEMENTS.     441 

the  lips  and  jaws.  The  action  of  these  muscles  gives  to  the  facies  a  very 
characteristic  and  distressed  appearance.  Very  striking  is  the  play  of  the 
nostrils  in  young  children  suffering  with  pneumonia.  The  entrance  of  air 
is  to  some  extent  favored  by  the  action  of  these  muscles,  but  the  ex- 
planation of  their  participation  in  the  dyspnoeal  movements  is  to  be  sought 
in  the  implication  of  associated  muscle  groups  in  the  intense  innervation 
supplied  to  the  essential  muscles  of  respiration. 

The  term  dyspnoea  is  sometimes  used  to  designate  the  sensation  of 
breathlessness  which  attends  difficult  breathing.  Hence  subjective  and 
objective  dyspnoea.  These  two  forms  are  usually  associated,  but  to  this 
statement  there  are  exceptions.  Cases  occur  in  which,  with  persistent 
obstruction  of  the  respiration  and  well-marked  objective  dyspnoea,  there 
is  no  sense  of  breathlessness  or  oppression.  Cyanosis  may  even  be  present 
without  subjective  dyspnoea.  As  death  approaches  and  objective  dyspnoea 
becomes  urgent  carbon-dioxide  narcosis  develops  and  subjective  dyspnoea 
disappears.  There  are  cases,  however,  in  which  objective  dyspnoea  is 
slight  or  absent  altogether,  yet  the  patient  complains  of  distressing  sub- 
jective dyspnoea.  To  this  category  must  be  referred  the  precordial  distress 
of  melancholia  and  the  frequent  desire  of  nervous  patients  to  take  a  series 
of  deep  inspirations.     Pure  subjective  dyspnoea  is  rare. 

Cyanosis  attends  every  obstruction  to  respiration  of  high  grade,  what- 
ever the  cause.  The  blood  becomes  progressively  richer  in  carbon  dioxide 
and  poorer  in  oxygen.  In  chronic  conditions  attended  with  dyspnoea  the 
organism  may  gradually  become  adjusted  to  subnormal  oxygenation  of 
the  blood,  so  that  the  other  functions  are  fairly  well  performed  and  the 
patient,  although  manifestly  dyspnceic,  especially  upon  exertion,  and  con- 
stantly cyanosed,  has  little  subjective  dyspnoea.  On  the  other  hand  a 
similar  degree  of  obstruction  to  respiration,  if  rapidly  established,  is  at- 
tended with  the  most  urgent  and  distressing  dyspnoea. 

Pneumothorax  affords  a  striking  example  of  the  adjustment  of  the 
organism  to  respiratory  disturbances  of  high  grade.  The  sudden  inter- 
ference with  respiration  causes  intense  objective  and  subjective  d3^spnoea, 
which  gradually  subsides  and  in  many  cases  wholly  disappears  so  long  as 
the  patient  is  at  rest. 

Dyspnoea  is  of  much  less  unfavorable  prognosis  when  the  cyanosis  is 
slight  than  when  it  is  deep  and  persistent. 

Forms  of  Dyspnoea. — Dyspnoea  as  the  result  of  pain  occurs  in 
pleurisy  and  especially  in  diaphragmatic  pleurisy,  peritonitis,  inflamma- 
tion of  the  diaphragm,  and  in  affections  of  the  intercostal  muscles,  as 
myalgia  and  trichinosis.  Deep  breathing  is  impossible;  the  respirations 
are  shallow  and  hurried.     The  difficulty  is  not  mechanical  but  functional. 

Dyspnoea  from  Diminution  of  the  Respiratory  Surface  or  Lim- 
itation OF  THE  Respiratory  Excursus. — These  conditions  are  commonly 
associated.  They  are  present  in  diseases  involving  the  parenchyma  of  the 
lungs,  such  as  croupous  and  bronchopneumonia,  large  infarcts,  congestion, 
and  the  like;  also  in  those  affections  in  which  the  capacity  of  the  thorax  is 
decreased,  as  pleural  and  pericardial  effusion,  pneumothorax,  tumors, 
massive  hypertrophy  of  the  heart,  and  kyphoscoliosis;  and  finally  when- 
ever the  movements  of  the  chest  are  hindered,  as  in  emphysema,  severe 


442  MEDICAL  DIAGNOSIS. 

chest-pain,  or  spasm  or  palsy  of  the  respiratory  muscles.  Under  these 
circumstances  the  tidal  air  is  diminished  and  the  number  of  respiratory 
acts  is  correspondingly  increased.  In  proportion  as  the  requirements  of  the 
organism  are  thus  satisfied  the  associated  symptoms, — subjective  dysp- 
noea and  cyanosis, — are  slight  or  absent.  Bodily  effort  increases  the  diffi- 
culty. The  deficiency  of  oxygen  asserts  itself  and  these  symptoms  become 
manifest  upon  moderate  exertion.  If  the  condition  be  unilateral,  as  in 
pleural  effusion,  vicarious  respiration  is  established. 

Dyspxcea  in  Circulatory  Derangements. — Valvular  lesions  cause 
dyspnoea  when  the  compensation  fails.  Myocardial  changes  act  in  the 
same  way.  There  is  a  transference  of  blood-pressure  from  the  arterial  to 
the  venous  side  of  the  circulation.  The  organs  receive  less  arterial  and 
retain  more  venous  blood  than  normal.  The  circulatory  derangement 
affects  the  respirator}"  centre,  with  the  result  that  the  breathing  is  increased 
both  in  frequency  and  depth.  Lesions  of  the  left  side  of  the  heart  cause 
overfilling  not  only  of  the  veins  of  the  general  circulation  but  also  of  those 
of  the  pulmonary  circuit.  The  overfilling  of  the  pulmonary  capillaries, 
which  ultimately  gives  rise  to  brown  induration,  is  an  additional  cause  of 
dyspnoDa,  not  so  much  because  of  the  space  occupied  bj^  the  blood  as  by 
reason  of  the  impairment  of  elasticity  in  the  congested  tissue  of  the  lung. 
The  alveolar  distention  remains  near  the  inspiration  point  and  the  respir- 
atory excursus  is  correspondingly  diminished.  The  loss  of  elasticity  acts 
as  a  direct  hindrance  to  breathing.  The  paroxysmal  attacks  of  dyspnoea 
in  such  cases  constitute  so-called  cardiac  asthma.  This  term  is  frequently 
used  to  describe  any  shortness  of  breath  occurring  in  disease  of  the  heart. 
It  is  preferable  to  restrict  it  to  the  attacks  which  bear  a  close  resemblance 
to  true  bronchial  asthma.  Such  attacks  often  come  on  at  night  after  the 
first  sleep.  In  both  conditions  the  form  of  dyspnoea  is  the  same.  There  is 
a  tendency  to  prolongation  of  the  respiratory  act  with  difficult  and  pro- 
longed expiration  attended  by  stridor.  To  the  habitual  overfilling  of  the 
pulmonary  capillaries  in  mitral  disease  must  be  ascribed  the  dyspnoea 
upon  exertion  which  is  so  common  in  this  condition  in  the  absence  of 
impaired  compensation.  A  further  cause  of  dyspnoea  in  circulatory  dis- 
turbances is  the  bronchial  catarrh  which  is  present  to  some  degree  in  most 
of  the  cases. 

Dyspncea  in  Obstruction  of  the  Upper  Air-passages. — The  stress 
upon  the  inspiratory  muscles  is  proportionate  to  the  degree  of  obstruction. 
The  respiration  tends  to  become  prolonged  and  deep.  In  many  cases,  how- 
ever, it  is  increased  in  frequency  and  correspondingly  superficial.  This  form 
of  dyspnoea  is  present  in  the  marked  stenosis  of  the  pharynx  which  occurs 
as  the  result  of  hypertrophy  of  the  tonsils  or  retropharyngeal  abscess,  in 
spasmodic  and  membranous  laryngitis,  in  oedema  or  spasm  of  the  glottis, 
in  paresis  of  the  abductor  muscles  of  the  larynx  (posterior  crico-arytenoids) 
and  in  narrowing  of  the  pharynx  and  trachea  by  tumors,  foreign  bodies,  and 
compression  from  outside,  as  in  the  case  of  aneurism  or  mediastinal  tumor. 

As  the  obstruction  reaches  a  high  grade  the  volume  of  air  in  the  lungs 
is  progressively  diminished  and  the  less  rigid  portions  of  the  thorax  yield 
to  the  pressure  of  the  external  atmosphere.  The  depressions  are  especially 
marked  in  the  epigastrium  and  the  suprasternal  and  postclavicular  regions. 


SYMPTOMS  AND  SIGNS:    RESPIRATORY  MOVEMENTS.     443 

In  young  chikh-en,  in  consequence  of  repeated  attacks  of  laryngitis  or 
bronchitis  the  cartilaginous  portions  of  the  wall  of  the  thorax  yield  and 
more  or  less  persistent  deformities  of  the  chest  arise.  Among  these  are  the 
wide,  shallow,  oblique  depressions  at  the  base  of  the  chest  known  as  Harri- 
son's furrows,  and  the  prominence  of  the  sternum,  known  as  chicken-breast. 

The  stridor  in  this  form  of  dyspnoea  is  characteristic.  It  is  commonly 
loud,  prolonged,  and  hissing  or  whistling  in  character  and  usually  much  more 
marked  upon  inspiration  than  upon  expiration, — a  fact  that  finds  explana- 
tion in  the  lateral  drawing  together  of  the  tissues  below  the  seat  of  obstruc- 
tion in  consequence  of  the  tendency  to  vacuum  caused  by  the  powerful 
inspiratory  effort  and  the  greater  force  of  the  inspiration  as  compared  with 
the  expiration.  In  fact  stridor  may  be  wholly  absent  during  the  expiration. 
When,  however,  patients  suffering  from  stenosis  of  the  upper  air-passages  in 
increasing  obstruction  become  obliged  to  use  the  abdominal  muscles  in 
active  expiration,  expiratory  stridor  becomes  marked  or  predominant. 

Dyspnoea  in  Bronchitis. — Dyspnoea  arises,  as  a  rule,  only  in  those 
cases  in  which  the  catarrhal  inflammation  involves  the  finer  tubes.  The 
lumen  is  narrowed  by  swelling  of  the  mucosa  and  the  presence  of  secretion 
or  exudate.  If  the  narrowing  involves  a  limited  number  of  bronchial 
tubes  the  difficulty  in  breathing  is  not  urgent  and  compensation  takes 
place  by  increase  in  the  respiration  frequency.  When  the  obstruction  in- 
volves a  great  number  of  bronchial  tubes  differences  in  type  of  the  dyspnoea 
arise  which  depend  upon  the  degree  of  obstruction.  In  so-called  capillary 
bronchitis  the  respiratory  surface  is  diminished  to  an  extent  correspond- 
ing with  the  number  and  distribution  of  the  lobules  involved;  dyspnoea 
with  hurried  respiration  then  results.  In  the  dry  bronchitis  of  the  middle- 
sized  tubes  it  is  yet  possible  for  a  sufficient  quantity  of  air  to  be  drawn 
into  the  lungs.  This  can  generally  be  accomplished  best  by  respiration  of 
diminished  frequency  and  abnormal  depth,  just  as  in  stenosis  of  the  larynx. 

Dyspnoea  in  Bronchial  Asthma. — The  breathing  is  slow,  the  ex- 
piration usually  prolonged  and  accompanied  with  stridor — expiratory 
dyspncea.  The  rales  can  be  heard  at  a  considerable  distance  from  the 
patient.  The  difficulty  is  not  to  get  the  air  into  the  lungs  but  to  get  it 
out.  Acute  emphysema  occurs  and  the  respiratory  excursus  is  greatly 
diminished;   hence  the  ''air  hunger." 

Dyspnoea  in  Emphysema. — The  chest  tends  to  assume  permanently 
the  inspiratory  form.  The  elasticity  of  the  lung  parenchyma  is  impaired. 
The  respiratory  excursus  is  correspondingly  diminished.  The  alveolar 
septa  are  in  many  places  destroyed,  together  with  the  intra-alveolar  blood- 
vessels. The  breathing  is  shallow  and  frequent.  The  patient  is  distressed 
for  breath,  especially  upon  the  slightest  exertion.  The  dyspnoea  is  increased 
by  the  bronchitis  which  is  so  common  in  emphysema.  Modifications  arise  in 
consequence  of  the  frequent  occurrence  of  bronchial  asthma  in  emphysema. 

So-called  Ur^emic  Dyspnoea. — This  form  may  occur  as  a  true  urse- 
mic  bronchial  asthma.  There  is  slowing  of  the  respiration  with  prolonged 
expiration  and  expiratory  stridor.  The  condition  is  not  common.  The 
dyspnoea  in  the  majority  of  the  cases  is  not  actually  uraemic  but  rather  a 
manifestation  of  cardiac  derangement,  bronchial  catarrh,  or  beginning 
pulmonary  oedema. 


444  MEDICAL  DIAGNOSIS. 

The  Dyspnoea  of  Fever. — Rise  of  temperature  is  usually  associated 
with  increase  in  respiration  frequency.  Artificial  elevation  of  temperature 
also  causes  hurried  breathing.  The  dyspnoea  is  doubtless  due  to  the  action 
of  heated  blood  upon  the  respiratory  centre.  As  it  bears  no  constant  rela- 
tion to  the  height  to  which  the  temperature  rises,  it  is  probably  due,  in 
part  at  least,  to  the  action  of  the  fever-producing  toxins.  Experience  has 
shown  that  febrile  diseases  in  which  the  respiration  frequenc}",  in  the 
absence  of  lung  complications,  is  very  high,  are  as  a  rule  of  serious  import. 

The  Dyspncea  of  An.^mia. — When  the  hsemogiobin  is  diminished, 
the  oxygen  requirement  of  the  organism  demands  the  most  complete  per-  ■ 
formance  of  the  respiratory  function.  There  is  no  hindrance  to  respiration 
and  the  breathing  is  quickened  and  increased  in  depth.  This  form  of 
dyspnoea  is  characteristic  of  high  grades  of  secondary  anaemia  such  as 
occur  in  hemorrhage,  in  advanced  pernicious  anaemia,  and  in  chlorosis, 
following  exertion.  It  is  a  symptom  of  internal  hemorrhage  and  occa- 
sionally of  hemorrhagic  pancreatitis. 

COUGH  AND  ALLIED  PHENOMENA. 

The  normal  rhj'thmical  expansions  and  contractions  of  the  thorax 
serve  the  physiological  purposes  of  respiration.  Certain  other  move- 
ments which  are  respiratory  in  character  serve  other  purposes.  Of  these 
some  are  voluntary,  others  involuntary,  some  purposeful,  others  spasmodic. 
Among  such  movements  are  the  following: 

Cough.— A  more  or  less  deep  inspiration  is  followed  by  an  expira- 
tory act  which  is  interrupted  bj'  repeated  partial  closure  of  the  glottis  and 
the  production  of  a  series  of  characteristic  sounds.  The  air  is  expelled 
through  the  narrowed  glottis  with  some  force  so  that  foreign  bodies,  such 
as  a  crumb,  mucus  in  the  respiratory  passages,  and  the  like,  are  swept  from 
the  upper  air-passages  into  the  mouth.  In  the  great  majority  of  cases 
cough,  whether  in  consequence  of  lesions  of  the  respiratory  organs  or  dis- 
ease or  irritation  in  distant  organs,  is  reflex  and  spasmodic.  It  may  be 
voluntarily  produced. 

Hawking  is  a  voluntary  act,  the  result  of  irritation  in  the  pharynx.  It 
resembles  cough  except  that  the  glottis  is  open  and  the  expiration  continuous. 

Sneezing  consists  in  a  deep  inspiration  followed  by  a  forcible  expira- 
tory^ blast  through  the  nose;  the  glottis  is  open  and  the  mouth  usually 
but  not  always  closed.  Sneezing  is  excited  by  irritation  of  the  terminal 
fibres  of  the  nasal  branches  of  the  fifth  pair  of  cranial  nerves  and  is  often 
preceded  by  peculiar  sensations  in  the  nose. 

Laughing  is  an  emotional  act  characterized  by  deep  inspiration  suc- 
ceeded by  repeatedly  interrupted  expiration  with  an  open  glottis  and 
vibrating  vocal  cords.  The  mouth  is  wide  open,  the  expiration  is  much  less 
forcible  than  in  coughing,  and  the  muscles  of  expression  give  a  character- 
istic appearance  to  the  face.  Laughing  may  be  voluntary  or  involuntary. 
When  very  violent  and  repeated  it  may  be  spasmodic  and  accompanied 
by  tears. 

■  Crying  closely  resembles  laughing.  It  cannot  in  fact  always  be  dis- 
tinguished from  laughing  and  the  one  may  readily  alternate  with  the  other 


SYMPTOMS  AND  SIGNS:   COUGH.  445 

in  young  children  or  patients  suffering  from  hysteria.     The  rhythm  and 
the  facies  are  different.    Crying  is  involuntary  and  accompanied  by  tears. 

Sobbing  follows  long  spells  of  crying  or  is  the  expression  of  deep 
grief.  It  is  characterized  by  interrupted  inspirations  with  a  partially 
closed  glottis,  followed  by  a  prolonged  quiet  expiration,  and  is  usually 
involuntary.  i 

Sighing  consists  in  a  prolonged  inspiration  attended  by  a  character- 
istic soft  sound.  The  mouth  is  closed  or  the  lips  but  slightly  parted;  it 
is  largely  voluntary. 

Yawning  consists  in  a  prolonged  deep  inspiration  through  the  widely 
opened  mouth  accompanied  by  a  peculiar  sound.  The  glottis  is  open  and 
the  expiration  short.  The  arms  are  thrown  out  and  the  shoulders  back. 
It  may  be  either  voluntary  or  involuntary  but  is  not  spasmodic. 

Snoring  occurs  during  sleep.  The  mouth  is  open  and  the  relaxed 
palate  is  thrown  into  vibration  by  the  in-  and  outflowing  air.  The  sound 
is  louder  during  inspiration.  It  is  much  more  liable  to  occur  when  the 
sleeper  is  on  his  back. 

Stertor  or  stertorous  breathing  resembles  snoring.  It  occurs  in 
apoplectic  and  other  comatose  states,  as  cerebral  concussion,  fracture  of 
the  skull,  epilepsy,  deep  anaesthesia,  alcoholic  stupor,  poisoning  by  opium, 
illuminating  gas,  and  other  narcotics,  pulmonary  cedema,  and  all  conditions 
in  which  excessive  amounts  of  mucus  or  fluid  are  accumulated  in  the 
bronchi,  and  frequently  in  the  death-agony.  Among  the  varieties  of  ster- 
tor are  buccal,  characterized  by  vibrations  of  the  lips  and  puffing  of  the 
relaxed  cheeks  during  expiration;  palatine,  in  which  the  soft  palate  vibrates 
with  the  in-going  and  out-going  air;  pharyngeal,  caused  by  the  sinking 
tack  of  the  base  of  the  relaxed  tongue  into  near  relation  with  the  posterior 
wall  of  thig  pharynx;  mucous,  the  coarse  snoring  sound  produced  by  the 
churning  of  the  respiratory  air  through  fluid,  such  as  mucus  or  blood  in  the 
trachea  or  larger  bronchial  tubes. 

Stridor  or  stridulous  breathing  is  that  noisy  form  of  breathing  caused 
by  obstruction  in  the  larynx  or  trachea.  This  symptom  may  be  present  in 
croup  and  diphtheria,  oedema  of  the  glottis,  laryngeal  tumors,  mediastinal 
new  growths,  and  aortic  aneurism.  Stridor  due  to  laryngeal  obstruction  is 
■commonly  accompanied  by  aphonia.  It  varies  greatly  in  character,  being 
harsh,  musical,  or  crowing. 

Hiccough  is  caused  by  a  sudden  spasmodic  contraction  of  the  dia- 
phragm accompanied  by  closure  of  the  glottis.  There  is  a  peculiar  abrupt 
sound  and  a  distressing  sensation  of  jerking  in  the  epigastrium.  It  is  due 
to  irritation  of  the  terminal  filaments  of  the  phrenic  nerve,  which  may  be 
direct  or  reflex.  It  may  occur  as  the  result  of  gastric  or  peritoneal  irrita- 
tion or  may  be  the  manifestation  of  a  derangement  of  the  nervous  system. 
Hiccough  is  occasionally  observed  after  excessive  or  injudicious  eating  or 
drinking,  in  gastric  disorders,  peritonitis,  the  so-called  typhoid  state,  and 
ursemia.  It  occurs  also  in  hysteria  and  may  constitute  a  pure  neurosis. 
The  hiccough  of  cerebral  disease,  as  hydrocephalus  or  meningitis,  is  doubt- 
less the  result  of  irritation  of  the  central  origin  of  the  phrenic  nerve.  The 
writer  knows  a  gentleman  in  whom  certain  kinds  of  tobacco  invariably 
produce  distressing  hiccough,  while  others  can  be  smoked  with  impunity. 


446  MEDICAL  DIAGNOSIS. 

Persistent  and  intractable  hiccough  occasionally  attends  the  closing  days  of 
fatal  illness  and  in  rare  instances,  occurring  as  a  neurosis,  has  caused  death 
by  exhaustion. 

Of  all  the  special  or  modified  respiratory  movements  cough  has  the 
most  important  bearing  upon  diagnosis  and  therefore  requires  more  ex- 
tended consideration. 

SIGNIFICANCE  OF  COUGH  IN  DIAGNOSIS. 

Etiological  Considerations. — Reflex  Cough. — Cough  in  the  vast  ma- 
jority of  instances  is  the  result  of  reflex  irritation  of  the  terminal  nerve  fila- 
ments of  the  vagus  distributed  to  the  respiratory  tract.  Irritation  of  the 
mucous  membrane  of  the  larynx  above  the  vocal  cords  does  not  produce 
cough  but  causes  gagging,  while  irritation  below  the  cords  gives  rise  to 
cough.  Especially  sensitive  areas  are  the  interarytenoid  space  and  the 
region  of  the  bifurcation,  while  the  general  mucous  membrane  of  the 
trachea  and  bronchi  shows  a  scarcely  inferior  irritability.  Lesions  of  the 
lung  parenchyma  probably  do  not  cause  cough,  though  they  are  usually 
connected  with  pathological  conditions  of  the  bronchi.  Pleural  irritation 
is  commonly  attended  by  this  symptom.  The  aspiration  of  a  pleural 
exudate  is  frequently  followed  by  prolonged  and  violent  cough. 

Irritation  of  the  nasal  mucosa,  which  is  supplied  with  sensory  nerve- 
twigs  from  the  trigeminus,  may  in  neurotic  individuals  produce  coughing 
with  lachrymation,  as  in  rose  cold,  haj^  fever,  and  similar  conditions.  In 
such  persons  the  slightest  touch  of  the  probe  in  the  sensitive  areas  may 
provoke  violent  attacks  of  coughing.  Less  common  is  cough  as  a  symp- 
tom of  hypertrophic,  atrophic,  or  vasomotor  rhinitis  or  of  polypi  or  devia- 
tions of  the  septum.  The  inhalation  of  dust  or  smoke,  irritating  chemical 
fumes,  as  those  of  ammonia,  bromine,  or  pungent  substances,  as  pepper, 
produces  cough  in  a  normal  respiratory  mucous  membrane.  Violent 
paroxysmal  cough  is  excited  by  the  insufflation  of  a  foreign  body,  as  a 
crumb  or  a  drop  of  liquid,  into  the  larynx  or  through  the  glottis.  The 
common  source  of  irritation  is  to  be  found  in  a  morbid  condition  of  the 
mucous  membrane  of  the  larynx,  trachea,  or  bronchi.  There  may  be 
merely  inflammation  and  hypersesthesia  with  altered  or  deficient  secretion; 
an  exudate  of  varying  consistence,  from  the  thin  fluid  of  bronchorrhoea  to 
the  tough  masses  of  tenacious  mucus  in  the  early  stages  of  acute  bron- 
chitis; or  the  solid  bronchial  casts  of  the  terminal  tubules  in  croupous 
pneumonia  or  fibrinous  bronchitis;  or,  finally,  the  material  in  the  bronchi 
may  be  derived  from  adjacent  structures  and  consist  of  blood,  as  in  broncho- 
pulmonary hemorrhage  or  an  aneurism,  or  pus  from  an  empyema,  a  sub- 
phrenic abscess,  or  an  abscess  of  the  liver. 

Cough  Occurs  as  a  Symptom  in  All  Forms  of  Respiratory  Catarrh. — 
In  acute  or  subacute  rhinitis  it  is  often  associated  with  sneezing;  in  laryn- 
gitis with  hoarseness  or  aphonia;  in  tracheitis  or  tracheobronchitis  with 
substernal  pain;  in  bronchitis  of  the  larger  tubes  with  tickling  sensations 
in  the  early  stages  and  a  mucopurulent  expectoration  later;  in  bronchitis 
of  the  smaller  tubes  with  dyspnoea  and  a  tendency  to  cyanosis;  in  pneu- 
monia with  fever  and  other  indications  of  acute  illness;   in  pleurisy  with  a 


SYMPTOMS  AND  SIGNS:   COUGH  IN  DIAGNOSIS.  447 

stitch  in  the  side.  Cough  is  a  prominent  symptom  in  bronchiectasis  and 
in  all  diseases,  both  acute  and  chronic,  in  which  the  respiratory  mucous 
membrane  is  primarily  in  a  morbid  condition  or  is  irritated  b}'  the  presence 
of  exudates  or  discharges  from  the  alveolar  tissues  or  other  sources.  The 
irritation  is  always  mechanical,  often  also  chemical.  Cough  is  therefore  a 
constant  and  suggestive  symptom  in  pulmonary  tuberculosis  in  all  its 
forms  and  at  all  stages  of  its  progress.  Cough  is  at  once  the  reflex  response 
to  the  irritation  and  the  effort  to  remove  the  cause  of  the  irritation,  and 
ceases  when  the  effort  is  successful.  The  offending  substance  ejected  is 
known  as  expectoration,  phlegm,  or  sputum,  or,  in  the  plural,  sputa. 

Exceptionally  there  are  cases  in  which,  with  the  most  pronounced 
symptoms  and  signs  of  disease  of  the  lungs,  cough  is  wholly  absent.  This 
may  occur  in  the  low  fevers,  the  pneumonia  of  drunkards,  the  cachectic, 
or  the  aged,  in  cerebral  disease,  and  shortly  before  death.  The  reflexes  are 
obtunded  and  bronchial  secretion  or  an  exudate,  the  presence  of  which  is 
manifested  by  rales,  fails  to  excite  cough.  The  sudden  cessation  of  cough 
in  grave  cases  of  pneumonia  or  advanced  phthisis  is  an  ominous  sign. 
Cough  is  sometimes  absent  because  the  bronchial  secretion  is  swept  on- 
ward by  the  ciliated  epithelium  to  the  larynx  and  removed  by  hawking. 
If  it  is  then  swallowed,  as  is  a  frequent  occurrence,  not  only  is  cough  absent 
but  also  expectoration. 

Much  less  common  is  cough  due  to  extrarespiratory  irritation.  The 
sufferers  are  usually  neuropathic. 

Pharyngeal  Cough. — Tickling  of  the  wall  of  the  pharynx  or  the  base  of 
the  tongue,  which  in  most  persons  is  resented  by  gagging,  in  some  is  fol- 
lowed by  cough.  Lymphoid  growths  in  the  nasopharynx  and  collections 
of  thick  mucus,  or  the  presence  of  inflammatory  exudates,  may  be  the 
cause  of  cough.  Elongation  of  the  uvula  and  paresis  of  the  palate  may 
excite  cough  by  producing  irritation  of  the  posterior  wall  of  the  pharynx, 
especially  during  recumbency. 

Ear  Cough. — Not  infrequently  paroxysmal  cough  is  produced  by  the 
presence  of  a  foreign  body  in  the  external  auditory  meatus  or  by  disease 
of  that  passage.  The  mere  introduction  of  the  speculum  may  cause  cough 
so  violent  as  to  make  the  examination  most  difficult.  The  afferent  nerve 
is  the  auricular  branch  of  the  pneumogastric  or.  according  to  others,  the 
auriculotemporal  branch  of  the  fifth  nerve. 

Stomach  Cough. — The  popular  explanation  of  certain  forms  of  cough 
as  a  manifestation  of  disorders  of  the  stomach  is  sustained  neither  b}^ 
pathological  nor  experimental  investigation.  The  morning  cough  of  the 
drunkard  is  to  be  accounted  for  by  the  pharyngeal  catarrh  which  accom- 
panies chronic  alcoholic  gastritis;  of  the  consumptive,  by  lesions  of  the 
lungs  or  larynx,  with  which  secondary  gastric  disorders  are  commonly 
associated.  The  cough  occasionally  observed  in  subacute  catarrhal  gas- 
tritis and  which  disappears  as  the  gastritis  improves  is  due  to  the  asso- 
ciated pharyngitis.  Bronchitis  is  very  common  in  chronic  alcoholism  and 
other  forms  of  ill  health  with  derangement  of  the  gastro-intestinal  tract, 
and  a  careful  investigation  of  the  cases  of  so-called  stomach  cough  will 
almost  always  demonstrate,  with  the  gastric  condition,  associated  lesions 
of  the  respiratory  tract  which  account  for  this  symptom. 


448  MEDICAL  DIAGNOSIS. 

Liver  Cough. — This  symptom  is  doubtless  due  to  irritation  of  the 
•diaphragmatic  pleura.  It  is  met  with  in  certain  cases  of  hypertrophy  of  the 
liver,  perihepatitis,  hydatids,  and  hepatic  and  subphrenic  abscess. 

Disease  or  enlargement  of  the  spleen  may  also  in  rare  cases  be  the 
cause  of  cough. 

Cough  may  exceptionally  be  provoked  by  pressure  in  the  region  of  the 
liver  or  spleen. 

For  some  years  the  writer  had  under  observation  a  case  of  ventral 
hernia  midway  between  the  tip  of  the  ensiform  cartilage  and  the  umbilicus 
in  the  median  line,  in  which  violent  paroxysmal  cough  attended  the  pres- 
ence of  the  tumor  and  immediately  subsided  upon  its  reduction. 

Dentition. — Cough  is  not  uncommon  during  the  first  dentition,  with- 
out manifestations  of  disease  of  the  respiratory  tract.  It  appears  before 
the  eruption  of  the  successive  groups  of  teeth  and  disappears  with  the 
completion  of  the  process. 

Mediastinal  Cough. — Mediastinal  tumor  or  abscess,  thoracic  aneurism, 
enlarged  bronchial  glands,  and  caries  of  the  dorsal  vertebrae  are  occasional 
causes  of  persistent  and  troublesome  cough.  Massive  hypertrophy  or  great 
dilatation  of  the  heart  is  also  in  some  instances  accompanied  by  cough. 

Nervous  Cough. — The  diagnosis  of  nervous  cough  is  only  to  be  made 
when,  in  default  of  direct  signs  or  symptoms  or  by  exclusion,  the  absence 
of  disease  of  the  respiratory  organs  or  other  lesions  recognized  as  the  cause 
of  this  symptom  can  be  established.  Not  rarely  cough  is  the  only  direct 
manifestation  of  a  bronchitis  or  pulmonary  tuberculous  process  in  which, 
for  the  time  being,  the  ordinary  physical  signs  are  lacking.  It  often  hap- 
pens that  the  diagnosis  of  nervous  cough  is  made  when  the  intensity  and 
persistence  of  the  cough  is  altogether  out  of  proportion  to  its  actual  physical 
■cause,  as  is  common  in  neurotic  individuals.  Nevertheless  in  some  cases 
cough  must  be  recognized  as  a  purely  nervous  phenomenon.  There  are 
persons  who  cough  whenever  their  feet  are  chilled  or  a  cold  air  blows 
upon  an  exposed  part  of  the  body.  Paroxysmal  cough  of  purely  nervous 
nature  is  not  uncommon  in  both  sexes  at  puberty.  Cough  is  one 
of  the  multitudinous  sym.ptoms  of  hysteria.  Under  certain  conditions 
cough  may  occur  in  neurotic  individuals  in  consequence  of  disease  or  irri- 
tation of  the  mammae  or  of  the  genital  organs  in  either  sex.  It  has  been 
shown  that  cough  may  be  excited  by  irritation  of  the  floor  of  the  fourth 
ventricle  above  the  centre  for  respiration.  Whether,  under  pathological 
conditions,  a  true  "centric  cough"  occurs  is  open  to  question.  Irritation 
of  a  ''cough  centre"  has  been  invoked  to  explain  hysterical  and  other 
coughs  of  purely  nervous  origin. 

Clinical  Varieties  of  Cough. — The  character  of  the  cough  is  of  impor- 
tance in  diagnosis.  It  is  modified  according  to  the  seat  of  the  irritation, 
whether  respiratory  or  extrarespiratory;  by  the  anatomical  structure 
involved,  as  the  larynx,  bronchi,  pleura;  by  the  amount  and  consistence 
■of  the  irritating  substance;  and  by  the  constitutional  peculiarities  of  the 
patient.    The  following  forms  demand  especial  consideration: 

Dry  Cough. — Patients  themselves  recognize  the  distinction  between 
dry  and  moist  cough.  Cough  due  to  irritation  of  the  respiratory  mucous 
membrane  is  dry  when  it  occurs  in  the  absence  of  secretion  or  if  the  secre- 


SYMPTOMS  AND  SIGNS:   COUGH  IN  DIAGNOSIS.  449 

tion  is  tough,  tenacious,  and  not  readily  dislodged.  Extrarespiratory 
cough — so-called  "  reflex  cough" — is  dry.  The  sound  is  hacking,  barking,  or 
ringing  and  is  not  accompanied  by  expectoration.  Dry  cough  is  frequently 
spoken  of  as  "unproductive."  It  occurs  in  the  early  stage  of  acute  bron- 
chitis, broncliial  asthma,  influenza,  pneumonia,  and  pleurisy,  in  affections 
of  the  upper  air-passages,  phthisis,  and  pertussis.  This  is  the  cough  which 
is  excited  by  the  inhalation  of  foreign  bodies,  irritating  fumes,  or  dust,  and 
by  extrarespiratory  causes.  It  results  from  pleural  irritation  and  is 
encountered  in  pleurisy  with  fibrinous  exudate  and  upon  the  withdrawal 
of  an  effusion. 

Loose  or  Moist  Cough. — This  cough  is  associated  with  sounds  indi- 
cating the  part  played  by  fluid  in  the  mechanism  of  its  production.  It 
differs  from  dry  cough  not  only  in  its  acoustic  characters  but  also  in  the 
occurrence  of  expectoration.  It  is  "productive."  Loose  cough  occurs  in 
the  later  stages  of  acute  bronchitis,  influenza,  and  pneumonia;  toward  the 
close  of  the  paroxysms  of  whooping-cough  and  asthma;  in  chronic  bron- 
chitis, bronchiectasis,  and  pulmonary  gangrene;  in  advanced  phthisis; 
and  in  all  conditions  attended  by  moderate  or  abundant  bronchial  secretion. 

Constant  and  Recurrent  Cough. — Adjectives  such  as  constant,  per- 
sistent, recurrent,  designate  peculiarities  of  the  cough  dependent  upon 
the  persistence  or  recurrence  of  its  cause.  So-called  nervous  cough  is 
usually  persistent;  also  the  cough  which  attends  diseases  of  the  upper  air- 
passages  and  acute  bronchitis  and  that  of  bronchorrhoea.  On  the  other 
hand,  in  chronic  bronchitis,  especially  when  there  is  bronchial  dilatation, 
the  cough  is  apt  to  occur  paroxysmaliy  at  varying  intervals.  The  expec- 
toration of  a  large  amount  of  matter  is  followed  by  relief.  After  a  time 
the  secretion  reaccumulates,  a  mere  overflow  into  the  bronchi  on  change 
of  posture  excites  cough,  and  the  process  is  repeated.  This  form  of  cough 
attends  the  later  stages  of  phthisis  with  large  vomicae  and  occurs  in  some 
cases  of  empyema  with  bronchopulmonary  fistula.  Recurrent  cough  is 
very  common  in  chronic  bronchitis  and  phthisis;  it  constitutes  the  "morn- 
ing cough"  of  these  conditions.  The  secretion  accumulates  slowly  during 
sleep  without  exciting  irritation.  On  waking,  the  patient  moves,  the 
accumulated  material  shifts  its  position  a  little,  the  bronchial  reflex  is 
brought  into  play,  cough  results  and  continues  until  the  offending  mass  is 
expelled. 

Paroxysmal  Cough. — Recurrent  cough  is  not  necessarily  paroxysmal, 
and  paroxysmal  cough  for  the  time  may  be  constant.  The  word  paroxj^sm 
conveys  the  idea  of  suddenness  and  intensity.  Such  is  the  cough  of  acute 
inflammatory  conditions;  that  caused  by  foreign  bodies  in  the  air-passages, 
the  insufflation  of  saliva,  and  the  like;  by  the  periodical  flooding  of  the 
bronchi  with  the  abundant  contents  of  the  cavities  in  phthisis,  bronchial 
dilatation,  pulmonary  abscess,  or  gangrene;  and  finally  that  of  pertussis. 
The  paroxysm  recurs  at  intervals  varying  from  an  hour  or  less  to  once  a 
day  or  longer.  In  the  case  of  cavities  or  a  bronchial  fistula  in  empyema 
the  interval  is  determined  by  the  accumulation;  in  pertussis  by  the  inten- 
sity of  the  neurosis.  In  the  latter  condition  the  cough  is  characteristic. 
Into  its  production  two  factors  enter:  an  abundant  tenacious  mucus  and 
a  pathological  nervous  excitabihty.  After  a  long  inspiration,  the  expira- 
29 


450  MEDICAL  DIAGNOSIS. 

tory  cough-efforts  succeed  each  other  with  such  rapidity  that  inspiration 
is  partial  or  absent  until  at  last  a  prolonged  inspiration  takes  place  which, 
by  reason  of  the  spasmodic  contraction  of  the  glottis,  is  attended  by  a 
harsh,  crowing  sound  or  whoop;  hence  the  common  term  whooping-cough. 
A  somewhat  similar  inspiratory  whoop  sometimes  attends  the  paroxysmal 
cough  of  other  diseases,  but  so  infrequently  that  in  the  vast  majority  of 
cases  the  phenomenon  justifies  the  diagnosis  of  whooping-cough.  The 
differential  diagnosis  involves  consideration  of  the  age  of  the  patient,  the 
presence  or  absence  of  an  epidemic,  history  of  exposure,  the  duration  and 
course  of  the  attack,  and  the  presence  or  absence  of  lesions  capable  of 
causing  violent  paroxysmal  cough  other  than  that  of  pertussis.  The  cough 
which  attends  enlargement  of  the  bronchial  glands,  mediastinal  tumor, 
caries  of  the  dorsal  vertebrae,  enlargement  of  the  heart,  and  pericardial 
effusion  is  paroxysmal  and  dry.  Quite  often  it  has  the  laryngeal  character. 
Very  violent  paroxysms  of  cough  frequently  result  in  retching  and  vomit- 
ing and,  as  a  result  of  the  venous  congestion  from  intrathoracic  pressure,, 
in  hemorrhage  from  mucous  surfaces  or  into  the  skin. 

Croupy  Cough. — A  dry  cough,  described  as  metallic,  ringing,  or  croupy^ 
is  characteristic  of  laryngeal  irritation.  The  voice  is  usually  hoarse  or 
aphonic,  though  it  may  be  unimpaired.  The  laryngeal  cough  occurs  in 
simple  or  exudative  laryngitis,  spasm  of  the  larynx,  from  the  inhalation  of 
smoke  or  dust,  as  the  result  of  the  irritation  produced  by  foreign  bodies 
in  the  larynx,  and  in  tuberculous,  syphilitic,  or  cancerous  ulceration. 
The  cough  of  hysteria  is  usually  laryngeal  in  character,  though  upon  laryn- 
goscopical  examination  neither  swelling  nor  paralysis  may  be  present. 
It  is  described  by  such  adjectives  as  barking  or  croaking  and  resembles 
other  hysterical  manifestations  by  the  readiness  with  which  it  may  be 
voluntarily  produced.  A  barking  laryngeal  cough,  in  the  absence  of  swell- 
ing of  the  laryngeal  mucosa  or  paralysis  of  the  vocal  cords  or  of  lesions 
directly  or  indirectly  involving  the  recurrent  laryngeal  nerves,  is  commonly 
hysterical. 

Suppressed  Cough.  —  Voluntary  efforts  to  suppress  cough  are  made 
under  circumstances  in  which  the  sound  of  the  cough  is  likely  to  annoy 
others  and  when  the  act  is  attended  by  pain,  as  in  pleurisy,  acute  perito- 
nitis, and  some  forms  of  acute  bronchitis.  The  suppressed  cough  is  usually 
lacldng  in  tone,  and  is  explosive  and  persistent. 

Undeveloped  Cough. — Incomplete  efforts  at  cough,  unattended  by 
the  characteristic  sound,  are  observed  in  cases  of  destructive  ulceration 
or  paralysis  of  the  vocal  cords  or  of  partial  paralysis  of  the  expiratory 
muscles.  This  form  of  cough  is  encountered  in  laryngeal  phthisis,  in  pa- 
tients suffering  from  bulbar  paralysis,  in  enormous  ascites  or  abdominal 
tumors,  and  in  conditions  attended  with  extreme  debility,  especially  the 
later  stages  of  croupous  and  bronchopneumonia,  chronic  bronchitis, 
pulmonary  oedema,  and  consumption. 

In  the  majority  of  instances  the  diagnostic  significance  of  the  symp- 
tom cough  is  direct  and  obvious.  It  is  the  indication  of  disease  affecting 
the  respiratory  organs,  manifested  more  or  less  fully  by  concurrent  signs 
and  symptoms;  in  a  far  smaller  proportion  of  cases  its  significance  is 
remote  and  obscure  and  only  to  be  learned  by  close  and  systematic  study 


SYMPTOMS  AND  SIGNS:    EXPECTORATION.  451 

of  the  various  organs  or  parts  to  derangements  of  which  it  may  be  clue. 
Important  among  these  derangements  are  diseases  of  the  intrathoracic 
circulatory  organs,  mediastinum,  ears,  teeth,  and  nose,  some  nervous  affec- 
tions, and  the  neurotic  constitution.  To  this  list  must  be  added  malinger- 
ing, since  cough  may  be  a  voluntary  act. 

THE  EXPECTORATION  OR  SPUTUM. 

These  terms  are  applied  to  material  voided  by  coughing  or  hacking. 
The  expectorated  substance  is  usually  a  secretion  or  exudate  derived  from 
the  mucous  membrane  of  the  nose,  pharynx,  larynx,  or  bronchial  tubes,  or 
from  the  alveoli.  It  may  consist  of  pus,  which  finds  its  way  into  the  air- 
passages  from  an  abscess  or  an  empyema,  or  of  blood  from  the  pulmonary 
vessels  or  an  aneurism.  With  these  substances  are  frequently  admixtures 
of  food,  drink,  and  the  secretions  of  the  mouth.  Macroscopic  and  micro- 
scopic foreign  bodies  which  have  found  their  way  into  the  respiratory 
passages  are  usually  voided  in  the  sputa. 

Any  of  these  substances  may  be  present  and  not  expectorated.  In- 
fants and  young  children  almost  always  swallow  the  sputa  and  older 
persons  frequently  do  so  as  a  habit  or  from  inability  to  expectorate  or  in 
abnormal  mental  states. 

The  naked-eye  examination  of  the  expectorated  matter  is  frequently 
of  great  use  in  diagnosis;  the  microscopic  examination  is  often  essential. 
For  the  ordinary  bed-side  examination  a  considerable  quantity  of  the 
sputum  should   be  collected,  preferably  in  a   transparent   glass   spit-cup. 

The  quantity  of  the  sputum  varies  according  to  the  nature  of  the  path- 
ological process.  Persistent  and  distressing  cough  may  yield  only  an 
occasional  small  tough  mass  of  tenacious  material,  as  in  dry  bronchitis  or 
beginning  phthisis.  In  other  patients  an  occasional  spell  of  coughing 
may  bring  up  enormous  quantities  of  material,  as  in  some  forms  of  chronic 
bronchitis,  bronchiectasis,  advanced  phthisis,  pulmonary  oedema,  and 
haemoptysis.  The  amount  of  pus  expectorated  in  empyema  with  broncho- 
pulmonary fistula  may  exceed  1000  c.c.  in  twenty-four  hours. 

The  consistence  bears  some  relation  to  the  amount.  An  abundant 
expectoration  is  usually  more  fluid  than  a  scanty  one.  Sputum  composed 
of  blood,  pus,  or  a  serous  fluid  is  always  thin;  that  consisting  of  mucus  or 
mucopus  usually  thick  and  frequently  tough  and  tenacious. 

The  reaction  of  fresh  sputum  is  commonly  alkaline.  After  standing 
for  some  hours  in  the  cup,  the  sputum  yields  an  acid  reaction — a  change 
due  to  decomposition  processes  caused  by  bacteria. 

The  color  and  translucency  vary  with  the  nature  of  the  disease. 
Mucous  expectoration  may  be  transparent  and  thin,  resembling  saliva  in 
consistency,  or  much  thicker  and  still  transparent.  In  proportion  as 
cellular  elements  are  present  the  sputum  becomes  thick  and  opaque, 
assuming  the  yellowish  or  greenish-yellow  hue  of  pus.  The  gradations  are 
expressed  by  the  terms  mucous,  mucoid,  mucopurulent,  and  purulent  ex- 
pectoration. Serous  expectoration  is  usually  clear  and  transparent,  some- 
times slightly  tinged  with  blood.  It  is  thin,  frothy,  and  abundant,  and 
occurs  in  oedema  of  the  lungs  and  in  the  rare  cases  of  perforation  of  a 


452  MEDICAL  DIAGNOSIS. 

serous  pleural  exudate.  The  albuminous  expectoration  which  exception- 
ally follows  the  aspiration  of  a  pleural  exudate  is  also  thin,  colorless,  and 
abundant.  The  color  is  red  when  the  sputum  is  admixed  with  blood. 
The  proportion  varies  from  pure  blood  to  a  mere  trace  sufficient  to  impart 
a  faint  pink  tinge.  Hemorrhagic  sputum  occurs  in  traumatism  of  the 
lungs,  in  the  blood-spitting  of  tuberculosis,  in  pulmonary  infarct,  and  in 
croupous  pneumonia.  It  is  also  present  in  cases  of  gangrene  of  the  lung, 
tumor  of  the  lung,  and  intense  pulmonarj'  congestion.  The  "rusty 
sputum''  of  pneumonia  owes  its  varying  shades  of  color  to  derivatives  of 
the  blood-coloring  matter.  In  rare  instances  the  sputum  of  pneumonia 
is  lemon-yellow  or  grass-green.  These  variations  suggest  the  changes  in 
color  that  take  place  in  the  subcutaneous  blood  extravasations  following 
a  bruise.  In  the  adynamic  and  septic  forms  of  croupous  pneumonia  and, 
more  rarely,  in  gangrene  of  the  lungs  the  expectoration  is  fluid  and  dark 
colored.  This  form  of  sputum  is  described  as  "prune-juice"  expectoration. 
The  sputum  in  malignant  disease  of  the  lungs  is  often  viscid,  tenacious, 
and  of  a  bright  red  color.  This  is  the  "currant-jelly"'  sputum  of  authors. 
A  stiU  more  objectionable  term  is  "anchovy-sauce"  sputum — a  term 
applied  to  brownish-red  sputum  such  as  is  seen  in  rupture  of  a  liver  abscess 
through  the  lungs,  the  peculiar  appearance  of  which  is  due  to  the  mixture 
of  altered  blood,  pus,  and  bile. 

Blood-streaked  sputum  may  occur  in  the  following  conditions: 
violent  cough,  acute  bronchitis,  or  disease  of  the  mitral  valves.  It  may 
result  from  the  admixture  of  blood  from  the  mouth,  as  in  the  case  of 
scurvy  and  other  forms  of  inflammation  of  the  gums  with  bleeding,  or 
of  ulceration  of  the  tonsils  or  pharj^nx,  or  from  the  oozing  of  blood  from 
an  aortic  aneurism  into  a  bronchus.  It  occurs  also  in  acute  broncho- 
pneumonia and  plastic  bronchitis.  It  is  very  often  observed  a  day  or  two 
after  an  attack  of  haemoptysis.  Under  these  circumstances  the  streaks  or 
masses  of  blood  are  clotted  and  dark.  Blood-streaked  sputum  is  not 
uncommon  during  the  course  of  pulmonary  phthisis. 

Yellow^  or  green  sputa  can  only  be  regarded  as  deriving  their 
color  from  altered  bile  pigment  when  icterus  or  at  least  yellowness  of  the 
conjunctiva  and  biliary  pigment  in  the  urine  are  actually  present.  Icteric 
sputum  may  occiu'  not  only  in  pneumonia  complicated  with  jaundice  but 
also  in  any  form  of  lung  disease  in  a  patient  suffering  from  jaundice.  A 
peculiar  brownish  tint  is  sometimes  seen  in  the  sputum  in  cases  of  chronic 
valvular  disease.  It  is  due  to  the  presence  of  amorphous  pigment  in  the 
epithelial  cells.  The  brownish  sputum  sometimes  seen  in  pulmonar}'  abscess 
and  other  destructive  processes  involving  the  lung  owes  its  color  to  the 
presence  of  hsematoidin  crystals,  which  are  also  the  source  of  the  coloring 
matter  in  the  ochre-yellow  purulent  sputum  of  liver  abscess  with  perfor- 
ation into  the  lung.  Greenish  sputum  is  sometimes  encountered  in  sarcoma 
of  the  lungs  and  very  rarely  in  carcinoma.  Remarkable  coloration  follows 
the  habitual  inhalation  of  certain  dust-particles.  Black  sputum  is  common 
in  those  who  breathe  an  atmosphere  laden  with  coal-dust  or  soot.  The 
pigment  particles  are  only  to  a  Hmited  extent  free  in  the  sputum;  much 
more  commonly  they  are  enclosed  in  round  or  oval  cells  which  are  in  part 
epithelial,  in  part  leucoc}i;es. 


SYMPTOMS  AND  SIGNS:   EXPECTORATION.  453 

The  color  of  the  sputum  varies  in  different  forms  of  pneumonoconiosis. 
In  anthracosis  it  is  often  of  an  intense  black;  in  the  siderosis  of  mirror 
polishers  it  may  be  ochre-red;  workers  in  lapis  lazuli  may  have  a  blue 
sputum,  and  so  on.  The  dust  particles  which  are  expectorated  are  those 
recently  inhaled  which  have  not  yet  penetrated  to  the  lung  parenchyma, 
as  is  shown  by  the  fact  that  the  color  disappears  from  the  sputum  in  the 
course  of  a  short  time  after  the  workman  has  abandoned  his  occupation. 
If  however  the  color  persists  or  returns  after  a  time,  it  is  the  sign  of  a 
destructive  process,  usually  tuberculous.  Various  colors  may  be  imparted 
to  the  sputum  by  articles  of  food  or  drink,  as  milk,  wine,  coffee,  or  medi- 
cines. Finally  after  the  sputum  has  been  ejected  it  may  undergo  color 
changes  in  consequence  of  the  growth  of  chromatogenous  bacteria  and 
thus  become  blue,  green,  yellow,  or  red.  The  Bacillus  pyocyaneus  may 
be  the  cause  of  a  blue  discoloration  of  the  sputum. 

Air. — Air  in  the  sputum  is  shown  by  the  presence  of  minute  bubbles. 
The  quantity  depends  upon  circumstances.  It  is  greater  in  sputum  from 
the  finer  than  in  that  from  the  larger  tubes,  in  sputum  of  thin  than  in  that 
of  thick  and  tenacious  consistency,  and  in  the  sputum  which  is  largely 
composed  of  mucus  than  in  that  which  is  chiefly  pus.  A  little  water  in 
the  spit-cup  enables  us  to  estimate  the  relative  amount  of  air,  as  it  affects 
the  specific  gravity;  sputa  which  float  contain  air;  those  which  sink  do  not. 
The  sputa  of  phthisis  and  bronchitis  often  present  the  appearance  of  flat 
circular  or  coin-shaped  masses — the  so-called  "nummular  sputa" — or  the 
masses  may  be  globular;  they  are  commonly  grayish-white  and  sink  in  water; 
sometimes  they  are  buoyed  up  by  the  small  bubbles  of  air  which  they  contain. 

Stratification, — Layer  formation  takes  place  in  the  collected  sputa 
of  chronic  bronchitis  with  abundant  expectoration — bronchorrhoea — of 
bronchiectasis,  putrid  bronchitis,  and  gangrene  of  the  lungs.  The  material 
is  of  thin  consistence  and  abundant.  As  a  rule  it  collects  in  three  well- 
defined  layers  which  can  be  studied  by  the  use  of  a  glass  spit-cup.  The 
upper  stratum  contains  air  and  is  often  frothy,  the  middle  is  fluid  and 
consists  of  mucus  or  pus-serum,  and  the  lower  is  sedimentary  and  made  up 
of  pus  corpuscles,  m.olecular  lung  detritus,  and  shreds  of  necrotic  tissue. 

Odor. — The  odor  of  fresh  sputum  has,  under  ordinary  circumstances, 
nothing  characteristic.  Speedy  decomposition  renders  it  offensive.  The 
sputum  of  putrid  bronchitis,  bronchiectasis,  gangrene  of  the  lung,  and 
perforating  empyema  is  always  heavy  and  fetid;  frequently  horribly, 
offensive.  In  abscess  of  the  lung  and  in  many  cases  of  advanced  phthisis 
also  it  is  offensive.  The  foulness  is  imparted  to  the  expired  air,  which 
not  infrequently  is  even  more  obnoxious  than  the  sputum.  It  is  probable 
that  in  the  cases  of  pulmonary  consumption  in  which  the  sputum  and 
breath  are  foul  there  is  already  cavity  formation,  though  too  small  in  some 
instances  to  be  recognized  by  the  methods  of  physical  diagnosis,  in  which 
the  secretion  collects  and  undergoes  decomposition.  Very  often  the  odor  is 
imparted  to  the  breath  by  offensive  material  in  the  crypts  of  the  tonsils  or 
by  decaying  teeth  or  other  necrotic  material  in  the  mouth — a  fact  that 
cannot  in  all  cases  be  established  by  the  use  of  deodorizing  mouth  washes, 
since  they  act  only  upon  the  surfaces  with  which  they  come  in  contact 
and  cannot  reach  deeply-seated  tissues  from  which  the  odor  may  proceed. 


454  MEDICAL  DIAGNOSIS. 

Other  Macroscopical  Characters  of  the  Sputum.  —  Very  often  the 
expectorated  material  presents  a  homogeneous  appearance,  as  is  the  case 
with  mucus,  pus,  blood,  etc.  Occasionally,  on  the  other  hand,  the  matter 
expectorated  at  different  times  varies  in  appearance  and  not  infrequently 
a  single  mass  consists  partly  of  mucus  and  partly  of  pus,  or  of  these  sub- 
stances with  masses  of  blood.  The  purulent  expectoration  of  an  empyema 
or  a  pulmonary  abscess  is  sometimes  flaky  or  thready,  best  shown  when 
the  sputum  is  suspended  in  water.  The  naked-eye  characters  of  the  sputum 
may  be  conveniently  studied  by  pouring  a  small  quantity  upon  a  plate  or 
slab  of  wliich  half  is  black,  the  other  half  white,  or  placing  a  specimen 
between  two  glass  plates  and  examining  it  over  a  white  and  black  back- 
ground alternately.  A  hand  lens  may  be  used  and  particular  objects 
removed  for  microscopical  examination.  Minute,  dirty  gray  masses  of 
necrotic  lung  tissue  containing  elastic  fibres  may  be  detected  in  the  spec- 
imen in  gangrene  and  abscess  of  the  lung  and  in  the  later  stages  of  phthisis; 
fragments  of  necrotic  cartilage  in  destructive  processes  involving  the 
bronchi,  the  trachea,  or  the  larynx,  and  in  rare  cases  shreds  of  tissue  from 
tumors  of  the  bronchi  or  lungs.  Minute,  dirty  white  or  yellowish  masses, 
in  some  instances  constituting  casts  of  the  smaller  bronchial  tubes,  are 
seen  in  fetid  bronchitis  and  gangrene  of  the  lungs.  These  masses  consist 
of  aggregations  of  bacteria  and  crystals  of  the  fatty  acids.  They  have  an 
intensel}^  disagreeable  odor.  Similar  masses  may  be  expectorated  in  lacu- 
nar tonsillitis  and  are  sometimes  present  in  the  crypts  of  the  tonsils  in 
the  absence  of  inflammation.  Curschmann's  spirals  are  visible  to  the  naked 
eye  and  may  be  studied  with  the  lens.  They  consist  of  twisted  masses 
which  may  reach  1  or  even  2  cm.  in  length  and  have  a  diameter  of  about  1 
mm.  These  masses  are  made  up  of  a  highly  refractive  central  undulating 
core  or  thread  around  which  are  coiled  spiral  filaments  which  are  sometimes 
branching.  The  central  core  was  at  one  time  thought  to  be  fibrinous,  but 
has  more  recently  been  shown  to  consist  of  a  substance  analogous  to  mucin. 
These  spirals  are  formed  in  the  finest  bronchial  tubes  as  the  product  of  an 
exudative  bronchiolitis,  and  as  this  pathological  process  is  frequently 
associated  with  bronchial  asthma  the  spirals  are  very  often  found  in  that 
disease  and  in  well-marked  cases  are  sometimes  present  in  great  numbers. 
The  association,  however,  is  by  no  means  constant;  cases  of  asthma  are 
occasionally  encountered  in  which  no  spirals  can  be  found  in  the  sputum, 
and  the  spirals  are  sometimes  present  in  the  expectoration  of  cases  of 
bronchitis  unattended  by  asthmatic  symptoms.  Curschmann's  spirals 
occasionally  appear  also  in  the  sputum  of  croupous  pneumonia  and  are 
then  seen  to  be  in  strong  contrast  with  the  fibrinous  casts  of  the  bronchioles 
which  occur  in  that  disease.  They  have  also  been  encountered  in  the 
sputum  of  pulmonary  phthisis.  Microscopically,  leucocytes,  notably 
eosinophiles,  epithelial  cells,  and  Charcot-Leyden  crystals  are  found  en- 
tangled in  the  spirals. 

Fibrinous  coagula,  recognizable  by  their  white  or  grayish-white  color, 
tough  consistence,  and  characteristic  form,  are  found  in  the  sputum  under 
varying  pathological  conditions.  They  are  usually  coughed  up  in  masses 
surrounded  with  mucus  and,  when  of  great  size,  with  difficulty.  In  diph- 
theria fibrinous  pseudomembrane   is  expectorated,  sometimes   in   irregu- 


SYMPTOMS  AND  SIGNS:    EXPECTORATION.  455 

lar  masses,  sometimes  as  a  fibrinous  mould,  more  or  less  incomplete,  of  the 
larynx  or  trachea.  When  the  diphtheritic  exudate  extends  to  the  bronchi, 
branching  casts  are  sometimes  coughed  up.  These  casts  may  be  easily 
recognized  in  the  sputum  and  are  of  great  importance  both  in  diagnosis 
and  prognosis.  Fibrinous  casts  are  common  in  croupous  pneumonia,  in 
the  sputum  of  which  they  are  frequently  present  in  great  numbers.  They 
can  be  readily  seen  when  the  sputum  is  shaken  with  water  in  a  test-tube, 
or  when  the  masses  of  mucus  in  which  they  are  embedded  are  shaken  out 
in  water  with  a  forceps.  In  pneumonic  sputum  the  fibrinous  casts  are 
small.  Similar  casts  consisting  chiefly  of  mucus  are  characteristic  of 
so-called  fibrinous  or  croupous  bronchitis  and  provoke  the  intense  paroxys- 
mal cough  of  that  disease. 

Foreign  bodies  that  have  found  their  way  into  the  air-passages  by 
aspiration  are  usually  expectorated  promptly.  They  may,  however, 
remain  in  a  bronchus  for  a  long  time  and  give  rise  to  symptoms  of  vary- 
ing intensity.  Instances  are  recorded  in  which  a  tooth,  cherry-pits  and  other 
seeds,  a  beard  of  wheat,  etc.,  have  been  expectorated  after  periods  of 
months  or  years.  Bronchial  concretions,  consisting  in  the  main  of  lime 
salts  and  sometimes  of  considerable  size,  are  in  rare  instances  found  in 
the  sputum.  They  occur  only  in  chronic  conditions  and  are  formed  in 
the  cavities  of  phthisis  and  bronchiectasis,  or  consist  of  fragments  of 
bronchial  glands  that  have  undergone  calcareous  degeneration  and  found 
their  way  into  the  bronchial  system.  Even  more  rare  is  the  presence  in 
the  sputum  of  echinococcus  daughter  cysts,  membranes,  or  booklets, 
which  have  found  their  way  from  the  lung,  pleura,  or  the  liver  into  the 
bronchi. 

The  Sputum  in  Different  Diseases. 

Bronchitis. — The  sputum  is  usually  mucoid  and  mucopurulent.  As  a 
rule,  at  the  beginning  of  an  acute  bronchial  catarrh  the  bronchial  secretion 
is  diminished  and  the  sputum  scanty.  In  the  course  of  some  days,  as  the 
symptoms  ameliorate,  the  expectoration  becomes  more  abundant,  less 
tenacious,  and  distinctly  purulent.  As  the  general  symptoms  improve 
there  is  a  gradual  diminution  in  the  quantity  of  the  sputum.  In  chronic 
bronchitis  the  expectoration  varies  greatly;  sometimes  it  is  more,  some- 
times less  purulent.  The  subjective  sensations  of  the  patient  are  usually 
better  when  the  sputum  is  of  moderate  amount,  worse  when  the  expec- 
toration is  suppressed  or  greatly  increased  in  quantity  (see  bronchitis). 

Fibrinous  or  Croupous  Bronchitis. — The  sputum  differs  from  that  of 
ordinary  bronchitis  in  that  from  time  to  time  it  contains  fibrinous  casts 
associated  with  blood.  Charcot-Leyden  crystals  are  also  present.  The 
expectoration  of  the  larger  casts  very  often  takes  place  after  distressing 
cough,  recurring  in  paroxysms  which  are  separated  by  periods  of  urgent 
dyspnoea. 

Pulmonary  Tuberculosis. — The  sputum  of  tuberculosis  presents  to 
the  naked  eye  nothing  characteristic.  All  varieties  of  sputum  that  occur 
in  ordinary  bronchitis,  from  mucous  to  purulent,  occur  in  phthisis.  In 
advanced  ulcerative  phthisis  purulent  expectoration  is  often  constant  and 
abundant.      For   the   provisional .  diagnosis    the    presence   of   the    minute 


456  MEDICAL  DIAGNOSIS. 

grayish  masses  which  frequently  contain  colonies  of  tubercle  bacilli  is 
important.  Very  often  the  sputum  has  an  offensive  odor;  this  is  espe- 
cially the  case  when  there  are  cavities,  the  contents  of  which  undergo 
stagnation  and  decomposition.  A  positive  diagnosis  rests  upon  the  pres- 
ence of  tubercle  bacilli  and,  in  the  absence  of  other  destructive  pulmonary 
lesions,  the  presence  of  elastic  fibres.  It  is  important  for  the  student  to 
bear  in  mind  that  there  is  no  constant  relation  between  the  abundance  of 
these  morphological  elements  and  the  intensity  of  the  process,  therefore 
the  gravity  of  the  prognosis.  There  are  cases  of  pulmonary  tuberculosis 
of  the  gravest  character  in  which  neither  tubercle  bacilli  nor  elastic  fibres 
are  found.  Very  often  these  are  cases  of  phthisis  florida  or  of  disseminated 
miliary  tuhercidosis  in  which  the  constitutional  symptoms  develop  in  ad- 
vance of  the  local  manifestations.  The  abundant  catarrhal  secretion,  so 
common  in  unfavorable  cases,  proportionately  diminishes  the  number  of 
tubercle  bacilli  present  in  single  specimens.  On  the  other  hand  tubercle 
bacilli  and  elastic  fibres  are  frequently  found  in  the  early  stages  at  a  period 
when  the  physical  examination  of  the  lung  yields  vague  and  uncertain  signs. 
The  diminution  or  temporary  disappearance  of  tubercle  bacilli  and  elastic 
fibres  from  the  sputum  cannot  be  regarded  as  indicating  a  favorable  prog- 
ress of  the  case  in  the  absence  of  the  general  clinical  indications  of  an  arrest 
of  the  process,  such  as  diminished  cough,  improved  appetite,  gain  in  weight, 
and  disappearance  of  fever.  In  a  suspected  case  the  presence  of  tubercle 
bacilli  in  the  sputum  justifies  a  positive  diagnosis.  Their  absence  cannot 
be  regarded  as  conclusive  until  repeated  examinations  have  been  made. 

Acute  Miliary  Tuberculosis.  —  The  sputum  is  that  of  ordinary 
catarrhal  bronchitis  and  does  not  contain  tubercle  bacilli  except  when 
there  is  an  associated  ulcerative  phthisis.  In  a  large  proportion  of  the 
cases  there  is  no  expectoration. 

Croupous  Pneumonia. — Hemorrhagic  sputum  is  characteristic.  Blood- 
spitting  may  be  the  initial  symptom.  At  first  the  sputum  is  commonly 
mucoid,  transparent  and  homogeneous;  after  twenty-four  hours  it  is 
blood-tinged  and  viscid  so  that  it  adheres  to  the  bottom  of  the  spit-cup 
when  turned  upside  down,  and  sometimes  has  to  be  wiped  from  the  lips 
or  face  of  the  patient.  At  first  red  from  unchanged  blood-coloring  matter 
it  gradually  becomes  rusty  or  orange-yellow  in  color.  Occasionally  the 
sputa  are  variable;  sometimes  mucoid,  sometimes  blood-streaked,  at 
other  times  pure  blood.  When  jaundice  is  present  the  sputum  may  be 
green  or  yellow  from  the  presence  of  bile  pigment.  Very  commonly  the 
sputum  contains  fibrinous  casts  of  the  smaller  tubes.  If  there  is  an  asso- 
ciated bronchitis  of  the  smaller  tubes  the  typical  pneumonic  sputum  may 
be  modified  by  the  presence  of  mucus  or  mucopus.  Fluid  sputum  of  a 
dark  brown  color — the  so-called  "prune-juice"  expectoration — is  an 
unfavorable  sign  since  it  may  indicate  a  beginning  oedema  of  the  lungs. 
In  some  instances  a  diminished  consistency  of  the  sputum  marks  the 
beginning  of  resolution.  The  amount  of  sputum  in  croupous  pneumonia 
is  very  variable.  In  children  and  the  aged,  and  in  adynamic  cases,  there 
may  be  none,  and  exceptionally  it  may  be  scanty  in  classical  cases  in  adults. 
A  quantity  amounting  to  200-500  c.c.  in  twenty-four  hours  is  not  uncom- 
mon.   The  amount  after  the  crisis,  abundant  at  first,  gradually  diminishes. 


SYMPTOMS  AND  SIGNS:   EXPECTORATION.  457 

In  some  cases  there  is  at  this  period  little  or  no  expectoration.  Under 
the  microscope  are  seen  leucocytes,  erythrocytes,  mucous  corpuscles,  epi- 
thelial cells,  and  occasionally  hsematoidin  crystals.  The  pneumococcus  of 
Weichselbaum  and  Frankel  is  present  in  the  vast  majority  of  cases,  and 
sometimes  Friedlander's  bacillus.  Fibrinous  casts  of  the  bronchioles  and 
moulds  of  the  alveoli  are  not  uncommon.  Chemically  the  expectoration  is 
particularly  rich  in  sodium  chloride. 

Bronchopneumonia,  Including  Aspiration  Pneumonia  and  Hypo= 
static  Pneumonia. — The  sputum  usually  presents  the  appearance  of  the 
ordinaxy  forms  of  bronchitis;  exceptionally  that  of  croupous  pneumonia. 
The  latter  is  intelligible,  since  not  only  in  the  clinical  phenomena  but  also 
in  the  histological  findings  there  are  cases  of  bronchopneumonia  which 
are  difficult  to  distinguish  from  croupous  pneumonia.  In  these  cases  the 
sputum  is  hemorrhagic  and  contains  fibrinous  exudate.  Bacteriologically 
a  mixed  infection  is  the  rule.  The  pneumococcus  and  Friedlander's  bacillus 
are  found  in  association  with  the  ordinary  pus-producing  and  other  organ- 
isms. The  Klebs-LofRer  bacillus  is  present  when  the  lesions  are  secondary 
to  diphtheria.  In  the  lobular  forms  the  streptococcus  is  the  common 
organism;   in  the  lobar  forms,  the  pneumococcus. 

Gangrene  of  the  Lungs. — The  intensely  offensive  odor,  abundance, 
fluidity,  and  dark,  dirty,  greenish-brown  color  are  characteristic.  Upon 
standing  the  sputum  separates  into  three  strata — an  upper  frothy  layer, 
which  may  contain  necrotic  particles  of  lung  tissue  which  float  by  reason 
of  entangled  air,  a  middle  thin  layer,  and  a  greenish-brown  sediment  which 
consists  in  part  of  leucocytes,  in  part  of  gangrenous  detritus.  Shreddy 
fragments  of  lung  tissue  of  considerable  size  and  frequently  showing  the 
alveolar  arrangement  may  be  picked  out  if  the  sediment  is  spread  upon  a 
glass.  Under  the  microscope  are  seen  elastic  fibres,  pigment  granules, 
crystals  of  the  fatty  acids,  cholesterin,  leucine  and  tyrosine  crystals, 
bacteria,  and  leptothrix.  Altered  blood-corpuscles  are  also  present.  When 
the  fluid  is  retained  in  the  gangrenous  cavity  for  some  time,  the  elastic 
fibres  may  undergo  solution  owing  to  the  action  of  a  peptonizing  ferment. 
The  odor  is  the  more  intense  in  proportion  as  the  communication  between 
the  gangrenous  areas  and  the  bronchi  is  more  free.  Cases  occur  in  which, 
in  the  absence  of  odor  during  life,  circumscribed  areas  of  gangrenous  lung 
have  been  found  upon  post-mortem  examination. 

Abscess  of  the  Lung. — The  sputum  is  essentially  purulent.  It  is 
offensive,  but  less  intensely  so  than  that  of  gangrene.  When  placed  in 
water  it  has  a  thready  or  granular  appearance.  When  the  perforation  is 
small  there  is  an  accompanying  catarrhal  bronchitis  and  the  sputa  are 
mucopurulent.  When,  however,  the  abscess  discharges  abruptly,  a  large 
amount  of  pus  commingled  with  masses  of  necrotic  lung  tissue  and  con- 
taining elastic  fibres  in  abundance  is  discharged.  Microscopically  the  spu- 
tum contains  hsematoidin,  cholesterin  and  fat  crystals  and  various  bacteria. 

Perforating  Empyema. — The  sputum  resembles  that  of  pulmonary 
abscess.  It  may  be  at  first  free  from  odor  but  in  the  course  of  a  little  time 
becomes  offensive.  It  is  voided  in  considerable  quantities  at  varying 
intervals.  Elastic  fibres  are  wholly  absent  or  are  present  in  small  numbers. 
Haematoidin  and  other  crystals  and  pyogenic  bacteria  are  present. 


458  MEDICAL  DIAGNOSIS. 

Putrid  Bronchitis. — The  expectoration  presents  characteristics  simi- 
lar to  that  of  perforating  empyema.  It  is  purulent  and  foul-smelling,  but 
does  not  contain  elastic  fibres.  It  is  voided  from  time  to  time  in  moder- 
ate amounts;  not  in  large  bulk  at  intervals  of  some  hours  as  is  the  case  in 
empyema  with  bronchopulmonary  fistula  and  bronchiectasis. 

Bronchiectasis. — In  saccular  bronchiectasis  the  sputum  is  sometimes 
mucopurulent,  sometimes  purulent.  It  is  brought  up  from  time  to  time 
in  severe  paroxysms  and  in  large  quantities — mouthfuls.  These  paroxysms 
may  follow  change  of  posture,  the  cough  reflex  being  excited  by  the  shift- 
ing of  accumulated  secretion  from  the  dilatation  to  the  normal  bronchial 
tube.  A  paroxysm  usually  occurs  in  the  morning.  The  color  of  the  expec- 
torated matter  may  be  gray  or  grayish-brown.  It  is  usually  fluid,  acid- 
smelling,  sometimes  extremely  fetid.  Upon  standing  it  separates  into 
three  layers,  an  upper  consisting  of  brownish  froth,  a  middle  thin  watery 
layer,  and  a  lower,  thick  and  granular.  Microscopically  the  sputum  con- 
sists of  pus  corpuscles,  epithelial  cells,  erythrocytes,  and  large  numbers  of 
crystals  of  the  fatty  acids.  Haematoidin  crystals  are  sometimes  seen.  In 
the  absence  of  bronchial  ulceration,  elastic  fibres  are  not  found,  nor  are 
tubercle  bacilli  present.  Nummular  sputa  are  uncommon.  In  many  cases 
the  sputum  cannot  be  distinguished  from  that  of  a  putrid  bronchitis. 
Hemorrhage  occasionally  occurs. 

(Edema  of  the  Lungs. — The  sputum  is  usually  thin,  frothy,  colorless 
or  slightly  blood-tinged,  and  abundant.  Upon  standing  it  deposits  a 
sediment  consisting  in  part  of  red  blood-corpuscles  and  in  part  of  ele- 
ments characteristic  of  the  antecedent  condition,  as  bronchitis  or  pneu- 
monia. It  is  largely  made  up  of  blood-serum  and  is  therefore  rich  in 
albumin.  In  the  rare  cases  in  which  perforation  of  the  lung  occurs  in 
serofibrinous  pleurisy  the  expectorated  matter  resembles  that  of  pulmonary 
oedema  but  is  richer  in  albumin.  A  very  abundant  sputum,  similar  in 
character,  is  sometimes  expectorated  after  paracentesis  thoracis,  begin- 
ning toward  the  close  of  the  operation — the  expectoration  alhumineuse  of 
the  French.  This  serous  sputum  is  the  result  of  an  acute  pulmonary 
oedema  following  the  dilatation  of  the  compressed  lung. 

Bronchopulmonary  Hemorrhage — Haemoptysis. — In  the  blood-spit- 
ting which  follows  traumatism,  the  rupture  of  an  aneurism,  the  lesions 
of  tuberculosis,  or  new  growths  involving  the  lungs  the  sputum  consists 
of  more  or  less  abundant,  bright  red,  frothy  blood.  The  distinction  be- 
tween venous  and  arterial  blood  cannot  be  made,  since  the  dark  blood  of 
the  pulmonary  arteries  becomes  oxygenized  and  frothy  during  its  course 
through  the  bronchial  tubes.  The  differential  diagnosis  between  haemop- 
tysis and  haematemesis  rests  upon  the  following  facts:  In  bronchopul- 
monary hemorrhage  the  blood  is  coughed  up.  In  gastric  and  oesopha- 
geal hemorrhage  it  is  vomited,  but  the  account  of  the  patient  or  his  friends 
is  not  always  satisfactory;  in  the  excitement  and  alarm  the  distinction 
may  not  be  made.  Moreover  violent  paroxj^smal  cough  may  on  the  one 
hand  be  followed  by  gagging  and  vomiting,  while  on  the  other  hand  some 
portion  of  vomited  blood  may  be  drawn  into  the  larynx  by  aspiration 
and  thus  excite  coughing.  The  examination  of  the  blood  itself  is  impor- 
tant.    Bright  red,  frothy  blood  may  usually  be  referred  to  a  lesion  of  the 


SYMPTOMS  AND  SIGNS:    EXPECTORATION.  459 

respiratory  tract;  blood  that  is  dark,  clotted,  and  free  from  air-bubbles, 
to  the  digestive  tract.  But  there  are  exceptions  to  this  rule.  In  profuse 
hemorrhage  from  the  stomach  the  blood  is  sometimes  vomited  so  rapidly 
that  it  is  bright  red  and  fluid,  while  in  abundant  pulmonary  hemorrhage, 
resulting  from  erosions  of  a  large  branch  of  the  pulmonary  artery,  the 
expectorated  blood  may  be  dark  in  color  and  contain  but  little  air. 

The  reaction  of  the  blood  in  haemoptysis  is  alkaline.  In  haematemesis 
which  occurs  during  digestion,  when  the  stomach  contains  a  large  amount 
of  acid  fluid,  the  reaction  may  be  acid.  Too  great  importance  cannot  be 
ascribed  to  the  reaction  of  the  blood  in  doubtful  cases,  since  vomited 
blood  is  frequently  alkaline.  The  presence  of  particles  of  food  in  the  blood 
is  of  importance  in  diagnosis. 

There  are,  however,  cases  in  which  the  distinction  between  haemoptysis 
and  haematemesis  cannot  be  immediately  made. 

The  condition  of  the  patient  prior  and  subsequent  to  the  bleeding  is 
in  doubtful  cases  of  greater  importance  than  the  appearance  of  the  blood. 
A  history  of  gastric  symptoms  before  the  blood  loss  or  the  occurrence  of 
such  symptoms  subsequently  is  common  in  bleeding  from  the  stomach. 
The  presence  of  altered  blood  in  the  stools  after  the  hemorrhage  points  to 
bleeding  from  the  stomach  rather  than  from  the  lungs.  On  the  other 
hand  the  mere  fact  that  the  patient  has  suffered  for  some  time  from  cough 
and  expectoration  is  suggestive  of  pulmonary  hemorrhage,  which  is  apt 
to  be  followed  for  some  days  by  the  occasional  expectoration  of  small 
blood-clots  or  of  sputum  mixed  with  blood.  When  due  consideration  is 
given  to  these  facts  errors  of  diagnosis  are  not  likely  to  occur. 

Hemorrhagic  sputum  is  occasionally  encountered  in  acute  bronchitis. 
This  sputum  is  to  be  distinguished  from  pneumonic  sputum  by  the  fact 
that  the  blood  is  present  in  streaks  rather  than  as  a  homogeneous  mixture. 
Profuse  haemoptysis  rarely  has  its  seat  of  origin  in  the  larynx  or  trachea, 
since  the  blood-vessels  of  these  organs  are  of  relatively  small  size.  On 
the  other  hand,  blood-streaked  sputa  are  not  uncommon  in  acute  catarrhal 
inflammation  of  the  trachea,  larynx,  or  pharynx.  There  are  forms  of 
hemorrhagic  bronchitis  characterized  by  blood-tinged  sputum  which  con- 
tinue for  some  days  or  weeks.  Such  cases  are  not  uncommon  during 
epidemics  of  influenza.  It  sometimes  happens,  especially  during  sleep, 
that  the  blood  in  epistaxis  trickles  into  the  pharynx  and  is  swallowed.  If 
vomited,  such  blood  may  be  regarded  as  due  to  gastric  ulcer.  If  the  blood 
in  the  pharynx  under  these  circumstances  excites  cough  and  is  ejected 
mingled  with  mucus,  it  may  be  erroneously  regarded  as  coming  from  the 
lungs.  If  the  trickhng  blood  be  seen  upon  the  wall  of  the  pharynx  the 
diagnosis  is  at  once  established  and  the  precise  site  from  which  it  comes 
may  be  determined  by  means  of  the  rhinoscope. 

Infarcts. — The  sputum  in  hemorrhagic  infarct  is  commonly  dark  in  color 
and  resembles  pure  blood,  from  which  it  differs  in  its  somewhat  tenacious 
consistence,  suggestive  of  pneumonic  sputum.  In  point  of  fact  the  sputa 
in  cases  of  pulmonary  infarct  may  vary  according  to  the  amount  of  bron- 
chial secretion  present  from  pure  blood  to  a  tenacious  blood-tinged  mucus. 

Chronic  Valvular  Disease. — Hemorrhagic  sputum  occurs  in  certain 
cases  of  valvular  disease  of  the  heart,  particularly  in  mitral  stenosis. 


460  MEDICAL  DIAGNOSIS. 


VI. 

CIRCULATION;    PULSATION;    RADIAL   PULSE;    ANOMALIES  OF 
THE  PULSE;    CAPILLARY  PULSE;   VENOUS  PULSE. 

CIRCULATION. 

The  term  arterial  pulse  is  used  to  designate  the  rhythmical  fluctua- 
tions of  the  arterial  pressure  which  correspond  to  the  contractions  of 
the  ventricles  of  the  heart.  These  rhythmic  fluctuations  depend  upon 
the  intermittent  injection  of  blood  from  the  ventricles  to  the  aorta, 
upon  the  resistance  to  the  arterial  flow  produced  by  friction,  and  upon 
the  elasticity  of  the  walls  of  the  arteries.  After  the  blood  enters  the  capil- 
laries the  pressure  is  no  lon^^er  intermittent,  but  is  continuous,  and  pulsa- 
tion under  normal  conditions  disappears.  The  pulse  may  be  affected 
by  changes  either  in  the  force  of  the  ventricular  contractions,  in  the 
elasticity  of  the  arteries,  or  in  the  peripheral  resistance,  and  by  vary- 
ing combinations  of  these  modifications.  The  examination  of  the  arterial 
pulse  is  therefore  obviously  of  great  diagnostic  importance.  By  this 
means  conclusions  may  be  reached  in  regard  to  a  wide  range  of  clinical 
facts,  including  the  innervation  of  the  heart,  the  power  of  the  heart  muscle, 
the  blood-pressure,  the  blood  loss  in  hemorrhage  and  anaemia  due  to  other 
causes,  the  condition  of  the  peripheral  arteries,  the  action  of  fever-pro- 
ducing toxins  upon  the  heart  and  blood-vessels,  and  finally,  under  certain 
conditions,  in  regard  to  the  presence  and  nature  of  valvular  lesions. 

PULSATION. 

Arterial  pulsation  may  be  studied  in  any  of  the  superficial  arteries. 
The  methods  employed  in  ordinary  clinical  work  are  palpation  and  inspec- 
tion. Auscultation  is  of  more  limited  apphcation  in  the  study  of  the  blood- 
vessels. The  results  obtained  by  the  use  of  the  sphygmograph  are  of 
more  value  in  clinical  research  and  for  purposes  of  record  and  comparison 
than  for  diagnosis. 

The  increase  in  the  contents  of  the  arterial  system  which  causes  the 
pulsation  is  accompanied  not  only  by  an  increase  in  the  diameter  of  the 
artery  at  any  given  point  but  also  by  an  increase  in  the  length  of  the  vessel. 
This  increase  in  length  results  in  a  more  or  less  marked  lateral  undulation 
and  exaggeration  of  the  curves  of  the  vessel,  normally  not  sufficient  to 
attract  attention,  but  conspicuous  in  the  temporal  arteries  of  emaciated 
persons  and  at  various  points  in  the  course  of  the  superficial  arteries  in 
conditions,  such  as  aortic  insufficiency,  which  are  attended  with  cardiac 
hypertrophy  and  relaxation  of  the  arterial  walls.  The  arterial  pulse, 
corresponding  to  a  contraction  of  the  ventricles,  is  not  perceptible  at 
the  same  moment  at  all  parts  of  the  body,  an  appreciable  interval  sepa- 
rating the  cardiac  impulse,  the  radial  pulse,  and  that  of  the  dorsal  artery 
of  the  foot. 


SYMPTOMS  AND  SIGNS:    PULSATION.  461 

The  Aorta  and  Its  Branches. — Pulsation  in  the  notch  of  the  ster- 
num is  occasionally  seen  in  aged  persons  in  the  absence  of  disease.  It 
occurs  in  dilatation  of  the  aorta  and  is  a  sign  of  aneurism  of  the  trans- 
verse portion  of  the  arch.  In  rare  cases  it  is  due  to  an  anomalous  distri- 
bution of  the  branches  of  the  aorta  in  this  region. 

Pulsation  at  the  root  of  the  neck  is  common  in  cardiac  hyper- 
trophy and  dilatation,  in  aortic  insufficiency,  and  in  neurotic  and  anaemic 
conditions,  especially  during  periods  of  physical  or  mental  excitement. 
It  is  a  prominent  symptom  of  exophthalmic  goitre.  Under  these  circum- 
stances pulsation  of  the  aorta  is  associated  with  a  heaving  impulse  in  the 
innominate  and  carotids,  communicated  to  the  overlying  tissues,  so  that 
throbbing  in  this  region  becomes  a  sign  of  importance.  It  is  often  accom- 
panied with  distention  of  the  veins  and  flushing  of  the  face. 

The  differential  diagnosis  between  dynamic  dilatation  of  the  arch  of 
the  aorta  and  aneurism  cannot  in  all  cases  be  made  during  life.  Not  rarely 
when  the  signs  of  dilatation  of  the  arch  and  enlargement  of  the  innominate 
and  right  carotid  have  been  well  marked  clinically,  the  vessels  have  been 
found  post  mortem  to  be  of  normal  measurement. 

Pulsation  of  the  subclavians  occurs  in  the  general  pulsation  at 
the  root  of  the  neck,  above  spoken  of.  It  is  usually  less  marked  than  that 
of  the  innominate  and  carotids.  Visible  pulsation  of  the  subclavians 
is  sometimes  present  in  consolidation  and  retraction  of  the  lung  in 
phthisis. 

Pulsation  of  the  abdominal  aorta  is  very  common.  It  may  often 
be  made  out  in  quite  thin  persons  under  normal  conditions  both  by  inspec- 
tion and  palpation.  Under  these  circumstances  it  is  of  very  slight  inten- 
sity. More  vigorous  pulsation  in  the  line  of  the  abdominal  aorta,  namely, 
in  the  median  line  or  slightly  to  the  left  of  it,  and  in  the  epigastric  zone 
is  an  important  sign  of  disease.  Objectively  the  pulsation  varies  in  degree. 
It  is  frequently  violent  and  throbbing  and  may  be  demonstrated  by  the 
motion  communicated  to  the  stethoscope  lightly  pressed  upon  the  surface. 
Subjectively  the  sensation  of  throbbing  is  annoying  and  frequently  dis- 
tressing. It  often  prevents  sleep.  Epigastric  pulsation  is  not  in  all  in- 
stances due  to  the  movements  of  the  aorta.  It  may  be  directly  due  to  the 
heart.  A  faint  pulsation  in  the  region  of  the  ensiform  cartilage  occurs  in 
physiological  over-action  of  the  heart,  in  hypertrophy  and  dilatation  of 
the  right  ventricle,  and  in  displacement  of  the  heart  towards  the  right  in 
consequence  of  left-sided  pleural  effusion  or  of  emphysema.  In  the  last 
named  condition  the  epigastric  pulsation  is  often  marked,  since  the  heart 
is  displaced  toward  the  median  line  and  the  right  ventricle  is  hypertro- 
phied.  The  pulsation  is  transmitted  to  the  left  lobe  of  the  liver.  It  is 
more  marked  in  the  neighborhood  of  the  ensiform  appendix  and  costal 
cartilages  than  toward  the  umbilicus,  and  nice  observation  will  show 
that  it  corresponds  in  time  to  the  cardiac  systole,  whereas  aortic  pulsation 
is  slightly  postsystolic. 

The  most  common  causes  of  pulsation  of  the  abdominal  aorta  are 
referable  to  the  nervous  system — simple  dynamic  pulsation.  The  throb- 
bing may  be  a  direct  manifestation  of  neurasthenia  or  hysteria,  or  it  may 
be  a  reflex  manifestation  of  disorders  of  the  gastro-intestinal  tract.     It  is 


462  MEDICAL  DIAGNOSIS. 

much  more  common  in  females  and  in  early  life.  It  occurs  also  as  the 
result  of  diminution  of  the  amount  of  blood  and  thus  becomes  one  of  the 
signs  of  anaemia  due  to  hemorrhage  or  other  cause.  Marked  epigastric 
pulsation  frequently  occurs  as  a  sign  of  enlarged  lymphatic  glands,  carci- 
noma of  the  stomach  or  pancreas,  or  other  form  of  tumor  overlying  the 
aorta.  In  rare  instances  fecal  accumulations  in  the  colon  transmit  the 
aortic  impulse  to  the  surface.  Thorough  evacuation  of  the  bowels  is  an 
imperative  preliminary  measure  in  the  diagnosis  of  doubtful  cases.  Finally 
it  may  be  due  to  an  aneurism. 

The  diagnostic  significance  of  this  sign  varies  greatly  and  in  some 
cases  is  only  to  be  determined  by  careful  study  of  the  associated  clinical 
phenomena.  In  simple  dynamic  pulsation  the  aorta  may  in  thin  persons 
frequently  be  felt  to  be  somewhat  dilated,  especially  during  the  paroxysm, 
but  no  distinct  tumor  formation  can  be  recognized.  The  symptoms  of 
neurasthenia  or  the  stigmata  of  hysteria  are  present  and  these  are  often 
associated  with  gastro-intestinal  symptoms.  The  throbbing  is  intense  and 
distressmg,  sometimes  diffused  but  never  distinctly  expansible.  It  can 
be  felt  when  the  patient  is  in  the  knee-elbow  posture.  The  throbbing  of 
anaemia  is  much  less  marked.  Pulsation  transmitted  from  the  aorta  through 
an  overlying  tumor  communicates  a  lifting  sensation  to  the  hand  upon 
palpation,  is  usually  circumscribed,  not  expansile,  and  disappears  when 
the  patient  is  examined  in  the  knee-elbow  position,  the  mass  falling  away 
from  the  aorta  under  the  action  of  gravity.  The  clinical  phenomena  of 
the  primary  condition  are  usually  more  or  less  well  defined.  Errors  of 
diagnosis  not  infrequently  occur  under  these  circumstances,  the  tumor 
being  mistaken  for  an  aneurism.  When  well  defined  the  pulsation  of 
an  abdominal  aneurism  is  characteristic.  If  the  aneurism  be  of  large  size 
there  is  dulness  continuous  with  that  of  the  left  lobe  of  the  liver.  In  thin 
persons  a  distinct  tumor  may  be  felt,  the  pulsation  is  expansile  and 
forcible,  and  persistent  rather  than  paroxysmal.  A  systolic  murmur  is 
very  commonly  heard  in  the  absence  of  pressure  of  the  stethoscope  or  the 
murmur  may'  be  audible  in  the  back.  In  some  cases  a  low-pitched  soft 
diastolic  murmur  is  heard.  In  many  cases  there  is  a  distinct  systolic  thrill. 
Both  the  murmur  and  thrill  may  occur  in  other  conditions  which  cause  an 
abrupt  narrowing  in  the  lumen  of  the  aorta,  and  may  be  produced  by  the 
pressure  of  the  stethoscope.  These  signs  are  occasionally  encountered 
in  the  epigastric  pulsation  of  nervous  diseases  and  in  tumors  of  various 
kinds  developing  in  relation  with  the  abdominal  aorta.  The  diagnosis  of 
aneurism  must  therefore  be  made  with  extreme  caution.  It  is  justified 
in  cases  in  which  there  is  a  distinct  tumor  with  expansile  pulsation  per- 
sisting in  the  knee-elbow  posture  and  when  radiating  pain,  vomiting,  and 
retardation  of  the  femoral  pulse  are  present.  The  pulsation  of  an  abdom- 
inal aneurism  may  be  manifest  in  the  left  hypochondrium  or  lumbar 
region.  The  X-rays  furnish  an  important  aid  to  diagnosis  in  doubtful 
cases.  Epigastric  pulsation  must  not  be  confounded  with  the  purely 
subjective  sensation  of  fluttering  in  the  left  hypochondrium  of  which 
hysterical  women  frequently  complain.  These  two  phenomena  are  en- 
tirely distinct,  though  they  are  frequently  present  in  the  same  case. 


SYMPTOMS  AND  SIGNS:    RADIAL  PULSE.  463 

RADIAL   PULSE. 

The  pulse  may  be  studied  in  any  superficial  artery.  For  this  purpose 
the  radial,  because  of  its  accessibility  and  convenience,  is  usually  selected. 
This  artery  is  palpated  over  the  flat  portion  of  the  radius  between  the 
styloid  process  and  the  tendon  of  the  radialis  internus.  In  an  anomalous 
distribution  of  the  artery  the  radial  pulse  must  be  sought  for  elsewhere. 
It  is  a  good  plan  to  compare  the  pulse  in  the  radials  of  both  sides.  It 
occasionally  occurs  that  a  small  arterial  twig  occupies  the  usual  position 
of  the  radial  while  the  main  branch  has  an  anomalous  course.  In  the 
absence  of  comparison  with  the  other  side  an  erroneous  conclusion  as  to 
the  volume  and  force  of  the  pulse  would  be  formed.  In  any  case  of  doubt 
the  pulse  in  the  bend  of  the  elbows  or  in  the  brachial  or  axillary  arteries 
upon  the  two  sides  may  be  compared.  Pathological  differences  in  volume, 
force,  and  time,  that  is  to  say,  retardation  upon  one  side,  are  due  to  the 
interference  with  the  flow  of  blood  in  the  artery  caused  by  endarteritis 
and  aneurism,  or  the  pressure  of  a  tumor  upon  the  wall  of  the  vessel.  Com- 
plete obliteration  results  from  embolism  or  thrombosis.  In  traumatism 
from  extensive  crushing  or  laceration  it  is  a  sign  of  destruction  of  the 
artery.  Retardation  of  the  femoral  pulse  upon  both  sides  may  occur  in 
aneurism  of  the  thoracic  or  abdominal  aorta.  On  one  side  it  is  commonly 
the  sign  of  aneurism  of  the  common  iliac  artery.  Under  certain  circum- 
stances it  is  convenient  to  study  the  pulse  in  the  temporals,  carotids,  or 
even  in  the  posterior  tibials. 

The  best  method  of  feeling  the  pulse  consists  in  the  application  of 
the  tips  of  three  adjacent  fingers,  that  of  the  index  finger  being,  according 
to  an  old  rule,  nearest  the  heart  of  the  patient.  Under  changing  pressure 
the  distention  of  the  artery  which  constitutes  the  pulse  is  recognized  and 
studied.  The  value  of  the  pulse  in  diagnosis  depends  largely  upon  the 
experience  and  judgment  of  the  physician.  In  the  study  of  the  pulse  the 
following  points  require  especial  consideration;  (a)  condition  of  the  arterial 
wall;  (b)  frequency;  (c)  rhythm;  (d)  volume;  (e)  celerity;  (f)  tension;  (g) 
dicrotism. 

The  condition  of  tlie  arterial  wall  enables  us  to  form  conclusions  as 
to  the  presence  or  absence  of  general  arteriosclerosis,  and  to  recognize 
the  modifications  of  the  pulse-wave  caused  by  changes  in  the  elasticity  of 
the  artery.  It  is  of  much  greater  diagnostic  importance  than  the  pulse- 
rate.  Empty  the  artery  by  pressure  and  roll  it  to  and  fro  upon  the  under- 
lying bone.  In  healthy  individuals  in  early  life  the  artery  is  felt  as  a  strand 
of  soft  elastic  tissue.  In  arteriosclerosis  and  in  those  conditions  in  which 
the  blood-pressure  is  habitually  high,  such  as  chronic  nephritis,  gout,  and 
lead  poisoning,  the  increased  resistance  of  the  artery  may  be  readily  recog- 
nized. It  feels  like  a  whip-cord,  under  the  fingers.  In  advanced  arterio- 
sclerosis calcareous  deposits  in  the  wall  of  the  artery — atheroma — can  be 
distinctly  felt ,  and  in  some  cases  these  deposits  are  so  coarse  and  irregular 
as  to  warrant  their  comparison  with  a  string  of  wampum.  Such  arteries 
are  often  tortuous.  These  changes  can  be  best  recognized  by  passing  the 
palpating  finger  gently  along  the  course  of  the  artery.  Important  as  is 
the  study  of  the  condition  of  the  walls  of  the  peripheral  arteries  for  the 


464  MEDICAL  DIAGNOSIS. 

diagnosis  of  arteriosclerosis,  it  is  nevertheless  necessary  to  call  attention 
to  the  fact  that  there  are  cases  of  very  advanced  sclerosis  of  the  aorta  and 
even  of  the  coronaries,  and  indeed  of  other  deeply  situated  vessels,  in 
which  the  superficial  arteries  upon  palpation  yield  no  indication  of  changes 
in  their  walls.  To  arteriosclerosis,  which  is  often  unequally  distributed, 
the  radial  shows  no  special  liability.  It  is  therefore  necessary  in  suspected 
cases  to  examine  carefully  the  superficial  arteries  in  various  parts  of  the 
body.  Increased  arterial  tension  and  an  accentuated  aortic  second  sound 
are  important  signs  of  arteriosclerosis. 

Frequency  of  the  Pulse. — By  this  term  is  indicated  the  number  of 
beats  in  a  minute.  It  is  convenient  to  count  the  radial  pulse  for  15  seconds 
and  multiply  the  result  by  4.  If  the  pulse  is  irregular  or  extremely  rapid  if 
becomes  necessary  to  count  for  an  entire  minute  and  to  repeat  the  counting 
in  order  to  avoid  error.  If  after  repeated  observation  wide  variations  in 
the  frequency  are  found,  the  extremes  may  be  recorded.  Various  devices 
have  been  suggested  for  the  counting  of  very  rapid  pulses.  If  regular, 
every  second  or  third  beat  may  be  counted  and  the  result  multiplied  re- 
spectively by  2  or  3;  or  a  dot  for  each  beat  may  be  made  with  a  pencil 
upon  a  sheet  of  paper.  These  methods  are  liable  to  error,  and  variations 
in  the  pulse-frequency  uncountable  by  ordinary  methods,  that  is,  exceeding 
200,  are  without  clinical  importance. 

The  pulse-frequency  is  modified  by  a  great  variety  of  physiological 
influences.  The  pulse  should  therefore  be  counted  regularly  under  simi- 
lar conditions.  When  this  is  impracticable  any  circumstance  liable  to 
influence  the  frequency  should  be  noted. 

Mental  excitement  in  nervous  individuals  exerts  a  marked  influence 
upon  the  frequency  of  the  pulse.  The  approach  of  the  physician  to  the 
bedside  or  the  entrance  of  the  patient  to  the  consulting  room  is  often 
followed  immediately  by  a  rapid  increase.  It  is  therefore  wise  to  post- 
pone the  taking  of  the  pulse  until  after  some  general  conversation  suffi- 
ciently prolonged  to  enable  the  patient  to  regain  his  equanimity. 

The  effect  of  muscular  effort  in  increasing  the  pulse-frequency  is  well 
known.  Athletic  sports,  running,  boxing,  stair-chmbing,  and  similar 
effort  may  be  followed  by  a  very  rapid  pulse-rate  which  is  nevertheless 
physiological.  During  convalescence  from  disease  and  in  feeble  and  deli- 
cate persons  slight  movements  of  the  body  increase  the  pulse-frequency, 
which  falls  again  after  a  period  of  rest.  If,  however,  the  effort  be  pro- 
longed the  return  to  the  normal  frequency  is  delayed. 

The  pulse-rate  is  modified  by  the  posture  of  the  body.  It  rises  imme- 
diately upon  change  from  the  recumbent  to  the  sitting  and  again  from  the 
sitting  to  the  standing  position.  The  frequency  attained  immediately  after 
these  changes  falls  again  in  a  little  time  but  not  to  the  normal  of  the  previous 
posture.  The  pulse-rate  for  the  same  individual  is  relatively  higher  while 
each  of  these  positions  is  maintained.  The  figures  in  healthy  individuals,  in 
the  absence  of  other  modifying  conditions,  are  approximately  in  the  recum- 
bent posture  66,  in  the  sitting  70,  in  the  standing  80  beats  per  minute. 

The  pulse-frequency  is  increased  during  the  digestion  of  food.  Hearty 
meals  and  alcoholic  beverages  render  the  increase  more  marked.  The 
diurnal  modifications  of  the  pulse  bear  a  definite  relation  to  the  periods 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  465 

of  taking  food.  They  occur,  however,  in  those  who  are  fasting  and  bear 
some  relation  to  the  diurnal  variations  of  the  temperature.  The  pulse's 
frequency  is  to  some  extent  modified  by  respiration,  being  sKghtly  in- 
creased upon  inspiration  and  diminished  upon  expiration.  It  is  higher 
after  paroxysms  of  cough.    It  varies  greatly  at  different  periods  of  life. 

Pulse-frequency  at  Different  Ages.— Rollet. 

At  birth 144-133  per  minute 

To  end  of  1st  year 143-123  per  minute 

10th  to  15th  year 91-  76  per  minute 

20th  to  60th  year 73-  69  per  minute 

Pulse-frequency  in  Childhood. — Vierordt. 

0-  1  year 134  per  minute 

1-  2  years 110. 6  per  minute 

2-  3  years 108  per  minute 

3-  4  years 108  per  minute 

4-  5  years 103  per  minute 

5-  6  years 98  per  minute 

6-  7  years 92 . 1  per  minute 

7-  8  years 94 . 9  per  minute 

8-  9  years 88. 8  per  minute 

9-10  years 91.8  per  minute 

10-11  years 87 . 9  per  minute 

11-12  years 89. 7  per  minute 

12-13  years 87. 9  per  minute 

13-14  years 86.8  per  minute 

In  general  terms  the  frequency  declines  with  advancing  years.  The 
pulse  in  women  is  about  7  beats  per  minute  more  rapid  than  in  men  of 
corresponding  age.  In  large  individuals  it  is  shghtly  slower  under  similar 
conditions  than  in  those  of  smaller  size. 

Cases  are  occasionally  observed  in  which  the  radial  pulse  is  less  fre- 
quent than  the  impulse  of  the  heart.  This  discrepancy  arises  in  conse- 
quence of  the  feebleness  of  certain  contractions  of  the  heart,  the  pulse- 
wave  not  reaching  the  radials.  Under  these  circumstances  the  pulse 
is  commonly  but  not  always  irregular.  In  every  case  of  irregularity  of 
the  pulse  it  is  desirable  to  count  the  contractions  of  the  heart  as  mani- 
fested in  the  precordial  impulse. 

In  general,  departures  from  the  normal  pulse-rate,  either  in  the  direc- 
tion of  increased  or  diminished  frequency,  arise  in  consequence  of  derange- 
ment of  the  nervous  mechanism  of  the  circulation.  Increase  may  be  due 
to  paresis  of  the  pneumogastric  or  irritation  of  the  sympathetic  nerves 
or  the  intracardiac  ganglia;  decrease  to  irritation  of  the  pneumogastric  or 
paresis  of  the  cardiac  sympathetic  nerves  and  ganglia.  Much  less  com- 
monly derangements  of  the  pulse-rate  arise  in  consequence  of  causes  affect- 
ing the  heart  itself. 

Increased  Frequency— Rapid  Heart.^ — Perhaps  the  most  common  cause 
of  an  increase  in  the  pulse-rate  is  the  action  of  the  fever-producing 
toxins.  We  find  it  therefore  in  the  febrile  infections,  the  increase  in  the 
pulse-frequency  bearing  a  general  relation  to  the  elevation  of  the  tem- 
perature. The  prognosis  in  severe  febrile  disease  is  more  favorable  where 
this  parallelism  is  maintained  than  in  those  cases  in  which  the  pulse-rate 
is  increased  out  of  proportion  to  the  rise  of  temperature;    the  very  rapid 

30 


466  MEDICAL  DIAGNOSIS. 

pulse  being  the  sign  of  special  implication  of  the  heart  or  vasomotor  sys- 
tem. In  the  acute  febrile  diseases  a  pulse-rate  of  140-160  in  the  adult, 
if  maintained  for  any  length  of  time,  is  of  itself  ominous.  In  children 
even  higher  pulse-rates  are  not  uncommon  in  cases  that  run  a  favorable 
course.  The  effect  of  the  specific  toxins  upon  the  mechanism  of  the 
circulation  is  by  no  means  constant.  A  knowledge  of  the  variations  is  of 
diagnostic  importance  in  doubtful  cases.  In  scarlet  fever  the  pulse-rate  is 
high — 120-160 — throughout  the  whole  course  of  the  attack;  in  diseases 
to  which  it  bears  some  resemblance,  such  as  angina  tonsillaris,  diphtheria, 
rubella,  and  measles,  the  pulse-rate  of  the  period  of  invasion  is  slower.  The 
pulse-rate  in  acute  miliary  tuberculosis  and  in  septicopysemic  conditions 
is  high,  out  of  proportion  to  the  temperature.  In  malignant  endocarditis 
the  pulse  is  rapid  both  during  the  febrile  paroxysms  and  in  their  intervals. 
In  puerperal  sepsis  a  high  pulse-rate  is  more  constant  than  elevation  of 
temperature.  Increased  pulse-frequency  is  common  in  the  early  stages  of 
phthisis  and  usually  persists  throughout  the  whole  course  of  the  disease,, 
alike  in  afebrile  periods  and  when  the  temperature  is  moderate  or  excessive. 

On  the  other  hand  the  pulse-frequency  of  enteric  fever  is  low  in  pro- 
portion to  the  temperature.  In  cases  of  average  severity  it  frequently 
does  not  exceed  100-110  with  a  temperature  range  during  the  fastigium 
of  102°  F.  (38.9°  C.)  A.M.  to  104°  F.  (40°  C.)  p.m.  This  fact  is  not  without 
importance  in  the  differential  diagnosis  between  enteric  fever  and  septic 
infections,  the  so-called  typhoid  form  of  malignant  endocarditis  and  acute 
miliary  tuberculosis.  A  very  rapid  pulse  in  enteric  fever  is  usually  the 
sign  of  an  inflammatory  complication  or  secondary  infection. 

A  frequent  pulse  occurs  in  acute  affections  of  the  heart,  endocarditis,, 
pericarditis,  and  myocarditis,  and  in  chronic  valvular  disease  in  the  stage 
of  failure  of  compensation.  Increased  pulse-frequency  after  slight  exer- 
tion occurs  in  most  forms  of  chronic  myocarditis,  in  general  muscular 
asthenia,  in  anaemia,  during  convalescence  from  acute  diseases,  and  in  con- 
ditions of  the  neighboring  organs  which  subject  the  heart  to  abnormal 
pressure,  as  pleural  effusion,  thoracic  aneurism,  massive  enlargement  of 
the  liver  and  spleen,  tympany,  and  ascites.  The  frequency  of  the  pulse  is 
increased  in  cardiac  palpitation  from  any  cause. 

The  pulse-frequency  is  greatly  increased  in  many  nervous  diseases. 
A  rapid  pulse  with  subnormal  temperature  is  characteristic  of  shock  and 
collapse.  Acceleration  of  the  pulse  is  a  constant  symptom  of  exophthal- 
mic goitre;  during  the  paroxysms  of  palpitation  the  pulse  is  often  un- 
countable. In  neurasthenia,  Addison's  disease,  the  primary  and  secondary 
anaemias,  arthritis  deformans,  and  locomotor  ataxia  the  pulse-frequency  is 
likewise  habitually  increased.  In  these  conditions  the  rapidity  of  the  pulse 
may  be  continuous  or  show  itself  only  after  moderate  exertion.  In  general 
terms  it  is  proportionate  to  the  severity  of  the  disease.  Pain  often  causes 
increase  in  the  pulse-rate.  Exceptionally  slowness  of  the  pulse  occurs  in 
connection  with  very  intense  pain.    In  either  case  the  derangement  is  reflex. 

Excesses  in  alcohol,  tobacco,  coffee  and  tea,  disorders  of  digestion, 
lack  of  sleep,  other  exhausting  influences,  and  lowered  blood-pressure 
.not  rarely  produce  abnormal  pulse-frequency.  Certain  drugs,  as  atro- 
pine, have  the  same  effect. 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  467 

Tachycardia — Pycnocardia — Heart  Hurry. — The  extreme  rapidity  which 
follows  violent  exercise  or  fright  may  persist  for  days  or  weeks;  the 
rate  may  reach  160-220,  The  condition  may  occur  as  a  pure  neurosis. 
Palpitation  and  dyspnoea  are  not  always  present.  The  patient  is  often 
able  to  attend  to  his  ordinary  duties.  Tachycardia  is  one  of  the  symp- 
toms of  the  neurasthenic  at  the  menopause  and  has  been  attributed  to 
reflex  irritation  from  ovarian  or  uterine  disease.  Thite  symptom  may  be 
due  to  lesions  such  as  a  tumor  or  clot  in  or  about  the  medulla  or  pressure 
upon  the  pneumogastrics. 

Paroxysmal  tachycardia  is  a  neurosis  characterized  by  attacks  of 
greatly  increased  action  of  the  heart  occurring  at  irregular  intervals  and 
without  obvious  cause.  The  attacks  usually  begin  abruptly  and  are  of 
varying  duration,  frequently  not  exceeding  an  hour  or  two.  The  pulse- 
rate  exceeds  200  and  is  sometimes  uncountable.  Subjective  symptoms 
may  be  absent.    In  many  of  the  cases  there  is  much  distress  and  oppression. 

Diminished  Frequency — Slow  Heart. — In  many  cases  the  normal  pulse- 
rate  does  not  exceed  60.  In  some  individuals  the  pulse  may  be  slow 
under  conditions  in  which  in  others  it  is  rapid.  This  is  often  the  case 
during  the  period  of  convalescence  from  pneumonia,  enteric  fever,'  rheu- 
matic fever,  and  diphtheria.  The  pulse  is  slow  while  the  patient  is  at  rest 
but  is  accelerated  by  slight  exertion.  It  is  the  slow  pulse  of  exhaustion 
and  occurs  in  young  persons  and  at  the  close  of  uncomplicated  cases.  Tran- 
sient slowing  of  the  pulse  is  a  postcritical  symptom  in  certain  febrile 
diseases,  as  pneumonia.  If  the  pulse-frequency  remains  high  during  an 
abrupt  fall  of  temperature  in  the  course  of  croupous  pneumonia,  pseudo- 
crisis  is  to  be  thought  of.  Slow  pulse  is  encountered  in  chronic  gastritis 
and  ulcer  and  cancer  of  the  stomach.  It  occurs  in  emphysema  but  is  not 
common  in  other  affections  of  the  respiratory  system.  It  is  not  rare  in 
aortic  stenosis  but  is  infrequent  in  other  valvular  diseases  of  the  heart. 
It  is  an  occasional  but  by  no  means  constant  symptom  in  chronic  myocar- 
ditis. Toxic  agents,  as  lead,  alcohol,  tobacco,  coffee,  digitalis,  and  opium, 
produce  slowing  of  the  pulse,  and  it  occurs  in  some  cases  of  primary  and 
secondary  anaemia,  diabetes,  and  myxoedema,  especially  while  the  patient 
is  at  rest. 

Bradycardia — Brachycardia. — The  pulse-rate  falls  as  low  as  40  and 
may  be  persistently  slow.  It  is  important  to  see  that  the  arterial  pulse 
corresponds  in  frequency  with  the  cardiac  contractions.  Bradycardia 
may  be  physiological  or  pathological.  In  rare  instances  it  is  a  peculiarity 
of  normal  individuals.  During  labor,  whether  premature  or  at  term,  the 
pulse  may  fall  to  40  or  below  it.  Slow  pulse  is  one  of  the  symptoms  of 
hunger  and  exhaustion.  Cachectic  individuals  have  usually  not  only 
subnormal  temperature  but  also  low  pulse-rate.  Slowing  of  the  pulse  occurs 
in  gall-stone  colic,  in  renal  and  hepatic  colic,  and  in  lead  colic.  It  is  asso- 
ciated with  acute  but  not  necessarily  with  chronic  jaundice.  Either  the 
circulatory  mechanism  becomes  habituated  to  the  bile  intoxication  or 
the  bile  salts  are  diminished  in  amount.  Bradycardia  occasionally  occurs 
in  disease  of  the  genito-urinary  tract,  especially  in  nephritis  and  in  uraemia. 
It  is  of  special  diagnostic  importance  in  acute  cerebral  disease  associated 
with    intracranial    pressure.      It   occurs   in    various   forms    of    meningitis, 


468  MEDICAL  DIAGNOSIS. 

especially  tubercular  meningitis,  in  which  considerable  elevation  of  tem- 
perature is  sometimes  associated  with  a  slow  pulse.  Chronic  cerebral 
compression,  such  as  results  from  tumor  or  hydrocephalus,  is  not  attended 
with  bradycardia  except  during  acute  exacerbations.  Apoplexy,  the 
postepileptic  state,  disease  of  the  medulla  and  diseases  and  injuries  of  the 
cervical  cord  may  be  associated  with  a  very  slow  pulse.  Bradycardia 
occurs  in  general  paresis,  mania,  and  melancholia.  It  constitutes  the 
essential  sign  of  heart  block.  A  very  slow  pulse  is  occasionally  associated 
with  shock  and  may  follow  the  rapid  evacuation  of  large  peritoneal  or 
pleuritic  effusion.     Certain  drugs,  as  opium  and  digitalis,  cause  slow  pulse. 

Rhythm. — Under  normal  conditions  the  pulse  is  regular  or  rhythmic, 
that  is  to  say,  the  individual  pulse-waves  are  of  like  volume  and  follow 
one  another  at  equal  intervals  of  time.  Physiological  derangements  of 
rhythm  are  slight  and  transient  and  occur  under  those  physiological  con- 
ditions which  are  attended  by  changes  in  the  pulse-frequency.  Marked 
disturbances  of  rhythm — arrhythmia — are  always  pathological  and  have 
their  source  either  in  functional  derangements  of  the  heart  or  demon- 
strable lesions  of  that  organ. 

The  causes  of  the  various  disturbances  of  rhythm  are,  (a)  psychic  or 
emotional,  (b)  central  organic  disease,  as  endarteritis,  hemorrhage,  con- 
cussion, or  compression,  (c)  reflex,  such  as  produce  the  cardiac  irregularity 
in  gastro-intestinal  derangements  and  diseases  of  the  liver,  kidneys,  or 
genito-urinary  organs,  (d)  toxic,  the  common  agents  being  tea,  coffee, 
tobacco,  and  alcohol,  and  finally  (e)  changes  in  the  heart  itself,  either  in 
the  ganglia,  in  which  fatty,  pigmentary,  and  sclerotic  changes  have  been 
described,  or  in  the  heart  muscle,  derangements  in  the  rhythm  of  the  pulse 
being  very  common  in  acute  and  chronic  dilatation  and  the  forms  of  de- 
generative myocarditis  which  result  from  sclerosis  involving  the  coronary 
arteries  and  their  branches. 

There  are  in  general  two  forms  of  arrhythmia:  first,  intermission,  in 
which  heart-beats  are  dropped  at  regular  or  irregular  intervals;  second, 
irregularity,  in  which  the  heart  beats  are  unequal  in  volume  and  force  or 
follow  each  other  at  irregular  intervals.  Inequality  in  volume  and  force 
and  inequality  in  interval  are  usually  associated.  The  irregular  pulse  is 
at  the  same  time  an  unequal  pulse. 

Intermission. — There  is  dropping  of  a  pulse-beat.  A  series  of  normal 
pulsations  is  interrupted  by  a  pause  corresponding  to  the  time  occupied 
by  one  or  more  beats.  The  dropping  may  be  constant  or  occasional  and 
recur  at  regular  or  irregular  intervals;  sometimes  every  third,  fourth,  or 
fifth  beat  is  dropped,  sometimes  only  one  or  two  in  a  minute.  Heart 
dropping  occurs  in  neurasthenic  persons  and  is  very  often  unsuspected  by 
the  patient.  In  some  instances  it  is  attended  by  a  sensation  in  the  pre- 
cordia  which  the  patients  describe  as  though  the  heart  had  stumbled 
or  turned  over.  This  subjective  sensation  or  even  the  knowledge  that 
there  is  intermission  of  the  pulse  greatly  aggravates  the  sufferings  and 
distress  of  the  neurasthenic  patient,  from  whom  it  is  therefore  desirable  to 
withhold  the  information  discovered  upon  an  examination  of  the  pulse. 
This  condition  occasionally  occurs  in  individuals  apparentl}^  in  excellent 
health.     On  the  other  hand,  it  is  sometimes  a  sign  of  myocarditis  and  of 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  469 

fatty  heart.  It  may  be  a  manifestation  of  the  effects  of  over-indulgence 
in  tea,  coffee,  or  tobacco  upon  the  innervation  of  the  heart. 

Irregularity. — Several  varieties  of  this  form  of  arrhythmia  are  de- 
scribed, among  which  the  following  are  the  more  important: 

Pulsus  Paradoxus  —  Kussmaid. — ^The  beats  during  inspiration  are 
more  frequent  but  less  full  than  during  expiration.  This  pulse  may  be 
sometimes  detected  in  healthy  children  during  sleep.  It  occurs  also  in 
forms  of  cardiac  asthenia,  large  pericardial  effusion,  and  chronic  medias- 
tinitis.  It  is  not  diagnostic  of  any  particular  disease,  but  is  occasionally 
associated  with  feeble  peripheral  circulation. 

Pulsus  Alternans. — Strong  and  weak  ventricular  contractions  alter- 
nate regularly  and  are  manifested  in  the  peripheral  arteries  by  alternate 
full  and  feeble  pulse-beats. 

Pulsus  Bigeminus  and  Pulsus  Trigeminus.  —  There  are  periodical 
irregularities.  In  the  former  two  pulse-beats,  in  the  latter  three,  are  asso- 
ciated in  groups  and  are  separated  by  a  more  or  less  distinct  pause.  This 
condition  occurs  in  mitral  disease  but  cannot  be  regarded  of  diagnostic 
importance. 

Pulsus  irregularis,  the  manifestation  of  a  heart's  action  wholly  irreg- 
ular both  in  time  and  in  volume.  When  very  rapid  it  indicates  the  condi- 
tion graphically  described  under  the  term  delirium  cordis.  This  irregular 
pulse  occurs  in  valvular  disease  with  ruptured  compensation,  especially  in 
disease  of  the  mitral  valves.  It  occurs  also  in  the  acute  myocarditis  of  the 
infectious  diseases,  in  exophthalmic  goitre,  and  in  some  cerebral  affections. 

Hirschfelder,  as  a  result  of  recent  studies  of  the  irregular  pulses, 
divides  them  into  four  groups: 

L  Those  of  neurogenic  origin.  This  form  of  arrhythmia  is  observed 
in  certain  phases  of  respiration,  in  children,  in  some  cases  of  meningitis, 
and  sometimes  in  the  convalescence  from  the  acute  febrile  infections.  It 
is  not  a  primary  manifestation  of  cardiac  disturbance. 

2.  Those  due  to  diminished  contractility  of  the  heart.  The  essential 
modification  of  rhythm  consists  in  the  pulsus  alternans,  in  which  with 
regularity  in  time  there  is  irregularity  in  volume,  each  alternate  beat 
being  small.  This  form  is  observed  in  very  rapid  action  of  the  heart  and 
in  some  cases  of  angina  pectoris.  It  is  the  sign  of  insufficient  strength  and 
too  rapid  action  of  the  heart. 

3.  Those  associated  with  heart  block,  whether  organic,  as  in  the 
Adams-Stokes  syndrome,  or  due  to  myocardial  weakness  and  stimulation 
of  the  vagus,  such  as  occurs  in  conditions  following  influenza  or  diphtheria 
or  in  connection  with  tumor  pressure  upon  the  vagus. 

4.  Those  due  to  abnormal  impulses,  extrasystoles.  The  extrasystoles 
which  arise  in  the  auricles  are  of  two  kinds,  those  resulting  from  impulses 
arising  abnormally  and  those  resulting  from  the  effort  of  an  hyperti'ophied 
auricle  to  overcome  an  obstruction  as  in  mitral  stenosis.  Those  arising  in 
the  ventricles  are  often  due  to  the  inability  of  the  heart  to  empty  itself. 

Volume. — The  volume  is  the  measure  of  the  lateral  excursus  of  the 
arterial  wall  under  the  influence  of  the  pulse-wave.  If  the  expansion  is 
marked  the  volume  is  correspondingly  great  and  the  pulse  is  said  to  be 
large  or  full — pulsus  magnus.     If  the  expansion  is  slight  the  pulse  is  said 


470  MEDICAL  DIAGNOSIS. 

to  be  small — pulsus  parvus.  The  large  pulse  is  commonly  a  pulse  of  low 
tension.  It  is  encountered  in  the  early  stage  of  the  acute  febrile  diseases 
and  in  conditions  of  hypertrophy  of  the  left  ventricle,  especially  when  asso- 
ciated with  relaxation  of  the  peripheral  vessels,  as  in  aortic  insufficiency. 
The  small  pulse  Ataxies  in  tension.  If  low  it  is  the  sign  of  feeble  action  of 
the  heart  or  diminished  amount  of  blood.  It  occurs  therefore  in  cardiac 
or  general  asthenia,  in  the  later  stages  of  acute  exhaustive  diseases,  in  the 
cachexias,  and  in  terminal  conditions.  The  pulse  is  small  and  of  low  ten- 
sion in  valvular  disease  of  the  heart  with  ruptured  compensation,  and 
small  and  usually  of  good  tension  in  aortic  and  mitral  stenosis.  The  pulse 
is  small  and  tense  in  unyielding  arteries,  whether  the  condition  be  tem- 
porary and  due  to  vasomotor  stimulation,  as  occurs  during  a  chill  or  in 
a^ute  peritonitis,  or  whether  it  be  persistent  in  consequence  of  fibroid 
changes  in  the  artery  itself,  as  in  arteriosclerosis. 

Failure  of  the  Radial  Pulse  when  the  Arms  are  Elevated. — Sewell 
has  recently  called  attention  to  the  fact  that  in  a  considerable  proportion 
of  persons  one  or  both  radial  pulses  fail  at  the  wrist  when  the  arms  are 
raised  passively  above  the  head.  This  phenomenon  is  intimately  connected 
with  phases  of  the  respiration,  and  a  pulse  which  has  disappeared  during 
quiet  breathing  may  reappear  upon  vigorous  respiration.  Sewell  regards 
it  as  a  sign  of  vasomotor  activity  and  as  belonging  to  the  series  of  physio- 
logic compensations.     It  is  not  of  diagnostic  importance. 

Celerity.— There  is  an  important  distinction  between  the  frequency 
and  slowness  of  the  pulse,  by  which  we  understand  the  number  of  beats 
in  a  minute,  and  the  quickness  and  tardiness  of  the  pulse,  by  which  is 
understood  the  mode  in  which  the  pulse-wave  develops  under  the  finger. 
The  pulse  is  said  to  be  quick — pulsus  celer — when  it  is  characterized  by  a 
wave  of  rapid  ascent  and  equally  rapid  recedence.  The  quick  pulse  is  a 
pulse  of  low  tension.  It  is  encountered  when  the  peripheral  vessels  are 
relaxed,  as  in  the  fevers  and  in  various  forms  of  anaemia.  Celerity  is  char- 
acteristic of  the  water-hammer  pulse  of  aortic  insufficiency.  This  pulse 
occurs  also  in  consequence  of  the  extreme  relaxation  of  the  peripheral 
arteries  in  many  cases  of  neurasthenia.  In  these  conditions  there  is  often 
a  visible  pulsation  in  the  superficial  arteries  associated  with  capillary  and, 
in  some  instances,  with  venous  pulsation. 

The  tardy  pulse — pulsus  tardus — is  characterized  by  the  gradual  rise 
and  equally  gradual  descent  of  the  pulse-wave.  It  is  a  pulse  of  high  tension 
and  is  encountered  in  arteriosclerosis,  advanced  age,  chronic  interstitial 
nephritis,  and  in  some  instances  during  the  attacks  of  angina  pectoris. 
The  pulse  in  aortic  stenosis  and  in  arteries  peripheral  to  an  aneurism  is 
commonly  tardy. 

Tension. — This  term  includes  those  qualities  of  the  pulse  which  indi- 
cate the  arterial  blood-pressure.  On  the  one  hand  the  adjectives  hard  and 
tense  are  sometimes  used  interchangeably  in  regard  to  the  pulse, — pulsus 
durus, — while  on  the  other  hand  the  adjective  soft  is  used  synonymously 
with  relaxed — pulsus  mollis.  The  clinician  must,  however,  be  constantly 
on  his  guard  against  confounding  rigidity  of  the  arterial  wall  with  intra- 
arterial tension  or  blood-pressure.  It  is  important  also  to  distinguish 
between  the  tension  corresponding  to  the  ventricular  systole  and  that 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  471 

corresponding  to  the  ventricular  diastole.  In  chronic  nephritis  the  tension 
of  the  pulse  is  commonly  increased  both  in  systole  and  diastole.  This 
is  also  true  of  the  pulse  in  aortic  stenosis.  In  these  conditions  the  artery 
remains  well  filled  in  the  interval  between  the  pulse-waves.  In  acute 
pyrexia  the  s3^stolic  blood-pressure  commonly  is  high,  the  diastolic  low; 
that  is  to  say,  the  arterial  contents  are  diminished  and  the  walls  relaxed 
in  the  interval  between  the  pulse-waves.  In  arteriosclerosis  both  the 
systolic  and  diastolic  tension  are  high.  In  valvular  disease  with  ruptured 
compensation  the  systolic  and  the  diastolic  tension  are  low. 

High  tension  occurs  in  chronic  interstitial  nephritis,  gout,  lead  poison- 
ing, and  in  the  diabetes  of  advanced  age.  The  pulse  is  small  and  tense  in 
the  early  stages  of  acute  peritonitis.  The  pulse  tension  is  increased  in 
pregnancy  and  in  some  forms  of  anaemia. 

The  pulse  of  low  tension  is  soft  and  compressible.  It  is  a  sign  of 
cardiac  and  general  asthenia  and  occurs  in  all  forms  of  depression  and 
exhaustion.  It  is  common  in  the  later  stages  of  the  acute  febrile  infections 
and  is  characteristic  of  enteric  fever  throughout  the  greater  part  of  its 
course.  The  pulse  of  obese  persons  is  very  often  of  low  tension.  Temporary 
diminution  of  arterial  tension  may  follow  hot  drinks,  alcoholic  beverages, 
the  hot  bath,  and  accompany  the  period  of  reaction  following  great  physical 
exertion  or  mental  excitement.  The  degree  of  pulse  tension  is  often  an 
individual  peculiarity.  In  some  families  persistent  high  arterial  tension  is 
common,  in  others  the  tension  is  low,  and  these  peculiarities  may  be  trans- 
mitted by  heredity.  The  statement  is  very  often  made  that  arterial  ten- 
sion increases  with  age.  In  this  connection  the  clinician  will  do  well  to 
recognize  the  distinction  between  histological  changes  in  the  arterial  walls 
and  increase  of  intra-arterial  pressure.  When  the  diastolic  pressure  is 
relatively  high  and  the  artery  remains  well  filled  between  the  beats,  the 
pulse  is  said  to  be  full — pulsus  plenus.  When  the  pulse-wave  is  very  full 
and  quick  and  the  vessels  are  soft  and  compressible,  the  pulse  is  sometimes 
spoken  of  as  gaseous.  When  the  artery  is  collapsed  between  the  beats, 
the  pulse  is  said  to  be  empty — pulsus  vacuus,  vet  inanis.  When  the  pulse- 
wave  is  very  small  and  the  artery  relaxed,  the  pulse  is  described  as  thready, 
running,  or  undulatory. 

The  blood-pressure  —  arterial  tension  —  may  be  estimated  by  the 
fingers;  but  this  method  is  inexact  and  subject  to  many  fallacies.  More 
exact  and  definite  measurements  are  made  by  various  forms  of  sphygmo- 
manometers. 

Dicrotism. — The  occurrence  of  a  secondary  pulse-wave  in  each  arterial 
beat  is  commonly  shown  in  normal  sphygmographic  tracings.  It  is  recog- 
nized by  the  finger  only  when  fairly  well  marked.  The  conditions  which 
favor  dicrotism  are  diminished  arterial  tension,  relaxed  capillaries, — both 
of  which  are  due  to  diminished  vasomotor  tonicity, — a  sudden  forcible 
ventricular  systole,  and  relaxation  of  the  arterial  walls.  Dicrotism  may  be 
occasionally  recognized  by  the  finger  in  persons  apparently  in  good  health. 
Such  individuals  usually  manifest  a  high  degree  of  vasomotor  instability, 
are  easily  fatigued  and  bear  acute  illness  badly.  The  clinical  condition 
in  which  dicrotism  is  most  marked  is  fever.  It  is  usually  well  developed  in 
enteric  fever  from  the  beginning  of  the  second  week. 


472  MEDICAL  DIAGNOSIS. 

ANOMALIES  OF  THE  PULSE. 

The  pulse  should  be  examined  not  only  in  both  radials  but,  under 
certain  circumstances,  in  the  superficial  arteries  elsewhere.  Retardation, 
smallness,  feebleness,  or  obliteration  of  the  pulse  on  one  side  of  the  body 
or  locally  may  be  caused  by  deviations  from  normal  anatomical  standards 
or  by  traumatism,  embolism,  thrombosis,  tumor  pressure,  and  aneurism. 

If  the  pulse  be  relatively  feeble  or  small,  or  if  it  be  absent  in  the  right 
radial,  it  may  indicate  an  aneurism  of  the  ascending  aorta  or  innominate; 
in  the  left  radial,  an  aneurism  of  the  transverse  or  descending  portion  of 
the  arch;  in  a  radial  of  either  side  it  may  indicate  the  presence  on  the 
same  side  of  embolism,  thrombosis,  aneurism  of  the  subclavian,  axillary, 
or  brachial  arteries,  cervical  or  axillary  tumors  exerting  pressure  upon  the 
vessel,  and  if  slight  in  degree  may  be  suggestive  of  pneumothorax  or  large 
pleural  effusion;  in  one  femoral,  popliteal,  or  posterior  tibial  artery  the  inter- 
ference of  the  circulation  may  be  due  to  aneurism,  tumor  pressure,  embo- 
lism, or  thrombosis;  in  these  vessels  on  both  sides,  to  abdominal  aneurism 
or  congenital  obliteration  of  the  aorta.  Osier  has  called  attention  to  entire 
absence  of  pulse  in  the  femorals  as  an  occasional  sign  of  aneurism  of  the 
abdominal  aorta. 

The  Pulse  in  Different  Conditions  of  the  Heart  and  BIood= vessels. — 
Myocarditis. — In  the  various  forms  of  arteriosclerosis  the  pulse  is  usu- 
ally feeble.  It  is  sometimes,  but  not  invariably,  irregular.  It  is  com- 
monly slow,  and  not  infrequently  bradycardia  is  present,  the  pulse  falling 
as  low  as  30  or  40  per  minute.  In  fatty  heart  the  pulse  may  show  the 
same  characters.  Extreme  fatty  changes  occur,  however,  without  modi- 
fication of  the  pulse,  which  may  remain  regular  and  of  moderate  strength. 

Mitral  Stenosis. — In  the  early  stages  the  frequency  of  the  pulse  is 
not  increased.  In  fact  the  pulse  is  sometimes  slower  than  normal.  It  is 
small  and  rather  tardy,  the  artery  not  well  filled,  the  successive  beats 
irregular  in  time  and  volume. 

Mitral  Incompetence. — The  modifications  depend  upon  the  extent 
of  the  lesion  and  the  condition  of  the  left  ventricle.  The  frequency  is  in- 
creased, the  volume  and  tension  are  diminished,  the  rhythm  usually,  but 
by  no  means  constantly,  irregular. 

Aortic  Stenosis. — In  uncomplicated  cases  the  pulse  is  slow,  its  vol- 
ume diminished,  its  tension  maintained,  the  artery  being  well  filled  during 
the  ventricular  diastole.      The  pulse  of  aortic  stenosis  is  usually  regular. 

Aortic  Incompetence.- — The  large  mass  of  blood  propelled  into  the 
aorta  by  the  dilated  and  hypertrophied  left  ventricle  causes  sudden  dis- 
tention of  the  arterial  system,  which  is  followed  by  an  equally  sudden 
collapse  resulting  from  the  failure  of  the  base  of  support  to  the  column  of 
blood  normally  supplied  by  the  aortic  valves;  characteristic  and  striking 
changes  in  the  arterial  pulse  result,  and  are  manifested  in  all  the  super- 
ficial arteries.  The  pulse  is  increased  in  frequency  and  usually  regular. 
The  artery  is  suddenly  distended,  the  pulse  being  quick,  jerking,  visible, 
and  abruptly  receding.  The  pulse  is  locomotor,  that  is  to  say,  the  visible 
arteries  are  elongated  and  their  curves  accentuated.  The  jerking,  visible, 
and  collapsible  character  of  the  pulse,  as  observed  in  the  arm  and  wrist,  is 


SYMPTOMS  AND  SIGNS  :   CAPILLARY  PULSE.  473 

intensified  by  elevating  the  member  above  the  head.  Very  often  there  is 
pulsation  at  the  root  of  the  neck,  and  in  well-developed  cases  there  is  dis- 
tinct pulsation  of  the  tissues  of  the  hands  and  feet — capillary  pulse — which 
may  be  felt  by  gently  grasping  the  hand  or  foot,  placing  the  thumb  upon 
the  palmar  or  plantar  surface  and  the  fingers  upon  the  dorsal  surface. 
With  the  ophthalmoscope  pulsation  of  the  retinal  arteries  may  be  seen. 
Capillary  and  the  so-called  penetrating  venous  pulsation  also  occur. 

The  pulse  of  aortic  incompetence  is  frequently  called  the  Corrigan 
pulse,  after  Sir  Dominic  Corrigan  who  first  systematically  studied  and 
described  its  peculiarities. 

Arteriosclerosis.  —  Modifications  of  the  pulse  in  arteriosclerosis 
depend  upon  the  peripheral  resistance  and  the  force  of  the  ventricular 
systole.  Sclerosis  and  high  tension  are  usually  associated.  The  pulse- 
wave  is  tardy,  sustained,  and  subsides  slowly,  the  vessel  remaining  full 
between  the  beats — diastolic  tension.  Pressure  of  the  finger  does  not 
readily  obliterate  the  pulse.  The  anastomotic  or  recurrent  pulse  may  be 
present,  but  disappears  upon  pressure  on  the  ulnar  artery.  An  effort  must 
be  made  to  discriminate  between  the  firmness  due  to  intra-arterial  tension 
and  that  due  to  thickening  of  the  arterial  wall.  If,  when  the  pulse-wave  is 
arrested  by  the  pressure  of  the  finger,  the  artery  can  be  felt  beyond  the 
point  of  compression,  its  walls  are  thickened. 

Aneurism.^ — In  symmetrical  arteries  a  difference  in  the  time  of  the 
maximum  impulse  or  a  difference  of  volume  of  the  pulse-wave  is  more 
significant  than  the  character  of  the  pulse-wave  in  a  single  artery.  If  an 
aneurism  lies  in  the  course  of  an  artery  the  pulse-wave  is  retarded  and  its 
curves  flattened.  In  the  case  of  an  aortic  aneurism  involving  the  arch 
below  the  origin  of  the  innominate  the  pulse-wave  on  the  two  sides  is 
alike.  When  the  aneurism  involves  the  transverse  portion  of  the  arch 
between  the  innominate  and  left  subclavian,  the  right  radial  pulse  may  be 
normal,  the  left  modified.  When  the  aneurism  involves  the  innominate, 
the  right  subclavian,  or  the  right  axillary,  the  right  radial  pulse  may  show 
the  aneurismal  modifications,  the  left  remaining  normal.  If  the  aneurism 
involves  the  left  subclavian  or  left  axillary  the  right  radial  pulse  remains 
normal  and  the  left  will  be  modified. 

CAPILLARY  PULSE. 

Normally  the  pulse-waves  penetrate  to  the  smallest  arteries  but  are 
lost  in  the  capillaries.  Under  certain  circumstances,  however,  the  pulse 
is  manifest  in  the  capillaries  and  shows  itself  upon  inspection  as  a  pulsatile 
flushing  and  fading  of  the  surface.  The  capillary  pulse  may  on  the  one 
hand  be  due  to  any  of  the  causes  that  favor  the  transmission  of  the 
pulse-wave  into  the  capillaries,  and  on  the  other  to  those  which 
interfere  with  the  flow  of  the  blood  from  the  capillaries  into  the  veins. 
Conditions  which  especially  favor  the  development  of  the  capillary 
pulse  are  relaxation  of  the  peripheral  circulation  and  rapid  discharge 
of  a  large  amount  of  blood  from  the  ventricle  into  the  arterial  system — 
pulsus  celer.  Capillary  pulse  is  occasionally  seen  in  areas  of  local  hyper- 
semia  and  inflammation,  as  in  whitlow,  and  patients  often  recognize  this 


474  MEDICAL  DIAGNOSIS. 

increased  pulsation  in  the  throbbing  character  of  the  pain.  Of  greater 
interest  is  the  capillary  pulse  of  aortic  incompetence.  It  is  seen  in  the 
pulsatile  changing  in  the  color  intensity  of  the  nail-bed — subungual  pulse 
— a  phenomenon  which  becomes  more  marked  when  the  nail  is  slightly 
pressed  near  its  edge  so  that  the  underlying  tissue  is  momentarily  pale. 
The  border  line  between  the  pink  and  white  advances  and  recedes  with 
each  cardiac  revolution.  The  capillary  pulse  can  be  distinguished  in  the 
ear,  lips,  cheek,  and  especially  distinctly  upon  the  forehead  at  a  point 
where  it  is  reddened  by  light  rubbing.  The  capillary  pulse  shows  clearly 
through  a  piece  of  glass  pressed  upon  the  mucous  surface  of  the  everted 
lip.  It  is,  however,  not  confined  to  aortic  regurgitation,  but  occurs  also  in 
pyrexia,  chlorosis,  and  other  forms  of  anaemia,  neurasthenia,  and  exoph- 
thalmic goitre.  The  capillary  pulse  of  aortic  incompetency  is  more  marked 
in  stages  in  which  the  compensation  is  good  and  disappears  upon  the 
failure  of  compensation. 

VENOUS  PULSE. 

Movements  in  the  veins  caused  by  respiration  must  be  first  con- 
sidered. The  modifications  of  intrathoracic  pressure  caused  by  respiration 
are  of  importance  in  connection  with  the  venous  circulation.  Inspira- 
tion hastens,  expiration  retards  the  flow  of  blood  in  the  veins.  These 
modifications  are  not  seen  upon  ordinary  quiet  breathing.  On  the  other 
hand  in  forced  respiration  and  dyspnoea  there  is  expiratory  venous  dis- 
tention and  inspiratory  venous  collapse,  best  seen  in  the  veins  of  the 
neck,  especially  when  they  have  been  enlarged  by  previous  congestion 
and  are  therefore  more  distinctly  visible.  Even  more  marked  is  the  influ- 
ence of  the  variations  of  intrathoracic  pressure  by  violent  cough  and 
prolonged  muscular  effort.  In  individuals  in  which  these  paroxysms  of 
intravenous  pressure  recur  through  long  periods,  as  in  those  who  suffer 
from  chronic  paroxysmal  cough,  the  veins,  especially  the  jugular,  become 
permanently  enlarged  so  that  during  the  paroxysms  the  patient  is  not 
only  cj^anosed  but  manifests  a  distinct  distention  of  the  vessels  at  the  root 
of  the  neck.  The  jugular  bulb  sometimes  appears  as  a  small,  sausage-like 
swelling  in  the  region  of  the  insertions  of  the  sternocleidomastoid  muscle. 

More  rarely  distention  of  the  veins  takes  place  during  inspiration; 
retraction  upon  expiration.  This  reversal  of  the  ordinary  conditions  is 
the  result  of  mechanical  interference  by  pressure  or  traction  upon  the 
great  veins  within  the  thorax,  such  as  occurs  in  chronic  mediastinitis, 
mediastinal  tumors  or  a  large  pericardial  or  pleural  effusion, — conditions 
in  which  Kussmaul's  pulsus  paradoxus  is  frequently  observed. 

The  Forms  of  Venous  Pulse. — Pulsation  in  the  veins  is  due  to  the 
movements  of  the  heart  and  has  the  cardiac  rhythm.  A  pulsation  com- 
municated by  the  underlying  carotids  is  sometimes  seen  in  the  external 
jugular  veins.  This  is  the  so-called  false  venous  pulse.  The  distinction 
between  this  and  true  venous  pulsation  is  usually  unattended  with  diffi- 
culty. The  more  extended  superficial  pulsation  due  to  the  greater  width 
of  the  vein  and  the  peculiar,  prolonged,  undulatory  movement  which  is 
characteristic  of  the  low  intravenous  tension   are  of  importance.      Upon 


SYMPTOMS  AND  SIGNS  :   VENOUS  PULSE.  475 

light  palpation  the  pulse  is  feeble  and  compressible  and  in  strong  contrast 
to  that  elicited  upon  palpation  of  the  underlying  artery.  Upon  compression 
of  the  vein  the  peripheral  pulsation  continues  or  may  be  increased  in 
consequence  of  the  distention;  upon  compression  of  the  artery  at  the  root 
of  the  neck  the  pulsation  wholly  disappears. 

True  Venous  Pulse. — Three  forms  are  encountered:  the  physiological 
or  negative  venous  pulse,  the  regurgitant  or  positive  venous  pulse,  and  the 
penetrating  or  positive  centripetal  venous  pulse. 

(a)  Negative  Venous  Pulse. — This  form  of  pulsation  in  the  veins  is 
called  normal  or  physiological  because  it  is  constantly  seen  in  the  exposed 
veins  of  animals  and  frequently  in  the  jugulars  of  human  beings  in  health. 
It  is  not  observed  in  all  persons,  simply  because  the  jugular  veins  in  many 
individuals  are  difficult  or  impossible  to  distinguish.  It  is  very  obvious 
upon  inspection  in  those  persons  in  whom  the  veins  are  distended  and 
plainly  visible.  The  physiological  venous  pulse  is  readily  distinguished 
from  positive  or  regurgitant  venous  pulsation  by  compression  of  the  vein 
with  the  finger.  The  pulsation  peripheral  to  the  point  of  compression 
ceases,  and  that  central  to  it  likewise  disappears  or  becomes  much  fainter. 
The  diminution  or  complete  disappearance  in  the  latter  case  makes  it 
evident  that  the  pulse-waves  are  not  transmitted  to  the  blood  in  the  veins 
by  the  cardiac  systole.  It  is  thus  apparent  that  the  continuous  blood 
stream  from  the  veins  is  rhythmically  restrained  and  hastened  by  the 
action  of  the  heart.  The  negative  venous  pulse  is  observed  only  in  the 
•external  jugulars.  It  is  presystolic  in  time.  The  collapse  of  the  vein  at 
the  time  of  the  ventricular  systole  is  attributed  to  the  negative  intratho- 
racic pressure  caused  by  the  diminution  in  the  size  of  the  heart  at  that 
moment  in  its  revolution.  During  the  ventricular  diastole  the  aspiration 
influence  ceases  and  the  blood  accumulates  in  the  veins.  It  may  be 
urged  against  this  statement,  however,  that  the  venous  pulse,  central 
to  the  point  of  compression,  though  always  reduced,  does  not  in  all 
cases  wholly  disappear;  but  the  external  jugular  cannot  be  entirely 
emptied  of  blood  as  there  are  tributary  veins  central  to  the  point  of 
compression.  In  some  cases  this  form  of  venous  pulsation  can  be  still 
further  reduced  by  simultaneous  compression  of  the  subclavian.  In 
order  to  determine  the  time  of  the  venous  pulse,  which  is  diastolic, 
— presystolic, — it  must  be  compared  with  the  carotid  pulse  which  is  of 
•course  systolic.  The  negative  venous  pulse  is  without  diagnostic  signifi- 
cance. A  knowledge  of  it  is  necessary,  however,  in  order  that  it  may  be 
differentiated  from  the  form  about  to  be  described. 

(b)  Positive  or  Regurgitant  Venous  Pulse. — This  form  of  venous 
pulsation  is  observed  in  tricuspid  incompetence.  During  the  ventricular 
systole  the  blood  regurgitates  into  the  right  auricle  and  the  pulse-wave  is 
transmitted  to  the  vein.  The  pulsation  is  presystolic-systohc  rather 
than  purely  systolic,  as  in  the  case  of  the  arterial  pulse.  When  the  valve 
in  the  jugular  is  competent  the  pulsation  is  more  marked  in  the  bulb,  but 
it  does  not  always  cease  at  the  level  of  the  valve  even  when  competent. 
The  regurgitation  is  interrupted,  but  a  positive  pulse-wave  of  similar  form, 
though  weaker,  is  induced  in  the  blood  which  accumulates  above  the 
"valve.     In  some  instances  the  closure  of  the  valve  under  the  influence 


476  MEDICAL  DIAGNOSIS. 

of  the  regurgitant  blood  wave  gives  rise  to  a  sound  distinctly  audible  upon 
auscultation.  In  the  majority  of  instances,  as  a  result  of  the  over-disten- 
tion  of  the  veins,  the  valve  becomes  insufficient  so  that  the  positive  pulse 
is  equally  perceptible  over  the  upper  portion  of  the  jugular.  The  dis- 
tinction between  the  positive  and  negative  venous  pulse  rests  upon  the 
correspondence  of  the  former  with  the  carotid  pulse  and  its  persistence 
in  the  pulsating  vein  below  the  point  of  compression.  In  fact,  for  reasons 
that  are  obvious,  it  persists  or  even  becomes  more  marked  between  the 
compressing  finger  and  the  heart,  while  it  disappears  entirely  beyond  the 
point  of  compression.  As  a  rule,  positive  venous  pulsation  is  observed  only 
in  the  jugulars.  In  very  pronounced  cases,  however,  it  may  be  manifest 
in  other  superficial  veins  more  distant  from  the  heart. 

This  form  of  pulsation  is  a  sign  of  tricuspid  incompetence.  It  has, 
however,  been  observed  in  two  extremely  rare  conditions  in  which  the 
lesions  likewise  favor  the  transmission  of  the  systolic  pulse-wave  to  the 
jugular  veins,  namelj^,  mitral  incompetence  with  persistent  foramen  ovale 
and  aneurism  of  the  aorta  communicating  with  the  descending  vena  cava. 

The  patient  should  be  examined  in  the  recumbent  posture  and  during 
very  quiet  breathing.  Before  making  compression  in  the  course  of  the 
vein  the  finger-nail  should  be  placed  upon  the  vein  at  the  root  of  the  neck 
and  lightly  drawn  upward  to  empty  the  vessel.  In  the  absence  of  regur- 
gitation the  vein  refills  slowly,  but  if  the  tricuspid  valves  be  incompetent 
the  vein  quickly  refills  from  below  and  again  pulsates. 

Pulsation  of  the  Liver. — In  advanced  cases  of  tricuspid  incompetence 
the  liver  becomes  enlarged  and  the  hepatic  veins  dilated  and  engorged. 
In  this  condition  the  organ  pulsates,  the  regurgitant  wave  being  trans- 
mitted through  the  inferior  vena  cava.  The  pulsation  may  be  recognized 
upon  palpation,  one  hand  being  placed  over  the  cartilages  of  the  lower 
ribs  to  the  right  of  the  ensiform  cartilage,  and  the  other  upon  the  side  at 
the  costal  margin.  An  expansive  pulsation  of  the  entire  organ  can  be  felt 
with  each  cardiac  impulse.  In  marked  instances  liver  pulsation  may  be 
made  out  upon  inspection.  Pulsation  of  the  liver  must  be  distinguished 
from  the  jogging  of  the  organ  by  a  powerfully  acting  h3'pertrophied  heart. 
It  must  also  be  distinguished  from  the  epigastric  pulsation  of  the  abdom- 
inal aorta — dynamic  pulsation — previously  described  and  from  aneuris- 
mal  pulsation.  In  very  rare  cases  of  aortic  regurgitation,  with  good  com- 
pensation and  no  sign  of  tricuspid  incompetence,  an  arterial  liver  pulse 
has  been  noted,  and  local  pulsation  with  double  murmur  has  been  observed 
in  acute  cholangeitis. 

(c)  Penetrating  or  Positive  Centripetal  Venous  Pulse. — This 
rare  phenomenon  is  due  to  the  fact  that  under  certain  conditions  the 
pulserwave  is  not  lost  in  the  capillaries  but  transmitted  through  them  to 
the  smaller  veins.  It  has  the  same  significance  as  the  capillary  pulse  and 
occurs  in  cases  of  aortic  incompetence  or  neurasthenia  with  great  vaso- 
motor relaxation.  It  has  been  observed  in  cases  in  which  the  capillary 
pulse  has  been  faintly  perceptible  or  absent  altogether.  It  is  associated 
with  quick  arterial  pulse  of  large  volume  and  is  manifest  not  in  the  jugulars 
but  in  the  small  veins  of  the  extremities,  and  disappears  upon  compression 
in  the  central,  not  in  the  peripheral,  portion  of  the  compressed  vein. 


SYMPTOMS  AND  SIGNS  :    LIPS.  477 

In  this  connection  diastolic  collapse  of  the  cervical  veins,  the  so-called 
Friedreich's  sign,  may  be  mentioned.  This  sign  occurs  in  chronic  adhesive 
pericarditis  but  is  of  no  great  diagnostic  value.  The  collapse  of  the  veins 
is  due  to  diastolic  intrathoracic  aspiration.  The  mechanism  is  the  reverse 
of  that  in  the  physiological  venous  pulse. 


VII. 

THE  DIGESTIVE  SYSTEM:    MOUTH;    LIPS;   TEETH;    GUMS; 

TONGUE. 

THE   MOUTH. 

The  most  important  method  of  examination  is  inspection.  The 
patient  should  be  placed  in  a  good  light.  The  illumination  is  more  satis- 
factory by  light  reflected  from  a  head  mirror.  The  mouth  should  be  opened 
widely  and,  according  to  the  part  to  be  examined,  the  tongue  should  be 
protruded,  drawn  back,  or  moved  from  side  to  side.  The  soft  palate  and 
pharynx  are  best  seen  upon  depression  of  the  base  of  the  unprotruded 
tongue  with  a  spatula  or  the  handle  of  a  spoon.  These  instruments,  if 
introduced  too  far,  cause  gagging.  The  examination  of  the  posterior  wall 
of  the  pharynx  is  facilitated  when  the  patient  pronounces  the  broad  a, 
thus  elevating  the  soft  palate.  In  conditions  of  delirium  or  unconscious- 
ness and  in  insane  patients  the  examination  of  the  mouth  is  often  attended 
with  great  difficulty.  In  some  instances  holding  the  nose  will  cause  the 
patient  to  open  his  mouth;  in  others,  if  necessary,  the  patient  must  be 
anaesthetized.  In  the  case  of  children  the  examination  is  best  conducted 
when  the  physician  and  mother  or  nurse  sit  viz-a-viz,  the  body  of  the  child 
resting  upon  the  knees  of  the  latter,  who  holds  his  hands,  the  head  upon 
the  lap  of  the  former,  who  opens  the  mouth  and  depresses  the  tongue 
with  the  spatula.  The  pharynx  is  best  seen  at  the  beginning  of  gagging. 
Palpation  by  means  of  the  finger  is  very  useful  in  detecting  the  presence 
and  location  of  foreign  bodies,  the  existence  of  retropharyngeal  abscess, 
and  especially  adenoid  vegetations  in  the  nasopharynx  and  other  similar 
conditions.  This  manoeuvre,  which  is  very  annoying  to  the  patient,  must  be 
executed  rapidly.  In  the  case  of  unruly  patients  or  children  the  danger  of 
being  bitten  is  not  to  be  overlooked.  Against  this  accident  a  guard  or 
shield  may  be  employed,  or  the  physician  may,  with  the  thumb  and  finger 
of  the  free  hand,  press  the  cheeks  of  the  patient  between  the  separated 
molars. 

THE  LIPS. 

The  lips  are  thick  and  coarse  in  habitual  mouth-breathers,  in  cretin- 
ism, and  in  myxo^dema.  They  are  parted  in  conditions  of  great  prostra- 
tion and  habitually  in  idiots  and  in  some  forms  of  insanity.  They  are  palHd 
in  anaemia  and,  like  the  nail-beds,  early  show  cyanosis  and  the  variations 
in  its  intensity.    The  lips  are  apt  to  be  dry  in  dyspnoea  and  in  obstruction 


478  MEDICAL  DIAGNOSIS. 

to  the  nasal  breathing.  Dryness  of  the  lips  is  associated  with  a  diminu- 
tion or  perversion  of  the  oral  secretion,  as  in  stomatitis,  glossitis,  and  tonsil- 
litis. The  lips  and  mouth  are  dry  and  the  latter  open  in  the  soporose  con- 
dition preceding  dissolution.  There  is  drooling  in  dentition,  mercurial 
salivation,  diphtheritic  paralysis,  bulbar  palsy,  and  idiocy.  In  these  condi- 
tions the  lips  are  apt  to  be  loose  and  pendulous.  Tremor  or  twitching  of 
the  lips  occurs  under  intense  emotion  or  may  be  a  symptom  of  nervous 
disease.  Convulsive  retraction  of  the  upper  lip  occasionally  occurs  as  a 
sign  of  intense  abdominal  pain.  Of  great  diagnostic  importance  is  the 
occasional  presence  upon  the  lips  of  aphthous  ulceration,  mucous  patches, 
sordes,  rhagades — linear  clefts  or  ulcerations  at  the  corners  of  the  mouth — 
or  the  scars  resulting  from  them.  The  last,  occurring  in  young  children, 
are  suggestive  of  hereditary  syphilis.  Herpes  labialis  is  common  in  certain 
individuals  in  feverish  colds,  and  occurs  with  such  frequency  in  pneumonia, 
ague,  and  cerebrospinal  fever  as  to  have  diagnostic  value.  It  is  very 
rare  in  enteric  fever.  This  vesicular  eruption  develops  rapidly  upon  an 
inflammatory  base  as  a  single  lesion  or  in  groups,  most  commonly  upon 
the  outer  border  of  the  lip,  occasionally  on  other  parts  of  the  face,  as  the 
nose,  the  cheeks,  or  the  ear.  These  positions  are  indicated  by  qualifying 
adjectives,  as  herpes  labialis,  facialis,  nasalis,  and  the  like.  The  contents 
of  the  vesicles  are  at  first  lymphoid,  later  purulent  and  scanty.  Their 
efflorescence  is  attended  by  annoying  burning  or  itching.  They  rapidly 
undergo  desiccation  with  the  formation  of  thick,  tightly  adherent  scabs. 
The  whole  process  is  of  short  duration. 

In  paralysis  of  the  seventh  nerve  the  angle  of  the  mouth  on  the  affected 
side  is  lowered.  In  drinking,  the  liquid  is  apt  to  escape.  In  smiles  or 
laughter  the  corner  of  the  mouth  is  immobile  and  in  attempts  to  show . 
the  upper  teeth  it  is  not  raised.  The  mouth  and  lips  are  drawn  toward 
the  sound  side.  The  labial  sounds  may  not  be  fully  formed.  It  is  im- 
portant to  note  that  the  displacement  of  the  angle  of  the  mouth  may 
be  due  to  loss  of  the  teeth  upon  ttie  opposite  side  or  to  retraction  as  the 
result  of  scar  formation. 

The  lips  are  extremely  sensitive  and  abscesses  and  acute  inflammatory 
processes  are  attended  with  great  pain.  They  are  sometimes  the  seat  of 
carbuncles.  They  undergo  extensive  necrosis  in  cancrum  oris.  The 
lip  may  be  lacerated  in  the  epileptic  convulsion,  but  this  is  not  common. 
It  may  be  the  seat  of  angioneurotic  oedema  or  may  be  greatly  swollen 
in  consequence  of  the  bites  of  insects.  The  lip  is  occasionally  the  seat 
of  the  initial  lesion  of  syphilis.  It  shows  more  or  less  extensive  super- 
ficial necrosis  extending  out  upon  the  chin  or  cheeks  after  the  taking  of 
corrosive  poisons  and  especially  in  carbolic  acid  poisoning.  Epithelioma 
of  the  lip  is  common.  It  shows  itself  as  an  irregularly  circular  or  oval 
ulcer  with  a  swollen,  infiltrated  base,  usually  upon  the  lower  lip,  de- 
veloping from  a  fissure  or  wart.  At  the  beginning  there  are  alternations 
of  scab  formation  and  open  ulceration.  After  a  time  the  submaxillary 
lymphatics  become  involved. 

The  differential  diagnosis  between  chancre  and  epithelioma  of  the 
lip  is  usually  unattended  with  difficulty.  The  chancre  occurs,  as  a  rule, 
early  in  life,  epithelioma  late.     In  chancre  the  lymphatics  are  involved 


SYMPTOMS  AND  SIGNS  :   TEETH.  479 

early;  in  epithelioma  late.  Chancre  is  commonly  circumscribed  and 
densely  indurated;  epithelioma  tends  to  spread  and  the  induration  is  less 
dense.  Healing  of  the  chancre  is  progressive,  especially  under  treatment; 
in  epithelioma  there  is  a  tendency  to  extend,  with  alternations  of  scab 
formation  and  ulceration.  In  the  former,  constitutional  symptoms  and 
secondary  rashes  occur. 

THE   TEETH. 

The  teeth  are  of  diagnostic  interest.  The  time  of  their  eruption  and 
shedding  in  children  and  their  state  of  preservation  in  adults  are  to  be 
considered.  Dentition  and  teething  are  terms  used  to  describe  the  cutting 
of  the  teeth. 

The  First  Dentition. — The  temporary  or  deciduous  teeth — the  so- 
called  milk  teeth — are  twenty  in  number;  in  each  jaw  two  central  incisors, 
two  lateral  incisors,  two  canines,  two  first  molars  and  two  second  molars. 
They  appear  with  considerable  regularity  as  to  order  and  time.  Their 
eruption  usually  takes  place  in  groups  of  four. 

The  first  group — the  lower  and  upper  central  incisors,  6  to  9  months. 
An  interval  of  1  to  3  months. 

The  second  group — the  upper  and  lower  lateral  incisors,  8  to  12  months. 
An  interval  of  1  to  3  months. 

The  third  group — the  four  anterior  molars,  12  to  15  months.  An 
interval  to  the  18th  month. 

The  fourth  group — the  four  canines,  18  to  24  months.  An  interval 
of  2  to  3  months. 

The  fifth  group — the  four  posterior  molars,  24  to  30  months. 

Healthy  children  usually  have  from  four  to  eight  teeth  before  they  are 
a  year  old,  and  cut  their  first  molars  between  a  year  and  a  year  and  a  half, 
the  canines  before  the  end  of  the  second  year,  and  should  complete  denti- 
tion by  the  cutting  of  the  second  molars  before  the  middle  of  the  third 
year.  The  first  teeth  are  usually  the  lower  central  incisors.  The  upper 
lateral  incisors  as  a  rule  appear  before  the  lower;  the  upper  first  molars 
usually  precede  the  lower  and  not  infrequently  appear  at  about  the  same 
time  with  the  lower  lateral  incisors. 

Precocious  dentition  occasionally  occurs.  It  is  of  no  special  signifi- 
cance. Delayed  dentition  occurs  as  the  result  of  malnutrition  either  from 
improper  feeding  or  disease.     It  is  especially  common  in  rickets. 

The  eruption  of  the  teeth  in  healthy,  well-nourished  children  com- 
monly takes  place  without  constitutional  disturbance.  At  most  transitory 
loss  of  appetite,  fretfulness,  disturbed  sleep,  a  slight  rise  of  temperature, 
100-102°  F.  (37.7-38.8°  C),  and  derangement  of  the  bowels  are  observed. 
In  feeble  and  poorly  nourished  infants,  especially  in  neurotic  families,  the 
perturbations  caused  by  dentition  may  be  more  severe,  the  foregoing 
symptoms  being  aggravated  and  the  temperature  reaching  higher  levels, 
103-104°  F.  (39.4-40°  C).  The  accidental  coincidence  of  gastro-intestinal 
derangements,  tonsillitis,  laryngitis,  and  bronchial  catarrh  is  very  com- 
mon, and  the  physician  must  be  on  his  guard  not  to  ascribe  to  dentition 
symptoms  which  are  due  to  other  causes.  On  the  other  hand  there  is 
danger  that  reflex  symptoms  due  to  the  irritation  of  dentition  will  be 


480  MEDICAL  DIAGNOSIS. 

erroneously  interpreted.  For  example,  annoying  spasmodic  cough;  with- 
out fever,  other  constitutional  disturbance  or  rales,  and  manifestly  reflex, 
frequently  accompanies  the  eruption  of  each  group  of  teeth.  Dentition 
may  be  the  exciting  cause  of  general  convulsions  in  feeble,  badly-nour- 
ished, rhachitic,  or  neurotic  children.  The  process  rarely  causes  eclampsia 
in  well-nourished  healthy  babies.  Tension,  tumefaction,  tenderness  of  the 
gums,  and  the  bluish-red  hue  of  deep  congestion  are  indications  for  the 
use  of  the  lancet. 

The  Second  Dentition. — The  permanent  teeth  in  each  jaw  consist  of 
two  central  and  two  lateral  incisors,  two  canines,  four  bicuspids,  and  six 
molars.    Their  eruption  takes  place  in  the  following  order: 

Anterior  molars, sixth  to  seventh  year. 

Central  incisors, seventh  to  eighth  year. 

Lateral  incisors, eighth  to  ninth  year. 

Anterior  bicuspids, tenth  to  eleventh  year. 

Posterior  bicuspids, tenth  to  eleventh  year. 

Canines, eleventh  to  twelfth  year. 

Second  molars, twelfth  to  fourteenth  year. 

Third  molars — wisdom  teeth, eighteenth  to  twenty-fifth  year. 

The  milk  teeth  are  gradually  displaced  by  the  permanent  teeth  and 
three  additional  molars  appear  on  the  sides  of  each  jaw,  so  that  the  twenty 
milk  teeth  are  replaced  by  the  full  set  of  thirty-two  permanent  teeth.  The 
second  dentition  begins  with  the  eruption  of  the  anterior  molars  some- 
where between  the  fifth  and  seventh  years.  Following  these  the  milk 
teeth  are  gradually  shed  in  the  order  in  which  they  appeared,  each  tooth 
being  forthwith  or  shortly  replaced  b}^  a  permanent  tooth. 

Shape  and  Structure  of  the  Teeth. — Defects  in  the  teeth  are  numer- 
ous, the  most  important  being  abnormalities  of  form,  and  especially  the  de- 
ficient development  of  enamel.  In  badly-nourished,  feeble  children  the 
milk  teeth  are  prone  to  caries. 

The  developing  teeth  are  influenced  by  malnutrition,  stomatitis, 
especially  that  produced  by  mercury,  and  constitutional  diseases,  as 
syphilis  and  rickets.  The  developmental  defects  show^  themselves  in  the 
permanent  teeth.  In  rickets  the  teeth  may  be  small  and  badly  formed. 
As  the  result  of  infantile  stomatitis  the  surfaces  of  the  teeth  are  pitted, 
owing  to  deficient  formation  of  enamel;  the  condition  is  sometimes  im- 
properly spoken  of  as  erosion.  These  changes  affect  the  incisors  and  ca- 
nines, which  are  pitted  by  areas  of  default  of  enamel,  and  are  of  a  bad 
color,  showing  a  transverse  furrow  across  all  the  teeth  at  the  same  level; 
the  first  permanent  molars  are  also  involved.  These  furrows  are  attrib- 
uted, probably  correctly,  to  severe  illness  in  early  life  and  are  regarded  as 
analogous  to  furrows  on  the  nails  which  occur  after  serious  disease. 

Hutchinson  Teeth. — In  congenital  syphilis  the  teeth  are  deformed 
and  present  appearances  regarded  by  Hutchinson  as  specific  and  peculiar. 
The  upper  central  incisors  are  affected.  They  are  peg-shaped,  short,  and 
narrow,  being  smaller  at  the  cutting  edge  than  at  the  root.  The  enamel  is 
commonly  well  formed  and  regularly  developed,  but  the  color  is  more 
j^ellow  than  that  of  the  other  teeth.  At  the  edge  of  the  teeth  there  is  a 
single  concave  notch  of  varying  depth  in  which  the  dentin  is  exposed. 
They  are  called  Hutchinson,  notched,  or  screw-driver  teeth.    These  defects 


SYMPTOMS  AND  SIGNS  :  GUMS.  481 

are  not  constant  nor  are  they  pathognomonic  of  syphilis,  as  they  are  some- 
times found  in  other  conditions,  especially  rickets.  In  the  presence  of  other 
signs  of  syphilis — rhagades,  keratitis,  iritis,  and  nodes — notched  teeth  ac- 
quire positive  diagnostic  importance. 

Caries. — Carious  and  neglected 
teeth  play  a  very  important  part 
in  the  causation  of  derangements  of 
digestion  from  imperfect  mastica- 
tion, and  are  themselves  not  rarely 
the  result  of  constitutional  disturb- 
ances. Extensive  and  rapid  dental 
caries  may  occur  after  serious  acute 

disease    and   in    constitutional    dis-  Fig.  i98-Hatchinson's  teeth. 

orders  as  rickets  and  diabetes.     It 

also  occurs  in  pregnancy.  The  teeth  become  loose  in  forms  of  stomatitis 
associated  with  swollen  and  ulcerated  gums,  such  as  are  encountered  in 
mercurial  ptyalism,  scurvy,  purpura,  and  phosphorus  poisoning.  Receding 
gums  with  exposure  of  the  neck  of  the  teeth  and  their  ultimate  loss 
occur  from  neglected  salivary  deposits,  pyorrhoea  alveolaris,  and  gouty 
conditions. 

Sordes — literally  filth — is  a  term  applied  to  collections  of  dark  brown 
foul  matter  upon  the  teeth  and  lips  in  low  fevers.  It  consists  of  food, 
epithelial  material,  and  altered  blood,  and  contains  micro-organisms  in 
great  numbers. 

THE  GUMS. 

The  gingival  mucous  membrane  is  pale  in  all  forms  of  anaemia;  it  is 
red  and  spongy  when  the  teeth  are  carious  or  ill-kept.  A  narrow  red  line 
along  the  margin  is  seen  in  some  cases  of  tuberculosis,  diabetes,  and  in 
cachectic  states;  also  in  alveolar  disease.  The  gums  are  red,  spongy,  and 
ulcerated  as  a  result  of  accumulated  tartar  and  gangrenous  and  mercurial 
stomatitis.     They  are  swollen,  spongy,  and  bleeding  in  scurvy. 

In  lead  poisoning  a  narrow  bluish-black  line  is  seen,  although  not 
invariably,  at  the  margin  of  the  gums.  The  color  is  not  uniform,  but, 
being  due  to  lead  sulphide  deposited  in  the  papillae  of  the  gums,  is  seen 
with  the  magnifying  glass  to  be  stippled.  This  line  may  form  rapidly 
after  exposure  and  disappear  in  the  course  of  a  few  weeks  under  treatment, 
or  it  may  persist  for  months.  It  is  usually  limited  in  extent.  A  similar 
line,  due  to  the  deposition  of  carbon  particles,  has  been  observed  in  miners. 
Such  lines  are  to  be  distinguished  from  the  deposits  of  black  matter  upon 
the  teeth  at  the  line  of  their  juncture  with  the  gums  in  untidy  persons  and 
smokers  who  neglect  the  mouth.  The  latter  disappears  upon  the  use  of  the 
tooth-brush,  or  the  two  lines  may  be  differentiated  by  slipping  the  corner 
of  a  piece  of  writing-paper  under  the  gum.  If  the  pigment  material  is  in 
the  gum  it  stands  out  plainly  against  the  white  paper;  that  on  the  tooth 
is  not  seen.  It  is  under  certain  circumstances  also  to  be  distinguished 
from  cyanosis  due  to  general  disturbances  of  the  circulation  or  local  in- 
flammatory processes.  In  cyanosis  the  discoloration  is  uniform  and  more 
intense  at  the  edges  of  the  gums  and  disappears  under  pressure. 

31 


482  MEDICAL  DIAGNOSIS. 

THE  TONGUE. 

Great  differences  of  opinion  exist  in  regard  to  the  value  in  diagnosis 
of  signs  presented  by  the  tongue.  To  the  careful  observer  an  exami- 
nation of  the  tongue  yields  information  of  diagnostic  importance.  This 
organ  should  be  studied  with  reference  to  its  motility,  size,  condition  of 
the  mucous  membrane  as  regards  color,  papillae,  dryness,  moisture,  coat- 
ing, and  the  presence  or  absence  of  various  lesions. 

(a)  Motility. — The  manner  in  which  the  tongue  is  protruded  upon 
request  is  often  suggestive.  Under  ordinary  circumstances  the  movement 
is  commonplace  and  familiar.  In  very  ill  patients  the  tongue  is  protruded 
slowly  and  incompletely.  In  the  advanced  stages  of  enteric  fever  the 
patient  protrudes  his  tongue  hesitatingly  and  does  not  immediately  with- 
draw it  unless  requested.  In  chorea  the  tongue  is  thrust  out  with  a  pecu- 
liar jerk  and  immediately  withdrawn.  In  well-marked  cases  it  is  impos- 
sible for  the  patient  to  keep  it  out  for  any  length  of  time.  Spasm  of  the 
muscles  of  mastication  renders  it  impossible  to  protrude  the  tongue.  The 
spasm  may  be  tonic  or  clonic;  in  rare  instances  it  occurs  as  an  independent 
affection.  It  is  usually  part  of  general  convulsive  disease.  In  the  tonic 
form  the  jaws  are  held  forcibly  together — lockjaw.  The  masseter  and 
temporal  muscles  are  tense  and  hard  and  the  spasm  is  frequently  attended 
with  pain.  It  is  an  early  and  prominent  symptom  in  tetanus  and  occurs 
also  in  tetany.  There  is  tonic  spasm  of  the  jaw  muscles  in  trismus  neona- 
torum and  strychnia  poisoning  and  sometimes  in  hysteria  and  epilepsy. 
Trismus  may  follow  exposure  to  cold  or  occur  as  the  result  of  reflex  irri- 
tation in  diseases  of  the  mouth,  teeth  or  jaw  or  of  irritative  lesion  in  the 
region  of  the  motor  nucleus  of  the  fifth  nerve.  Clonic  spasm  of  the  muscles 
of  the  jaw  is  seen  in  the  chattering  of  the  teeth  which  occurs  after  exposure 
to  cold,  in  some  conditions  of  mental  excitement,  and  during  a  chill.  Its 
rare  occurrence  as  a  substantive  affection  has  been  noted.  Pain  and 
swelling  of  the  tissues  about  the  angle  of  the  jaw,  such  as  attend  disease  of 
the  bones,  mumps,  suppurative  tonsilhtis,  and  trichinosis  involving  the 
masticatory  muscles,  may  prevent  the  opening  of  the  mouth  and  pro- 
trusion of  the  tongue. 

General  tremor  of  the  tongue  occurs  in  alcoholism  and  in  conditions 
of  asthenia.  Tremor  and  fibrillary  contractions  are  observed  in  patients 
presenting  bulbar  symptoms  with  atrophy  of  the  tongue  and  may  be  espe- 
cially pronounced  in  progressive  bulbar  atrophy.  Fibrillary  contrac- 
tions are  occasionally  seen  in  healthy  individuals. 

Paralysis  of  the  tongue  results  from  disease  of  the  hypoglossal  nerves. 
When  one  nerve  is  involved  the  base  of  the  tongue  is  slightly  higher  upon 
the  paralyzed  side,  and  motion  within  the  mouth  toward  that  side  is 
impaired.  When  the  tongue  is  protruded  it  deviates  to  the  paralyzed  side, 
being  pushed  by  the  geniohyoglossus  on  the  normal  side;  there  is  slight 
difficulty  in  chewing  and  swallowing.  When  both  hypoglossal  nerves  are 
involved  the  tongue  cannot  be  moved  within  the  mouth  and  cannot  be 
protruded;  mastication  and  articulation  are  greatly  impaired.  Palsy  of 
the  tongue  from  nuclear  disease  is  usually  associated  with  a  similar  condi- 
tion of  the  lips,  pharynx,  and  larynx.    The  power  of  protruding  the  tongue 


SYMPTOMS  AND  SIGNS  :   TONGUE.  483 

is  impaired  in  paresis,  diphtheritic  palsy,  progressive  muscular  atrophy, 
and  some  forms  of  hemiplegia.  Slight  deviation  toward  the  paralyzed 
side  may  occur  in  cases  of  hemiplegia  in  which  the  face  is  affected. 
When  the  fibres  of  the  hypoglossal  are  involved  within  the  medulla  after 
leaving  their  nuclei,  there  may  be  paralysis  of  the  tongue  on  one  side 
and  paralysis  of  the  limbs  on  the  other,  and  the  tongue  w^hen  protruded 
deviates  toward  its  sound  side.  Other  causes  of  nuclear  or  infranuclear 
lesions  of  the  hypoglossal  are  lead  poisoning,  basal  meningitis,  and  tumors 
of  the  base. 

Spasm  of  the  tongue  is  very  rare.  It  may  be  unilateral  or  bilateral 
— tonic  or  clonic.  It  is  usually  one  of  the  manifestations  of  some  other 
convulsive  disease,  as  spasm  of  the  facial  muscles,  tetanus,  epilepsy,  or 
chorea.  Tonic  spasm  may  occur  in  hysteria  and  as  the  result  of  reflex 
irritation  of  the  fifth  nerve.  The  tongue  is  contracted  and  rigid.  Clonic 
spasm  is  much  more  common.  Spasm  of  the  lingual  muscles  occurs  in 
stuttering.  It  is  an  occasional  symptom  in  disseminated  sclerosis,  general 
paresis,  and  melancholia.  There  are  cases  of  paroxysmal  clonic  spasm  in 
which  the  tongue  is  thrust  out  and  drawn  in  as  often  as  forty  or  fifty  times 
a  minute.  In  this  affection  the  spasm  is  usually  bilateral;  the  attacks 
may  occur  during  sleep. 

The  frsenum  of  the  tongue  may  be  abnormally  short — a  congenital 
defect  which,  by  limiting  the  movements  of  the  tongue,  interferes  with 
nursing  in  the  new-born  and  with  articulation  later. 

(b)  Size  of  the  Tongue. — Variations  in  the  size  of  the  tongue  are  of 
diagnostic  importance.  The  tongue  is  slightly  enlarged  and  flabby  in 
various  conditions  of  ill  health  and  especially  in  chronic  gastritis,  forms  of 
anaemia,  scurvy,  and  typhus  fever.  Under  these  circumstances  the  edges 
are  indented  by  the  teeth. 

Enlargement  of  the  tongue,  or  macroglossia,  is  usually  congenital  but 
may  occur  in  later  life.  In  the  congenital  form  the  tongue  and  very  often 
the  lips  are  greatly  enlarged  by  an  increase  in  all  the  tissue  elements,  an 
increase  in  the  fibrous  tissue  alone,  or  from  the  development  of  tumor-like 
masses — true  lymphangioma.  The  organ  may  become  so  large  that  it 
projects  beyond  the  teeth,  in  some  cases  attaining  twice  its  normal  size. 
The  surface  is  dry,  fissured,  or  ulcerated  from  contact  with  the  teeth,  and 
deformity  of  the  bony  structures  results  from  pressure.  The  lymph-vessels 
are  dilated  and  in  some  instances  there  are  actual  cysts. 

Great  enlargement  takes  place  in  acute  inflammation  of  the  tongue, 
such  as  glossitis,  inflamed  ranula,  erysipelas,  angina  Ludovici.  The  tongue 
is  frequently  much  enlarged  in  actinomycosis.  One  side  only  may  be 
involved  in  the  inflammatory  process — hemiglossitis.  The  tongue  is  some- 
what enlarged  in  acromegaly  and  myxcedema.  Localized  swelling  may  be 
caused  by  tumors,  as  gumma  or  carcinoma.  The  tongue  in  rare  instances 
becomes  cyanosed  and  oedematous  from  obstruction  to  the  return  of  the 
venous  blood. 

Diminution  in  the  size  of  the  tongue  may  be  the  result  of  a  temporary 
shrinking  or  of  atrophy.  The  tongue  may  be  uniformly  diminished  in 
size  after  hemorrhage,  during  convalescence  from  enteric  fever,  or  in  con- 
ditions of  advanced  emaciation. 


484  MEDICAL  DIAGNOSIS. 

Atrophy  of  the  tongue  is  the  result  of  disease  in  the  path  of  the  hypo- 
glossal nerve.  If  the  lesion  be  supranuclear  there  is  no  wasting  of  the 
tongue.  There  may  be  some  degree  of  paralysis.  Ordinarily  this  condi- 
tion constitutes  an  element  of  hemiplegia.  In  nuclear  or  infranuclear 
paralysis  the  tongue  is  atrophied  on  one  or  both  sides  according  as  the 
lesion  is  unilateral  or  bilateral.  The  muscular  tissue  is  alone  affected, 
ordinary  sensation  and  taste  remaining  practically  normal.  The  reaction 
of  degeneration  is  present  in  the  wasted  half  of  the  tongue. 

Facial  hemiatrophy  is  usually  associated  with  hemiatrophy  of  the 
tongue  on  the  same  side.  Local  diminution  in  the  size  of  the  tongue  may 
follow  the  resorption  of  a  gumma  or  extensive  scar  formation  following  a 
deep  ulcer. 

(c)  Mucous  Membrane. — The  color  of  the  organ  itself  is  to  be  dis- 
tinguished from  the  coating.  The  tongue  is  pale  in  anaemia;  red  in  in- 
flammation, as  glossitis  and  stomatitis,  and  in  the  infectious  diseases,  as 
measles,  scarlatina,  and  enteric  fever;  dark  red  in  conditions  of  prostra- 
tion; bluish  in  cyanosis;  yellow  in  jaundice.  It  is  stained  various  colors 
by  ingested  articles — red  or  purple  by  fruits  or  wine,  black  by  iron,  bis- 
muth, or  charcoal,  yellow  by  rhubarb,  tobacco,  or  licorice  root,  brown  by 
chocolate  and  opium.  Ingestion  of  corrosive  substances  may  give  rise  to 
staining  with  superficial  necrosis.  Ammonia,  corrosive  sublimate,  sul- 
phuric, carboKc,  and  oxalic  acids  turn  the  tongue  white;  hydrochloric, 
nitric,  chromic,  and  picric  acids  yellow;  the  caustic  alkalies  turn  it  red. 
Local  discoloration  of  the  tongue  is  caused  by  telangiectatic  patches, 
purpura,  ecchymoses,  and  infarcts.  Patches  of  pigmentation  may  mark 
the  site  of  healed  glossitis  or  occur  as  manifestations  of  Addison's  disease. 
In  the  latter  condition  the  color  is  bluish-  or  grayish-black  and  the  areas  of 
pigmentation  are  associated  with  similar  areas  of  pigmentation  upon  the 
buccal  mucous  membrane  and  the  lips.  The  "black  tongue"  or  nigrities 
is  a  rare  affection  of  parasitic  origin.  It  is  characterized  by  irregular 
areas  of  blackish-brown  or  black  color,  with  enlargement  of  the  papillae, 
which  occupy  the  middle  of  the  dorsum  of  the  tongue.  The  discoloration 
begins  as  a  small  spot  and  extends;  after  a  time  desquamation  occurs 
which  goes  on  slowly.  The  condition  may  become  chronic.  It  is  to  be 
distinguished  from  staining  of  the  tongue  caused  by  iron,  bismuth,  and 
the  like,  and  from  purposeful  discoloration  in  malingering. 

Moisture. — The  normal  tongue  owes  its  moisture  to  the  buccal  secre- 
tions and  saliva.  A  physiological  increase  of  these  secretions  occurs  in 
hunger  and  is  excited  by  the  sight  or  odor  of  food.  Such  an  increase  is 
also  promoted  by  sapid  and  stimulating  substances  and  by  mastication. 
It  is  called  salivation  or  ptyalism.  It  occurs  during  dentition,  menstrua- 
tion in  some  instances,  often  during  pregnancy — usually  in  the  early 
months  but  sometimes  throughout  the  whole  period.  Jaborandi  and  its 
alkaloid  pilocarpine,  muscarine,  tobacco,  mercury,  gold,  copper,  and  the 
iodine  compounds  excite  an  increased  flow  of  saliva.  A  pathological  in- 
crease of  saliva  occurs  in  forms  of  glossitis  and  stomatitis,  especially  that 
induced  by  mercury,  sometimes  in  the  fevers,  in  the  epileptic  paroxysm, 
and  in  some  forms  of  idiocy  and  nervous  disease.  It  has  been  observed 
in  disease  of  the  pancreas. 


SYMPTOMS  AND  SIGNS  :   TONGUE.  485 

Xerostomia — dry  mouth — is  a  condition  characterized  by  arrest  of 
the  sahvary  and  buccal  secretions.  The  condition  is  rare.  It  was  first 
described  by  Jonathan  Hutchinson.  The  tongue  is  red,  dry,  and  fissured; 
the  buccal  mucous  membrane  is  smooth  and  dry.  Movements  of  the  parts 
involved  in  articulation,  mastication,  and  deglutition  are  attended  with 
difficulty.  In  some  cases  the  dryness  extends  to  the  nostrils  and  eyes  and 
is  accompanied  by  distressing  itching.  Slight  enlargement  of  the  salivary 
glands  has  been  observed  but  is  not  constant;  most  of  the  cases  occur  in 
women  of  neurotic  constitution.  In  a  case  under  my  observation  in  a 
woman  aged  thirty  this  condition  developed  during  the  convalescence 
from  an  attack  of  epidemic  influenza.  It  has  been  suggested  that  the 
disease  is  due  to  involvement  of  a  hypothetical  centre  controlling  the 
salivai'y  and  buccal  secretions. 

Dryness  of  the  tongue  occurs  in  mouth-breathing,  with  thirst,  after 
violent  exertion,  in  febrile  and  septic  states,  conditions  of  profound  pros- 
tration, and  as  the  result  of  loss  of  fluid  in  diabetes  mellitus  and  insipidus. 
It  is  an  important  symptom  of  atropine  poisoning,  and  attends  facial 
paralysis.  Dryness  of  the  tongue  occurs  under  other  conditions  attended 
with  extreme  loss  of  fluid  from  the  body,  as  in  hemorrhage  and  cholera. 

The  papillae  of  the  tongue  are  often  swollen,  giving  it  a  warty,  granu- 
lar appearance.  This  condition  is  seen  in  catarrhal  and  other  forms  of 
stomatitis,  in  some  forms  of  chronic  gastritis,  and  sometimes  in  the  acute 
febrile  infections.  The  enlarged  fungiform  papillae  of  the  tongue  in  scarlet 
fever  have  given  rise  to  the  unfortunate  term  "strawberry  tongue,"  which 
by  some  teachers  is  understood  to  mean  a  tongue  covered  with  a  white 
fur  through  which  the  tip  of  the  papillae  show,  and  by  others  to  mean  the 
rough  bright  red  tongue  which  follows  the  separation  of  the  coating.  The 
latter  is  sometimes  called  the  "raspberry  tongue."  In  conditions  of  pros- 
tration, such  as  attend  the  later  stages  of  infections  or  sepsis,  and  in  some 
constitutional  diseases,  as  diabetes,  the  tongue  sheds  its  epithelium  and 
the  papillae  undergo  atrophy.  This  condition  is  usually  attended  with 
dryness  and  glossing  of  the  surface.  The  papillae  at  the  border  of  the 
tongue  are  sometimes  greatly  enlarged  in  gouty  individuals.  Patients  are 
occasionally  alarmed  upon  the  discovery  of  the  large  circumvallate  papillae 
at  the  root  of  the  tongue  and  hesitatingly  accept  the  assurance  that  they 
are  normal. 

Coating  of  the  Tongue. — This  subject  involves  a  consideration  also 
of  the  general  condition  of  the  mucous  membrane  as  regards  color,  dry- 
ness and  moisture,  and  the  condition  of  the  papillae.  The  presence  or 
absence  of  coating  is  determined  by  local  and  constitutional  conditions. 
It  does  not  follow,  as  is  very  often  assumed,  that  the  condition  of  the 
tongue  is  directly  dependent  upon  the  condition  of  the  mucous  membrane 
of  the  stomach.  On  the  contrary  the  diagnostic  significance  of  coated 
tongue  will  be  best  understood  by  the  clinician  who  realizes  the  fact,  of 
which  there  is  abundant  clinical  demonstration,  that  the  condition  of  the 
tongue  as  regards  coating  and  allied  phenomena  is  largely  dependent  upon 
constitutional  influences  which  are  likewise  exerted  upon  other  mucous 
surfaces.  Coating  of  the  tongue  occurs  in  many  morbid  conditions,  es- 
pecially dyspeptic  states  and  in  fevers,  and  is  usually  associated  with  loss 


486  MEDICAL  DIAGNOSIS. 

of  appetite;  yet  there  are  healthy  individuals  with  good  appetite  whose 
tongue  is  constantly  furred.  A  coated  tongue  is  present  in  acute  and 
chronic  gastric  catarrh,  while  on  the  other  hand  gastric  ulcer  is  very  often 
accompanied  by  a  clean  tongue  and  good  appetite.  The  coating  or  fur  is 
composed  of  accumulated  epithelium  and  food  detritus  and  contains  great 
numbers  of  micro-organisms.  The  immediate  cause  of  the  extraordinary 
proliferation  and  accumulation  of  epithelial  elements  is  not  well  understood. 
That  the  absence  of  coating  is  not  merely  dependent  upon  mechanical  con- 
ditions associated  with  drinking  and  the  ingestion  of  food  is  clearly  shown 
by  clinical  experience.  The  coating  of  the  tongue  like  its  mucous  membrane 
is  very  often  stained  by  articles  of  food  and  drink  or  by  drugs. 

Coating  of  the  Tongue  in  Local  and  General  Conditions. — (a)  Local- 
ized COATING  of  the  tongue  results  from  the  irritation  of  a  tooth  and  sur- 
rounds traumatic  and  other  circumscribed  lesions. 

(b)  UisnLATERAL  COATING  of  the  tougue  is  sometimes  seen  in  trifacial 
neuralgia  involving  the  infra-orbital  branch.  It  may  occur  also  in  uni- 
lateral palsy  of  the  tongue. 

(c)  A  UNIFORM  THIN,  WHITISH  COATING  is  habitual  to  many  persons 
in  health,  especially  mouth-breathers,  smokers,  and  those  who  are  troubled 
by  subacute  catarrhal  processes  involving  the  pharynx  and  stomach.  It 
occurs  also  in  constitutional  disturbances  attended  by  slight  fever. 

(d)  A  THiCKisH,  PASTY,  YELLOW- WHITE  FUR  is  commou  in  those  ad- 
dicted to  excesses  at  table  or  in  tobacco  or  alcohol.  It  is  attended  with  a 
disagreeable  taste.  On  rising  it  usually  involves  the  greater  portion  of  the 
dorsum  of  the  tongue,  but  disappears  in  part  or  wholly  during  the  day. 
In  many  persons  this  coating  remains  upon  the  back  part  of  the  tongue 
continuously.  Its  disappearance  is  to  some  extent  due  to  movements  of 
the  tongue,  friction  against  the  teeth,  the  mechanical  effects  of  food  and 
drink,  and  increased  flow  of  salivary  and  buccal  secretions.  A  slightly 
enlarged,  flabby,  indented  tongue  covered  with  fur  of  this  kind  very  often 
accompanies  chronic  gastritis. 

(e)  A  THICK,  UNIFORM,   MOIST,  WHITISH  OR  YELLOWISH-WHITE  COATING 

with  abrupt  edges  is  seen  in  the  early  stages  of  the  acute  febrile  diseases. 
In  consequence  of  the  diminished  amount  and  altered  character  of  the 
salivary  and  buccal  secretions,  this  coating  presently  loses  its  moisture 
and  becomes  dry  and  darker  in  color.  After  a  time  it  separates,  leaving 
the  tongue  moist  and  of  normal  appearance  if  convalescence  has  begun, 
or  dry,  hard,  red  or  brown,  and  denuded  of  epithelium  if  the  fever  con- 
tinues and  particularly  if  the  patient  falls  into  the  so-called  typhoid  condi- 
tion. Under  these  circumstances  the  tongue  becomes  fissured  both  longi- 
tudinally and  transversely.  In  some  cases  a  deep  median  fissure  forms, 
on  each  side  of  which  there  is  a  thick,  rough,  dry,  brownish  fur,  the  tip  and 
edges  of  the  tongue  being  red  and  denuded;  or  again  the  tongue  may  be 
dry,  red,  and  glazed.  It  is  protruded  upon  request  tremulously  and  slowly 
and,  owing  to  the  accompanying  mental  condition,  is  not  immediately 
withdrawn.  The  disappearance  of  the  crusty  coating,  the  redevelopment 
of  epithelium,  and  the  return  of  moisture  are  favorable  signs.  The  tongue 
may  be  dry,  brown,  and  incrusted  in  the  last  stages  of  chronic  diseases  of 
the  nervous  system,  and  in  cancer,  nephritis,  and  pulmonary  tuberculosis. 


SYMPTOMS  AXD  SIGNS  :   TOXGUE.  487 

(f)  The  thick  white  fur  of  the  acute  febrile  diseases  is  sometimes 
penetrated  by  the  greatly  enlarged  filiform  j^apillse  which  appear  as  scat- 
tered bright  red  minute  points.  This  constitutes  one  of  the  forms  of  so- 
called  "strawberry  tongue."  It  occurs  with  some  frequency  in  scarlet 
fever,  but  is  not  diagnostic  of  that  disease,  since  it  may  be  present  in 
other  acute  febrile  infections. 

(g)  A  DENSE,  WHITE,  FLAKY  COATING  is  sometimes  seen  upon  the 
tongue  of  patients  who  are  fed  upon  an  exclusive  milk  diet.  A  somewhat 
similar  appearance  may  be  presented  by  children  suffering  from  thrush — 
a  condition  caused  by  saccharomyces  albicans,  which  begins  on  the  tongue 
in  the  form  of  slightly  elevated  pearly  white  spots  which,  by  increase  in 
size  and  coalescence,  may  cover  the  greater  part  of  the  dorsum  of  the 
tongue. 

(h)  General  hypertrophy  of  the  papill.e  gives  rise  to  a  peculiar 
appearance  which  suggests  coarse  plush.  This  is  the  shaggy  tongue.  It  is 
seen  in  gastro-intestinal  and  constitutional  diseases  in  advanced  life,  but  is 
sometimes  present  in  elderly  people  whose  health  is  good.  The  shaggy 
tongue  is  frequently  also  fissured,  the  plush-like  surface  being  divided  by 
conspicuous  deep  longitudinal  and  transverse  lines  of  separation.  The 
color  is  usually  deep  red.  Upon  the  supervention  of  acute  illness  it  quickly 
becomes  dry,  hard,  and  full,  usually  remaining  rough. 

A  red,  dry  tongue,  denuded  of  epithelium,  glistening  and  resembling 
raw  beef — the  beefy  tongue — occurs  in  dysentery  and  chronic  intestinal 
catarrh.    It  is  seen  also  in  hepatic  abscess. 

Other  conditions  of  the  tongue  may  be  of  diagnostic  importance: 
fissures,  ulcers,  mucous  patches  and  plaques,  tumors,  and  cicatrices. 

(a)  Fissures  of  the  tongue  are  often  seen  in  healthy  persons  in  ad- 
vanced life.  They  may  be  the  signs  of  a  superficial  chronic  glossitis  caused 
by  habitual  use  of  tobacco  or  irritating  food  or  drink.  The  median  longi- 
tudinal fissure  is  commonly  the  most  marked  and  readily  becomes  ulcer- 
ated. Transverse  fissures  are  common.  Sometimes  the  fissures  are  forked 
or  curved.  Fissures  may  be  deep  and  inflamed,  the  result  of  extending 
glossitis — dissecting  glossitis — or  syphilis.  Fissures  are  common  in  chronic 
hepatic  disease,  chronic  colitis,  and  diabetes  mellitus.  Local  fissures  or 
notches  at  the  edge  of  the  tongue  may  arise  from  the  irritation  of  a  broken 
or  carious  tooth  or  from  syphilitic  ulceration. 

(b)  Ulcers  of  the  Tongue. — Simple  excoriations  occur  as  the  result  of 
slight  traumatism  or  scalding,  or  spontaneously  in  dyspeptic  conditions. 
Aphthous  stomatitis  is  characterized  by  small,  slightly  depressed  spots 
with  grayish  bases  and  bright  red  mai-gins.  They  occur  at  the  edges  and 
tip  of  the  tongue,  on  the  frsenum,  and  elsewhere  about  the  mucous  mem- 
brane of  the  lips  and  mouth.  The  ulcers  are  preceded  by  vesicles  and  are 
-attended  with  great  pain.  The  buccal  secretions  are  increased.  The  ulcers 
may  appear  singly  or  in  series  or  crops.  They  occur  in  transient  gastric 
derangements  and  in  women  at  the  menstrual  period.  There  is  an  indi- 
vidual predisposition  to  them. 

A  chronic,  recurrent  herpetic  eruption  of  the  buccal  mucous  mem- 
brane, sometimes  associated  with  erythema  multiforme,  has  been  observed 
in  neurotic  persons. 


488  MEDICAL  DIAGNOSIS. 

Riga's  disease  is  an  affection  occurring  about  the  time  of  the  first 
dentition  and  characterized  by  a  pearly  white  pseudomembrane  beneath 
the  tongue  and  upon  the  frsenum,  with  induration  and  ulceration.  It  is 
endemic  and  sometimes  epidemic  in  Southern  Italy. 

Superficial  ulcers  with  a  red  glazed  surface  occur  upon  the  tongue  in 
various  forms  of  chronic  glossitis.  They  are  of  irregularly  round  or  oval 
shape  with  infiltrated  edges  and  are  usually  extremely  painful.  Ulceration 
of  the  tongue  is  commonly  attended  with  salivation.  Tuberculosis  of  the 
tongue  shows  itself  in  the  form  of  circumscribed,  indolent,  irregularly 
extending  ulceration  with  a  necrotic  or  caseous  base.  The  edges  are  usually 
sHghtly  infiltrated  but  sharply  defined.  This  ulcer  is  extremely  painful 
upon  contact  and  is  sometimes  attended  by  salivation.  The  lesions  may 
be  single  or  multiple  and  are  usually  secondary  to  tuberculous  disease  of 
the  lungs.  The  glands  at  the  angle  of  the  jaw  are  not  usually  enlarged. 
Syphilis  is  a  common  cause  of  ulceration  of  the  tongue.  In  secondary 
syphilis  superficial  and  linear  ulcers  are  common  at  the  border  of  the 
tongue  as  the  result  of  the  irritation  of  the  teeth.  A  single  ulcer  with  an 
indurated  base  and  enlargement  of  the  cervical  glands  may  be  the  initial 
lesion  of  syphilis.  A  mucous  patch  may  undergo  ulceration,  and  in  later 
syphilis  a  gumma  may  become  necrotic,  forming  a  deep  foul  ulcer.  In 
some  instances  difficulty  attends  the  differential  diagnosis  of  a  single 
ulcer,  which  may  be  due  to  tuberculosis,  syphilis,  or  maHgnant  disease. 
The  resemblances  upon  inspection  and  palpation  may  be  very  close. 
In  the  first  there  are  usually  evidences  of  tuberculosis  of  the  larynx  or 
lungs  and  the  presence  of  tubercle  bacilli  in  the  scrapings.  In  cases  not 
otherwise  to  be  determined  inoculation  experiments  should  be  performed. 
In  the  initial  lesion  of  syphilis  the  induration  is  dense  and  circumscribed. 
The  age  and  habits  of  the  patient  are  to  be  taken  into  consideration.  Great 
enlargement  and  tenderness  of  the  lymphatics  of  the  neck  constitute  im- 
portant symptoms.  The  evolution  of  the  process  and  the  development  of 
mucous  patches,  cutaneous  rashes,  fever,  and  the  like  make  the  diagnosis 
clear.  In  gummatous  ulceration  the  enlarged  surface  is  greater  and  the 
infiltration  less  dense.  The  therapeutic  test  is  important;  the  ulcer  heals 
under  antisyphilitic  treatment.  A  carefully  taken  clinical  history  sheds 
light  upon  a  doubtful  case.  In  epithehoma  of  the  tongue  the  diagnosis 
may  be  reached  by  exclusion.  The  process  tends  to  spread,  the  sub- 
lingual lymphatics  become  involved,  the  ulcer  is  foul  and  indolent,  and 
the  patient  is  almost  always  past  middle  age. 

The  ulcer  frequently  observed  on  the  frsnum  of  the  tongue  in  whoop- 
ing-cough is  traumatic.  It  results  from  the  violent  impact  of  the  under 
surface  of  the  tongue  against  the  sharp  lower  incisors  during  the 
paroxysm. 

(c)  Mucous  Patches  and  Plaques,  —  The  multiple  grayish-white 
superficial  lesions  of  syphilis  known  as  mucous  patches  occur  upon  the 
tongue  as  well  as  upon  the  soft  palate,  cheeks,  and  lips.  A  sHghtly 
raised,  smooth,  red,  oval-shaped  area  sometimes  seen  in  the  middle  of 
the  dorsum  of  the  tongue  in  pipe  smokers  is  known  as  the  smoker's 
patch.  The  surface  is  smooth  and  sometimes  white  or  pearly  white  in 
appearance. 


SYMPTOMS  AND  SIGNS  :   TONGUE.  489 

Xanthelasma  occasionally  appears  upon  the  sides  of  the  tongue  in  the 
form  of  yellowish,  soft,  slightly  raised,  oblong  patches.  It  occurs  in  vari- 
ous conditions  but  is  noticeably  frequent  in  chronic  jaundice  and  diabetes. 

Leucoplakia  is  a  condition  characterized  by  the  development  of  irreg- 
ular white  or  pearly-white  smooth  patches  upon  the  tongue  which  show 
no  tendency  to  ulcerate.  They  are  hard  to  the  touch  and  gradually 
extend,  sometimes  becoming  papillomatous.  These  patches  may  be  the 
starting-point  of  epithelioma.  The  condition  is  described  under  various 
terms,  as  buccal  psoriasis,  ichthyosis  and  keratosis  mucosce  oris.  They 
present  some  points  of  similarity  to  the  lesions  of  syphilitic  glossitis, 
which  is,  however,  more  common  at  the  edge  and  tip  of  the  tongue  than 
on  the  dorsum  and  yields  to  antisyphilitic  medication. 

Eczema  of  the  tongue — geographical  tongue.  This  condition  is  char- 
acterized by  the  formation  of  irregularly  annular  patches  upon  the  tongue. 
There  is  desquamation  of  the  epithelium.  The  process  is  attended  with 
burning  and  itching.  The  patches  extend  at  the  margins  with  new  forma- 
tion of  epithelium  in  the  centre.  The  borders  are  slightly  red  and  well 
defined  but  without  induration.  The  condition  is  more  common  in  infants 
and  children  than  in  adults.    The  process  is  recurrent  and  protracted. 

(d)  Tumors  of  the  Tongue. — Solid  tumors  of  the  tongue  are  usually 
tuberculous  or  syphilitic.  They  invade  the  substance  of  the  organ,  usually 
presenting  toward  its  dorsal  surface.  Tuberculous  nodules  break  down, 
promptly  giving  rise  to  an  indolent  ulceration  with  caseation.  Gummata 
rapidly  undergo  extensive  necrosis  but  yield  to  treatment.  Retention 
cysts  occur  in  connection  with  the  tongue.  Ranula  is  the  most  common; 
it  is  due  to  an  obstruction  and  dilatation  of  a  duct  of  the  sublingual  or 
submaxillary  glands.  Mucous  cysts  also  occur.  Echinococcus  cysts, 
which  develop  as  a  rule  by  preference  in  highly  vascular  structures,  are  rare 
in  the  tongue. 

(e)  Cicatrices.  —  Scars  upon  the  tongue  tell  the  tale  of  former 
traumatism,  as  the  accidental  biting  of  the  tongue,  a  fall  or  blow  upon 
the  chin  when  the  tongue  is  between  the  teeth,  or  the  grinding  of  the 
teeth  during  the  clonic  convulsions  of  epilepsy.  They  may  be  the  indica- 
tions of  former  active  diseases,  especially  syphilis.  Sclerosis  of  the  tongue 
with  local  deformity  is  a  common  result  of  the  healing  of  gummatous 
ulceration. 

The  buccal  mucous  membrane  is  commonly  implicated  in  infections 
involving  the  other  organs  of  the  mouth,  especially  the  various  forms  of 
stomatitis.  It  is  very  often  the  starting-point  of  the  progressive  gangre- 
nous affection  known  as  noma  or  cancrum  oris. 


490  MEDICAL  DIAGNOSIS. 


VIII. 

THE  DIGESTIVE  SYSTEM  (CONTINUED):     THE  PALATE: 
TONSILS;   PHARYNX. 

The  passage  from  the  mouth  to  the  oesophagus  by  wa}'  of  the  pharynx 
is  called  the  fauces  or  isthmus  faiicium.  It  is  bounded  above  by  the  soft 
palate,  laterally  b}^  the  palatine  arches  and  tonsils,  and  below  by  the  base 
of  the  tongue.  These  structures  are  covered  with  mucous  membrane  con- 
tinuous with  that  of  the  mouth  and  are  liable  to  the  same  morbid  processes. 
An  inspection  of  these  parts  yields  information  of  importance  in  the  diag- 
nosis of  local  and  constitutional  disease.  Infection  may  take  place  di- 
rectl}^  or  by  extension  from  the  mouth  and  nasopharynx.  Forms  of  angina 
— simplex,  follicular,  suppurative,  and  diphtheritic — result.  When  the 
tonsils  are  principally  or  alone  involved  the  condition  is  spoken  of  as 
tonsillitis.  The  underlying  muscular  structures  may  be  involved  by 
extension.  The  tonsils  and  adjacent  lymph  structures  are  points  of  inva- 
sion for  the  infecting  agents  in  rheumatism  and  other  affections.  There  are 
forms  of  acute  tonsillitis  that  are  essentially  rheumatic.  In  children  the 
articular  manifestations  of  rheumatic  fever  and  chorea  frequently  show  a 
definite  relationship  to  tonsillitis  and  the  latter  affection  is  not  rarely 
followed  by  endocarditis  and  chorea.  The  tonsils  ma}-  be  the  port  of 
invasion  for  tuberculosis  or  the  seat  of  tuberculous  lesions. 

Subacute  and  chronic  pharyngeal  inflammation  may  be  secondary 
to  gastric  disorders  or  to  the  gouty  diathesis.  The  pharynx  is  sometimes 
involved  in  rheumatism.  Paralysis  of  the  soft  palate  and  spasm  and 
paralysis  of  the  pharynx  occur.  Superficial  ulceration  of  the  pharjmx 
is  very  common  in  advanced  pulmonar}'    tuberculosis. 

General  redness  of  the  faucial  mucous  membrane  occurs  in  simple 
inflammations  and  in  many  of  the  specific  febrile  affections,  as  rotheln, 
the  variolous  diseases,  influenza,  and  erysipelas.  In  the  exanthemata, 
especially  measles,  scarlatina,  varicella,  and  variola,  there  are  efflorescences 
corresponding  to  the  cutaneous  eruptions.  In  these  situations  the  pocks 
of  varicella  and  variola,  owing  to  the  action  of  warmth  and  moisture, 
lose  their  roof  in  the  vesicular  stage  and  are  converted  into  small  cir- 
cular or  oval  superficial  ulcerations  with  purulent  or  necrotic  bases  and 
a  more  or  less  marked  areola.  Redness  of  the  mucous  membrane  in  this 
region  is  a  symptom  of  chronic  gastritis  or  the  action  of  certain  drugs,  as 
the  iodine  compounds  and  belladonna,  and  of  corrosive  poisons. 

Hemorrhage  occurs  into  the  mucous  membrane  in  the  form  of  petech- 
ise,  infarcts,  and  extravasations,  and  there  is  bleeding  from  these  surfaces 
in  general  hemorrhagic  states.  These  tissues  are  pallid  in  the  anaemias, 
3'ellow  in  jaundice,  and  show  a  bluish  tint  in  cyanosis.  The  mucous 
patches  of  syphiHs  may  be  seen. 

Pain  is  a  prominent  symptom  in  angina,  especially  in  the  acute  forms. 
It  may  be  spontaneous,  but  is  excited  by  the  movements  of  deglutition 
and  bv  contact  of  articles  of  food  and  drink  with  ulcerated  surfaces.     Pain 


SYMPTOMS  AND  SIGNS  :   PALATE.  491 

and  tickling  referred  to  the  pharynx  may  be  symptomatic  of  acute  rhini- 
tis. These  symptoms  are  common  in  hay  fever.  Sensations  of  dryness 
and  tickhng  accompanied  by  the  inchnation  to  hawk  and  clear  the  throat 
are  constant  symptoms  of  pharyngitis.  Annoying  hawking  is  especially 
excited  by  disease  of  the  nasopharynx. 

Dysphagia  is  common.  It  varies  in  degree  and  may  be  due  to  pain  or 
to  mechanical  obstruction.  When  dysphagia  is  marked  both  these  causes 
are  commonly  operative.  In  suppurative  tonsillitis  and  retropharyngeal 
abscess  dysphagia  may  be  complete.  It  is  a  symptom  of  the  various  forms 
of  stomatitis  and  glossitis  as  well  as  of  tonsiUitis  and  pharyngitis.  Painful 
dysphagia  referred  to  the  pharynx  is  a  common  symptom  in  cases  showing 
no  signs  of  inflammation  of  the  mucous  membrane — rheumatic  pharyngitis. 
The  angina  which  attends  diphtheria,  scarlet  fever,  measles,  varicella,  and 
variola  is  accompanied  by  dysphagia  which  is  often  distressing. 

Dyspnoea  may  become  an  important  symptom  in  suppurative  tonsil- 
litis, retropharyngeal  abscess,  and  erysipelas  extending  to  the  pharynx. 

Chronic  interference  with  respiration  accompanied  by  mouth-breath- 
ing results  from  hyperplasia  of  the  tonsils  and  especially  from  hyperplasia 
of  the  pharyngeal  tonsil — adenoid  vegetations.  In  severe  acute  angina  and 
in  certain  chronic  diseases  involving  the  tonsils  and  pharynx,  as  cancer 
and  forms  of  syphilis,  the  drainage  of  the  fauces  is  interfered  with  and  the 
accumulating  secretions  and  exudates  undergo  decomposition.  The  odor 
of  the  breath  may  be  intense,  fetid,  and  disgusting.  Accumulations  of 
epithelial  cells,  leucocytes,  and  bacteria  in  the  tonsillar  crypts  are  very 
common  in  chronic  lacunar  tonsillitis  and  in  individuals  presenting  no 
other  symptoms  of  disease  of  the  throat.  They  appear  as  small  white  or 
yellowish-white  concretions  which  sometimes  undergo  calcareous  changes. 
They  ai-e  sometimes  expectorated  and  should  be  removed  by  the  curette. 
They  impart  a  disagreeable  odor  to  the  breath. 

THE  PALATE. 

Developmental  deformities  do  not  fall  within  the  scope  of  this  work. 
A  narrow,  high,  arched  palate  is  regarded  as  among  the  stigmata  of  degen- 
eration. Circumscribed  ulceration  of  the  mucous  membrane  of  the  hard 
palate  is  frequently  met  with  in  the  new-born  or  may  be  caused  in  artifi- 
cially-fed children  by  the  irritation  of  the  rubber  nipple.  The  ulceration 
thus  caused  is  sometimes  described  under  the  term  Bednar's  aphtha.  In 
young  children  patches  of  thrush  are  not  uncommon  upon  the  hard  palate. 
Abscess  formation  attended  with  great  pain  occasionally  involves  the 
mucous  membrane  of  the  hard  palate  in  connection  with  alveolar  disease. 
Perforations  occur  as  the  result  of  syphilis. 

The  soft  palate  in  health  is  freely  movable  and  symmetrical.  The 
form  of  the  uvula  varies  in  different  persons.  As  a  result  of  defective 
development  it  is  sometimes  bifid.  It  may  be  attached  laterally  to  the 
soft  palate  or  tonsil  or  to  the  posterior  wall  of  the  pharjmx  in  consequence 
of  adhesive  inflammation  in  diphtheria  or  syphilis.  Perforation  of  the 
soft  palate  is  almost  always  the  result  of  syphilis.  In  very  rare  instances 
it  has  followed  scarlet  fever.     The  uvula  varies  in  length  normally.     It 


492  MEDICAL  DIAGNOSIS. 

frequently  becomes  elongated  in  angina  and  bronchitis.  Under  these 
circumstances  it  causes  irritation  of  the  base  of  the  tongue  and  excites 
cough,  especially  in  the  recumbent  posture;  the  mechanical  violence  of 
intense  paroxysmal  cough  elongates  the  uvula  and  thus  a  vicious  circuit 
is  established.  It  becomes  elongated  and  cedematous  in  cases  of  debility, 
anaemia,  and  anasarca.  When  greatly  oedematous  the  uvula  becomes 
globular  and  may  attain  the  size  of  a  cherry,  interfering  with  swallowing 
and  breathing  and  producing  a  constant  disposition  to  hawk.  In  consti- 
tutional hemorrhagic  states  submucous  extravasation  of  blood  may  occur 
in  the  uvula.  In  very  rare  instances  crops  of  vesicles  resembling  herpes 
show  themselves  upon  the  palate. 

Anaesthesia  of  the  hard  and  soft  palate  and  of  the  anterior  two-thirds 
of  the  tongue  occurs  in  lesions  of  the  sensory  division  of  the  fifth  nerve. 
The  tactile  sense  is  usually  lost  before  the  pain.  The  palate  is  innervated 
by  the  accessory  nerve  to  the  vagus.  Paralysis  of  the  soft  palate  occurs  in 
bulbar  palsy,  basal  tumors,  and  meningitis  of  the  base.  By  far  the  most 
common  cause  is  postdiphtheritic  neuritis.  Upon  inspection  while  the 
patient  pronounces  the  long  a  the  palate  and  uvula  are  thrown  back  and 
elevated.  Under  normal  circumstances  the  extent  of  this  movement  is 
the  same  on  both  sides.  In  unilateral  paralysis  movement  upon  the  af- 
fected side  is  greatly  diminished.  In  bilateral  paralysis  the  whole  palate 
remains  relaxed  and  motionless,  the  voice  has  a  nasal  character,  the  pro- 
nunciation of  certain  consonants — gutturals — is  impaired,  and  upon  attempts 
to  swallow,  liquids  are  returned  through  the  nose.  Lesions  involving  the 
nerve-supply  of  one  side  cause  unilateral  paralysis. 

THE  TONSILS. 

The  tonsils,  also  called  amygdalce  from  their  almond  shape,  lie  at  the 
side  of  the  pharynx  between  the  anterior  and  posterior  palatine  folds. 
They  are  larger  in  childhood  than  in  adult  Hfe  and  early  undergo  senile 
involution.  The  greater  part  of  their  surface  is  exposed  to  inspection  by 
ordinary  methods.  Upon  gagging  they  are  rotated  forward.  In  inflamma- 
tion the  mucosa  is  reddened  and  swollen  and  the  surface  covered  with  a 
mucoid  or  mucopurulent  secretion  which  may  be  tinged  with  blood.  In 
follicular  or  lacunar  tonsilHtis  this  secretion  develops  in  the  crypts,  pro- 
ducing whitish-yellow  spots.  These  may  by  extension  and  coalescence 
form  patches  upon  the  tonsils  presenting  a  superficial  resemblance  to  diph- 
theria. The  pseudomembrane  thus  formed  is  not  usually  distinctly  mar- 
ginate  and  corresponds  in  appearance  to  the  points  of  exudate  seen  to 
occupy  adjacent  crypts.  It  is  not  developed  in  the  mucosa  but  lies  upon  it, 
as  may  be  seen  upon  removing  it  by  wiping  or  gentle  scraping.  A  pseudo- 
membranous exudate  frequently  forms  in  the  course  of  various  infections, 
as  scarlet  fever,  measles,  pertussis,  enteric  fever,  and  variola.  In  a  great 
majority  of  these  cases  the  Streptococcus  pyogenes  is  the  active  organism. 
As  a  rule  the  development  of  this  form  of  pseudomembrane  does  not 
constitute  a  serious  complication  of  the  primary  disease.  It  may,  how- 
ever, give  rise  to  an  intense  angina  with  local  sloughing  and  grave  con- 
stitutional disturbance.     A  general  streptococcus  infection  is  by  no  means 


SYMPTOMS  AND  SIGXS  :    PHARYXX.  493 

infrequent.  A  pseudomembranous  exudate  occurs  in  its  most  typical  form 
as  a  manifestation  of  diphtheria.    It  is  caused  by  the  Klebs-Loffler  bacillus. 

In  suppurative  tonsillitis  or  quinsy  one  or  both  tonsils  may  be  in- 
volved. The  earliest  symptoms  are  those  of  an  ordinary  acute  angina — 
pain,  dryness,  dysphagia,  with  fever  and  other  symptoms  of  constitutional 
disturbance.  The  tonsils  are  enlarged,  dusky  red,  and  oedematous.  They 
may  even  meet,  or  if  one  only  is  involved  it  may  extend  some  distance 
beyond  the  median  Hne.  In  many  instances  there  is  salivation.  The  breath 
is  foul,  the  glands  of  the  neck  enlarged,  and  the  patient  opens  his  mouth 
only  partially  and  with  great  difficulty.  After  suppuration  occurs  fluctua- 
tion may  be  felt. 

Enlargement  of  the  tonsils  is  common  in  children.  It  may  be  due  to 
repeated  attacks  of  acute  tonsillitis  or  to  a  chronic  inflammatory  process 
leading  to  a  hj'perplasia  of  the  lymphoid  elements.  The  tonsillar  crypts 
are  enlarged.  In  some  cases  a  probe  may  be  introduced  to  the  depth  of  a 
centimetre  or  more.  Partial  or  complete  adhesions  of  the  anterior  pillars 
to  the  tonsils  are  seen,  and  these  structures  are  sometimes  thin,  red,  and 
stretched  by  the  enlargement  of  the  tonsil.  In  some  instances  the  tonsils 
are  dense  and  firm,  the  connective-tissue  stroma  predominating.  Enlarge- 
ment of  the  tonsils  is  very  often  associated  with  adenoid  vegetations  in 
the  pharyngeal  vault.  Mouth-breathing  and  its  concomitant  derange- 
ments accompany  this  condition.  Ulceration  of  the  tonsils  is  not  very 
common.  In  syphilis  the  primary  chancre  has  occurred  upon  the  tonsils. 
In  secondary  syphilis  mucous  patches  are  very  common  in  this  region,  and 
in  the  tertiary  stage  gumma  may  give  rise  to  enlargement  of  the  tonsil 
and,  upon  breaking  down,  result  in  deep  circular  ulceration  with  a  necrotic 
base  and  little  hypersemia  of  the  surrounding  tissue.  Tuberculous  ulcera- 
tion of  the  tonsils  is  not  common. 

THE  PHARYNX. 

This  organ  may  be  divided  into  an  upper  portion — the  nasopharynx — 
and  a  lower  portion — the  oropharynx.  The  former  may  be  examined  by 
palpation  with  the  finger  or  by  the  rhinoscopic  mirror;  the  latter  by  direct 
inspection  in  a  good  light.  Small  foreign  bodies,  as  fish-bones  or  a  beard 
of  wheat,  may  be  recognized  upon  inspection;  larger  foreign  bodies,  as  an 
artificial  denture  or  fragment  of  meat  or  bone,  by  inspection  or  palpation. 
The  presence  of  adenoid  vegetations  due  to  hyperplasia  of  the  pharyngeal 
tonsil  may  be  thus  determined.  Papillomatous  masses  sometimes  fill  the 
vault  of  the  pharynx,  extending  into  the  posterior  nares  and  greatly  inter- 
fering with  respiration.  By  occluding  the  orifices  of  the  Eustachian  tubes 
they  cause  deafness  and  middle-ear  disease. 

Cyanosis  and  Pulsation. — Cyanosis  of  the  pharyngeal  mucosa  may 
result  from  general  derangements  of  the  circulation  or  respiration  or  from 
local  causes,  as  obstruction  to  the  return  flow  of  the  blood  by  way  of  the 
superior  vena  cava,  from  aneurism  or  from  mediastinal  tumor.  In  aortic 
regurgitation  pulsation  of  the  capillary  vessels  may  be  seen  or  unilateral 
pulsation  may  be  the  manifestation  of  a  tortuous  internal  carotid  artery 
or  aneurism  of  that  vessel.    In  the  oozing  that  takes  place  from  the  pharynx 


494  MEDICAL  DIAGNOSIS. 

in  intense  congestion  or  hemorrhagic  states  the  blood  may  be  swallowed 
and  accumulate  in  the  stomach.  If  vomited  the  hemorrhage  may  be 
attributed  to  a  lesion  of  the  stomach.  This  error  of  diagnosis  may  be 
avoided  by  careful  inspection  of  the  pharynx. 

Pharyngitis. — In  acute  inflammation  of  the  oropharynx  the  mucosa 
is  congested  and  reddened.  The  patient  complains  of  tickling  and  dryness 
with  a  constant  desire  to  hawk.  The  secretions  are  diminished  and  al- 
tered. There  is  dryness  with  thin  flakes  or  a  whitish  exudate,  to  be  seen 
only  upon  close  examination.     The  constitutional  symptoms  are  slight. 

Rheumatic  angina  is  characterized  by  sore  throat  and  dysphagia 
referred  to  the  pharynx.  In  the  majority  of  the  cases  the  signs  upon  in- 
spection are  not  distinctive. 

Chronic  pharyngitis  may  develop  insidiously  or  as  the  result  of  re- 
peated acute  attacks.  The  mucosa  is  at  first  reddened  and  shows  dis- 
tended vesicles;  later  it  is  relaxed  and  presents  a  granular  or  warty  appear- 
ance— granular  pharyngitis,  due  to  hyperplasia  of  the  lymph  elements. 
The  secretion  is  mucoid  or  purulent  and  undergoes  desiccation,  forming 
dry  crusts  or  scales  which  very  often  communicate  an  offensive  odor  to  the 
breath.  The  process  extends  into  the  nasopharynx.  There  is  very  often 
a  free  mucoid  or  mucopurulent  secretion  which  gives  rise  to  the  sensation 
of  dropping  or  trickling  into  the  throat  and  causes  hawking.  In  other 
cases  the  secretion  is  slight  and  the  mucous  membrane  reddish-brown,  dry, 
atrophic,  smooth  and  glistening — 'pharyngitis  sicca.  The  pseudomembra- 
nous exudate  of  diphtheria  frequently  extends  into  the  pharynx;  the  exudate 
of  pseudodiphtheritic,  diphtheroid,  or  diplococcus  inflammation  commonly 
appears  upon  the  tonsils  and  does  not  as  a  rule  involve  the  pharynx. 

Ulceration  of  the  pharyngeal  wall  is  not  uncommon.  Limited  areas  of 
superficial  ulceration  occur  in  chronic  pharyngitis.  Small  round  or  oval 
ulcers  upon  the  posterior  wall  are  sometimes  seen  in  enteric  fever.  Irregu- 
lar superficial  patches  of  ulceration  are  frequently  seen  in  the  later  stages 
of  consumption.  The  bases  are  necrotic  and  grayish-yellow.  The  ulcera- 
tion may  involve  the  greater  part  of  the  posterior  pharyngeal  wall  and 
cause  intensely  painful  dysphagia.  Ulceration  of  the  pharyngeal  wall 
occurs  also  in  syphilis.  In  the  secondary  stage  it  is  very  often  superficial 
and  associated  with  mucous  patches.  In  the  tertiary  stage  it  results  from 
the  breaking  down  of  gummata  which  heal  satisfactorily  under  treatment, 
leaving  white  cicatrices. 

Ulceration  of  the  pharynx  may  occur  in  connection  with  the  various 
forms  of  pseudomembranous  inflammation  and  attends  cancer  and  lupus. 
The  etiological  diagnosis  of  ulceration  of  the  pharynx  is  frequently  attended 
with  difficulty.  As  in  the  case  of  the  tongue,  tubercle,  cancer,  and  syphilis 
are  to  be  differentiated.  A  careful  anamnesis  is  important.  The  asso- 
ciated clinical  phenomena  are  very  often  characteristic.  In  tuberculosis 
the  presence  or  absence  of  tubercle  bacilli  and  the  inoculation  test  are 
important;  in  syphilis  the  therapeutic  test. 

Acute  phlegmonous  inflammation  of  the  pharynx  may  result  from 
traumatism  or  foreign  bodies  in  the  pharynx. 

Acute  infectious  phlegmon,  a  rare  condition,  characterized  by  anginal 
symptoms,  dysphagia,  rapid  abscess  formation,  swelling  of  the  neck,  and 


SYMPTOMS  AND  SIGNS  :    CESOPHAGUS.  495 

severe  constitutional  symptoms,  may  result  from  direct  traumatism, 
the  injury   caused   by  foreign  bodies,   or   arise   spontaneously. 

Retropharyngeal  abscess  manifests  itself  upon  inspection  and  palpa- 
tion as  a  projecting  fluctuating  tumor  upon  the  posterior  wall  of  the  pharynx 
in  the  median  line.  Attendant  phenomena  are  restlessness,  dysphagia,  and 
changes  in  the  voice,  which  becomes  nasal  or  metallic  as  the  result  of  pres- 
sure. Retropharyngeal  abscess  is  a  rare  affection.  It  has  been  observed 
in  children  previously  in  apparent  good  health  as  a  sequel  of  the  infectious 
diseases,  particularly  scarlet  fever  and  diphtheria,  and  in  caries  of  the 
cervical  vertebrae. 

Angina  Ludovici :  Ludwig's  Angina  ;  Cellulitis  of  the  Neck. — A  rap- 
idly developing  phlegmonous  inflammation  of  the  tissues  about  the  floor  of 
the  mouth  is  described  under  these  names.  It  apparently  results  from 
trauma  or  some  lesion  about  the  roots  of  the  teeth  or  from  infection  of  the 
submaxillary  gland.  It  may  occur  as  the  result  of  secondary  infection  in 
the  specific  fevers,  particularly  diphtheria  and  scarlet  fever.  The  inflamma- 
tion is  the  result  of  streptococcus  infection.  Swelling  usually  appears  first 
in  the  submaxillary  region  of  one  side  and  rapidly  spreads,  with  diffuse 
dull  redness  and  brawny  induration  of  the  neck.  The  tendency  is  to  speedy 
suppuration  and  extensive  gangrene  with  general  septicaemia.  The  disease 
is  rare  and  very  fatal. 

The  innervation  of  the  pharynx  is  derived  from  the  pharyngeal  plexus, 
formed  by  the  combination  of  the  glossopharyngeal  and  branches  of  the  vagus. 

Spasm  of  the  pharynx  is  a  functional  disorder.  It  is  common  in  neuro- 
pathic individuals.  It  is  the  cause  of  ordinary  gagging  and  occurs  in  hydro- 
phobia and  as  a  convulsive  manifestation  of  hysteria — globus  hystericus. 

Motor  palsy  of  the  pharynx  occurs  in  postdiphtheritic  neuritis,  acute 
ascending  paralysis,  and  bulbar  paralysis.  It  may  result  from  lesions  at 
the  base  of  the  brain.  It  is  commonly  bilateral.  There  is  difficulty  in 
swallowing  and  food  is  not  properly  passed  into  the  oesophagus.  Particles 
of  food  may  pass  into  the  larynx  and,  when  there  is  associated  paralysis 
of  the  soft  palate,  into  the  posterior  nares.  Fluids  are  regurgitated 
through  the  nose.     In  unilateral  lesions  the  power  of  deglutition  remains. 

Anaesthesia  of  the  pharynx  is  produced  by  bromidism  and  the  local 
application  of  cocaine. 


IX. 

THE  DIGESTIVE  SYSTEM  (CONTINUED):  THE  CESOPHAGUS. 

The  upper  limit  of  this  organ  is  about  at  the  level  of  the  cricoid  car- 
tilage and  opposite  the  sixth  cervical  vertebra.  It  terminates  in  the  car- 
diac orifice  of  the  stomach  opposite  the  upper  border  of  the  body  of  the 
eleventh  thoracic  vertebra.  It  has  a  short  infradiaphragmatic  course  of 
about  one  and  a  half  centimetres.  It  begins  about  six  inches — fifteen  cm. 
— from  the  incisor  teeth,  is  about  nine  and  a  half  inches — twenty-four  cm. 
— in  length,  and  varies  from  three-fourths  to  one  and  a  fourth  inch — two 
to  three  cm. — in  diameter,  the  narrowest  parts  being  at  the  commence- 


496  MEDICAL  DIAGNOSIS. 

ment,  in  the  middle,  where  it  is  crossed  by  the  left  primary  bronchus,  and 
at  its  point  of  entrance  into  the  stomach.  The  oesophagus  is  in  relation 
with  the  trachea,  the  left  bronchus,  the  thyroid  body,  the  peribronchial 
lymph-glands,  the  pneumogastric  and  recurrent  laryngeal  nerves,  the 
aorta,  the  azygos  vein,  the  thoracic  duct,  and  the  pericardium  and  pleurae. 
Nearly  its  whole  course  is  in  the  posterior  mediastinum. 

The  principal  methods  of  examination  are  auscultation,  direct  inspec- 
tion of  the  interior  of  the  oesophagus,  the  use  of  the  sound,  and  the  Ront- 
gen  rays.  Ordinary  inspection,  palpation,  and  percussion  are  of  no  prac- 
tical value,  although  the  first  two  of  these  methods  may  reveal  a  tumor 
upon  the  left  side  of  the  neck  when  there  is  a  diverticulum  or  new  growth  in 
the  cervical  portion. 

Auscultation.  —  Upon  auscultation,  the  stethoscope  being  placed  to 
the  left  of  the  ensiform  cartilage  or  to  the  left  of  the  spine  opposite  the 
tenth  rib,  a  gurgling  sound  may  be  heard  six  seconds  after  the  act  of  swal- 
lowing, as  determined  by  the  movement  of  the  larynx.  This  murmur  is 
due  to  the  propulsion  of  the  liquid  or  bolus  of  food  into  the  stomach  and 
is  not  to  be  confounded  with  the  sound  to  be  heard  over  the  cervical  part 
of  the  oesophagus  during  swallowing.  The  absence,  delay,  or  prolongation 
of  the  first-named  sound  is  evidence  of  obstruction  at  the  lower  end  of  the 
oesophagus. 

OEsophagoscopy.  —  Direct  inspection  may  be  practised  through  a 
suitable  tube  or  instrument  with  proper  illumination.  The  mucosa  in 
acute  inflammation  is  reddened,  swollen,  and  lax;  in  chronic  inflammation, 
grayish-white,  covered  with  a  viscid  mucus,  and  shows  dilated  veins.  The 
instrument  may  be  used  as  a  sound  to  determine  the  presence  or  absence 
of  dilatation  or  narrowing.  Ulceration,  new  growths,  and  cicatrices  may 
be  recognized,  and  fragments  of  ulcerated  tissue  have  been  removed  through 
the  cesophagoscope  for  examination.  Foreign  bodies  may  be  located  and 
have  been  removed  by  instruments  passed  through  the  tube  when  their 
removal  by  ordinary  methods  has  proved  impracticable. 

The  (Esophageal  Sound.  —  The  ordinary  rubber  tube  used  in  the 
examination  and  treatment  of  diseases  of  the  stomach  may  be  utilized  or 
oesophageal  bougies  especially  made  for  the  purpose.  The  latter  are  of 
whalebone  or  narrow  blades  of  metal  with  rounded  edges  and  provided 
with  adjustable  olive-shaped  tips  made  of  hard  rubber,  ivory;  or  metal  and 
of  various  sizes.  The  sound  is  introduced  in  the  same  manner  as  the 
stomach  tube.  It  may  pass  directly  into  the  stomach  or  be  arrested  by 
some  obstruction.  The  location  of  the  stenosis  can  be  readily  deter- 
mined by  measuring  the  distance  from  the  teeth  upon  withdrawing 
the  instrument.  No  force  is  to  be  used.  Feeble  and  ansemic  patients 
may  faint  during  this  examination  and  neurotic  or  hysterical  indi- 
viduals may  have  local  spasm  or  even  general  convulsions.  Under 
such  circumstances  the  instrument  should  be  immediately  withdrawn. 
Sounding  must  be  performed  with  due  caution,  since  there  is  the 
danger  of  injury  or  perforation  of  the  wall  of  the  oesophagus,  the  rup- 
ture of  an  aneurism,  or  the  laceration  of  the  varicose  veins  of  the  oesopha- 
geal plexus  in  atrophic  cirrhosis.  By  the  use  of  the  sound  the  location  of 
strictures,   dilatations,  diverticula,   ulceration  or  at  least  areas  of  sensi- 


SYMPTOMS  AND  SIGNS:    (ESOPHAGUS.  497 

tiveness,  and  the  presence  or  absence  of  foreign  bodies  and  their  location 
may  be  learned.  The  careful  use  of  this  instrument  yields  information  as  to 
whether  or  not  a  stricture  is  dilatable  or  rigid  and  unyielding. 

The  X=rays. — The  presence  and  position  of  foreign  bodies  in  the 
oesophagus  may  be  ascertained  by  this  method  of  examination,  and  in 
appropriate  cases  information  in  regard  to  tumors  of,  or  in  relation  with, 
the  oesophagus.  The  possibility  that  a  large  atheromatous  plate  in  the 
aorta  may  be  mistaken  for  a  foreign  body  in  the  gullet  is  to  be  borne  in 
mind. 

Symptoms  of  disease  of  the  oesophagus  are  dysphagia,  pain,  and  the 
regurgitation  of  food. 

Dysphagia  varies  according  to  the  disease  and  its  site  and  is  com- 
monly greater  with  solids  than  with  fluids;  the  pain  may  be  sharply  local- 
ized or  diffuse;  the  regurgitation  of  food  may  be  partial  or  complete  and 
take  place  immediately  or  not  for  some  time. 

The  oesophagus  is  subject  to  developmental  defects,  of  which  the 
most  important  is  atresia.  Liquids  are  immediately  regurgitated  and  the 
sound  cannot  be  passed.  Death  results  from  inhalation  pneumonia  or 
starvation. 

Alterations  in  Calibre. — The  oesophagus  may  be  narrowed  or  dilated. 
Very  often  these  two  conditions  are  combined,  the  tube  being  narrowed 
at  one  point  and  dilated  at  another. 

Narrowing  may  be  intrinsic,  due  to  lesions  of  the  oesophagus  itself, 
as  congenital  defect,  stricture  from  inflammation,  cicatrix  or  neoplasm, 
or  muscular  spasm;  or  extrinsic,  due  to  pressure  from  without.  The 
symptoms  vary.  In  the  first  instance  they  are  chiefly  dysphagia,  pain,  and 
regurgitation;  in  the  second  there  are  superadded  to  these  the  symptoms 
of  the  disease  causing  the  compression.  Narrowing  may  be  a  congenital 
defect.  Its  position  in  this  case  is  usually  at  the  upper  or  lower  extremity. 
The  chief  symptom  is  dysphagia. 

In  inflammatory  and  cicatricial  stenosis  there  is  a  history  of  accidental 
or  intentional  swallowing  of  a  caustic  or  corrosive  fluid,  or  the  history 
may  point  to  ulceration  as  the  result  of  traumatism  produced  by  a  foreign 
body,  softened  glands,  syphilis,  or  peptic  ulcer  at  the  cardia.  Ninety 
per  cent,  of  the  cases  of  stenosis  are  due  to  cancer,  which  acts  by  infil- 
trating the  walls  and  causing  the  development  of  contracting  connective 
tissue.  In  stricture  arising  from  cicatrix  the  dysphagia  comes  on  gradually 
and  is  progressive  and  permanent.  It  may  begin  abruptly  and  at  first  be 
caused  by  solids  only;  later  by  fluids.  Associated  spasm  may  cause  varia- 
tions in  degree,  but  there  are  no  intervals  of  complete  relief  as  in  spas- 
modic stricture.  The  bougie  is  always  arrested  at  the  same  distance  from 
the  teeth.  Food  is  regurgitated  shortly  after  it  is  taken  and,  unless  acid 
in  itself,  shows  an  alkaline  reaction.  Subjectively  it  seems  to  stop  at  or 
near  the  manubrium.  There  is  actual  progressive  starvation  and  cor- 
responding emaciation.  Signs  of  pressure  upon  the  recurrent  pharyngeal 
nerves  are  rare  in  cicatricial  stenosis. 

Malignant  stricture   of    the    oesophagus    is   commonly   carcinomatous. 
A  limited  number  of  cases  of  sarcoma  have  been  reported.     Carcinoma  is 
more  common  in  men  than  in  women.     It  is  rare  before  forty  and  most 
32 


498  MEDICAL  DIAGNOSIS. 

frequent  between  fifty  and  sixty.  It  occurs  with  about  equal  frequency 
in  the  upper  and  the  lower  half  of  the  organ.  The  symptoms  are  not 
very  different  from  those  of  cicatricial  stricture.  Pain  is  more  prominent; 
it  is  usually  referred  to  the  gullet;  sometimes  to  the  back  between  the 
shoulder-blades.  The  food  is  commonly  returned  shortly  after  it  is  taken 
and  is  sometimes  streaked  with  blood,  or  it  may  contain  fragments  of 
necrotic  tissue.  The  obstruction  may  become  complete  by  the  impaction 
of  food  in  the  stricture.  Cough  is  common,  and  hoarseness,  aphonia  or 
complete  loss  of  voice  may  result  from  involvement  of  the  recurrent  laryn- 
geal nerves.  Hunger,  at  first  urgent,  gives  place  to  indifference  to  food. 
Thirst  is  troublesome,  the  mouth  dry,  the  breath  foul,  and  hiccough  fre- 
quent.   The  progress  of  the  disease  is  rapid. 

Spasmodic  Stricture. — OEsophagismus  occurs  in  neurotic  persons  and 
especially  in  hysterical  women.  It  has  some  points  of  resemblance  ta 
the  "globus  hystericus."  It  may  be  due  to  mental  shock  or  prolonged 
depressing  emotions,  but  it  is  more  frequently  due  to  reflex  irritation  in 
disorders  of  the  gastro-intestinal  or  reproductive  tract.  In  rare  instances 
it  accompanies  disease  of  the  larynx,  and  it  often  recurs  in  diseases  of 
the  oesophagus.  It  occurs  in  human  rabies  and  in  the  hysterical  counter- 
feits of  that  disease,  and  has  been  observed  in  cerebrospinal  fever,  tetanus, 
and  epilepsy.  Dysphagia  is  paroxysmal  and  of  varying  degree.  It  comes  on 
abruptly  and  often  passes  away  as  rapidly  as  it  came.  Food  is  regurgitated 
suddenly  and  with  force.  There  are  gulping  sounds.  The  difficulty  in 
swallowing  is  produced  by  liquids  as  well  as  by  solids.  The  patients  often, 
complain  of  pain  which  is  constricting  and  burning  in  character.  Emacia- 
tion does  not  usually  occur.  The  bougie  is  not  always  arrested  at  the  same 
level  and  may  usually  be  passed  by  firm  pressure  beyond  the  point  of  re- 
sistance and  into  the  stomach. 

Pressure. ^Narrowing  of  the  oesophagus  by  pressure  from  without 
may  be  caused  by  enlargement  of  the  thyroid  body,  as  in  goitre,  Graves's 
disease,  cystic  degeneration,  or  tumors  involving  that  organ  or  enlarged 
lymph-glands.  Within  the  thorax  a  mediastinal  tumor,  dislocation  back- 
ward of  the  sternal  end  of  the  clavicle,  prevertebral  abscesses  and  tumors, 
aneurism  of  the  aorta,  a  distended  diverticulum  or  massive  pericardial 
effusion  may  compress  the  oesophagus.  The  essential  symptom  is  dys- 
phagia. The  sound  may  usually  be  passed  with  persistent  gentle  pressure. 
If  there  is  reason  to  suspect  the  presence  of  an  aneurism  the  sound  must 
not  be  used.  The  oesophagus  adjusts  itself  to  external  pressure  to  a  re- 
markable degree  and  unless  it  is  extreme  the  symptoms  are  slight. 

Obstruction  from  plugging  may  result  in  infants  from  excessive  pro- 
hferation  of  the  thrush  fungus;  at  any  period  of  life  from  any  foreign  body 
swallowed  by  accident  or  design.  Common  among  these  are  masses  of 
meat,  fragments  of  bone,  artificial  dentures,  jack-stones  and  other  small 
playthings.  Pedunculate  polypi  and  other  tumors  may  obstruct  the 
oesophagus  without  causing  stricture. 

Diverticula  or  circumscribed  lateral  dilatations  are  of  two  kinds, 
those  caused  by  internal  pressure — pulsion  diverticula — and  those  brought 
about  by  the  contraction  of  fibrous  tissue  outside  the  organ — traction 
diverticula. 


SYMPTOMS  AND  SIGNS:   (ESOPHAGUS.  499 

Pulsion  diverticula  first  show  themselves  by  discomfort  or  a  sense 
of  obstruction  after  swallowing  food,  usually  referred  to  the  sternal  region 
and  often  attended  by  cough.  After  a  time  liquids  only  can  be  taken  and 
are  sometimes  regurgitated  and  swallowed  again  and  again  before  reach- 
ing the  stomach.  Portions  of  food  may  be  regurgitated  several  hours 
after  having  been  swallowed.  Pressure  or  upward  stroking  of  the  left 
side  of  the  neck  may  aid  in  the  regurgitation  of  food.  A  tumor  is  not 
often  present.  Upon  auscultation  the  sound  produced  by  the  passage  of 
food  into  the  stomach  is  absent.  A  sound  may  be  introduced  into  the 
diverticulum,  the  blind  end  of  which  may  be  eight  inches — twenty  cm.^ 
or  more  from  the  teeth;  it  may  pass  into  the  stomach  and  be  freely  mov- 
able in  that  organ;  or  one  sound  may  be  passed  into  the  diverticulum 
and  while  it  is  still  in  place  another  may  be  passed  beyond  it  into  the 
stomach.  The  symptoms  increase  in  severity  and  in  many  cases  there  is 
progressive  emaciation.    As  a  rule  the  progress  of  the  disease  is  tardy. 

Traction  diverticula  are  usually  situated  upon  the  anterior  or  lateral 
wall  and  near  the  bifurcation  of  the  trachea.  They  are  funnel-shaped 
and  vary  in  depth  from  one-half  to  three-quarters  of  an  inch  and  are 
usually  single  but  may  be  multiple.  They  commonly  give  rise  to  no  symp- 
toms. Particles  of  food  or  foreign  bodies  may,  however,  be  caught  in 
them  and  cause  ulceration  and  perforation,  with  bronchopneumonia, 
pulmonary  gangrene,  mediastinitis  or  pericarditis  and  pleurisy.  A  posi- 
tive diagnosis  cannot  be  made. 

Ulceration  may  cause  tenderness,  dysphagia;  perforation  the  secondary 
lesions  just  mentioned;  and  rupture,  which  usually  results  from  the  presence 
of  a  foreign  body,  may  cause  gangrenous  mediastinitis  and  pleurisy. 

(Esophageal  hemorrhage  may  result  from  ulcer,  cancer,  the  presence 
of  foreign  bodies,  the  rupture  of  an  aneurism  or  of  the  dilated  veins  of  the 
oesophageal  plexus  in  thrombosis  of  the  portal  vein  or  in  atrophic  cirrhosis 
of  the  liver. 

The  bleeding  may  be  occasional  or  constant  and  vary  in  quantity  from 
a  trifling  amount  to  a  copious  loss  which  is  quickly  fatal.  The  associated 
symptoms  may  render  the  diagnosis  easy,  but  in  the  case  of  varicose  veins 
the  differential  diagnosis  from  gastric  hemorrhage  is  often  difficult.  The 
presence  of  other  symptoms  of  portal  obstruction  and  the  fact  that  the 
blood  is  regurgitated  rather  than  vomited  are  to  be  considered,  but  the 
blood  may  be  discharged  into  the  stomach  and  subsequently  vomited. 

Inflammation  of  the  CEsophagus. — OEsophagitis  is  attended  by  local- 
ized or  diffuse  pain  upon  swallowing,  prostration,  and  in  the  severe  acute 
forms  by  chills  and  fever.  There  may  be  tenderness  upon  pressure  and 
upon  bending  the  spine;  for  this  reason  the  head  is  held  rigid.  Abscess 
formation  may  show  itself  by  a  circumscribed  swelling  upon  one  side  of 
the  neck  with  pressure  upon  the  larynx  and  hoarseness  and  dyspnoea.  In 
the  phlegmonous  form  pus  may  be  expectorated  and  in  the  chronic  cases 
a  glairy,  viscid  mucus. 

Tuberculous  and  syphilitic  ulcerations  occur  as  local  manifestations  in 
these  diseases,  and  their  presence  is  to  be  suspected  when  there  is  dyspha- 
gia, persistent  substernal  pain,  or  the  regurgitation  of  blood-stained  mucus 
in  connection  with  the  general  phenomena  of  these  diseases  respectively. 


500  MEDICAL  DIAGNOSIS. 

Paralysis.  —  The  cesophageal  muscles  are  sometimes  paralyzed  in 
central  or  peripheral  diseases  of  the  nervous  system.  Lesions  in  the  neigh- 
borhood of  the  origin  of  the  pneumogastric  nerves,  such  as  hemorrhage, 
softening,  tumor,  or  sclerosis,  are  among  the  central  causes;  pressure 
neuritis  of  the  pneumogastric  from  enlargement  of  the  lymphatic  glands, 
or  disease  of  the  vertebrae  and  toxic  neuritis  after  diphtheria  or  in  chronic 
alcoholism  or  lead  poisoning  are  among  the  peripheral  causes.  Difficulty 
of  swallowing,  without  pain,  is  a  characteristic  symptom.  It  develops 
gradually  or  abruptly,  according  to  the  cause.  The  food  produces  a  sense 
of  weight  or  pressure  and  a  large  bolus  is  more  readily  swallowed  than 
small  morsels.  Fluids  may  be  regurgitated.  Gurgling  sounds  attend  the 
act  of  swallowing,  but  the  normal  sound  at  the  cardia  is  not  heard.  The 
bougie  passes  freely. 


X. 

THE  DIGESTIVE  SYSTEM  (CONTINUED):  APPETITE;  THIRST; 
ERUCTATIONS;  REGURGITATION;  NAUSEA;  VOMITING: 
THE  VOMITUS;  DEFECATION;  CONSTIPATION;  DIARRHCEA; 
TENESMUS;  PAINFUL  DEFECATION;  FECAL  INCONTI- 
NENCE;   CHARACTER  OF  THE  DISCHARGES. 

Appetite,  thirst,  the  frequency  of  defecation  and  the  consistency  and 
other  characters  of  the  stools  vary  within  wide  limits  in  health.  They  are 
to  a  considerable  extent  influenced  by  habit  and  the  mode  of  life  of  the 
individual.  Beyond  these  limits  they,  together  with  certain  associated 
symptoms,  acquire  clinical  significance  of  importance  in  disease  of  the 
digestive  organs  and  other  local  and  general  affections. 

APPETITE. 

Appetite  is  dependent  upon  the  state  of  the  gustatory  nerves,  the 
condition  of  the  stomach,  and  the  requirements  of  the  organism  as  a  whole. 

The  appetite  for  food  may  be  diminished,  lost — anorexia;  increased — 
polyphagia  or  hulijnia;  perverted — pica  or  parorexia;  or  insatiable — acoria. 

Loss  of  appetite  varies  from  mere  indifference  to  food  to  complete 
anorexia.  It  is  symptomatic  of  the  most  varied  morbid  states,  the  enu- 
meration of  which  would  comprise  a  nosological  system. 

The  appetite  is  more  or  less  impaired  in: 

(a)  The  acute  infections.  The  absence  of  the  normal  desire  for  food 
is  due  chiefly  to  the  toxaemia,  and  in  part  to  the  subacute  gastritis  which 
is  usually  present. 

(b)  The  chronic  infections,  especially  in  the  active  stages  of  syphilis, 
tuberculosis,  and  malaria,  and  in  the  conditions  of  malnutrition  and  cachexia 
to  which  these  diseases  give   rise. 

(c)  Septic  conditions,  both  acute  and  chronic,  and  in  all  forms  of 
local  suppuration.     Loss  of  appetite  in  the  absence  of  gastric  disease  or 


SYMPTOMS  AND  SIGNS:    APPETITE.  501 

other  adequate  obvious  cause,  especially  when  associated  with  persistent 
leucocytosis,  may  be  symptomatic  of  local  suppuration  in  some  part  of 
the  body. 

(d)  Pyrexia.  Fever  is  attended  by  loss  of  appetite  as  in  any  of  the 
foregoing  conditions,  and  this  symptom  is  commonly  present  in  the  early 
convalescence  from  febrile  diseases.  A  notable  exception  to  the  latter 
statement  occurs  in  enteric  fever,  in  which  hunger  is  usually  a  prominent 
and  urgent  symptom  after  the  defervescence. 

(e)  All  forms  of  anaemia,  chronic  wasting  diseases,  and  in  many 
functional  and  organic  diseases  of  the  nervous  system.  The  loss  of  appe- 
tite is  not  only  an  important  symptom  in  these  conditions  but  it  is  also 
an  etiological  factor.  A  vicious  circuit  is  established.  The  inability  to 
take  food  aggravates  the  condition  that  causes  it. 

A  remarkable  suppression  of  the  desire  for  food  is  manifest  in  certain 
cases  of  hysteria.  There  are  instances  in  which  the  suppression  of  appe- 
tite is  maintained  for  long  periods,  as  in  "fasting  girls."  Deception  is  to 
be  guarded  against.  To  hysteria  is  to  be  referred  the  condition  described 
by  Gull  as  anorexia  nervosa,  in  which  there  is  not  only  complete  loss  of 
appetite  but  also  absolute  inability  to  take  food,  with  the  gravest  symp- 
toms of  inanition,  sometimes  ending  in  death. 

(f)  Cachexias  and  terminal  states.  The  patient  is  not  only  unable 
to  take  food  save  in  minimum  quantities,  but  life  is  also  often  maintained 
without  it  for  considerable  periods — a  fact  due  to  the  extreme  limitation 
of  vital  activities. 

(g)  Toxic  conditions.  Complete  loss  of  appetite  attends  all  acute 
toxic  conditions,  and  there  is  great  impairment  in  chronic  intoxications, 
as  that  of  lead,  arsenic,  or  mercury.  The  anorexia  is  due  in  part  to  the 
general  malnutrition;  in  part  to  local  disorder  of  the  organs  of  digestion. 
In  chronic  alcoholism  appetite  is  irregular  and  enfeebled  and  at  the  close 
of  a  debauch  is  completely  lost.  Aversion  to  food  is  frequently  the  fore- 
runner of  an  attack  of  delirium  tremens. 

(h)  Psychic  states.  Depressing  emotional  conditions,  such  as  result 
from  worry,  anxiety,  suspense,  and  grief,  are  usually  attended  with  anorexia. 
The  impairment  of  appetite  under  these  circumstances  is  largely  depend- 
ent upon  the  temperament  of  the  individual. 

(i)  Functional  or  organic  disease  of  the  stomach.  Appetite  may 
persist  normally  or  in  some  abnormal  form  in  the  gastric  neuroses,  and 
is  maintained  in  some  cases  of  gastric  ulcer.  Patients  suffering  from 
disease  of  the  stomach  frequently  have  a  craving  for  food  which  is  im- 
mediately dispelled  upon  attempts  to  eat.  Loss  of  appetite  not  infre- 
quently results  from  a  monotonous  or  inadequate  dietary.  Under  these 
circumstances  the  appetite  frequently  returns  when  the  patient  is  per- 
mitted to  take  ordinary  food.  There  is  a  French  proverb  to  the  effect 
that  appetite  comes  with  eating. 

Polyphagia  is  a  term  used  to  indicate  excessive  or  voracious  eating. 
It  may  be  occasional,  as  in  the  convalescence  from  enteric  fever  or  in  chil- 
dren suffering  from  whooping-cough,  the  frequent  vomiting  caused  by  the 
paroxysms  not  permitting  the  absorption  of  sufficient  food  to  -meet  the 
needs  of  the  organism;   or  persistent,  as  in  diabetes. 


502  MEDICAL  DIAGNOSIS. 

Bulimia  and  acoria  are  terms  used  to  designate  an  insatiable  appetite. 
This  is  symptomatic  of  certain  insanities  and  some  forms  of  idiocy  and 
occurs  in  paroxysms  in  certain  cases  of  hysteria,  neurasthenia,  epilepsy, 
and  exophthalmic  goitre.  In  polyphagia  the  patient  eats  large  quanti- 
ties of  food  and  is  for  the  time  being  satisfied.  In  bulimia  the  ordinary 
sense  of  satiety  after  eating  does  not  occur.  Acoria  is  the  loss  of  the 
sensation  of  satiety. 

Pica  or  parorexia  is  a  craving  for  unnatural  articles  of  food — a  de- 
praved appetite.  It  is  seen  in  some  cases  of  hysteria,  chlorosis,  and  in 
pregnancy.  These  terms  are  also  employed  to  designate  a  nervous  craving 
for  special  articles  of  diet  or  for  articles  that  are  not  fit  for  food. 

THIRST. 

Thirst  is  in  some  instances  an  individual  peculiarity.  There  are 
persons  who  rarely  experience  the  sensation  of  thirst  and  do  not  con- 
sume enough  fluid  to  fully  meet  the  requirements  of  the  body;  others 
who  without  impairment  of  health  manifest  an  habitually  abnormal 
desire  for  fluid. 

Impaired  Thirst. — The  sensation  of  thirst  is  diminished  in  soporous 
states,  even  when  the  buccal  and  salivary  secretions  are  diminished  and 
the  mouth  and  tongue  are  dry,  as  in  enteric  fever. 

Increased  thirst  is  symptomatic  of  many  morbid  states.  It  is  a  con- 
stant symptom  in  fevers  and  occurs  in  all  conditions  attended  with  abun- 
dant or  profuse  loss  of  fluids,  and  is  proportionate  to  the  dehydration  of 
the  tissues.  It  therefore  attends  profuse  sweating  both  physiological 
and  pathological,  abundant  diuresis  from  any  cause,  persistent  vomiting, 
abundant  watery  discharges  from  the  bowels,  and  sudden  copious  hemor- 
rhage. It  occurs  at  the  time  of  crisis  from  acute  diseases,  as -croupous 
pneumonia;  in  the  polyuria  of  hysteria  and  persistently  in  diabetes  insipi- 
dus and  mellitus;  in  the  copious  vomiting  of  acute  irritant  poisoning  and 
in  some  cases  of  uraemia;  after  the  action  of  eiaterium  and  other  drugs 
producing  large  watery  discharges  from  the  bowels;  in  cholera  nostras 
and  Asiatica  and  after  all  kinds  of  abundant  hemorrhages  both  pathologi- 
cal and  traumatic.  An  unusual  desire  for  water  is  observed  in  some  cases 
of  chronic  gastritis.  Persistent  excessive  thirst  is  very  often  the  first 
symptom  to  attract  attention  in  diabetes.  The  arrest  of  the  buccal  secre- 
tions in  xerostomia  or  dry  mouth  gives  rise  to  continued  and  distressing 
thirst.  Polydipsia  is  a  term  used  to  describe  the  habitual  taking  of  fluid 
in  excessive  amounts. 

ERUCTATIONS,  REGURGITATION,  NAUSEA,  AND 

VOMITING. 

The  oesophagus  enters  the  stomach  at  an  angle,  forming  a  valve- 
like fold  which  serves  to  prevent  the  return  of  the  contents  of  the 
stomach.  The  relation  of  the  central  tendon  of  the  diaphragm  to  the 
oesophagus  is  such  that  it  closes  the  oesophageal  opening  only  at  the 
time  of  inspiration. 


SYMPTOMS  AND  SIGNS:    NAUSEA.  503 

Eructations  or  Belching. 

The  spasmodic  forcible  discharge  of  gas  or  air  from  the  mouth  is  a 
common  symptom.  It  may  come  from  the  oesophagus;  much  more  com- 
monly it  comes  from  the  stomach.  It  is  sometimes  odorless,  frequently 
offensive.  It  may  consist  of  air  swallowed  with  the  food  or  with  the  saliva, 
or  of  the  gaseous  products  of  the  chemical  decomposition  of  the  food  in 
the  stomach.  The  eructations  may  be  occasional  or  occur  in  paroxysms 
lasting  for  periods  of  some  hours.  Eructations  are  symptomatic  of 
acute  indigestion  such  as  results  from  over-eating,  various  forms  of 
gastritis  and  other  organic  affections  of  the  stomach,  or  they  may  be  of 
nervous  origin.  Large  quantities  of  odorless  gas  are  sometimes  forcibly 
expelled  at  intervals  during  a  period  of  several  hours  in  hysterical  and 
neurasthenic  individuals,  the  stomach  at  the  same  time  being  tensely 
distended. 

Regurgitation. 

The  liquid  portions  of  the  food,  and  in  some  instances  the  solids,  are  re- 
turned to  the  mouth  without  the  violence  characteristic  of  vomiting.  Regur- 
gitation from  the  oesophagus  occurs  as  a  symptom  of  stricture,  dilatation  or 
diverticulum,  the  food  being  returned  immediately  or  after  an  interval.  Re- 
gurgitation from  the  stomach  may  be  due  to  over-distention  with  food,  or 
drink  and  relaxation  of  the  cardiac  orifice.  The  regurgitation  of  considerable 
quantities  of  an  opalescent,  slightly  alkaline  fluid  is  spoken  of  as  water-brash. 

Merycism  or  rumination  is  the  regurgitation  of  solid  food  from  the 
stomach  to  the  mouth,  when  it  is  again  chewed  and  swallowed.  The  food 
is  returned  in  small  portions  without  nausea.  This  phenomenon  appears 
at  first  to  be  the  result  of  regurgitation,  later  a  habit. 

Pyrosis  or  heart=>burn  is  a  burning  sensation  behind  the  sternum," 
extending  to  the  pharynx.  It  is  often  accompanied  by  eructation  and 
sometimes  by  the  regurgitation  of  an  acid  fluid.  It  is  due  to  the  ejection 
of  the  gastric  contents  into  the  cesophagus.  It  occurs  in  hyperchlorhydria 
but  may  appear  as  a  neurosis  when  the  gastric  secretion  is  normal. 

Nausea. 

Nausea  or  sickness  at  the  stomacli  is  closely  associated  with  vomiting 
in  its  mechanism  and  clinical  significance.  It  belongs  to  the  group  of 
abnormal  sensations  referred  to  the  stomach,  and  occurs  in  functional 
and  organic  affections.  Those  causes  which  excite  vomiting  also  excite 
nausea,  though  the  latter  may  occur  in  the  absence  of  the  former.  The 
term  "nervous  nausea"  is  applied  to  this  symptom  when  it  arises  in  con- 
stitutional disorders  and  diseases  of  the  central  nervous  system.  It  is 
common  in  neurasthenia  and  hysteria  and  is  very  often  the  result  of  reflex 
irritation  in  distant  organs,  for  example,  the  uterus  and  ovaries.  Nausea 
is  very  common  in  the  early  stages  of  pregnancy,  and,  associated  with 
retching  and  vomiting,  constitutes  in  pregnancy  the  syndrome  known  as 
morning  sickness,  which  in  exceptional  cases  is  persistent  and  intractable 
and  may  even  cause  death. 


504  MEDICAL  DIAGNOSIS. 

Vomiting. 

Vomiting  is  the  forcible  expulsion  of  the  contents  of  the  stomach 
through  the  mouth.  In  exceptional  cases  the  contents  of  the  intestines 
may  also  be  expelled  through  the  mouth — fecal  or  stercoraceous  vomiting. 

The  Muscular  Mechanism. — The  act  of  vomiting  is  a  complex  reflex 
movement  in  which  many  muscles  take  part.  There  is  usually  a  sensation 
of  nausea  and  a  reflex  flow  of  saliva  into  the  mouth,  accompanied  or  fol- 
lowed by  a  series  of  more  or  less  violent  retching  movements  which  consist 
of  deep  inspirations  with  closure  of  the  glottis.  As  a  result  of  these  move- 
ments the  stomach  is  compressed  by  the  diaphragm  and  the  negative  pres- 
sure in  the  thorax  and  especially  in  the  oesophagus  is  decidedly  increased. 
In  the  course  of  these  retching  movements  the  act  of  vomiting  is  brought 
about  by  a  sudden  convulsive  contraction  of  the  abdominal  muscles  which 
exerts  additional  pressure  upon  the  stomach.  With  this  the  cardiac  orifice 
of  the  stomach  is  dilated  and  the  stomach  contents  are  forced  through  the 
oesophagus,  the  glottis  being  closed  by  the  adductor  muscles  and  the  nasal 
chambers  shut  ojff  from  the  pharynx  by  the  contraction  of  the  posterior 
pillars  of  the  fauces  upon  the  palate  and  uvula.  In  the  vomiting  of  uncon- 
sciousness, as  in  anaesthesia,  the  laryngeal  muscles  may  relax  and  vomited 
matters  be  insufflated  into  the  trachea,  and  in  violent  vomiting  the  material 
may  in  part  be  forced  past  the  palate  and  uvula  and  ejected  through  the  nose. 

It  is  not  uncommon  for  the  contents  of  the  duodenum  to  be  forced 
by  the  violence  of  the  contraction  of  the  abdominal  muscles  through  the 
pylorus,  so  that  the  vomitus  consists  of  bile-stained  material  and  some- 
times of  pure  bile. 

The  muscles  concerned  in  vomiting  are  respiratory.  The  act  consists 
essentially  in  the  simultaneous  spasmodic  contraction  of  the  diaphragm, 
an  inspiratory  muscle,  and  the  abdominal  or  expiratory  muscles,  contrac- 
tion of  the  muscular  fibres  of  the  stomach  being  altogether  of  subsidiary 
importance. 

The  Nervous  Mechanism. — The  reflex  nature  of  vomiting  is  shown 
by  the  frequency  with  which  it  is  produced  by  the  stimulation  of  sensory 
nerves  and  by  injuries  to  various  parts  of  the  central  nervous  system. 
Disagreeable  emotions  and  derangements  of  the  equilibrium  of  the  body, 
irritation  of  the  mucous  membrane  of  various  parts  of  the  alimentary 
canal,  pathological  states  of  the  genito-urinary  tract,  and  lesions  or  injuries 
of  the  brain  may  all  cause  vomiting.  Vomiting  may  also  be  caused  by 
direct  action  upon  the  medullary  centres,  as  in  the  case  of  drugs — apomor- 
phine  and  various  narcotics — and  by  or  in  the  toxaemia  of  the  infections 
and  autointoxications,  as  uraemia  and  cholaemia. 

The  causes  are  many,  but  the  most  common  is  irritation  of  the  sensory 
fibres  of  the  gastric  mucous  membrane.  In  this  case  the  afferent  path  is 
by  way  of  the  sensory  fibres  of  the  vagus;  the  efferent  path  by  way  of  the 
motor  fibres  innervating  the  muscles  concerned  in  the  act  of  vomiting, 
namely,  the  vagi,  the  phrenics,  and  the  spinal  nerves  distributed  to  the 
abdominal  muscles.  It  is  now  generally  conceded  that  there  is  a  definite 
vomiting  centre  situated  in  the  medulla  in  close  proximity  to  the  respira- 
tory centre. 


SYMPTOMS  AND  SIGNS:   VOMITING. 


505 


The  readiness  with  which  children  vomit  is  due  in  part  to  the  greater 
reflex  excitability  of  the  nervous  system  in  early  life;  in  part  to  the  posi- 
tion of  the  stomach,  which  is  more  nearly  vertical  than  in  adults.  The 
undeveloped  state  of  the  fundus  and  the  defective  closure  of  the  cardia 
increase  the  liability  of  infants  to  vomiting,  which  often  occurs  without 
effort  as  a  mere  regurgitation  of  a  portion  of  the  food  upon  change  of 
posture  or  sKght  pressure  upon  the  epigastrium. 


Brain 


Pharynx 


Liver  and  gall-bladder 


Stomach 

Kidney  and  ureter 

Intestines 

Uterus 

Bladder 

Vesical  nerves 


Vomiting  centre 
in  the  medulla 


—  Spinal  cord 


Vagus 

Pulmonary  branches 

Splanchnic  nerves 
Gall-duct 


Renal  nerves 
Mesenteric  nerves 
Vesical  nerves 
Uterine  nerves 


Fig.  199. — Diagram  of  afferent  nerves  which  may  excite  the  vomiting  centre. 
Modified  from  Briinton. 

1.  Vomiting  from  Direct  Irritation  of  tlie  Terminal  Fibres  of  the  Vagus 
in  tlie  Stomacii. — Vomiting  from  this  cause  is  very  common.  It  may 
result  from  anatomical  lesions  of  the  stomach  itself  and  from  quantitative 
and  qualitative  abnormalities  of  the  contents  of  the  organ.  Vomiting 
is  a  common  phenomenon  in  various  forms  of  gastritis.  In  acute  gastric 
catarrh  there  is  vomiting  of  the  gastric  contents  followed  by  mucus 
often  stained  with  bile;  a  sense  of  relief  is  then  experienced.  In  chronic 
gastric  catarrh  vomiting  is  common;  it  occurs  at  various  intervals  after 
the  taking  of  food.  Frequently,  and  especially  in  the  gastric  catarrh  of 
alcoholic  subjects,  there  is  distressing  vomiting  of  tough  mucus  on  rising — 
vomitus  matutinus  potatorum.     Vomiting  is  common  in  peptic  ulcer  of  the 


506  MEDICAL  DIAGNOSIS. 

stomach  and  is  frequently  provoked  by  the  intake  of  food,  which  also 
causes  pain.  The  pain  very  often  precedes  the  vomiting  and  is  relieved 
by  it.  The  vomiting  which  attends  carcinoma  ventriculi  is  a  common 
and  distressing  symptom.  It  is  not  often  present  until  the  disease  has 
made  considerable  progress.  It  may  occur  when  the  stomach  is  empty, 
but  usually  follows  the  ingestion  of  food,  after  varying  intervals.  When 
the  growth  involves  the  cardia  food  may  be  immediately  vomited;  when 
the  pylorus,  after  an  interval  of  several  hours.  Vomiting  may  be  absent 
in  carcinoma  of  the  fundus  or  lesser  curvature.  In  stenosis  of  the  pylorus 
from  carcinoma  or  other  cause  food  is  retained  in  the  stomach,  which  grad- 
ually undergoes  dilatation,  and  is  vomited  after  some  hours  or  a  day  or 
two — retention  vomiting.  The  vomiting  of  large  quantities  of  fluid  after 
considerable  intervals  of  time  is  characteristic  of  gastric  dilatation.  Vom- 
iting does  not  occur  in  gastrectasis  of  slight  degree  and  in  the  extreme 
cases,  by  reason  of  the  impaired  contractility  of  the  wall  of  the  stomach, 
may  wholly  cease — an  unfavorable  symptom.  Vomiting  is  a  common 
symptom  of  cholera  morbus  and  cholera  Asiatica  and  may  be  regarded 
as  the  direct  result  of  the  inflammation  of  the  gastric  mucous  membrane. 
It  usually  occurs  after  the  diarrhoea,  sometimes  coincidently  with  it, 
scarcely  ever  before  it.  Vomiting  in  cholera  is  usually  unattended  with 
effort,  is  frequently  repeated,  and  ceases  or  alternates  with  singultus  in 
the  algid  stage.  The  vomitus  is  liquid  and  sometimes  resembles  the  rice- 
water  discharges.  This  symptom  occurs  in  hyperacidity  and  hypersecre- 
tion and  may  be  so  persistent  in  cases  of  gastric  hyperesthesia  that  all 
food  is  promptly  ejected.  External  pressure  upon  the  stomach,  as  in  peri- 
carditis, ascites,  or  pericardial  effusion,  may  cause  vomiting. 

2.  Vomiting  from  Central  Irritation  of  the  Vagus. — To  this  cause  must 
be  referred  the  vomiting  which  is  so  common  in  diseases  of  the  brain 
and  its  membranes — anaemia,  hypersemia,  concussion,  sea-sickness,  Meni- 
ere's disease,  tumor,  abscess,  and  various  forms  of  meningitis.  So-called 
cerebral  vomiting  is  characterized  by  the  absence  of  nausea,  its  sudden- 
ness, projectile  character,  and  the  fact  that  it  occurs  independently  of  the 
taking  of  food.  Vomiting  of  gastric  origin  is  mostly  followed  by  a  sense 
of  relief,  while  that  dependent  upon  cerebral  causes  usually  aggravates 
the  symptoms,  probably  because  of  the  mechanical  disturbance  produced 
by  the  act.  Vomiting  is  an  early  and  important  symptom  in  tuberculous 
meningitis  and  cerebrospinal  fever. 

3.  Reflex  Vomiting. — The  following  forms  are  to  be  considered: 

(a)  Vomiting  produced  by  irritation — tickling — of  the  base  of  the 
tongue  or  the  fauces.  Nausea,  gagging,  and  vomiting  are  frequently  caused 
by  the  unskilful  use  of  the  tongue-depressor  or  the  laryngoscopic  mirror. 
In  the  older  medicine  tickling  the  throat  with  a  feather  often  played  the 
part  of  an  emetic.  When  the  mucous  membrane  is  abnormally  sensitive, 
as  in  neurotic  individuals  or  as  the  result  of  acute  or  chronic  catarrh,  very 
slight  irritation  of  the  fauces  may  cause  vomiting.  The  vomiting  of  acute 
angina,  that  caused  by  efforts  to  dislodge  tough  masses  of  mucus,  that 
attendant  upon  hypertrophy  of  the  tonsils,  and  the  vomiting  which  accom- 
panies the  paroxysm  of  pertussis  must  be  referred  to  this  group.  The 
irritation  caused  by  partially  detached  diphtheritic  membrane  sometimes 


SYMPTOMS  AND  SIGNS:   VOMITING.  507 

produces  efforts  at  vomiting  which  may  have  the  favorable  effect  of  wholly- 
detaching  the  mass. 

The  vomiting  of  consumption  is  sometimes  an  early  symptom;  it  i-s 
more  common  and  troublesome  in  the  later  stages.  It  is  frequently  caused 
by  severe  paroxysms  of  coughing.  The  vomiting  of  phthisis  may  be  cerebral, 
as  from  tuberculous  meningitis,  of  which  it  is  often  an  early  and  ominous 
symptom;  due  to  pressure  upon  the  vagi  by  caseous  glands;  the  mani- 
festation of  irritation  of  the  peripheral  distribution  of  the  vagi;  pulmonary, 
pharyngeal,  or  gastric  or  mechanical,  as  from  the  succussion  of  urgent  cough. 

(b)  The  vomiting  of  peritonitis,  which  is  frequently  severe  and  intract- 
able and  always  significant. 

(c)  That  caused  by  irritation  of  the  intestinal  mucous  membrane.  In 
some  instances  the  action  of  purgatives  is  preceded  by  vomiting.  This 
symptom  may  attend  intestinal  parasites,  colic,  enterocolitis,  appendicitis, 
strangulated  hernia,  intussusception,  torsion,  and  ileus.  In  any  form  of 
obstruction  of  the  bowel  retroperistalsis  may  occur  with  vomiting,  which 
gradually  becomes  stercoraceous. 

(d)  That  attendant  upon  visceral  diseases  of  various  kinds,  as  biliary 
and  renal  colic,  acute  nephritis,  pyelitis,  cystitis,  Addison's  disease,  and 
acute  yellow  atrophy  of  the  liver. 

(e)  That  which  is  symptomatic  of  disorders  of  the  female  sexual  organs. 
Vomiting  is  common  in  anomalies  of  menstruation,  uterine  displacements, 
and  pelvic  exudates  and  new  growths. 

Of  especial  importance  is  the  vomiting  of  pregnancy.  A  little  mucus 
is  thrown  up  with  great  nausea  and  effort  when  the  patient  rises  in  the 
morning.  Commonly  the  vomiting  does  not  recur  until  the  next  day; 
sometimes  it  is  persistent  and  distressing.  Usually  it  ceases  after  a  few 
months.     The  pernicious  form  has  been  spoken  of  above. 

(f)  So-called  nervous  vomiting.  The  most  typical  form  is  that  which 
occurs  in  hysteria.  It  depends  upon  the  hyperaesthesia  and  abnormal 
motility  of  the  stomach  and  upon  quantitative  and  qualitative  changes 
in  the  gastric  secretions.  The  vomitus  is  often  of  large  amount  and  con- 
sists of  thin  fluid.  It  is  a  notable  fact  that  notwithstanding  persistent 
vomiting  hysterical  patients  lose  little  weight. 

The  persistent  vomiting  of  Leyden  is  a  form  of  nervous  vomiting 
characterized  by  recurrent  attacks  coming  on  without  obvious  cause  or  as 
the  result  of  slight  indigestion,  fatigue,  or  worry,  and  lasting  from  some 
hours  to  several  days.  The  vomiting  is  copious  and  continuous;  the 
abdomen  retracted  and  the  bowels  constipated.  There  is  epigastric  pain 
together  with  intense  headache  and  intolerance  of  light  and  sound.  The 
pulse  is  frequent  but  there  is  no  fever. 

The  gastric  crises  which  occur  in  tabes,  and  less  frequently  in  acute 
myelitis,  disseminated  sclerosis  and  paresis,  are  to  be  mentioned  in  this 
connection.  Together  with  distressing  pain  there  is  vomiting,  usually 
persistent  and  uncontrollable.  Food  is  at  first  ejected,  then  a  colorless 
.stringy  fluid  and  in  some  cases  a  blood-stained  mucus.  There  is  vertigo 
and  a  sense  of  sinking  at  the  pit  of  the  stomach.  The  attack  lasts  from 
some  hours  to  two  or  three  days.  In  the  intervals  there  may  be  no  signs 
of  gastric  disease. 


508  MEDICAL  DIAGNOSIS. 

The  vomiting  of  migraine  belongs  to  the  category  of  nervous  vomiting. 

(g)  Reflex  vomiting  may  accompany  diseases  of  the  heart,  especially 
myocarditis,  fatty  heart  and  angina  pectoris.  Vomiting  due  to  cardiac 
disease  is  not  infrequently  associated  with  hiccough, 

4.  Direct  Irritation  of  the  Centre  for  Vomiting.  —  This  form  is  less 
frequent.     It  arises  under  the  following  conditions: 

(a)  The  action  of  certain  emetics  of  which  apomorphine  is  a  type. 

(b)  The  action  of  toxic  substances  in  the  blood,  as  for  example  those 
present  in  nephritis  both  acute  and  chronic.  Vomiting  is  an  early  and 
ominous  symptom  in  many  cases  of  uraemia  and  not  rarely  the  first  indica- 
tion of  contracted  kidneys.  Ursemic  vomiting  occurs  independently  of 
the  taking  of  food  and  is  often  severe  and  distressing. 

(c)  As  an  early  manifestation  of  the  toxaemia  of  the  acute  infections, 
especially  in  childhood.  Vomiting  may  attend  the  stage  of  onset  in  scarlet 
fever,  croupous  pneumonia,  diphtheria,  and  other  acute  febrile  diseases. 

The  Gross  Characteristics  of  the  Vomitus. 

The  general  appearance,  quantity,  odor,  and  reaction  of  the  ejected 
material  is  of  importance  in  diagnosis.  These  peculiarities  depend  largely 
upon  the  presence  or  absence  of  food  in  the  stomach,  its  character  and  the 
time  that  has  elapsed  since  its  ingestion.  When  vomiting  occurs  directly 
after  eating,  the  food  shows  little  or  no  change.  On  the  other  hand,  if  some 
hours  have  elapsed  there  may  be  no  trace  of  food.  In  retention  vomiting, 
however,  it  is  not  uncommon  to  find  particles  of  food  taken  at  a  previous 
meal  or  upon  a  preceding  day.  In  sucklings  the  appearance  of  the  vomited 
milk  is  of  importance.  The  presence  of  curds  indicates  the  presence  of 
the  milk-curdling  ferment;  an  uncurdled  milk  some  time  after  nursing 
shows  the  absence  of  normal  gastric  secretions  and  may  be  the  sign  of 
grave  changes  in  the  stomach. 

Aside  from  the  presence  of  food  the  following  peculiarities  are  of 
diagnostic  importance: 

Watery  Fluid  and  Mucus. — The  vomitus  may  consist  of  a  watery 
fluid  containing  little  or  no  mucus.  This  is  common  in  the  morning  in 
chronic  gastric  catarrh,  especially  that  of  alcoholic  subjects.  If  the  reac- 
tion is  alkaline,  the  fluid  usually  consists  of  saliva  that  has  been  swallowed 
during  the  night  and  the  vomitus  consists  largely  of  saliva  in  cases  in  which 
prolonged  nausea  has  preceded  the  act  of  vomiting.  If  the  reaction  be 
acid  the  vomitus  consists  either  of  gastric  fluid  in  excess — hypersecretion — 
or  of  food  and  mucus  that  have  undergone  acid  fermentation.  More  com- 
monly the  vomited  matter  contains  mucus  and  in  some  cases  of  acute  and 
chronic  gastric  catarrh  it  is  composed  of  masses  of  tenacious  mucus.  The 
vomiting  of  hyperacid  gastric  juice  occurs  in  peptic  ulcer  of  the  stomach 
and  in  neurotic  conditions,  as  migraine,  hysteria,  the  gastric  crises  of  tabes 
and  exophthalmic  goitre.  In  some  cases  of  cholera  the  contents  of  the 
intestines  are  forced  into  the  stomach  and  vomited,  presenting  the  usual 
characters  of  the  rice-water  discharges  and  containing  the  comma  bacilli 
of  Koch. 


SYMPTOMS  AND  SIGNS:    VOMITING.  509 

Bilious  Vomiting. — Bile  is  very  commonly  present,  imparting  a  green 
or  yellow  color.  It  occurs  after  repeated  or  violent  vomiting  and  is  of  no 
great  diagnostic  importance.  The  early  vomiting  of  considerable  amounts 
of  bile  occurs  in  some  cases  of  peritonitis  and  intestinal  obstruction. 

Vomiting  of  Blood  —  Haematemesis  —  Qastrorrliagia.  —  This  symptom 
occurs  in  a  number  of  morbid  conditions  and  is  of  great  importance  in 
diagnosis.  The  differential  diagnosis  between  haematemesis  and  haemopty- 
sis has  already  been  considered.  The  vomited  blood  may  be  bright 
red  and  fluid — a  sign  that  it  has  remained  in  the  stomach  but  a  brief 
period;  or  it  may  consist  of  reddish  or  reddish-brown  clots  that  have 
formed  during  a  longer  period;  or  finally  it  may  present  the  appearance  of 
cofTee  grounds,  indicating  that  it  has  been  subjected  to  the  action  of  the 
gastric  juice  for  a  sufficient  time  to  undergo  partial  digestion,  with  altera- 
tion of  the  haemoglobin  and  destruction  of  the  erythrocytes.  In  some 
instances  a  superficial  resemblance  to  recent  blood  may  be  due  to  the  pres- 
ence of  red  wine  or  various  reddish-colored  fruits  or  the  jellies  or  preserves 
made  from  them;  in  others  altered  blood — "coffee  grounds" — may  be 
suggested  by  the  presence  in  the  vomitus  of  coffee,  cocoa,  minute  frag- 
ments of  boiled  or  over-cooked  meat,  and  certain  drugs,  as  the  prepara- 
tions of  bismuth  and  iron.  As  a  rule  these  uncertainties  may  be  settled 
by  close  inspection  and  an  inquiry  into  the  facts,  but  there  are  rare  cases 
in  which  a  chemical,  microscopic,  or  spectroscopic  examination  may  be 
necessary  to  determine  the  question.  Bright  red  blood  is  usually  vomited 
in  considerable  amounts  and  in  association  with  small  clots,  while  the 
altered  blood  which  resembles  coffee  grounds  is  mixed  with  the  vomitus 
in  small  quantities. 

Not  all  blood  ejected  from  the  stomach  is  derived  from  the  vessels 
of  that  organ.  Blood  is  frequently  swallowed  and  then  vomited.  In 
haemoptysis  a  portion  of  the  blood  coughed  up  is  often  swallowed.  Blood 
readily  finds  its  way  from  the  nasal  chambers  or  pharynx  into  the  stomach, 
especially  when  the  patient  is  in  the  recumbent  posture.  The  blood  oozing 
from  the  bitten  tongue  in  the  epileptic  paroxysm  may  be  swallowed  during 
the  postepileptic  stupor  or  the  vomited  blood  may  be  derived  from  the 
vessels  of  the  oesophagus.  Blood  may  be  swallowed  by  malingerers,  who 
sometimes  suck  it  from  a  wound  made  for  the  purpose  in  the  mouth  or 
upon  the  hand  or  forearm.  In  very  rare  instances  infants  vomit  milk 
stained  with  blood  derived  from  a  fissured  or  ulcerated  nipple. 

Bleeding  from  the  stomach  occurs  under  various  conditions,  of  which 
the  following  are  important: 

1.  Circulatory  Derangements. — Portal  obstruction  and  the  re- 
sulting passive  hyperaemia  of  the  gastric  mucosa  lead  to  haematemesis. 
This  symptom  therefore  occurs  in  cirrhosis  of  the  liver,  in  malignant  and 
other  tumors  of  the  porta,  and  in  adhesive  pylophlebitis.  Copious  haematem- 
esis, occurring  in  hepatic  cirrhosis  and  terminating  fatally,  occasionally 
arises  from  rupture  of  the  veins  of  an  enlarged  oesophageal  plexus.  The 
visceral  congestions  resulting  from  cardiac  mural  and  valvular  disease 
tend  also  to  hemorrhage.  Haematemesis  is  occasionally  encountered  in 
massive  enlargement  of  the  spleen. 


510  MEDICAL  DIAGNOSIS. 

2.  H-EMic  Disorders.  —  Hsematemesis  is  frequently  symptomatic 
of  the  grave  anaemias.  It  occurs  in  pernicious  anaemia,  leukaemia,  haemo- 
philia, scurvy,  and  purpura  haemorrhagica,  in  profound  jaundice,  and  after 
extensive  burns.  It  has  been  observed  in  phosphorus  poisoning  and  in 
acute  yellow  atrophy  of  the  hver. 

3.  The  I>rFECTiONS. — Vomiting  of  blood  is  of  occasional  occurrence 
in  epidemic  influenza,  tj^phus,  relapsing  fever,  and  dengue.  It  is  a  promi- 
nent event  in  some  forms  of  pernicious  malarial  fever,  malignant  variola, 
and  yellow  fever.  In  the  last  the  vomiting  of  altered  blood — hlack  vomit — 
is  characteristic. 

4.  Traumatis:^!. — Contusions  of  the  epigastric  region,  as  from  a  blow 
or  kick,  crushing,  and  other  injuries,  are  sometimes  followed  by  the  vomit- 
ing of  blood.  The  vomitus  is  often  blood-streaked  after  prolonged  or 
violent  vomiting.  Under  this  caption  must  be  placed  the  direct  injury  to 
the  gastric  mucosa  caused  by  the  corrosive  poisons,  caustic  alkahes,  the 
mineral  acids,  arsenic,  and  the  like. 

5.  Specific  Axatomical  Lesioxs  of  the  Stomach.  —  Cancer  is  a, 
common  cause  of  gastric  hemorrhage.  The  blood  is  usually  dark  and 
altered  and  rarely  profuse,  slight  oozing,  either  continuous  or  frequently 
repeated,  being  the  rule.  Even  more  common  is  gastric  ulcer.  The  blood 
is  usuallj^  abundant,  bright  red,  and  fluid.  Copious  haematemesis  is  sug- 
gestive of  ulcer.  Free  and  even  lethal  bleeding  may  occur  in  superficial 
erosions,  aifd  profuse  hemorrhage  may  come  from  the  erosions  of  the  gas- 
tric mucous  membrane  which  sometimes  occur  after  operations  upon  the 
abdomen  and  especially  in  cases  in  which  the  omentum  has  been  wounded. 
In  gastric  and  duodenal  ulcer,  especially  the  latter,  the  blood  may  not  be 
vomited  but  is  passed  in  the  stools.  Miliary  aneurism  is  a  rare  cause  of 
gastric  hemorrhage.  It  is  not  common  for  death  to  result  directly  from 
the  bleeding,  wliich  is  often  repeated  from  time  to  time.  Anaemia,  fre- 
quently of  high  grade,  results.  Syncope  with  or  without  general  convul- 
sions maj'  immediately  follow  profuse  hemorrhage.  Hemiplegia  and 
amaurosis,  which  may  be  followed  by  optic  atrophy,  are  rare  sequelae. 

6.  Certain  Xervous  Affections. — Haematemesis  is  an  occasional 
event  in  hysteria,,  and  cases  of  gastric  bleeding  have  occurred  in  apparently 
healthy  individuals  in  the  absence  of  any  local  or  general  condition  to 
account  for  it,  and  without  a  second  appearance.  This  symptom  is 
comparatively  infrequent  in  epilepsy  and  in  general  paresis,  and  Schiff 
and  others  have  directed  attention  to  it  as  a  rare  phenomenon  in  local 
cerebral  disease.  In  the  newborn  it  may  occur  as  an  isolated  symptom 
or  with  hemorrhage  from  other  mucous  tracts. 

7.  Fatal  gastric  hemorrhage  may  result  from  the  rupture  of 
an  aneurism  of  the  aorta  or  its  branches  into  the  stomach.  Under  such 
circumstances  death  may  occur  from  blood  loss  without  vomiting,  the 
stomach  being  distended  with  blood. 

Fecal  or  Stercoraceous  Vomiting. — This  is  a  significant  symptom  in 
acute  obstruction  of  the  bowel.  The  anatomical  condition  may  be  strangu- 
lation, intussusception,  volvulus,  or  abnormal  contents.  The  last  of  these — 
fecal  masses,  biliary  calculi,  and  enteroliths — may  cause  acute  obstruction 
by  the  sudden  shifting  of  their  position.     Vomiting  comes  on  early  and  is 


SYMPTOMS  AND  SIGNS:   DEFECATION.  511 

persistent.  The  vomitus  consists  at  first  of  the  contents  of  the  stomach,  then 
of  bile  or  bile-stained  material,  and  finally  of  a  brownish  or  blackish  fluid  of 
a  distinctly  fecal  odor.  In  this  fluid  masses  of  fecal  matter  ma}^  be  present. 
Retroperistalsis  not  rarely  occurs  in  peritonitis  and  in  some  eases  stercora- 
ceous  vomiting  is  the  result  of  a  gastro-intestinal  fistula.  Chronic  intesti- 
nal obstruction  is  not  usually  attended  by  this  form  of  vomiting  even 
when  of  high  grade.     In  the  terminal  paroxysms,  however,  it  may  occur. 

Purulent  vomiting  is  rare  and  not  usually  dependent  upon  primary 
disease  of  the  stomach;  it  may,  however,  occur  in  phlegmonous  gastritis. 
The  more  common  cause  is  perforative  ulceration  of  the  wall  of  the  stomach 
in  hepatic  abscess  or  empyema. 

Parasites  in  the  Vomit. — The  Ascaris  lumbricoides  occupies  the  upper 
part  of  the  small  intestine.  From  this  position  it  finds  its  way  readily 
into  the  stomach  and  is  often  ejected  with  the  vomit.  In  rare  cases  the 
segments  of  taenia  are  present  in  vomited  matter  and  the  booklets  and 
fragments  of  echinococcus  cysts  have  been  observed;  so  also  trichinellae  and 
the  larvse  of  insects. 

The  quantity  of  the  vomitus  depends  upon  the  volume  of  the  stomach 
contents  and  the  intensity  of  the  act  of  vomiting.  Very  significant  is  the 
retention  vomiting  of  pyloric  obstruction  and  the  large  fluid  vomiting  in 
gastrectasis  from  other  causes. 

The  Odor. — The  vomit  is  commonly  sour-smelling  and  often  intensely 
acid.  It  is  ammoniacal  in  ursemia  and  fecal  in  acute  intestinal  obstruction 
and  in  some  cases  of  peritonitis.  The  odor  of  the  vomitus  in  poisoning  is 
sometimes  of  great  diagnostic  importance.  Striking  examples  are  carbolic 
acid,  the  garlicky  smell  in  phosphorus  poisoning,  that  of  bitter  almonds 
in  poisoning  by  hydrocyanic  acid  and  nitrobenzole,  the  vinegar-like  odor 
in  poisoning  by  acetic  acid,  and  the  smell  of  ammonia;  less  significant 
are  the  odors  of  alcohol  or  laudanum. 

The  reaction  is  commonly  acid.  Where  there  is  an  excess  of  saliva, 
bile,  or  blood  the  reaction  is  alkaline.  In  hypersecretion  the  reaction  is 
intensely  acid  and  patients  speak  of  their  teeth  being  set  on  edge  by  the 
taste.     In  uraemia  the  reaction  may  be  alkaline. 

The  taste  of  the  vomitus  is,  according  to  the  patients,  commonly  sour 
and  when  bile  is  present,  bitter.     Blood  imparts  a  salty  or  sweetish  taste. 

DEFECATION. 

Significance  of  Abnormal  Defecation.  —  The  indigestible  parts  of 
the  food,  with  debris,  bacterial  masses,  and  secretions  from  the  intestinal 
tract,  pass  slowly  through  the  large  intestine  and  reach  the  sigmoid  flexure, 
in  which  they  accumulate.  As  the  semisolid  or  solid  material  passes  into 
the  rectum  it  stimulates  the  sensory  nerves  of  that  part  of  the  intestine, 
giving  rise  to  a  peculiar  sensation  and  desire  to  defecate.  This  material 
is  retained  in  the  rectum  by  the  two  sphincter  muscles,  the  internal  of 
which  is  a  band  of  the  circular  layer  of  involuntary  muscles  of  the  rectum. 
Upon  the  passage  of  fecal  matter  into  the  rectum  the  internal  sphincter 
passes  into  a  condition  of  tonic  contraction,  the  relaxation  of  which  marks 
the  beginning  of  the  act  of  defecation.    The  internal  sphincter  is  composed 


512  MEDICAL  DIAGNOSIS. 

of  unstriped  muscular  fibre  and  receives  its  innervation  from  the  sympa- 
thetic system  and  from  the  sacrospinal  nerves.  The  external  sphincter 
ani  is  made  up  of  striated  muscular  fibres  and  is  to  a  large  extent  under  the 
control  of  the  will.  Upon  intense  rectal  stimulus  the  voluntary  control 
is  overcome  and  this  sphincter  is  also  relaxed.  The  act  of  defecation  is 
therefore  in  part  voluntary  and  in  part  involuntary.  The  voluntary  factor 
is  made  up  of  the  inhibition  of  the  external  sphincter  and  the  simultaneous 
action  of  the  abdominal  muscles,  the  diaphragm  being  contracted  and  the 
glottis  closed.  Pressure  is  thus  exerted  upon  the  abdominal  and  pelvic 
viscera,  with  the  result  that  the  contents  of  the  descending  colon  and  sig- 
moid flexure  are  forced  into  the  rectum.  This  pressure  is  augmented  by 
deep  inspiration  and  fixation  of  the  respiratory  muscles.  The  involun- 
tary factor  consists  in  the  contraction  of  the  muscles  of  the  rectum,  in 
particular  the  circular  layer,  and  the  relaxation  of  the  internal  sphincter, 
in  part  the  result  of  reflex  stimulation  from  the  lumbar  cord  and  in 
part  from  automatic  peristaltic  movements.  The  action  of  defecation  is 
essentially,  however,  an  involuntary  reflex,  as  is  well  seen  in  infants  and 
in  soporose  states. 

Under  normal  conditions  the  bowels  move  once  a  day,  the  act  being, 
like  sleep  and  the  taking  of  food,  of  diurnal  rhythmical  recurrence.  There 
are  healthy  individuals,  however,  in  whom  the  rhythm  is  not  diurnal,  but 
at  intervals  of  two  or  three  days  or  exceptionally  longer,  and  in  whom  efforts 
to  bring  about  the  diurnal  movement  by  means  of  purgatives  are  followed 
by  manifest  derangements  of  health.  The  normal  periodical  movement  of 
the  bowels  is  maintained  by  the  observation  of  a  fixed  hour  for  this  function, 
and  various  derangements,  especially  constipation,  result  from  the  neglect 
of  this  rule. 

It  is  important  for  the  physician  to  inform  himself  as  to  the  periodicity, 
frequency,  and  character  of  the  bowel  movements  and  in  certain  cases  to 
inspect  the  stools.  Departures  from  the  normal  in  respect  of  this  function 
relate  to  constipation,  diarrhoea,  tenesmus,  painful  defecation,  fecal  incon- 
tinence, and  the  character  of  the  discharges. 

CONSTIPATION. 

Constipation — costiveness — infrequent  or  difficult  evacuation  of  faeces; 
retention  of  faeces.  This  condition  is  of  great  and  varied  diagnostic  impor- 
tance. Its  cause  may  be  constitutional  or  intestinal.  Very  often  several 
causes  are  associated. 

The  more  important  constitutional  or  general  causes  of  constipation  are: 

1.  Personal  peculiarity:  Sluggishness  of  the  bowels  is  frequently  an 
hereditary  and  family  tendency.  It  is  far  more  common  in  persons  of  dark 
than  in  those  of  fair  comjDlexion  and  is  especially  associated  with  the  traits 
that  constitute  the  bilious  temperament. 

2.  Unhygienic  habits,  as  want  of  proper  exercise,  the  failure  to  observe 
regularity  in  the  hour  of  defecation  or  to  devote  to  the  act  sufficient  time, 
irregularity  or  undue  haste  in  meals  and  the  eating  of  unwholesome  food  or 
of  excessive  quantities  of  food.  From  this  point  of  view  constipation  is 
primarily  not  a  condition  of  the  body  but  a  condition  of  the  mind.    On  the 


SYMPTOMS  AND  SIGNS:   CONSTIPATION.  513 

other  hand  too  Httle  food  or  a  diet  consisting  largely  of  proteid  substances 
or  which  contains  a  minimum  of  undigested  residuum  tends  to  constipa- 
tion. It  is  obvious  that  a  sufficient  bulk  of  residual  material  is  required  to 
form  the  fecal  mass  and  excite  peristalsis.  The  insufficient  ingestion  of 
fluid  tends  also  to  cause  constipation. 

3.  Dehydration  of  the  tissues  by  profuse  and  frequently  repeated 
sweating,  diuresis  from  the  action  of  drugs,  the  polyuria  of  diabetes  insip- 
idus and  mellitus,  or  repeated  hemorrhages  is  attended  by  constipation. 

4.  The  febrile  infections,  except  those  in  which  diarrhoea  is  an  especial 
symptomj  are  characterized  by  a  tendency  to  constipation.  Even  in 
these  affections  constipation  very  often  gives  way  in  the  later  course  of  the 
attack  to  diarrhoea,  and  the  latter  may  assume  the  guise  of  a  critical  dis- 
charge, as  sometimes  occurs  in  croupous  pneumonia. 

5.  The  habitual  use  of  purgative  drugs  is  a  fruitful  cause  of  constipation. 

6.  Constipation  is  a  very  common  condition  in  the  anaemias,  especially 
in  chlorosis,  and  is  often  a  troublesome  symptom  in  neurasthenia  and 
hysteria. 

7.  General  asthenia  and  cachectic  states  are  very  often  attended  by 
constipation;  so  also  conditions  in  which  the  abdominal  muscles  are  over- 
distended  and  their  contraction  hampered,  as  obesity,  ascites,  large  ab- 
dominal tumors,  and  pregnancy. 

Among  local  causes  of  constipation  the  following  are  to  be  considered: 

1.  Alterations  in  the  quantity  and  quality  of  the  intestinal  juices  and 
a  deficiency  of  bile  or  pancreatic  secretion.  Under  these  circumstances 
constipation  may  be  an  important  symptom  of  fever,  chronic  diseases  of  the 
gastro-intestinal  tract,  and  diseases  of  the  liver,  biliary  passages,  and  the 
pancreas.  It  is  to  be  borne  in  mind  that  the  normal  presence  of  bile  in  the 
intestine  constitutes  a  powerful  stimulus  to  peristalsis. 

2.  The  motor  mechanism  of  the  intestine  may  be  at  fault.  The  defect 
may  be  nervous,  as  in  organic  disease  of  the  nervous  system — myelitis, 
meningitis,  and  tetanus,  or  functional,  as  in  hysteria  and  neurasthenia. 
Or  the  defective  intestinal  innervation  may  be  the  manifestation  of  a  general 
asthenia.  The  arrest  of  peristalsis  and  tympanites  in  severe  enteritis, 
some  cases  of  appendicitis  and  in  peritonitis  and  acute  pancreatitis  are 
primarily  due  to  derangements  of  the  nerve-supply  to  the  bowel,  second- 
arily to  paresis  of  its  muscular  wall.  Chronic  intestinal  catarrh  and  portal 
congestion  from  hepatic  or  cardiac  disease  are  often  attended  by  constipation 
due  to  impaired  nutrition  of  the  muscular  coat  of  the  bowel.  Atonj^  of  the 
colon  and  especially  of  the  muscular  wall  of  the  sigmoid  flexure  is  an  im- 
portant local  cause  of  constipation.  Dilatation  of  the  colon  is  attended 
with  constipation.  Large  collections  of  scybala  may  accumulate  in  the 
sigmoid  flexure  and  be  felt  upon  palpation  of  the  abdomen.  Constipation 
due  to  this  cause  is  encountered  in  neurasthenia  and  hysterical  persons 
and  is  common  in  the  insane.  It  occurs  also  in  bed-ridden  and  elderly 
individuals. 

3.  Local  disease  of  the  rectum  or  anus  or  of  adjacent  organs  is  a  com- 
mon cause  of  constipation.  When  such  conditions,  as  is  usuall}-  the  case, 
render  the  act  of  defecation  painful,  the  patient  is  apt  to  postpone  it  unduly 
and  there  is  very  often  reflex  spasm  of  the  sphincters  which  renders  it  for 

33 


514  MEDICAL  DIAGNOSIS. 

the  time  impossible.  Under  these  circumstances  fecal  material  accumu- 
lates in  the  rectum  and  sigmoid  flexure  of  the  colon  and  greatly  adds  to  the 
discomfort  of  the  patient.  Such  local  disorders  are  inflamed  hemorrhoids, 
anal  fissure,  irritable  ulcer,  prostatic  inflammation  or  abscess,  and  a  tender 
retroverted  uterus  or  prolapsed  ovary. 

4.  ConstijDation  is  observed  in  malignant  disease  of  the  oesophagus, 
pylorus  and  bowel  and  in  other  chronic  conditions  in  which  a  minimum  of 
food  is  ingested  or  that  which  is  taken  cannot  pass  onward  or  is  persistently 
vomited. 

5.  This  symptom  may  be  due  to  a  contracted  condition  of  the  bowel — 
so-called  spasmodic  constipation.  The  narrowing  of  the  bowel  may  be  the 
result  of  ulcerative  colitis  or  dysentery;  a  manifestation  of  hysteria  or  of 
the  atrophic  processes  of  advanced  life.  The  bowel  may  be  in  a  condition 
of  permanent  contraction  or  spasm  at  one  part  and  dilated  elsewhere. 
The  stools  are  small  and  sausage-shaped  or  they  may  be  liquid  with  hard 
scybalous  masses  varying  in  size  from  a  marble  to  a  walnut.  Spasmodic 
constipation  occurs  in  the  pelvic  disorders  of  women  and  in  chronic  lead 
poisoning. 

6.  Strangulated  hernia  is  attended  with  acute  constipation.  Laxatives 
are  without  effect.  There  are  vomiting  and  abdominal  distention.  Pain  is 
usually  present.  Similar  symptoms  attend  volvulus  and  other  forms  of 
intra-abdominal  strangulation.  In  intussusception,  the  sausage-like  tumor, 
tenesmus,  bloody  mucus,  and  a  relaxed  anus  are  significant.  Acute  reten- 
tion of  faeces  with  the  signs  of  obstruction  demands  very  careful  and  sys- 
tematic examination  of  the  abdomen,  a  digital  exploration  of  the  rectum, 
and  examination  of  the  hernial  rings. 

Chronic  intestinal  obstruction  may  be  due  to  foreign  bodies,  very  large 
gall-stones,  tumors  within  the  gut  or  exerting  pressure  upon  its  wall,  masses 
of  scybala,  and  strictures  of  every  kind.  The  constipation  is  gradually 
developed;  occasionally  interrupted  by  watery  diarrhoea  and  sometimes 
by  attacks  with  the  symptoms  of  acute  obstruction.  Three  facts  are  of 
great  importance:  First,  that  fluid  fecal  matter  may  work  its  way  past 
the  obstruction  from  time  to  time;  second,  that  the  dilated  and  con- 
gested bowel  below  the  obstruction  may  discharge  a  thin  fecal-stained 
mucus;  and,  finally,  that  both  these  conditions  are  occasionally  mistaken 
for  diarrhoea. 

7.  Constipation  in  infants.  Constipation  in  the  new-born  may  be 
due  to  imperforate  anus  or  a  congenital  stricture.  In  some  cases  it  results 
from  dilatation  of  the  colon,  which  may  attain  enormous  dimensions,  or  it 
may  be  due  to  simple  atony  of  the  large  bowel. 

Constipation  in  sucklings  and  especially  in  bottle-fed  infants  is  often 
due  to  deficiency  of  the  intestinal  secretions,  the  faeces  being  dry  and  hard. 
This  condition  has  been  attributed  to  insufficient  water  and  a  deficiency  of 
fat  in  the  food.  In  older  children  attention  to  the  hour  of  defecation  and 
regular  habits  are  as  important  as  in  later  Hfe.  Constipation  often  results 
from  enterocolitis,  from  impairment  of  the  contractility  of  the  muscular 
wall  and  derangement  of  the  normal  secretions.  Acute  constipation  is 
frequently  symptomatic  of  mechanical  obstruction  by  foreign  bodies,  hard- 
ened and  impacted  faeces,  twists,  and  intussusception. 


SYMPTOMS  AND  SIGNS:    DIARRHCEA.  515 

Associated  Symptoms. — Sensations  of  pressure  and  distention  in  the 
abdomen,  uneasiness  and  pain,  especially  in  the  course  of  the  transverse 
colon,  loss  of  appetite,  a  furred  tongue,  a  disagreeable  taste,  and  uneasy 
precordial  sensations  are  common.  Patients  very  often  attribute  these 
phenomena  to  derangements  of  the  liver  or  stomach.  An  effectual  purge 
is  of  diagnostic  importance.  The  results  very  often  show  that  these  symp- 
toms are  due  to  constipation. 

Of  especial  importance  are  the  morbid  phenomena  in  the  distribution 
of  the  hemorrhoidal  veins  that  result  from  constipation.  Pain  before  and 
after  defecation,  protrusion  of  the  dilated  blood-vessels,  bleeding  and  the 
discharge  of  stringy  mucus  are  common.  Paroxysmal  neuralgic  pain 
referred  to  the  coccyx  or  the  suprapubic  region  or  to  the  inner  aspect  of  the 
thigh  are  less  frequent.  Gastric  catarrh  with  manifold  symptoms  and 
occasional  implication  of  the  duodenum  and  bile  passages  also  occurs.  In 
some  instances  catarrhal  jaundice  results  and  in  chronic  constipation  a 
slight  icteric  discoloration  of  the  conjunctiva  is  often  seen. 

Constitutional  derangements  are  not  less  common.  They  consist 
of  headache,  vertigo,  depression  of  spirits,  disinclination  for  work,  and 
debility.  Actual  neurasthenia  with  the  most  varied  and  depressing  symp- 
toms may  result  from  obstinate  and  prolonged  constipation.  It  is  on  the 
other  hand  important  to  bear  in  mind  that  nervous  disease  is  a  frequent 
cause  of  constipation  and  that  the  most  troublesome  constipation  may 
occur,  for  example,  in  hysteria.  Under  such  circumstances  a  vicious  circuit 
is  established,  the  constipation  aggravating  and  intensifying  the  symptoms 
of  the  disease  of  which  it  is  itself  a  symptom. 

The  duration  of  constipation  is  largely  dependent  upon  its  cause. 
Simple  forms  resulting  from  neglect  of  hygienic  laws  may  last  three  or  four 
days;  more  troublesome  cases  may  resist  usual  treatment  for  weeks. 
Stubborn  constipation  with  severe  symptoms  suggests  mechanical  obstruc- 
tion of  the  bowel.  The  passage  of  flatus  is  a  favorable  sign.  In  tran- 
sient constipation  the  indican  in  the  urine  is  not  increased;  in  chronic 
obstruction  it  is  apt  to  be  increased. 

DIARRHCEA. 

Abnormal  frequency  and  diminished  consistence  of  the  stools.  This 
symptom  is  of  the  most  varied  significance.  It  results  from  increased 
peristalsis,  particularly  when  the  large  intestine  is  affected,  from  diminished 
absorption  of  the  contents  of  the  bowel,  from  an  excess  of  fluid  in  the  bowel 
either  in  consequence  of  hypersecretion  of  the  substances  entering  into  the 
formation  of  the  succus  entericiis  or  of  transudation  of  serum,  and  in  rare 
instances  from  direct  abnormal  communication  between  the  stomach  or 
small  intestine  and  the  colon. 

Diarrhoea  may  therefore  be  symptomatic  of  deranged  innervation  of 
the  bowel,  mechanical  or  chemical  irritation  by  its  contents,  the  action  of 
toxic  substances,  either  in  the  bowel  or  in  the  blood-current,  as  in  poisoning, 
autointoxication  or  the  infections,  defective  nutrition  or  circulatory  de- 
rangements of  the  wall  of  the  bowel,  or  local  disease,  as  ulceration  or  new 
growths  in  the  bowel  itself  or  adjacent  organs. 


516  MEDICAL  DIAGNOSIS. 

Diarrhoea  may  be  primary  or  secondary  or  it  may  be  acute  or  chronic. 
The  number  of  stools  varies  from  3  or  4  to  30  or  more  in  the  course  of 
twenty-four  hours,  their  consistency  from  semisohd  to  watery,  and  their 
color,  odor,  and  other  physical  characters  vary  within  equally  wide  ranges 
(see  pp.  518,  519). 

The  recognition  of  the  following  forms  of  diarrhoea  is  essential: 

1.  Nervous  diarrhoea.  This  symptom  may  denote  mere  increase  of 
peristalsis  in  the  absence  of  any  lesion  of  the  intestine,  in  hysteria, 
neurasthenia,  the  intestinal  crises  of  tabes,  exophthalmic  goitre,  Addison's 
disease,  movable  kidney,  in  the  first  dentition,  and  in  emotional  disturb- 
ances in  healthy  individuals  of  neurotic  temperament.  The  character- 
istic manifestations  of  the  underlying  nervous  disorder  are  of  diagnostic 
importance.  The  stools  are  of  gruel-like  consistence  and  contain  noth- 
ing of  pathological  importance.  The  attack  begins  abruptly  and  is  of 
short  duration. 

2.  Irritation  of  the  intestine  secondary  to  constitutional  conditions. 
Diarrhoea  may  occur  in  uraemia,  hyperpyrexia,  extensive  burns,  sudden 
chilling  of  the  surface,  certain  infectious  conditions,  as  malaria  and  septi- 
caemia, and  as  the  result  of  the  subcutaneous  injection  of  such  purgatives 
as  podophyllin  or  magnesium  sulphate.  The  urine  should  be  examined 
in  every  case. 

3.  Increased  intestinal  fluid.  The  stools  are  abnormally  frequent 
and  watery  after  the  administration  of  the  hydragogue  cathartics  and  in 
cholera  nostras  and  Asiatica. 

4.  Irritation  of  the  intestine  by  various  ingesta,  or  pathological 
bowel  contents.  Abnormal  peristalsis  and  looseness  of  the  bowels  is  caused 
by  indigestion,  intestinal  parasites,  local  fecal  accumulations,  poisoning 
by  the  salts  of  mercury,  antimony,  arsenic,  copper  and. so  forth,  the  pur- 
gative drugs,  organic  acids  derived  from  the  food  or  from  its  decomposition 
in  the  stomach  or  intestines,  mushroom  poisoning,  unaccustomed  or  im- 
proper articles  of  diet,  bulky  or  indigestible  food,  large  quantities  of  cold 
food  or  drink,  or  the  administration  of  enemata.  In  all  cases  the  anamnesis 
and  physical  examination  are  of  diagnostic  importance. 

5.  Abnormal  irritability  of  the  bowel.  Diarrhoea  may  be  the  mani- 
festation of  an  idiosyncrasy,  and  is  symptomatic  of  catarrhal  inflammation 
and  of  ulcerative  processes  of  all  kinds,  from  superficial  erosions  from 
mechanical  irritation  to  the  specific  ulcerations  of  enteric  fever,  dysentery, 
or  tuberculosis. 

6.  Impaired  absorption.  Diarrhoea  is  not  rarely  due  to  extensive 
ulceration  or  atrophy  of  the  mucosa,  amyloid  disease,  and  portal  congestion. 
The  diarrhoea  of  tabes  mesenterica  is  largely  due  to  failure  in  fat  absorption. 

7.  Mucous  colitis  —  membranous  enterocolitis.  This  syndrome  is 
characterized  by  paroxysmal  diarrhoea  accompanied  by  severe  hypogastric 
or  left  ihac  pain  and  the  discharge  of  masses  of  mucus  or  membranous  casts 
of  the  bowel.  The  attack  occurs  at  varying  intervals,  and  the  disease  is 
observed  in  neurotic  persons,  usually  women. 

8.  Under  very  unusual  circumstances  a  fistulous  communication 
between  the  stomach  or  upper  part  of  the  intestine  and  the  colon — 
usually  its  transverse  part — may  be  the  cause  of  diarrhoea  with  stools 


SYMPTOMS  AND  SIGNS:  TENESMUS.  517 

containing  undigested  food  and  conversely  of  the  eructation  of  intestinal 
gas  or  the  vomiting  of  fecal  material. 

9.  Lienteric  diarrhoea.  Normal  stools  are  usually  more  or  less  homo- 
geneous. They  frequently,  however,  contain  such  indigestible  articles  as 
seeds,  husks,  the  capsules  of  berries,  fruit  pits,  and  the  like.  The  diarrhoea 
caused  by  excessive  quantities  of  food  or  the  ingestion  of  food  that  cannot 
be  digested,  or  which  attends  forms  of  enteritis  that  interfere  with  normal 
digestion  is  characterized  by  the  presence  in  the  stools  of  undigested  or 
only  partially  digested  particles  of  food  and  is  known  as  lienteric.  Frag- 
ments of  food  may  be  recognized  in  the  stools  shortly  after  it  has  been 
eaten.  This  form  of  diarrhoea  may  be  acute,  as  after  errors  in  diet  or  acute 
enteritis,  or  chronic,  as  in  chronic  intestinal  catarrh. 

Associated  Symptoms. — Diarrhoea  is  often  unattended  by  any  symp- 
tom other  than  the  frequent  recurrence  of  the  peculiar  sensation  which 
invites  to  the  closet.  Usually  there  is  uneasiness  in  the  abdomen,  which 
may  be  associated  with  local  or  general  pain,  often  colicky,  and  tenderness. 
Severe  diarrhoea  is  attended  with  thirst,  appetite  is  impaired,  and  there  is 
debility  proportionate  to  the  urgency  of  the  intestinal  symptoms.  Local 
or  general  tympanitic  distention  of  the  bowel  also  occurs.  Vomiting  is 
common,  especially  in  the  diarrhoeas  of  infancy.  The  loss  of  fluid  not  only 
causes  thirst,  but  may  give  rise  to  f  aintness,  collapse,  cramps  of  the  muscles, 
subnormal  temperature,  diminution  of  urine  even  to  suppression  and  albu- 
minuria. The  acidity  of  the  urine  is  increased  and  it  gives  the  reaction 
for  indican. 

TENESMUS. 

Rectal  tenesmus — painful,  ineffectual,  and  usually  long-continued 
straining  at  stool.  This  symptom  occurs  alone,  but  it  is  very  often  asso- 
ciated with  vesical  tenesmus,  partly  because  of  the  anatomical  relationship 
of  the  organs,  partly  because  of  the  common  action  of  some  of  the  causes. 
It  consists  of  spasm  of  the  musculature  concerned  in  defecation  and  micturi- 
tion. The  violent  spasmodic  contractions  are  repeated  at  short  intervals 
and  are  attended  with  such  distress  that  in  extreme  cases  children  fall  into 
general  convulsions  and  adults  faint.  The  discharge  consists  of  small 
amounts  of  stringy,  sometimes  bloody,  mucus  from  the  anus  or  a  few  drops 
of  urine  as  the  case  may  be.  Rectal  tenesmus  occurs  in  the  course  of  irri- 
tating lesions  of  the  rectum  and  anus,  whether  these  be  primary  or  second- 
ary. It  is  a  symptom  of  intussusception,  dysentery,  polypus,  adenoma  and 
malignant  tumors  of  the  rectum  and  sigmoid  flexure,  proctitis  and  peri- 
proctitis, hydatid  cysts  of  the  pelvis,  mechanical  injuries  to  the  rectum  by 
foreign  bodies,  or  in  exceptional  cases  in  highly  neurotic  persons  it  may 
follow  digital  or  instrumental  examination.  Tenesmus  is  not  a  common 
symptom  of  hemorrhoids  or  fissure  of  the  anus.  It  may  be  caused  by  im- 
pacted faeces,  masses  of  round  worms,  the  presence  of  foreign  bodies,  and,  in 
connection  with  vesical  tenesmus,  by  stone  in  the  bladder.  It  is  also  a 
distressing  symptom  in  acute  inflammation  and  abscess  of  the  prostate 
gland.  Tenesmus  is  easily  recognized.  Its  cause  may  be  obscure.  When 
it  is  violent  or  persistent  a  digital  or  proctoscopic  examination  should  be 
made  under  local  or  general  anaesthesia. 


518  MEDICAL  DIAGNOSIS. 

PAINFUL  DEFECATION. 

The  pain  may  be  such  as  to  cause  fecal  impaction  from  voluntary 
postponement  of  the  act.  The  passage  of  a  large  hard  fecal  mass  is  attended 
with  pain  under  normal  conditions.  In  proctitis,  inflamed  hemorrhoids, 
fissure  of  the  anus,  prolapsus,  irritable  ulcer,  and  malignant  disease  of  the 
rectum  pain  upon  defecation  is  a  conspicuous  symptom.  It  is  usually  pres- 
ent in  inflammation  of  the  prostate  and  is  sometimes  symptomatic  of  acute 
inflammatory  affections  of  the  pelvic  organs  in  women. 

FECAL  INCONTINENCE. 

This  symptom  may  be  due  to  local  causes,  as  laceration  of  the  peri- 
neum involving  the  anal  sphincters,  surgical  over-stretching,  and  malig- 
nant or  syphilitic  disease  of  the  rectum;  more  commonly  it  is  due  to 
general  conditions  which  profoundly  affect  the  nervous  system,  as  coma 
from  any  cause,  myelitis  and  other  diseases  of  the  spinal  cord,  grave  chorea, 
convulsive  diseases,  as  epilepsy,  tetanus,  and  strychnine  poisoning,  and 
certain  severe  infections,  as  enteric  fever,  dysentery,  cholera  Asiatica  and 
nostras  and  cholera  infantum.  Involuntary  discharges  very  often  precede 
dissolution.  The  unclean  habits  of  some  forms  of  insanity  cannot  be 
placed  in  this  group  of  symptoms. 

THE  GROSS  PHYSICAL  CHARACTERS  OF  THE 

STOOLS. 

The  fecal  discharges  of  the  healthy  adult  are  of  brownish  color,  cyhn- 
drical  form,  soft  soHd  or  semisolid  consistency,  150  to  200  grammes  in 
daily  quantity,  usually  neutral  or  faintly  alkaline  in  reaction  when  passed, 
and  emit  the  offensive  characteristic  odor. 

Abnormal  variations  in  these  respects  constitute  diagnostic  criteria 
of  some  importance.  The  macroscopic  examination  is  too  often  neglected. 
Laboratory  investigation  is  sometimes  necessary  (see  p.  217). 

1.  The  color,  which  is  due  to  the  presence  of  altered  bile  pigment, 
principally  hydrobilirubin,  may  be  modified  by  certain  articles  of  diet  or  by 
drugs.  It  may  be  rendered  black  by  .blueberries  or  by  iron,  manganese, 
or  bismuth;  yellow  by  rhubarb,  colchicum,  senna,  or  santonin;  green 
by  spinach  or  calomel  or  by  certain  chromatogenous  bacteria.  In 
suckhngs  and  others  who  subsist  upon  an  exclusive  diet  of  milk  the  fseces 
are  golden  yellow  or  whitish;  in  those  who  hve  largely  on  meat  they  are 
brownish-black  in  color,  and  this  is  also  the  case  with  fecal  matter  long 
retained  in  the  bowel  as  in  obstruction.  In  jaundice  due  to  obstruction 
they  are  grayish  or  putty-colored.  When  they  are  increased  and 
thinned  by  intestinal  hypersecretion  or  transudation  their  color  is  usually 
light  brown  or  yellowish;  when  very  watery,  as  in  cholera,  they  are  of  a 
dirty-gray  color — rice-water  discharges.  The  presence  of  blood  colors  the 
stools  red  or  black:  red  when  the  blood  comes  in  considerable  quantity 
under  active  peristalsis  from  the  ileum  as  in  enteric  fever,  or  when  it  comes 
from  the  lower  bowel  as  in  dysentery,  or  from  the  rectum  as  in  piles;  black 


SYMPTOMS  AND  SIGNS:    STOOLS.  519 

when  it  is  derived  from  the  upper  regions  of  the  gastro-intestinal  tract  as  in 
peptic  ulcer,  or  when  it  is  thoroughly  mixed  with  the  stool. 

2.  The  form  is  lost  in  diarrhoea,  the  discharge  being  gruel-like  or  watery 
in  consistence.  The  normal  C3dindrical  or  sausage-shaped  stool  may  be 
modified  in  various  conditions  of  the  lower  bowel.  In  prolapsus  ani  or 
stricture  of  the  rectum,  more  rarely  in  intussusception,  the  diameter  may 
be  much  narrowed — pipe-stem  stools;  in  stricture  or  cancer  of  the  rectum 
or  the  pressure  of  an  enlarged  prostate  gland  or  abscess  or  in  large  pelvic 
tumors  impinging  upon  the  rectum  the  stools  may  be  flattened  or  ribbon- 
shaped;  in  constipation  from  any  cause,  but  especially  that  which  results 
from  atony  and  distention  of  the  colon,  they  often  assume  the  form  of 
irregular,  round,  hard  masses  like  the  dung  of  sheep — scybala. 

3.  The  consistence  is  increased  in  constipation.  The  fluid  is  resorbed 
and  the  mass  tends  to  become  hard  and  dry.  The  consistence  is  diminished 
in  diarrhoea.  Serous  stools  are  observed  in  cholera  Asiatica,  cholera  nostras 
and  cholera  infantum;  in  poisoning  by  antimony,  arsenic,  and  mushrooms. 
Small,  dribbling,  serous  stools  occur  in  some  cases  of  intestinal  obstruction 
from  cancer  and  other  causes.  Serous  stools  contain  little  or  no  fecal 
matter. 

4.  The  quantity  varies  greatly.  It  is  diminished  when  the  diet  is 
concentrated  or  consists  principally  of  meat;  increased  when  the  diet  is 
largely  made  up  of  starchy  and  vegetable  foods.  The  amount  voided  at 
one  effort  depends  of  course  upon  the  frequency  of  the  act  and  may  attain 
in  cases  of  constipation  as  much  as  1000  grammes.  The  quantity  in 
diarrhoea  is  increased  by  the  hypersecretion  of  the  intestinal  glands  and 
the  transudation  of  serum  from  the  blood-vessels.  In  starvation  the  total 
quantity  may  not  exceed  90  grammes  a  day. 

5.  The  reaction  and  odor.  The  reaction  is  faintly  acid  in  nursing 
infants  and  alkaline  in  some  forms  of  intestinal  fermentation.  The  acidity 
is  due  to  carbohydrate  fermentation  or  the  presence  of  fatty  acids.  The 
reaction  is  of  no  great  diagnostic  value.  Depending  upon  the  amount  of 
proteid  decomposition  and  the  putrefactive  bacteria  present,  the  odor  of 
the  stools  is  more  or  less  offensive.  Diets  that  allow  much  proteid  resi- 
due to  reach  the  large  bowel  usually  give  foul-smelling  movements.  A 
milk  diet  in  health  gives  an  almost  odorless  stool.  Indol  and  skatol, 
■derivatives  of  proteid  decomposition,  are  mainly  responsible  for  the 
characteristic  fecal  odor. 

The  odor  in  healthy  infants  is  sour  and  unlike  the  fecal  odor  of  the 
stools  of  adults.  The  so-called  "  albuminous  decomposition"  in  the  faces 
of  infants  and  the  resulting  putrid  odor  are  due  to  the  decomposition  of 
the  undigested  proteid  of  the  milk  in  the  large  intestine.  In  cholera 
infantum  it  is  sometimes  faintly  musty,  sometimes  suggestive  of  the 
washings  of  meat.  In  the  absence  of  bile  the  stools  have  a  peculiarly 
offensive  odor. 

The  presence  of  milk  curds  in  the  stools  of  infants  indicates  an  error 
in  the  quantity  or  quality  of  the  food  and  is  one  of  the  earlier  symptoms  of 
enterocolitis;  the  presence  of  curds  in  the  stools  of  adults  who  are  taking 
a  milk  diet,  as  in  enteric  fever,  constitutes  an  indication  for  the  use  of 
alkalies  in  connection  with  the  milk  or  a  reduction  in  its  quantity. 


520  MEDICAL  DIAGNOSIS. 

Abnormal  Substances  in  the  Stools. — In  lienteric  diarrhoea  the  stools 
contain  undigested  particles  of  food.  Other  abnormal  substances  are  by 
no  means  uncommon  and  may  be  of  great  diagnostic  importance.  Among 
these  are  mucus,  blood,  pus,  fat  in  excess,  gall-stones,  intestinal  sand,  con- 
cretions, intestinal  parasites,  sloughs,  and  foreign  bodies  that  have  been 
swallowed. 

Mucus. — Minute  particles  of  mucus  may  be  observed  upon  the  surface 
of  the  formed  stools  in  health.  Large  quantities  covering  the  stools  or 
expelled  with  them  in  masses  indicate  a  deranged  secretion  of  the  mucous 
glands  of  the  colon  or  rectum.  Masses  of  mucus  that  may  be  shaken  out 
in  water  into  sheets  or  tubular  casts  of  the  intestine  are  diagnostic  of 
membranous  colitis.  Mucus  intimately  admixed  with  the  fecal  matter  may 
come  from  the  small  bowel.  Mucus  in  the  stools  is  symptomatic  of  mechan- 
ical or  pathological  irritation  of  the  bowel  and  is  seen  in  such  conditions  as 
impacted  faeces,  foreign  bodies,  intestinal  parasitism,  new  growths,  intus- 
susception, and  all  forms  of  dysentery,  enterocolitis,  and  proctitis. 

Blood. — A  distinction  is  made  between  "hemorrhage  from  the  bowel" 
— the  discharge  of  red  blood  unmixed  with  fecal  matter — and  ''melaena" — 
blood  intimately  mixed  with  the  faeces  and  occurring  in  the  form  of  "  tarry" 
or  pitch-like  masses,  usually  of  semisolid  consistence  and  glistening  appear- 
ance. The  difference  consists  chiefly  in  the  time  the  blood  remains  in  the 
intestine  and  therefore  in  general  terms  indicates  the  portion  of  the  gut 
into  which  it  has  been  discharged.  If,  as  in  the  case  of  peptic  ulcer  of  the 
stomach  or  duodenum,  the  hemorrhage  has  been  high  up  in  the  intestinal 
tract,  the  blood  remains  a  considerable  time  in  the  bowel,  and  is  subjected 
to  mechanical  conditions  by  which  it  is  incorporated  with  the  fecal  contents, 
undergoing  at  the  same  time  a  sort  of  digestion  by  which  its  physical 
characters  are  much  changed.  If,  on  the  other  hand,  the  blood  is  poured 
out  lower  down  in  the  bowel  and  under  the  influence  of  an  active  peri- 
stalsis is  speedily  evacuated,  it  maintains  the  characteristic  appearance  of 
fresh  blood,  often  bright  red  and  sometimes  commingled  with  recently 
formed  clots.  The  appearance  of  the  evacuations  therefore  is  of  diagnostic 
importance  in  this  respect.  On  the  other  hand,  a  copious  hemorrhage  from 
the  ileum,  as  in  enteric  fever  with  active  peristaltic  movement,  usually 
shows  itself  in  the  discharge  from  the  bowel  of  bright  red  blood,  while  a 
slow  oozing  from  the  colon  with  tardy  onward  propulsion  in  the  bowel 
may  appear  in  the  stools  as  ''coffee-ground"  or  even  as  "tarry"  material. 

Blood  is  frequently  present  in  the  stools  in  quantities  so  minute  that 
its  presence  can  onl}^  be  detected  by  chemical  examination — occult  blood 
(Part  II,  p.  220). 

The  more  important  causes  of  blood  in  the  stools  are  portal  congestion, 
ulceration  of  the  intestinal  mucosa,  neoplasmata  and  in  particular  malig- 
nant disease  of  the  gut,  intestinal  parasites,  embolism  of  the  mesenteric 
arteries,  intussusception,  and  traumatism. 

1.  Portal  Congestion. — This  occurs  in  cirrhosis  of  the  liver,  portal 
thrombosis,  and  dilatation  of  the  hemorrhoidal  veins — piles.  The  diagnosis 
of  hemorrhoids  rests  upon  the  habitual  or  occasional  discharge  of  bright 
red  blood  wath  the  stools,  the  appearance  and  habits  of  the  patient,  and  the 
signs  obtained  upon  inspection  or  a  digital  examination. 


SYMPTOMS  AXD  SIGNS:    STOOLS.  521 

2.  Ulcerative  Processes  in  the  Bowel. — Intestinal  hemorrhage  occur- 
ring in  the  course  of  an  attack  of  enteric  fever  is  of  positive  diagnostic  im- 
portance. It  means  the  erosion  of  an  arterial  twig  in  an  ulcer.  If  the 
hemorrhage  is  profuse  it  may  at  once  lead  to  collapse  with  the  associated 
sj^mptoms  of  internal  hemorrhage;  if  slight,  the  stools  may  be  tarry  or 
contain  slight  amounts  of  red  blood  without  symptoms.  In  either  case  the 
appearance  of  blood  in  the  stools  is  of  prognostic  importance,  since  it 
denotes  deep  ulceration  which  may  be  followed  in  a  day  or  two  by  a  more 
abundant  blood  loss  or  by  pei'foration.  Other  ulcerative  processes  that 
lead  to  the  appearance  of  blood  in  the  stools  are  dysentery,  syphilis,  and 
tuberculosis.  Under  these  conditions  the  blood  appears  in  the  form  of 
streaks  or  stripes  upon  the  stools  or  admixed  with  mucus  or  pus.  Dysen- 
teric stools  may  present  the  appearance  of  meat  washings  or  of  masses  of 
blood  commingled  with  liquid  fecal  matter.  The  mere  presence  of  blood 
in  the  stools  does  not  under  ordinary  circumstances  justify  a  diagnosis. 
The  anamnesis  and  a  systematic  investigation  of  the  present  condition  of 
the  patient  are  necessary. 

3.  Malignant  Disease  of  the  Bowel. — Blood  in  the  stools  is  in  many 
cases  the  first  symptom  to  attract  the  attention  of  the  patient  to  carcinoma. 
The  stools  are  not,  however,^  characteristic,  and  a  systematic  examination, 
which  may  reveal  the  presence  of  an  abdominal  tumor,  is  necessary.  General 
failure  of  health,  secondary  anaemia,  signs  of  intestinal  obstruction,  and 
cachectic  phenomena  are  confirmative. 

4.  Intestinal  Parasites. — The  Ankylostomum  duodenale  is  a  common 
cause  of  persistent  melsena  among  workers  in  the  soil  and  miners.  Grie- 
singer  first  drew  attention  to  this  parasite  as  the  cause  of  Egyptian  chlorosis. 
The  worms  infest  the  upper  portion  of  the  small  intestine  and  are  very 
abundant  in  the  jejunum.  The  diagnosis  rests  upon  the  prevalence  of  the 
condition  among  workmen  in  tunnels,  brick-yards,  excavations.,  and  the 
like,  and  the  presence  of  the  ova  in  the  stools. 

5.  Embolism,  of  the  Mesenteric  Arteries — Infarction  of  the  Bowel. — 
In  consequence  of  valvular  lesions  of  the  heart,  but  with  no  great  frequency, 
emboHsm  of  this  distribution  may  occur.  It  is  probable  that  the  occlu- 
sion of  small  vessels  produces  no  symptoms  of  importance  and  that  the  cir- 
culation may  be  reestablished.  If  the  superior  mesenteric  artery  is  occluded, 
or  a  large  branch,  the  symptoms  are  sudden  collapse,  violent  colicky  pains, 
signs  of  peritonitis,  and  thin,  blood-tinged  stools  or  hemorrhage  from 
the  bowel. 

6.  Intussusception. — This  affection  occurs  in  infancy  and  childhood. 
Bloody  stools  are  of  diagnostic  importance  since  they  occur  in  at  least 
sixty  per  cent,  of  the  cases  either  spontaneously  or  after  the  administration 
of  an  enema.  The  blood  is  commonly  mixed  with  mucus.  Associated 
symptoms  are  tenesmus  and  a  sausage-shaped  tumor  in  the  line  of  the  colon. 
Vomiting  and  tympany  are  less  common. 

7.  Traumatism. — Injuries  of  the  bowel  as  a  cause  of  bloody  stools 
commonly  involve  the  rectum,  and  when  they  do  not  penetrate  the  peri- 
toneum may  be  readily  overlooked.  The  abundant  venous  supply  favors 
free  bleeding,  and,  since  the  blood  is  often  retained  in  consequence  of 
spasm  of  the  sphincters,  the  signs  for  a  time  may  be  simply  those  of  inter- 


522  MEDICAL  DIAGNOSIS. 

nal  hemorrhage  and  collapse.  The  anamnesis  is  of  importance  and  a  digi- 
tal examination  reveals  the  actual  condition.  The  presence  of  foreign 
bodies  may  be  thus  discovered  in  children,  idiots,  and  insane  persons. 

8.  Constitutional  Conditions. — Intestinal  hemorrhage  is  occasionally 
symptomatic  of  leukaemia,  hemophilia,  purpura  hsemorrhagica,  and  scurv}'. 
This  symptom  is,  however,  so  closely  associated  with  the  general  phenomena 
of  those  diseases  that  it  is  of  secondary  importance  in  their  diagnosis. 

9,  Miscellaneous  Causes  of  Intestinal  Hemorrhage. — Bloody  stools  are 
of  infrequent  occurrence  in  consequence  of  the  rupture  of  an  aneurism  of 
the  abdominal  aorta  into  the  bowel,  jaundice,  acute  yellow  atrophy  of 
the  Hver,  phosphorus  poisoning,  yellow  fever,  pernicious  malarial  fever, 
and  very  rarely  septicaemia. 

Concealed  Hemorrhage.  —  Concealed  intestinal  hemorrhage  may 
occur  in  the  foregoing  conditions.  If  small  it  may  give  rise  to  no  symp- 
toms, although  prolonged  and  unsuspected  bleeding  may  be  the  cause  of 
profound  secondary  anaemia  with  its  usual  symptoms;  if  large  the  hemor- 
rhage, while  not  for  a  time  appearing  at  the  anus,  occasions  the  symptoms 
of  internal  hemorrhage, — namely,  collapse,  restlessness,  air-hunger,  pallor, 
a  pinched  face,  cold  extremities,  a  rapid,  weak,  even  imperceptible  pulse, 
urgent  thirst,  and  a  tendency  to  syncope. 

Pus. — In  small  quantities  pus  may  be  present  in  the  stools  in  dysen- 
tery, enteritis,  colitis,  proctitis,  and  in  ulceration  of  the  colon  or  rectum 
due  to  malignant  growths  or  syphilis.  Small  amounts  of  pus  may  be  present 
in  the  stools  in  profuse  leucorrhoea  or  urethritis;  but  under  these  cir- 
cumstances its  appearance  is  without  diagnostic  importance,  since  the 
associated  symptoms  will  fully  explain  it.  In  large  quantities  and  usually 
in  single  discharges,  or  in  large  quantities  at  irregular  intervals,  pus  may 
be  present  in  the  stools  in  consequence  of  the  rupture  of  an  abscess,  or 
the  establishment  of  a  fistulous  communication  between  a  purulent  collec- 
tion and  the  bowel.  Such  abscesses  are  usually  periproctic,  pelvic,  or 
perinephric;  sometimes  appendicular;  and,  less  commonly,  in  the  gall- 
bladder, hepatic  or  infradiaphragmatic. 

Fatty  Stools. — The  appearance  of  the  discharges  is  greasy  and  glisten- 
ing. An  excess  of  neutral  fat  is  present  in  obstructive  jaundice  and  in  vari- 
ous forms  of  pancreatic  disease.  Fatty  diarrhoea,  with  icterus  and  sugar  in 
the  urine,  has  been  observed  in  acute  suppurative  pancreatitis.  Over- 
feeding and  indigestion  in  infants  may  be  the  cause  of  fatty  stools,  and 
Biedert  has  described  a  fat  diarrhoea  in  which  the  percentage  of  fat  is 
enormously  increased.  The  condition  is  primary  in  which  the  ingestion  of 
fat  is  excessive  and  which  may  be  corrected  by  modification  of  the  food, 
and  secondary  which  is  due  to  catarrhal  inflammation  of  the  intestine  or 
disease  of  the  pancreas. 

Gallstones — Biliary  Calculi.  —  Gall-stones  have  been  found  to  be 
present  in  Europeans  in  from  5  to  10  per  cent.  In  the  East  gall-stones  are 
said  to  be  extremely  rare.  Gall-stones  vary  in  size  from  a  concretion  barely 
perceptible  to  the  naked  eye  to  the  size  of  a  walnut  or  larger.  They  are 
spherical,  oval,  or  angular,  the  surface  being  smooth,  mammillated,  or 
faceted.  When  large  they  are  commonly  single;  when  small  they  may 
number  hundreds.    In  a  case  of  mine  the  small  stones  numbered  by  actual 


SYMPTOMS  AND  SIGNS:    STOOLS.  523 

count  300.  When  extremely  small  they  are  described  as  biliary  or 
intestinal  sand.  Their  color  varies  from  a  whitish-gray  to  dark  yellow 
or  brown,  sometimes  black.  Their  consistence  is  usually  firm,  but  they 
are  often  friable,  being  crushed  by  pressure  between  the  thumb  and 
forefinger,  wdth  crystalline  fracture.  In  some  cases,  however,  they  are 
extremely   hard. 

Intestinal  Sand. — Small  brown  or  green  calculi,  spherical  or  irregular 
in  shape  and  of  rough  surface,  and  varying  in  size  from  grains  of  sand  to 
small  shot,  are  sometimes  present  in  the  stools  in  considerable  quantity. 
This  material  may  or  may  not  be  preceded  by  attacks  of  colic.  These 
calculi  are  of  variable  composition.  They  consist  in  some  instances  of 
inorganic  salts,  as  calcium  carbonates  and  phosphates,  magnesia  and  iron, 
together  with  organic  matter,  bacteria  and  urobilin.  Cholesterin  is  not 
present.  A  nucleus  may  sometimes  be  demonstrated.  It  is  formed  of  a 
grain  of  quartz  sand  or  a  minute  particle  of  the  case  of  a  fruit  seed.  In 
other  very  rare  cases  calcium  sulphate  has  been  the  chief  constituent. 
This  form  of  intestinal  sand  occurs  in  intestinal  neuroses  of  the  secre- 
tory type. 

Pancreatic  Calculi. — Kinnicutt  has  recently  studied  the  subject  of  the 
discharge  of  pancreatic  calculi  during  life.  The  decisive  evidence  of  pan- 
creatic lithiasis  consists  in  the  presence  of  the  characteristic  concretions  in 
the  stools.  They  are  composed  chiefly  of  calcium  carbonate.  They  are 
extremely  rare — a  fact  due  in  part  to  the  small  size  of  the  calculi  and 
their  friability,  so  that  they  may  be  voided  in  fragments  or  particles  not 
easily  recognized. 

Intestinal  Concretions  —  Enteroliths.  —  Concretions  of  various  kinds 
occur  in  the  stools.  They  are  comparatively  rare.  The  following  forms  are 
encountered: 

1.  Hard  round  fecal  masses — scybala.  They  occur  in  chronic  consti- 
pation, especially  in  elderly  people,  and  in  cases  in  which  after  abdom- 
inal operation  partial  obstruction  of  the  bowel  occurs  as  the  result  of 
adhesions. 

2.  Enteroliths.  Earthy  concretions  are  sometimes  observed  in  the 
stools.  They  are  largely  composed  of  magnesium  phosphate,  the  alkaline 
carbonates,  and  organic  matter.  They  are  hard,  dense,  and  made  up  of  con- 
centric layers  about  a  chalky  nucleus  that  very  often  surrounds  a  foreign 
body.  They  are  usually  oval  and  are  very  rarely,  when  several  are  present, 
faceted,  and  occur  in  early  and  middle  life. 

3.  Concretions  composed  of  vegetable  fibres  or  of  hairs  that  have 
been  swallowed  are  light,  porous,  usually  of  irregular  shape,  and  frequently 
show  upon  section  open  spaces  or  cavities  in  their  substance.  They  are 
sometimes  found  in  the  caecum  and  may  attain  the  size  of  an  orange.  They 
are  sometimes  made  up  of  the  insufficientl)^  ground  husks  of  oats  or  the 
capsules  of  small  fruits.  They  occur  more  commonlj'  in  early  life  and  in 
females. 

4.  Certain  drugs  and  similar  substances,  as  chaik,  magnesia,  bismuth, 
and  shellac,  when  taken  in  undue  quantities,  form  intestinal  concretions, 
which  appear  in  the  stools  and  reveal  their  true  nature  only  upon  chemical 
examination. 


524  MEDICAL  DIAGNOSIS. 

Intestinal  concretions  when  of  small  size  occasion  no  characteristic 
symptoms.  When  of  larger  size  they  may  be  arrested  at  a  point  of  stenosis 
of  the  bowel;  or  upon  the  occurrence  of  contraction  and  oedematous  swell- 
ing, and  they  may  then  give  rise  to  the  symptoms  of  intestinal  obstruction. 
Large  concretions  are  usually  arrested  in  the  caecum,  in  the  colon,  or  in  the 
ampullae  of  the  rectum,  less  frequently  above  the  ileocsecal  valve.  Obstruc- 
tion in  the  upper  part  of  the  small  intestine  may  be  caused  by  concretions 
formed  in  the  stomach  or  by  gall-stones. 

Intestinal  Parasites.  —  The  Ascaris  lumbricoides  —  round  worm  —  and 
its  ova  are  frequently  found  in  the  stools  of  children  and  young  adults. 
Oxyuris  vermicularis  —  thread-worm,  pin-worm  —  a  very  common  para- 
site, infests  the  rectum  and  colon;  intestinal  cestodes  —  tape-worms  — 
of  which  the  common  forms  are  the  Tcenia  saginata  or  mediocanellata, 
the  Tcenia  solium,  and  the  Bothriocephalus  latus,  show  themselves  in  the 
stools  in  the  form  of  segments  or  proglottides,  and  their  ova  are  usually 
present  in  great  numbers  (see  p.  858). 

Sloughs. — The  invaginated  portion  of  the  bowel  in  intussusception 
may  slough  off  en  masse  and  be  discharged  from  the  bowel.  Polypi  of  the 
intestine  or  rectum  may  also  become  detached  by  sloughing  and  be  dis- 
charged with  the  faeces.  Masses  of  necrotic  tissue  may  become  separated 
from  malignant  or  other  ulcerating  growths  in  the  intestine  and  be  dis- 
charged with  the  faeces.  They  are  to  be  distinguished  from  fragments  of 
undigested  meat.  The  intestinal  sloughs  in  enteric  fever  may  sometimes 
be  recognized  in  the  stools  and  are  often  mistaken  for  milk  curds. 

Foreign  Bodies. — The  most  diverse  articles  may  be  found  in  the  stools, 
having  been  swallowed  by  accident  or  design.  Small  articles  of  all  kinds 
may  be  swallowed  by  children,  idiots,  and  dements;  bird-seed  and  the  like 
by  hysterical  persons;  coins,  rings,  and  gems  by  professional  thieves; 
nails,  glass,  fragments  of  china,  etc.,  by  fakirs,  and  such  articles  as  artificial 
teeth  or  even  a  clinical  thermometer  by  unconscious  persons,  and  all  of 
these  things  have  been  voided  with  the  stools. 


XL 

THE    SKIN;    PHYSIOLOGICAL   AND    PATHOLOGICAL   CHANGES 

AND  THEIR  SIGNIFICANCE;    (EDEMA;    SUPERFICIAL 

VASCULAR  CHANGES;  NAILS;  HAIR. 

THE  SKIN. 

Changes  in  the  skin  not  only  occur  as  manifestations  of  cutaneous  affec- 
tioris  but  they  also  constitute  important  diagnostic  signs  of  diseases  of  the 
internal  organs.  The  methods  of  examination  are  inspection  and  palpation. 
The  clothing  is  to  be  so  arranged  as  to  facilitate  the  necessary  investigation. 

The  condition  of  the  skin  varies  within  physiological  limits  at  different 
periods  of  life  and  in  the  sexes.  In  infancy  and  childhood  the  skin  is  dis- 
tensible, elastic,  full,  of  fine  texture,  and  faint  rosy  color.     The  capillary 


SYMPTOMS  AND  SIGNS:   SKIX.  525 

circulation  is  active,  pressure  causes  local  pallor  which  quickly  disappears. 
In  middle  life  the  skin  is  finer,  softer,  and  shows  more  physiological  tur- 
gescence  in  women  than  in  men.  With  advancing  age  the  skin  loses  its 
elasticity.  Partly  for  this  reason,  partly  on  account  of  the  diminished 
amount  of  subcutaneous  fat;  and  partly  because  of  the  larger  development 
of  connective  tissue,  wrinkles  develop.  The  skin  in  elderly  persons  is  paler 
and  more  abundantly  pigmented  than  in  the  young.  The  skin  of  very  fat 
persons  frequently  has  a  disagreeable  unctuous  feel;  it  may  be  firm  and 
tense  or  loose  and  flabby.  The  skin  is  sometimes  flabby  and  relaxed  in 
fat  babies  who  are  not  properly  fed.  In  the  cachexias  of  infancy,  such 
as  that  of  congenital  syphilis  or  marasmus,  the  skin  is  muddy,  loose, 
inelastic,  and  sometimes  wrinkled  like  that  of  old  men. 

Color. — The  normal  tint  of  the  skin,  the  so-called  flesh  color,  depends 
upon  the  blood  showing  through  the  upper  layers  of  the  integument  and 
the  epidermis.  The  changes  in  color  are  quantitative  and  qualitative, 
physiological  and  pathological.  Quantitative  changes  consist  in  varying 
degrees  of  color,  from  blushing  to  blanching.  They  are  best  observed  upon 
the  face.  On  the  other  hand  qualitative  changes  in  the  color  of  the  skin 
are  studied  best  upon  other  parts  of  the  body  where  the  flesh  color  is  paler 
and  less  variable.  The  mucous  membrane  of  the  conjunctiva,  lips,  and 
mouth  must  always  be  examined. 

Variations  in  the  flesh  color  depend  upon  the  amount  of  blood  in  the 
cutaneous  vessels,  the  amount  of  the  blood-coloring  matter,  that  is,  the 
percentage  of  haemoglobin,  and  the  thickness  of  the  tissues  covering  the 
vessels.  It  is  obvious  that  since  any  of  these  factors  may  vary  in  degree 
the  quantitative  changes  in  the  color  of  the  skin  do  not  always  have  the 
same  diagnostic  significance. 

Pallor. — The  skin  may  be  pale  by  reason  of  general  or  local  deficiency 
of  blood,  that  is  to  say,  in  consequence  of  anaemia  or  of  contraction  of  the 
capillaries.  The  various  forms  of  anaemia  have  in  common  a  diminution 
in  the  coloring  matter  of  the  blood — oligochromcemia.  Pallor,  even 
when  persistent,  does  not  in  all  instances  justify  a  diagnosis  of  anaemia, 
since  there  are  many  habitually  pale  persons  whose  blood  shows  upon 
examination  a  practically  normal  constitution  both  as  regards  the  erythro- 
cytes and  the  haemoglobin.  Many  such  individuals  present  no  symptoms 
of  constitutional  or  local  disease  and  regard  themselves  as  in  perfect  health. 
The  pallor  in  these  cases  is  due  to  an  abnormality  of  the  skin,  either  an 
unusual  opaqueness  of  the  superficial  layers  or  a  deficiency  in  the  blood 
supply  or  a  combination  of  these  two  conditions.  If  the  conjunctival 
mucous  membrane  and  that  of  the  lips  and  mouth  present  a  normal 
appearance,  the  pallor  is  due  to  the  first  of  these  anomalies.  In  the  major- 
ity of  instances,  however,  marked  and  persistent  pallor  is  associated  with 
other  evidences  of  more  or  less  decided  derangement  of  health.  Even 
under  these  circumstances  in  a  certain  proportion  of  the  cases  the  blood 
shows  no  abnormal  change.  Two  explanations  of  the  pallor  may  be  ad- 
vanced: first,  a  reduction  in  the  total  quantity  of  the  blood,  which  never- 
theless retains  its  constituent  elements  in  normal  proportion;  second,  that 
the  skin,  particularly  of  the  face,  as  the  result  of  abnormal  conditions  of 
the  circulation  receives  a  diminished  amount  of  blood.     Since  we  have  no 


526  MEDICAL  DIAGNOSIS. 

clinical  method  of  determining  the  total  volume  of  blood  in  the  body,  the 
first  of  these  explanations  is  purely  theoretical  and  without  practical 
apphcation.  The  second  explanation  finds  support  in  the  constant  presence 
of  other  symptoms  indicative  of  circulatory  derangements,  among  which 
are  a  small  and  feeble  pulse,  general  asthenia,  over-filling  of  the  super- 
ficial veins,  shght  cyanosis,  faintness,  and  dizziness.  The  part  played  by 
enfeeblement  of  the  heart's  action  on  the  one  hand  and  by  vasomotor 
derangements  on  the  other  cannot  in  all  cases  be  satisfactorily  determined. 
Lowered  blood-pressure  does  not  necessarily  induce  pallor,  since  in  this 
condition  the  lumen  of  the  peripheral  vessels  is  widened  and  their  contents 
increased;  but  diminished  blood-pressure  gives  rise  to  pallor  when  the  chief 
factor  in  its  production  is  cardiac  weakness  and  the  vasomotor  tonus  is 
maintained.  Increased  vasomotor  tonus  may  be  the  cause  of  pallor  of 
high  intensity.  Among  the  more  important  diseases  in  which  pallor  occurs 
as  the  result  of  a  diminution  in  the  blood  supply  to  the  vessels  of  the  face, 
without  marked  changes  in  the  composition  of  the  blood,  are  gastro-intes- 
tinal  affections,  both  acute  and  chronic,  diseases  of  the  heart,  pulmonary 
consumption  and  other  chronic  infections — conditions  ultimately  leading 
to  anaemia  which  in  many  cases  is  profound.  To  this  group  the  transient 
pallor  of  intense  emotion,  nausea,  vertigo,  syncope  and  collapse,  in  which 
vasomotor  derangements  and  cardiac  failure  are  associated  in  the  produc- 
tion of  lowered  blood-pressure,  bears  a  close  etiological  relation.  Indoor 
occupations,  dependence  upon  artificial  light,  mining  and  the  like  cause 
permanent  pallor. 

Clinically  the  following  points  are  important:  (a)  Transient  pallor  is 
caused  by  cardiac  failure,  as  in  nausea,  rigors,  syncope,  and  shock,  or  by 
vasomotor  spasm,  as  in  the  intense  emotions  of  fright,  fear,  anger,  in  pain, 
epilepsy,  and  other  paroxysmal  neuroses.  Transient  pallor  is  frequently 
but  not  always  followed  by  more  or  less  intense  flushing. 

(b)  Sudden  and  more  persistent  pallor  accompanies  hemorrhage,  acute 
poisoning,  and  overwhelming  infection — the  malignant  forms.  Associated 
with  other  symptoms  of  collapse  it  is  a  striking  and  suggestive  sign  of 
internal  hemorrhage,  such  as  may  occur  in  a  large  pulmonary  cavitj^;  as  the 
result  of  the  rupture  of  an  aortic  aneurism  into  the  pericardial,  pleural,  or 
peritoneal  sac;  in  consequence  of  a  perforating  lesion  in  peptic  ulcer  or 
enteric  fever;  in  rupture  of  the  sac  in  ectopic  gestation,  or  in  concealed 
uterine  hemorrhage  before  or  after  parturition.  Small  hemorrhages  do  not 
necessarily  cause  pallor  except  when  frequently  repeated  or  persistent. 

(c)  Gradually  developing  pallor  is  a  symptom  of  almost  all  serious 
acute  and  chronic  diseases.  In  the  acute  infections  it  usually  passes  olT  with 
convalescence;  in  the  chronic  diseases  its  intensity  is  very  often  a  measure 
of  the  gravity  of  the  case.  It  is  sometimes  seen  in  altered  conditions  of 
living,,  as  in  the  case  of  young  immigrant  girls  who  during  the  process  of 
acclimatization  not  rarely  permanently  lose  their  color  without  changes  in 
the  blood  or  other  signs  of  ill  health.  The  pallor  in  persistent  slight  hemor- 
rhage, such  as  occurs  in  neglected  hemorrhoids,  is  very  often  intense,  as 
is  the  pallor  of  chlorosis,  pernicious  anaemia,  and  the  secondary  anaemias 
which  occur  in  chronic  poisoning,  chronic  infections,  chronic  suppurative 
processes,  nephritis,  and  valvular  and  mural  disease  of  the  heart. 


SYMPTOMS  AND  SIGNS:    SKIN.  527 

Redness.  —  The  change  in  the  color  of  the  face  is  quantitative. 
It  is  due  to  two  causes:  first,  thinness  and  transparency  of  the  super- 
ficial layers  of  the  integument;  second,  increased  fulness  of  the  capillaries 
—  hypercemia.  An  abnormally  high  haemoglobin  percentage  cannot  of 
itself  be  regarded  as  a  cause  of  the  increased  redness  of  the  complexion. 
Whether  or  not  a  true  plethora  occurs  is  undecided.  Physiologically  we 
find  the  redness  of  the  skin  of  the  face  greater  in  persons  who  live  in  the 
open  air  and  are  especially  exposed  to  sunlight  and  the  wind,  which  increase 
the  cutaneous  circulation.  An  abnormally  transparent  skin  is  the  evident 
cause  of  the  blooming  redness  of  the  cheeks  occasionally  seen  in  chlorotic 
g\v\&~  chlorosis  JJorida.  Very  characteristic  in  these  cases  is  the  contrast 
between  the  color  of  the  skin  and  the  blue-white  conjunctivae.  Among  the 
physiological  causes  of  intensification  of  the  color  of  the  skin  are  powerful 
muscular  effort  and  the  action  of  external  heat,  as  in  hot  baths,  friction  of 
the  surface,  exposure  to  fire  or  heat,  radiation  from  other  sources,  sunburn 
and  the  like.  Extreme  cold  also  produces  cutaneous  hyper aemia  of  the  face. 
Habitual  exposure  to  heat  or  cold,  especially  when  associated  with  moist- 
ure, causes  the  chronic  purplish  hyperaemia  of  the  hands  frequently  seen 
in  washerwomen  and  bartenders  who  are  otherwise  in  good  health. 

Transient  reddening  of  the  skin  dependent  upon  vasomotor  influences 
occurs  under  certain  psychic  influences,  especially  embarrassment  and 
shame.  The  reddening  of  the  skin  in  such  cases  is  not  restricted  to  the  face 
but  may  spread  over  the  throat  and  even  the  upper  part  of  the  chest. 
In  these  latter  situations  it  may  be  irregularly  distributed  in  such  a  way 
as  to  give  rise  to  errors  in  diagnosis  as  regards  actual  disease  of  the  skin,  as 
erythema,  especially  in  sensitive  persons,  and  particularly  in  women  when 
it  is  necessary  to  remove  the  clothing  from  the  upper  part  of  the  body  for 
the  purposes  of  examination.  One-sided  flushing  of  the  face  occurs  in 
certain  forms  of  migraine  and  in  affections  of  the  cervical  sympathetic. 

In  addition  to  the  foregoing  facts  the  flushing  incident  to  pyrexia, 
certain  infections,  and  the  action  of  drugs  deserves  attention. 

Fever. — The  flushing  of  the  skin  in  acute  febrile  conditions  is  very 
characteristic.  It  is  often  attended  with  slight  turgescence  and  sometimes 
with  a  tendency  to  sweat.  The  flush  of  fever  is  usually  widely  distrib- 
uted over  the  surface.  It  is  -more  marked  in  young  persons  of  fair  com- 
plexion than  in  older  persons  and  in  brunettes.  It  has  a  tendency  to 
localize  itself  iji  the  cheeks  where  it  is  sometimes  circumscribed  or  unilateral, 
as  in  croupous  pneumonia.  Circumscribed  flushing  of  the  cheeks  in  persons 
otherwise  pallid  is  a  very  striking  phenomenon  in  the  hectic  fever  of  ad- 
vanced phthisis.  In  children  the  fever  flush  is  sometimes  so  intense  as  to 
suggest  the  existence  of  erythema  or  scarlatina.  In  rare  instances  pyrexia! 
flushing  occurs  during  the  first  week  of  enteric  fever,  especially  in  young 
persons  of  fair  skin,  and  may  be  so  marked  as  to  give  rise  for  a  time  to 
uncertainty  in  diganosis. 

Tache  cerebrate  is  a  cutaneous  vasomotor  phenomenon  which  occurs 
especially  in  young  persons  in  acute  febrile  affections,  as  cerebrospinal 
meningitis,  enteric  fever,  and  influenza,  in  certain  functional  nervous 
affections,  as  hysteria,  neurasthenia,  and  sometimes  in  organic  diseases  of 
the  brain  and  spinal  cord.     It  is  called  forth  by  slight  irritation  of  the 


528  MEDICAL  DIAGNOSIS. 

sldn,  such  as  is  produced  by  tapping  with  the  finger-tip  or  drawing  the 
finger  or  a  pencil  smartly  over  the  surface.  A  white  spot  or  line  appears 
and  is  shortly  followed  by  a  bright  red  discoloration  which  persists  for 
several  minutes. 

Dermatographism. — This  condition,  closely  allied  to  the  above,  is  not 
uncommon  in  neurotic  persons,  particularly  in  those  who  suffer  from 
urticaria.  Wheals  may  be  produced  by  drawing  the  finger  or  a  pencil 
somewhat  firmly  over  the  surface.  Letters  and  other  symbols  may  be 
brought  out  in  a  conspicuous  manner  and  often  last  for  several  hours. 
The  itching  characteristic  of  urticaria  does  not  occur. 

Drugs. — The  reddening  of  the  face  caused  by  alcohol  is  of  diagnostic 
importance.  The  expression  "flushed  with  wine"  is  significant.  The 
slightly  turgid,  purplish-red  face  of  chronic  alcoholism,  with  its  distended 
venules,  is  unfortunately  too  familiar.  The  flush  produced  by  the  nitrites 
and  especially  by  the  inhalation  of  amyl  nitrite  resembles  the  blushing  due 
to  psychic  causes.  Flushing  of  the  face  follows  the  administration  of  cer- 
tain poisons,  as  belladonna,  opium,  and  hyoscyamus. 

Cyanosis. — This  term  is  used  to  designate  the  dusky  blue  or  purplish 
color  of  the  skin  dependent  upon  the  circulation  in  the  capillaries  of  blood 
abnormally  rich  in  carbon  dioxide  and  poor  in  oxygen.  Cyanosis  may  be 
general  or  local. 

General  cyanosis  is  dependent  upon  two  factors,  first,  deficient  oxy- 
genation of  the  blood  in  the  lungs,  as  the  result  of  which  the  arterial  blood 
reaches  the  capillaries  containing  less  oxygen  and  darker  in  color  than 
normal;  second,  stasis  in  the  venous  radicals,  resulting  in  an  accumulation 
of  venous  blood  in  the  capillaries  of  the  skin,  which  by  the  retardation  in 
its  flow  becomes  richer  in  carbon  dioxide  and  darker  in  color.  Since  the 
conditions  are  universal  it  may  be  assumed  that  the  bluish  discoloration 
exists  not  only  in  the  skin  but  in  all  the  tissues  of  the  body.  Only  in  its 
intense  forms  does  cyanosis  show  itself  in  all  parts  of  the  surface.  When 
slight  it  appears  in  certain  parts  only  and  here  it  is  in  all  instances  more 
intense  than  elsewhere.  These  regions  are  the  face  and  especially  the  cheeks, 
the-  tip  of  the  nose,  the  ears,  lips  and  mucous  surface  of  the  mouth,  which 
have  an  especially  abundant  capillary  circulation  and  translucent  integu- 
ment. Other  points  in  which  cyanosis  is  especially  manifest  are  the  hands 
and  feet,  particularly  the  terminal  phalanges  and  the  nails,  in  which  blood 
stasis  is  favored  by  their  remoteness  from  the  heart. 

The  primary  derangement  may  be  respiratory  or  circulatory.  The 
interdependence  of  the  respiration  and  circulation  is  such,  however,  that 
when  cyanosis  is  marked  there  is  general  derangement  of  both  in  varying 
proportion. 

Respiratory. — All  conditions  which  interfere  with  the  respiratory 
function  and  thus  reduce  the  aeration  of  the  blood  may  give  rise  to  cyanosis. 
They  are  comprised  in  four  groups: 

(a)  All  affections  which  interfere  with  the  access  of  air  to  the  vesicular 
structure  of  the  lungs,  such  as  retropharyngeal  abscess,  stenosis  of  the  larynx 
caused  by  pseudomembranous  exudate,  as  in  diphtheria,  oedema  of  the 
glottis,  pseudocroup,  laryngismus  stridulus,  pertussis,  paralysis  of  the 
abductor  muscles,  tumors  of  the  larynx,  foreign  bodies  in  the  pharynx. 


SYMPTOMS  AND  SIGNS:   SKIN.  529 

larynx,  trachea,  or  bronchi,  all  forms  of  stenosis  of  the  trachea,  including 
thyroid  enlargement  and  other  deep-seated  tumors  of  the  neck,  as  well 
as  mediastinal  and  other  intrathoracic  tumors,  strangulation,  bronchitis, 
and  bronchial  asthma. 

(b)  Affections  which  interfere  with  the  action  of  the  respiratory 
muscles,  including  paralysis  and  atrophy  such  as  occur  in  bulbar  paralysis 
and  peripheral  neuritis;  spasmodic  contraction  of  these  muscles,  as  that  of 
tetanus  or  epilepsy;  painful  affections,  such  as  myalgia,  pleurisy,  and 
peritonitis,  in  which  the  respiratory  movements  are  instinctively  restrained; 
finally,  the  action  of  drugs,  such  as  opium  and  its  preparations,  which 
depress  the  respiratory  centres. 

(c)  Affections  which  diminish  the  respiratory  surface.  This  group 
includes  all  forms  of  consolidation  of  the  lung,  croupous  pneumonia,  bron- 
chopneumonia, including  tuberculous  infiltration  and  acute  miliary  tuber- 
culosis, atelectasis,  pressure  atelectasis  from  pleural  and  pericardial  effusion 
and  pneumothorax.  In  emphysema  the  respiratory  surface  is  not  only 
greatly  restricted  but  its  functional  integrity  is  also  impaired. 

(d)  Conditions  in  which  respiratory  movements  are  restricted  and  the 
respiratory  surface  is  circumscribed  by  subdiaphragmatic  pressure,  as  in 
hydramnion,  enormous  ascites,  enlargement  of  the  liver  or  spleen,  or  mas- 
sive abdominal  or  pelvic  tumors. 

Under  all  these  circumstances  the  aeration  of  the  blood  in  the  lungs  is 
diminished  and  venous  stasis  is  favored  by  the  reduction  in  the  normal 
aspiratory  function  of  the  lungs  which  constitutes  an  important  factor  in 
the  circulation.  The  absence  of  cyanosis,  often  observed  in  advanced 
phthisis  with  extensive  destruction  of  the  lungs  and  very  limited  respira- 
tory movement,  is  probably  due  to  the  great  wasting  of  the  body  and  corre- 
sponding reduction  in  the  mass  of  the  blood,  to  the  aeration  of  which  the 
remaining  limited  vesicular  structure  is  still  adequate.  Cyanosis  is  marked 
in  proportion  as  the  interference  with  respiration  is  rapid  and  urgent.  In 
chronic  cases  the  interference  may  reach  a  high  grade  without  causing  cyan- 
osis during  repose,  though  this  symptom  may  apjoear  upon  slight  exertion. 

Circulatory. — Primary  derangements  of  circulation  which  cause  cyan- 
osis may  be  referred  to  the  following  groups: 

(a)  Affections  of  the  heart  and  arteries,  including  valvular  disease  with 
impaired  or  ruptured  compensation,  myocarditis,  acute  dilatation  of  the 
heart,  the  cardiovascular  changes  which  occur  in  chronic  nephritis,  other 
forms  of  arteriosclerosis,  and  pericarditis. 

In  persistent  foramen  ovale  and  other  forms  of  cardiac  malformation, 
such  as  stenosis  of  the  pulmonar}^  arterj^,  there  is  very  often  marked  and 
continuous  cyanosis.  To  this  condition  of  congenital  cyanosis  the  term 
morbus  cceruleus  has  been  given.  In  acquired  conditions  permitting  an 
admixture  of  venous  blood  with  arterial  within  the  vessels,  as  in  the  very 
rare  cases  of  aneurism  of  the  aorta  communicating  with  the  vena  cava, 
cyanosis  is  a  suggestive  symptom. 

(b)  Conditions  affecting  the  pulmonary  circulation.  In  disease  of  the 
mitral  valve,  both  stenosis  and  insufficiency,  even  when  compensation  is 
good  there  may  very  often  be  seen,  especially  upon  exertion,  a  slight  degree 
of  cyanosis.    This  is  a  manifestation  of  the  changes  caused  by  the  habitual 

34 


530  MEDICAL  DIAGNOSIS. 

increase  of  tension  in  the  pulmonary  circuit  and  the  bronchial  catarrh 
which  to  some  degree  is  almost  constantly  present.  Though  having  its 
primary  cause  in  the  circulatory  apparatus  this  form  of  cyanosis  must  be 
looked  upon  as  respiratory. 

Pressure  upon  the  pulmonary  artery  or  veins  by  massive  pericardial 
effusion,  mediastinal  tumor  or  aneurism  is  a  very  common  cause  of  cyanosis. 
The  circulation  of  the  pulmonary  capillaries  is  obstructed  in  many  of  the 
conditions  involving  the  respiratory  apparatus  which  give  rise  to  cyanosis. 
Blueness  of  the  general  surface,  very  often  intense,  is  produced  by 
overdoses  of  certain  of  the  coal-tar  derivatives,  especially  acetanilid,  by 
nitrobenzole,  and  by  poisoning  with  illuminating  gas. 

Local  cyanosis  results  from  venous  stasis,  from  compression  of  the 
part  or  from  venous  thrombosis.  Cyanosis  of  the  head  and  neck  or  an  upper 
extremity  may  result  from  the  pressure  of  a  tumor  or  aneurism  upon  the 
jugular,  subclavian,  innominate,  or  descending  cava,  the  distribution  of 
the  cyanosis  corresponding  with  the  point  of  pressure.  Similar  cyanosis  of 
one  or  both  lower  extremities  may  result  from  pressure  involving  iliac  veins 
or  the  ascending  vena  cava  or  from  venous  thrombosis.  Local  venous 
thrombosis  giving  rise  to  cyanosis  of  an  arm  is  sometimes  seen  in  cancer 
of  the  breast  with  secondary  implication  of  the  axillary  glands. 

Cyanosis,  often  of  high  grade,  results  from  vasomotor  derangements. 
To  this  cause  must  be  referred  the  cyanotic  discoloration  of  the  extremities 
and  ears  which  follows  exposure  to  intense  cold,  the  cyanosis  of  paralyzed 
members,  and  the  bluish  discoloration  of  the  hands  which  occurs  in  hyster- 
ical and  neurasthenic  persons.  In  the  latter  group  of  cases  the  local  cyanosis 
is  sometimes  associated  with  oedema — the  blue  osdema  of  French  authors- 
Local  cyanosis  is  seen  in  intense  inflammation  involving  the  skin. 
The  conditions  which  give  rise  to  cyanosis,  namely,  retarded  circula- 
tion and  reduced  oxygenation,  interfere  with  the  local  production  of  animal 
heat.  In  cyanosis  the  skin  and  extremities  show  reduction  of  surface 
temperature. 

Jaundice — Icterus. 

These  terms  are  used  to  designate  the  peculiar  pathological  yellow 
discoloration  of  the  skin,  mucous  membranes,  and  fluids  of  the  body  caused 
by  the  circulation  in  the  blood  of  bile  pigment.  The  change  is  qualitative. 
There  are  two  forms,  obstructive  and  toxsemic. 

Obstructive  Jaundice. — This  is  the  more  common  form.  The  dis- 
charge of  bile  into  the  intestine  is  interfered  with  wholly  or  in  pai't  by 
stenosis  or  closure  of  the  bile  passages.  As  a  result  there  is  resorption  of 
the  bile,  the  pigments  of  which  discolor  the  tissues  in  shades  varying  from 
light  yellow  to  a  dark  brownish-yellow  or  olive-green.  The  darker  shades 
of  jaundice  result  either  from  change  of  the  original  bile  pigments  to  darker 
pigmentary  bodies  or  from  their  excessive  accumulation  in  the  skin.  The 
more  intense  and  darker  forms  of  jaundice  occur  in  protracted  cases.  In 
permanent  obstruction  the  color  may  be  greenish-black  or  bronze — the 
so-called  black  jaundice. 

Among  the  more  important  causes  of  obstructive  jaundice  are  catarrhal 
inflammation  of  the  mucous  membrane  of  the  duodenum  or  the  common 


SYMPTOMS  AND  SIGNS:   SKIN.  531 

duct;  gall-stones  and  parasites,  as  the  round  worm,  in  the  ducts;  stricture  or 
obliteration  of  the  duct;  tumors  developing  in  the  duct  or  exerting  pressure 
upon  its  orifice;  external  pressure  upon  the  duct  by  tumors  of  the  liver, 
stomach,  pancreas,  kidney,  or  omentum,  or  by  enlarged  glands  in  the  porta, 
or  in  rare  instances  by  aneurism  or  fecal  accumulation. 

The  yellow  discoloration  is  observed  first  and,  when  slight,  only  in 
the  conjunctivae  and  the  mucous  membrane  of  the  mouth.  Its  presence 
may  be  detected  by  pressure  upon  the  mucous  membrane  of  the  everted 
lip  with  a  glass  slide,  thus  expressing  the  blood  and  permitting  the  yellow 
stain  of  the  tissues  to  become  apparent.  It  is  sometimes  distinct  at  certain 
pale  areas  of  the  hard  palate.  The  shghter  grades  of  icterus  cannot  be 
recognized  in  artificial  light.  Superficial  resemblances  to  jaundice  are  seen 
in  the  dirty  yellow  or  muddy  discoloration  of  the  malarial  and  malignant 
cachexias.  In  these  conditions  the  absence  of  yellowness  in  the  conjunc- 
tival and  oral  mucous  membranes  is  conclusive.  The  collections  of  yellow 
subconjunctival  fat  occasionally  seen  in  elderly  persons  are  only  in  the 
most  remote  way  suggestive  of  jaundice.  The  yellow  discoloration  which 
occurs  in  picric  acid  poisoning  presents  superficial  resemblances  to  jaun- 
dice.    The  absence  of  bile  pigment  in  the  urine  is  important. 

Pruritus  is  a  troublesome  symptom.  It  is  usually  more  marked  in  the 
chronic  cases.  Lesions  of  the  skin,  the  result  of  scratching,  are  not  uncom- 
mon. Sweating  is  common  and  may  be  locaHzed.  Urticaria,  furuncles, 
lichen,  xanthelasma,  and  other  diseases  of  the  skin  occur.  In  some  of  the 
chronic  cases  circumscribed  patches  of  dilatation  of  the  capillary  vessels 
and  minute  arteries — telangiectasis — develop  in  the  skin  of  the  face  and 
body  and  occasionally  upon  the  mucous  membranes.  In  protracted  and 
severe  cases  there  may  be  hemorrhages  into  the  skin,  usually  in  the  form 
of  purpuric  spots  upon  the  lower  extremities,  but  sometimes  as  large 
ecchymoses,  and  in  some  instances  spontaneous  bleeding  from  the  mucous 
membranes  occurs.  The  blood  in  chronic  jaundice  coagulates  very  slowly — 
ten  to  twelve  minutes,  instead  of  about  four  in  the  case  of  normal  blood — 
and  troublesome  and  even  fatal  hemorrhage,  usually  in  the  form  of  uncon- 
trollable capillary  oozing,  may  follow  operation  or  injury.  The  sweat  is 
bile-stained  and  discolors  the  clothing.  The  urine  contains  bile  pigment 
and  may  show  the  color  reaction  to  Gmelin's  test  before  the  yellow  tint 
appears  in  the  mucous  membranes  or  the  skin.  The  color  varies  from  light 
yellow  with  a  greenish  tinge  to  a  deeply  opaque  black-green.  In  intense  or 
long-standing  jaundice  the  urine  commonly  contains  albumin  and  tube 
casts  which  are  bile-stained.  Upon  agitation  the  dark  urine  of  jaundice  is 
frothy  and  is  often  popularly  compared  to  porter.  The  sputa  are  not  often 
bile-stained,  except  when  pneumonia  is  present.  On  the  other  hand  the 
saliva  very  rarely  shows  the  yellow  discoloration,  which  is  likewise  absent 
in  the  tears  and  milk. 

As  no  bile  is  discharged  into  the  intestine  the  stools  are  of  a  pale  drab 
or  clay  color.  They  are  usually  pasty  and  very  fetid.  The  absence  of  bile 
in  the  faeces  is  of  importance  in  the  differential  diagnosis  between  obstruc- 
tive and  toxsemic  jaundice.  Commonly  there  is  constipation;  occasionally 
diarrhoea.  The  pulse,  in  obstructive  jaundice  especially,  in  recent  cases  is 
usually  slow  and  may  fall  to  30  or  lower.    The  frequency  of  the  respiration 


532  MEDICAL  DIAGNOSIS. 

is  also  diminished,  in  some  instances  to  10  or  8  per  minute.  The  tem- 
perature may  be  subnormal.  These  symptoms  are  attributed  to  the 
action  of  the  bihary  salts,  which  undergo  resorption  together  with  the 
bile  pigment.  They  are  not  constant  and  when  present  not  necessarily 
unfavorable. 

The  patient  is  usually  depressed  and  irritable.  In  severe  cases  melan- 
cholia may  develop.  The  liability  to  the  occurrence  of  the  condition  called 
cholsemia  constitutes  a  serious  danger  in  persistent  jaundice.  The  patient 
falls  into  the  so-called  typhoid  state,  with  fever,  rapid  pulse,  dry  tongue, 
and  muttering  dehrium.  Convulsions  and  coma  develop  and  rapidly  prove 
fatal.  This  group  of  symptoms  resembles  uraemia.  They  have  been  attrib- 
uted to  poisoning  by  cholesterin — cholestersemia.  The  toxic  substances 
have  not  been  determined. 

Toxasmic  Jaundice. — The  jaundice  is  associated  with  the  presence  of 
various  poisons  in  the  blood  which  act  directly  upon  the  red  blood-corpuscles 
and  in  some  cases  upon  the  liver-cehs.  Among  these  poisons  are  (a)  snake 
venom,  phosphorus,  arsenic,  chloral  hydrate,  chloroform,  and  ether;  (b) 
toxins  elaborated  within  the  organism  in  the  course  of  the  specific  infec- 
tious diseases,  as  yellow  fever,  relapsing  fever,  malaria,  pneumonia,  enteric 
fever,  typhus,  and  scarlatina;  (c)  the  toxins  of  septic  conditions,  pyaemia, 
malignant  endocarditis,  acute  yellow  atrophy  of  the  hver,  Weil's  disease, 
and  epidemic  jaundice.  The  symptoms  are  generally  less  intense  than  in 
obstructive  jaundice.  The  discoloration  of  the  skin  is  usually  slight; 
exceptionally,  as  in  the  case  of  acute  yellow  atrophy  and  malignant  jaun- 
dice, it  is  intense.  The  stools  are  colored  with  bile,  sometimes  deeply. 
The  urine  may  be  dark  from  increase  in  the  normal  urinary  pigments  but 
gives  little  or  no  reaction  for  bile  pigment.  Toxic  jaundice  of  slight  degree 
frequently  appears  during  the  course  of  febrile  affections  and  under  other 
circumstances  and  may  be  without  unfavorable  prognostic  significance. 
On  the  other  hand  in  many  cases  the  conditions  in  which  this  form  of 
jaundice  occurs  are  attended  with  profound  constitutional  disturbance, 
manifest  in  intense  fever,  delirium,  suppression  of  urine,  hemorrhages  into 
the  skin  and  from  mucous  surfaces,  convulsions  and  coma,  and  verj^  often 
terminate  in  death. 

The  jaundice  due  to  obstructive  changes  in  the  bile  passages  was 
formerly  spoken  of  as  hepatogenous;  toxaemic  jaundice  as  hcematogenous. 
Concerning  the  mode  of  origin  of  toxaemic  jaundice  there  is  much  diversity 
of  opinion  and  the  cases  differ  among  themselves.  In  groups  of  cases  there 
is  probable  resorption  of  bile  pigments  from  the  liver  as  the  result  of  patho- 
logical processes  involving  the  finer  ducts  or  the  hver  parenchyma  itself. 
Some  pathologists  attribute  the  icterus,  so  common  in  pneumonia,  to  a 
catarrh  of  the  finer  bile  passages  dependent  upon  venous  stasis,  while  others 
attribute  it  in  part  at  least  to  the  interference  with  the  respiratory  move- 
ment of  the  diaphragm  caused  by  the  consohdation  of  the  lung,  and  result- 
ing in  an  accumulation  in  the  smaller  ducts  of  bile  which  undergoes  resorp- 
tion. The  rapid  course  and  profound  disorganization  of  the  liver  in  acute 
atrophy  and  in  phosphorus  poisoning  suggest  the  possibility  that  other 
forms  of  grave  toxaemic  jaundice  may  be  due  to  as  yet  unknown  paren- 
chymatous changes  in  the  Hver.     On  the  other  hand  most  of  the  poisons 


SYMPTOMS  AND  SIGNS:    SKIN.  533 

which  cause  icterus  exert  a  destructive  influence  upon  the  erythrocytes. 
It  has  been  shown  experimentally,  however,  that  the  yellow  pigment  in 
poisoning  by  certain  substances,  as  toluylendiamine,  is  not  formed  in  the 
blood  but  in  the  liver,  the  haemoglobin  being  transformed  into  biliary 
pigment  in  that  organ.  As  a  result  of  this  transformation  the  bile  pigments 
accumulate  in  the  liver  in  such  quantity  that  they  cannot  be  wholh^  excreted, 
a  certain  portion  undergoing  resorption.  In  consequence  of  these  facts 
the  term  hcematohepatogenous  has  been  suggested  for  this  form  of 
jaundice.  In  the  present  state  of  knowledge  the  etiological  designation 
toxaemic  jaundice  is  to  be  preferred.  The  term  toxEemic-obstructive  jaun- 
dice has  been  suggested  by  Hunter. 

Normal  and  Abnormal  Pigmentation — Melanoderma. — The  physiological 
pigmentation  of  the  skin  shows  wide  variations  not  only  in  different  races 
but  in  different  individuals  of  the  same  race.  Among  the  fair-skinned  a 
blonde  and  a  brunette  type  are  recognized.  The  latter  is  characterized  by  a 
darker  color  of  the  hair,  skin,  and  iris.  Normally  the  skin  is  more  deeply  pig- 
mented in  the  exposed  portions  of  the  body  to  which  the  light  and  air  have 
free  access  than  elsewhere;  upon  extensor  than  upon  flexor  surfaces  in 
the  region  of  the  joints;  and  about  the  nipples,  linea  alba,  and  genital  or- 
gans. During  pregnancy  the  pigmentation  in  these  latter  situations  is 
greatly  increased,  especially  in  brunettes,  and  upon  the  face  and  in  other 
portions  of  the  body  there  are  occasionally  seen  irregular,  abnormally  pig- 
mented areas  known  as  chloasma  gravidarum — masque  des  femmes  enceintes. 
Patchy  pigmentation  of  the  skin  is  a  common  symptom  of  uterine  disease. 
In  sedentary  persons  of  constipated  habit  irregular  patchy  pigmentation 
of  the  skin  is  common,  especially  about  the  face  and  eyes. 

Freckles  or  ephelides  are  another  physiological  pigmentation  of  the 
skin  without  diagnostic  importance.  The  pigmentation  appears  in  cir- 
cumscribed spots  varying  from  one  to  several  millimetres  in  diameter, 
chiefly  upon  the  face,  but  also  in  other  parts  of  the  body,  especially  the 
backs  of  the  hands  and  arms.  They  are  more  common  in  fair  than  dark 
persons  and  are  almost  always  present  in  individuals  with  red  hair.  The 
spots  are  more  abundant  and  the  pigmentation  deeper  in  summer  than  in 
winter,  when  they  sometimes  wholly  disappear. 

The  pigmentation  following  measles  and  showing  the  characteristic 
form  and  arrangement  of  the  eruption  is  not  wholly  without  interest  to  the 
clinician,  and  the  localized  pigmentation  which  follows  the  application  of 
sinapisms  and  blisters  deserves  passing  mention. 

The  vagabond's  skin  is  a  term  applied  to  the  diffuse  pigmentation 
resulting  from  lousiness  and  dirt  and  the  scratching  caused  by  these  condi- 
tions. The  pigmentation  sometimes  reaches  a  very  high  grade.  It  may 
be  arranged  in  a  very  characteristic  manner  in  stripes  corresponding  to  the 
lines  of  scratching.  This  condition  has  been  confounded  with  the  pig- 
mentation of  Addison's  disease. 

Melanosarcoma,  especially  when  generahzed,  very  often  produces  a 
deep  and  widespread  cutaneous  pigmentation.  Under  these  circumstances 
in  exceptional  cases  the  urine  also  contains  abnormal  pigment. 

In  advanced  pulmonary  tuberculosis  a  striking  brownish  discol- 
oration of  the  face  or  the  whole  body  is  sometimes  observed. 


534  MEDICAL  DIAGNOSIS. 

In  ABDOMINAL  NEW  GROWTHS,  especially  cancer  or  lymphoma,  diffuse 
cutaneous  pigmentation  occasionally  occurs.  It  is  not  uncommon  in  tuber- 
culosis of  the  peritoneum. 

In  HtEmachromatosis,  such  as  occurs  in  hypertrophic  cirrhosis,  dia- 
betes, and  other  conditions,  pigmentation  of  the  skin  may  be  present. 

Exophthalmic  goitre  maybe  associated  with  abnormal  pigmentation. 

Gastric. — In  rare  instances  diffuse  pigmentation  attends  gastric  ulcer 
and  dilatation. 

In  SCLERODERMA  cutaneous  pigmentation  may  be  general  and  of 
high  grade. 

Cardiac. — In  chronic  disease  of  the  heart  and  arteriosclerosis  diffuse 
pigmentation  may  occur. 

Addison's  Disease. — The  bronze  discoloration  of  this  affection  is 
clinically  the  most  important  form  of  abnormal  pigmentation  of  the  skin. 
It  usually  shows  itself  first  upon  exposed  surfaces,  as  the  hands  and  face, 
and  is  more  intense  in  those  regions  in  which  the  skin  is  normally  more 
deeply  colored  than  elsewhere.  It  begins  as  a  faint  smoke-gray  discolora- 
tion and  progressively  deepens  to  an  intense  bronze  or  mulatto  hue.  In 
the  diffuse  smoky  coloration  isolated  intense  dark  brown  points  may  be 
distinguished.  The  grayish  pigment  patches  seen  upon  the  mucous  mem- 
brane of  the  mouth  are  characteristic  of  Addison's  disease.  The  palms  and 
soles  as  well  as  the  nails  commonly  remain  pigment  free.  The  discolora- 
tion of  Addison's  disease  may  suggest  intense  jaundice,  but  the  general 
condition,  the  yellow  staining  of  the  conjunctivae  and  the  mucous  mem- 
brane of  the  mouth,  and  the  presence  of  bile  pigment  in  the  urine  are  of 
positive  diagnostic  importance. 

Hepatic  Disease. — The  peculiar  discoloration  of  the  skin  occasion- 
ally seen  in  cirrhosis  and  other  diseases  of  the  liver  demands  consideration. 
The  color  is  a  dirty  brownish-gray.  It  is  to  be  differentiated  from  icterus 
by  the  color  itself,  the  absence  of  staining  of  the  mucous  membranes,  and 
the  condition  of  the  urine.  This  pigmentation  is  of  especial  interest  in 
connection  with  the  bronzing  of  the  skin  that  occurs  in  certain  cases  of 
diabetes — diabete  bronze — developing  late  in  hsemachromatosis  and  asso- 
ciated with  pigmentary  cirrhosis  of  the  liver  and  pancreas.  The  color 
suggests  Addison's  disease,  but  the  presence  of  grape  sugar,  the  physical 
signs  of  hepatic  cirrhosis  without  jaundice,  and  the  absence  of  the  char- 
acteristic symptoms  of  Addison's  disease  are  of  diagnostic  importance. 

Arsenomelanosis. — The  pigmentation  of  the  skin  produced  by  the 
prolonged  administration  of  arsenic  in  full  doses  sometimes  presents  a  very 
close  resemblance  to  Addison's  disease.  In  a  majority  of  the  cases  it 
entirely  disappears  when  the  drug  is  withheld;  exceptionally  it  is  persistent. 
It  is  important  to  know  that  in  some  instances  the  pigmentation  of  the  skin 
has  followed  the  use  of  arsenic  in  moderate  doses. 

Argyria. — The  prolonged  administration  of  silver  nitrate  results  in 
the  deposition  of  particles  of  metallic  silver  or  its  albuminate  in  the  internal 
organs  and  in  the  skin.  The  resulting  discoloration  is  a  peculiar  bluish- 
gray  which  is  more  intense  upon  the  face  and  hands  and  is  not  changed  by 
pressure.  The  discoloration  may  be  observed  in  the  mucous  membrane 
of  the  mouth.     It  is  persistent  and  not  amenable  to  treatment. 


SYMPTOMS  AND  SIGNS:   SKIN.  535 

Albinism  is  a  term  used  to  designate  developmental  deficiency  of  pig- 
ment. In  albinos  the  skin,  hair,  and  eyes  are  conspicuous  by  the  absence 
of  pigment.  The  affection  may  be  partial  or  universal.  It  is  frequently 
associated  with  other  developmental  defects,  especially  coloboma.  N3^s- 
tagmus  is  common. 

Vitiligo  is  a  condition  of  the  skin  characterized  by  deficiency  of  pig- 
ment. The  patches  are  usually  circumscribed,  very  often  distinctly  margi- 
Tiate,  and  sometimes  surrounded  by  a  zone  of  pigmentation  slightly  deeper 
than  normal.  It  may  occur  on  any  part  of  the  body,  but  is  common  on  the 
back  of  the  neck  and  shoulders,  the  abdomen,  and  scrotum.  There  are  no 
subjective  symptoms.     It  occurs  in  adolescents  and  young  adults. 

Leucoderma  or  pigment  atrophy,  usually  circumscribed  or  irregularly 
distributed,  is  encountered  in  exophthalmic  goitre,  myxoedema,  sclero- 
derma, and  other  constitutional  disturbances. 

Moisture. — There  are  wide  variations  in  the  activity  of  the  sweat- 
glands  within  physiological  limits.  Perspiration  is  excited  by  those  causes 
which  determine  an  active  blood  supply  to  the  skin.  It  is  therefore  more 
abundant  in  warm  weather,  after  exercise,  hot  baths,  and  hot  drinks.  An 
outburst  of  sweating  may  occur  in  connection  with  sudden  intense  emotion. 
A  pathological  increase  of  perspiration  is  termed  hyperidrosis;  its  absence 
anidrosis.  These  terms  are  commonly  used  to  designate  conditions  in  which 
the  increase  or  absence  are  persistent  or  habitual. 

Hyperidrosis. — Free  perspiration  attends  certain  febrile  diseases, 
especially  rheumatic  fever,  some  cases  of  enteric  fever,  acute  polyneuritis, 
miliary  fever,  and  septic  conditions.  A  critical  decline  of  fever,  whether 
■spontaneous  or  the  result  of  the  administration  of  antipj^retics,  is 
almost  always  attended  by  more  or  less  abundant  sweating.  Perspiration 
is  one  of  the  processes  by  which,  both  physiologically  and  pathologically, 
the  temperature  of  the  body  is  lowered.  Profuse  sweating  attends  the 
crisis  in  pneumonia,  relapsing  fever,  and  typhus.  Sweating  is  often  abund- 
ant toward  the  close  of  enteric  fever  when  the  temperature  curve  assumes 
a  distinctly  remittent  or  intermittent  type.  The  fall  of  temperature  in  the 
ague  paroxysm  is  almost  always  attended  with  copious  sweating.  That 
'Of  the  hectic  fever  of  phthisis  and  other  wasting  diseases  usually  occurs 
during  the  night  or  toward  morning.  It  is  attended  with  abundant  sweat- 
ing—  Jiight-sweats  —  and  is  of  unfavorable  prognostic  significance.  Pro- 
fuse sweating  occurs  in  some  cases  of  phthisis  in  the  absence  of  fever. 
Sudden  abundant  sweats  are  accompanied  by  sensations  of  great  weakness 
and  prostration  which  are  in  part  due  to  the  relaxation  of  the  vessels  fol- 
lowing the  sudden  withdrawal  of  fluid.  Excessive  sweating  occurs  in  the 
convalescence  from  some  diseases.  It  occurs  in  collapse,  urgent  dyspnoea, 
and  sometimes  accompanies  severe  paroxysms  of  pain.  In  rare  instances 
■of  diabetes  abundant  perspirations  have  alternated  with  polyuria.  In- 
creased sweating  sometimes  attends  the  suppression  of  urine  that  occvu-s 
in  certain  forms  of  nephritis.  Under  these  circumstances  crystals  of  urea 
may  accumulate  upon  the  skin  and  especially  upon  the  face. 

liocahzed  sweating  is  not  uncommon  in  pathological  conditions. 
Hyperidrosis  of  the  hands  and  feet  occasionally  occurs  in  neurotic  inth'vidu- 
.als  and  sometimes  in  persons  otherwise  healthy.     The  condition  is  very 


536  MEDICAL  DIAGNOSIS. 

annoying.  The  sweat  is  usually  copious  and  foul-smelling.  Axillary  sweat- 
ing is  an  annoying  constitutional  peculiarity.  Sweating  of  the  head, 
especially  during  sleep,  is  an  important  symptom  in  rickets.  Unilateral 
sweating  of  the  head  or  face  occurs  in  certain  nervous  diseases,  as  migraine 
and  neuralgia,  and  may  result  from  pressure  upon  the  sympathetic  by  a 
thoracic  aneurism  or  mediastinal  tumor.  Localized  sweating  depends 
upon  vasomotor  derangements.  Diaphoresis  follows  the  administration 
of  certain  drugs,  especially  ammonium  acetate,  pilocarpine,  and  many  of 
the  coal-tar  derivatives. 

Anidrosis. — Abnormal  dryness  of  the  skin  occurs  under  conditions  in 
which  an  excess  of  fluid  is  withdrawn  from  the  body  by  way  of  its  internal 
surfaces,  or  very  little  water  reaches  the  blood  by  way  of  the  gastro-intes- 
tinal  tract — for  example,  profuse  diarrhoea,  continuous  vomiting,  diabetes 
mellitus  and  insipidus,  chronic  nephritis  with  polyuria,  and  the  deprivation 
of  fluid.  The  dry  skin  of  myxoedema  and  general  anasarca  is  largely  attrib- 
utable to  the  interference  with  the  cutaneous  circulation  resulting  from 
tension. 

Modifications  in  the  Perspiration. — Perspiration  when  abundant  usually 
has  a  peculiar  acid  odor.  That  in  rheumatic  fever  is  acid  and  ill- 
smelling;  the  sweat  of  the  hands,  feet,  and  axilla  is  almost  always  foul; 
that  in  certain  forms  of  nephritis  has  a  urinous  odor.  The  sweat  may  be 
discolored — chromidrosis — yellow  from  biliary  pigments  in  jaundice;  blue 
from  the  action  of  the  Bacillus  pyocyaneus.  There  are  instances  recorded 
of  the  sweating  of  a  blood-stained  fluid  or  blood  in  hysterical  females — 
hcematidrosis — and  there  exists  a  term — menidrosis— to  describe  vicarious 
menstruation  by  way  of  the  skin.  These  conditions  are  of  no  importance 
in  diagnosis.  Various  colored  perspiration-stains  upon  the  linen  are  not  to 
be  mistaken  for  instances  of  chromidrosis.  It  may  prevent  error  to  call 
attention  to  the  fact  that  some  of  the  aniline  dyes  undergo  more  or  less 
marked  changes  in  color  under  the  action  of  perspiration. 

Fulness  of  the  Skin — Turgor. — The  normal  appearance  of  fulness 
of  the  sldn  is  due  to  the  blood  and  lymph  in  its  vascular  and  lymph  spaces. 
It  varies  in  different  individuals  and  in  different  parts  of  the  body,  and  is 
more  pronounced  in  females.  In  connection  with  an  abundant  panniculus 
it  has  much  to  do  in  causing  the  condition  described  by  the  French  as 
emhonj)oint.  Increased  fulness  of  the  skin  is  seen  in  fever  and  other  con- 
ditions attended  by  active  cutaneous  circulation;  decreased  fulness  in  all 
conditions  in  which  the  cutaneous  circulation  is  diminished  without  stasis, 
particularly  in  emaciation,  the  cachexias,  and  under  the  deprivation  of 
fluid.  Increased  fulness  is  manifested  by  rounding  of  the  contours,  espe- 
cially those  of  the  face,  and  usually  by  a  deeper  color  of  the  skin,  while 
diminished  fulness  produces  accentuation  of  the  angles  and  is  usually 
associated  with  more  or  less  pallor.  In  the  former  condition  the  skin  is 
smooth,  soft,  and  elastic;  when  pinched  up  into  folds  it  rapidly  reassumes 
its  normal  surface.  In  the  latter  such  folds  only  slowly  disappear.  Normal 
fulness  or  turgor  is  to  be  distinguished  from  oedema  and  anasarca  by  the 
pathological  amount  of  fluid  in  the  skin  in  the  latter,  the  loss  of  the  normal 
cutaneous  elasticity,  and  by  the  persistence  of  the  pitting  made  by  pressure 
of  the  finger.     The  difference  between  "looking  well"  and  "looking  bad" 


SYMPTOMS  AND  SIGNS:   SKIN. 


537 


Fig.  200. — d 
atous  ueplinti 


very  often  depends  upon  slight  transient  variations  in  the  normal  fulness 
of  the  face,,  which  is  diminished  in  conditions  of  exhaustion  and  depression 
and  increased  after  repose  and  in  pleasur- 
able excitement.  The  turgor  of  the  skin 
is  usually  increased  in  exophthalmic  goitre. 
Greatly  diminished  fulness  of  the  sldn  such 
as  occurs  in  ileus,  peritonitis,  cholera,  and 
some  cases  of  shock,  and  which  precedes 
death,  gives  rise  to  the  facies  Hippocratica 
seen  in  these  conditions. 

CEdema — Dropsy. — An  abnormal  accu- 
mulation of  serous  fluid  collects  in  the  lymph 
spaces  of  the  skin  and  the  subcutaneous 
connective  tissue  as  the  result  of  a  disturb- 
ance of  the  balance  between  the  fluid  which  transudes  from  the  capillaries  and 
that  which  is  taken  up  by  the  lymphatics.     This  disturbance  of  balance  may 

be  due  to  (a)  venous  obstruction, 
(b)  altered  condition  of  the  blood 
—  hydrcemia,  (c)  inflammation, 
and  (d)  oedema  of  nervous  ori- 
gin. The  diagnostic  significance 
of  oedema  depends  upon  its 
location,  extent,  and  mode  of 
development  and  its  causal  rela- 
tions to  local  or  constitutional 
diseases.  General  oedema  is  de- 
scribed under  the  term  anasarca. 
The  skin  is  distended  and  the. 
normal  surface  landmarks  oblit- 
erated. When  oedema  is  marked 
the  surface  is  tense,  pallid,  and 
glistening.  In  rapidl}--  devel- 
oping recent  oedema  it  has  a 
translucent  appearance.  In 
some  surfaces,  especially  upon 
the  abdomen  and  thighs,  trans- 
parent parallel  stripes  appear, 
similar  to  those  seen  on  the 
abdomen  in  pregnancy.  These 
are  due  to  the  collection  of  the 
fluid  in  the  lines  of  separation 
of  the  distended  tissues  or  in 
the  enlarged  lymphatic  spaces. 
They  usually  disappear  upon 
the  subsidence  of  the  oedema 
without  leaving  traces.  Occa- 
sionally they  leave  permanent  irregular  linear  scars.  In  oedema  of 
high  grade,  especially  under  the  influence  of  irritation  or  slight  trau- 
matism of  the  skin,  blebs  may  form  upon  the  epidermis  which  rupture 


Fig.  201. — Oildema  of  the  legs  with  cutaneous 
blebs  in  a  case  of  subacute  parenchymatous  nephritis. — 
Jefferson  Hospital. 


538 


MEDICAL  DIAGNOSIS. 


and  are  followed  by  the  discharge  of  serous  fluid.  Occasionally;  espe- 
cially upon  the  legs  and  ankles,  transudation  of  the  fluid  takes  place 
through  minute  openings  of  the  skin  without  bleb  formation.  Under 
these  circumstances  infection  may  occur,  giving  rise  to  erysipelatous 
or  other  inflammation.  The  pale  color  of  the  skin  in  oedema  is  caused 
by  diminished  capillary  circulation  from  compression.  The  oedem.atous 
parts  are  sometimes  cyanosed  and  in  inflammatory  oedema  the  skin 
is  reddened. 

The  normal  elasticity  of  the  skin  is  impaired  by  tension  and  the  inhibi- 
tion of  fluid.  Pressure  upon  the  oedematous  part  gives  rise  to  pitting  which 
only  slowly  disappears.  Where  the  skin  is  normally  distensible  and  elastic 
the  pitting  is  more  transient.     This  is  especially  the  case  in  children.     In 


Pig.  202.- 


-QSdema  of  abdominal  wall  and  thighs  in  ascites  due  to  atrophic  cirrhosis  of  the  liver .- 

Hospital. 


-Jefferson 


moderate  oedema  of  long  standing  a  gradual  increase  in  the  subcutaneous 
■connective  tissue  develops  and  pitting  is  less  marked  and  more  transient. 

(a)  Venous  Obstruction. — Factors  in  the  production  of  this  form  of 
oedema  are  diminished  general  muscular  activity,  impaired  pumping  action 
of  the  organs  of  respiration,  diminution  of  the  aspiratory  force  of  the  heart 
in*  diastole  and  positive  pressure  on  the  veins.  Coincidently  the  return 
flow  of  the  lymph  which  is  brought  about  by  the  same  forces  that  maintain 
the  venous  circulation  is  impeded.  This  form  of  dropsy  is  frequently  asso- 
ciated with  effusion  into  the  great  serous  sacs.  The  fluid  which  collects  is 
clear,  usually  colorless,  of  low  specific  gravity,  fibrin  free,  and  contains  a 
.slightly  smaller  amount  of  proteids  than  the  blood- serum.  It  is  to  be 
distinguished  from  an  inflammatory  exudate  which  is  often  turbid,  some- 
times bloody,  of  high  specific  gravity,  and  usually  contains  masses  of  fibrin. 
Ohanges  in  the  tissues  and  particularly  in  the  endothelium  of  the  lymph- 
spaces  also  play  an  important  part  in  oedema-formation — so-called  "vital 
secretory"  processes. 

The  collection  of  serous  fluid  in  the  pericardium  is  known  as  hydroperi- 


SYMPTOMS  AND  SIGNS:    SKIN. 


539 


cardiuTTi,  in  the  pleural  cavity  as  hydrothorao:,  in  the  peritoneal  cavity  as 
hydroperitoneum  or  ascites,  in  the  brain  as  hydrocephalus,  in  the  joints  as 
hydrarthrosis.  Any  of  the  affections  of  the  heart  and  lungs  which,  by  inter- 
fering with  the  return  of  the  venous  blood,  cause  cyanosis  may  also  cause 
CEdema.  Cyanosis  and  oedema  are  therefore  frequentl}^  associated.  This 
form  of  oedema  appears  earliest  and  reaches  its  fullest  development  in  those 
regions  in  which  the  circulation,  by  reason  of  remoteness  from  the  heart 
and  the  influence  of  gravity,  is  less  active,  as  in  the  extremities  and  the 
lumbar  regions  and  other  dependent 
portions  in  bedridden  patients.  The 
face  at  first  is  free  and  becomes 
cedematous  only  when  the  anasarca 
reaches  a  high  grade.  Gravity  plays 
an  important  part  in  the  localization 
of  the  oedema.  CEdema  of  the  legs 
and  feet  while  the  patient  is  in  the 
upright  position  may  alternate  with 
oedema  of  the  back  and  thighs  when 
he  is  in  the  recumbent  posture.  The 
patient  who  is  apparently  free  from 
oedema  while  in  bed  may  show 
oedema  of  the  feet  and  ankles  when 
he  first  rises.  In  prolonged  main- 
tenance of  the  lateral  decubitus  the 
oedema  is  more  marked  upon  the  de- 
pendent side.  In  anasarca  of  high 
grade,  partly  on  account  of  their 
dependent  position  and  partly  on  ac- 
count of  the  distensibility  of  the  skin, 
the  penis  and  scrotum  and  the  labia 
majora  become  enormously  swollen. 

Local  oedema  may  be  due  to 
the  obstruction  of  a  venous  trunk  by 
thrombosis  or  pressure.  CEdema  of 
the  arm  from  the  pressure  of  enlarged 
axillary  lymphatics  upon  the  veins, 
and  the  oedema  of  the  leg  in  throm- 
bosis of  the  femoral  vein  are  familiar  examples.  Obstructive  oedema  of  the 
lower  extremities  is  frequently  secondary  to  peritoneal  effusion,  such  as 
results  from  cirrhosis  or  portal  thrombosis  or  from  chronic  peritonitis. 
The  accumailation  of  the  fluid  presses  upon  the  inferior  vena  cava  or  the 
common  iliac  veins.  In  other  cases  the  oedema  of  the  lower  extremities 
and  the  peritoneal  effusion  are  due  to  the  same  cause.  When,  upon  investi- 
gation, the  signs  of  peritoneal  effusion  are  found  to  have  preceded  the 
oedema  of  the  limbs,  the  latter  condition  is  usually  secondary. 

(b)  Altered  Condition  of  the  Blood — Hydraemia. — A  watery  condition  of 
the  blood  is  a  common  cause  of  oedema  and  other  forms  of  dropsy.  To  this 
condition  may  be  referred  those  forms  of  oedema  which  occur  in  nephritis, 
chronic  wasting  diseases,  the  anaemias,  and  cachexias.     Not  infrequently 


Fig.  203. — OSdema  of  left  leg  due  to  a  thrombus  in 
the  external  iliac  vein. — German  Hospital. 


540  MEDICAL  DIAGNOSIS. 

associated  cardiovascular  disorders  are  present  which  interfere  with  the 
venous  circulation,  and  in  such  cases  the  oedema  from  venous  obstruction 
and  the  oedema  of  hydrsemia  are  combined.  This  form  of  oedema  differs 
markedly  from  the  oedema  of  venous  obstruction  in  its  early  localization, 
which  is  dependent  much  less  upon  remoteness  from  the  heart  and  the  action 
of  gravity  and  much  more  upon  the  peculiarities  of  the  lymph  structures. 
It  is  characteristic  of  the  oedema  of  certain  forms  of  nephritis  that  it  first 
appears  in  the  face  and  especially  about  the  eyelids.  With  this  early  oedema 
of  the  face  pretibial  oedema  is  often  associated  and  is  sometimes  present 
in  cases  of  nephritis,  especially  the  chronic  interstitial  forms  in  which  facial 
oedema  is  shght  or  absent  altogether.  The  oedema  of  acute  nephritis  often 
develops  rapidly  and  reaches  a  very  high  grade.  Not  infrequently  it  is 
associated  with  effusion  into  the  serous  sacs.  In  that  form  of  nephritis 
characterized  by  contraction  of  the  kidney  oedema  is  very  often  slight  in 
amount  and  a  late  manifestation,  first  showing  itself  when  the  hyper- 
trophied  heart  begins  to  fail.  In  the  subacute  and  chronic  forms  of  paren- 
chymatous nephritis  the  oedema  is  usually  moderate,  showing,  however, 
temporary  increases  which  accompany  exacerbations  of  the  disease.  In 
the  hydrsemia  resulting  from  large  or  frequently  repeated  hemorrhage, 
oedema  is  often  pronounced.  (Edema  of  the  feet  and  ankles  is  a  very 
unfavorable  symptom  in  pulmonary  consumption.  Occurring  in  the  ab- 
sence of  renal  disease  or  especially  in  the  absence  of  conditions  giving  rise 
to  venous  obstruction  it  is  commonly  an  indication  of  approaching  death. 

(c)  Inflammatory  CEdema. — The  local  oedema  in  the  region  of  in- 
flammatory and  suppurative  processes  is  of  diagnostic  importance.  It 
is  sometimes  known  as  collateral  oedema.  The  color  of  the  surface 
varies  from  a  faint  blush  to  a  deep,  mottled,  cyanotic,  purplish  red. 
It  is  due  to  obstruction  of  the  lymph  circulation  by  the  inflammatory 
exudate.  In  some  instances  it  appears  to  be  caused  by  an  accumulation 
of  the  fluid  part  of  the  exudate  in  the  tissues  surrounding  the  inflammatory 
focus.  It  occurs  in  the  region  behind  the  ear  in  mastoid  disease;  about  the 
angle  of  the  jaw  in  mumps  and  parotid  bubo;  at  the  base  of  the  thorax  in 
empyema.  It  is  an  important  sign  of  hepatic  abscess,  acute  suppurative 
gall-bladder  disease,  and  is  sometimes  seen  in  the  right  lower  quadrant  of 
the  abdomen  in  appendicular  abscess.  It  constitutes  the  so-called  collar 
of  brawn  in  severe  anginose  scarlatina. 

(d)  (Edema  of  Nervous  Origin. — The  rare  cases  of  sudden  transitory 
oedema  of  the  face  and  neck,  sometimes  associated  with  symptoms  of  oedema 
of  the  respiratory  or  gastro-intestinal  mucous  membranes,  must  be  ascribed 
to  angioneurotic  derangements.  The  mechanism  which  causes  it  remains 
unknown.  The  condition  known  as  angioneurotic  oedema  is  characterized 
by  the  sudden  occurrence  of  local  oedematous  swellings  of  transient  duration 
upon  the  face,  hands,  and  elsewhere.  Forms  of  localized  oedema,  described 
under  the  term  giant  urticaria,  are  of  angioneurotic  origin.  The  acute 
oedema  associated  with  urticaria  and  gastro-intestinal  crises  which  occurs 
in  severe  purpura,  and  the  cases  of  oedematous  swelling  and  tumefaction  of 
the  whole  arm  upon  exertion,  are  to  be  referred  to  this  group.  The  local 
oedema  occurring  as  a  symptom  in  peripheral  multiple  neuritis  and  the 
oedema  of  beriberi  are  probably  of  nervous  origin,  as  is  hysterical  oedema. 


SYMPTOMS  AXD  SIGNS:   SKIX.  541 

(e)  (Edema  due  to  Other  Causes. —CEclema  neonatorum  is  a  rare  condi- 
tion sometimes  confused  with  sclerema,  from  which,  however,  it  is  patho- 
logically distinct.  It  is  encountered  in  feeble  infants,  especially  those  born 
prematurely  or  exposed  to  cold  after  birth.  Cases  of  hereditary  oedema 
have  been  described.  The  oedema  is  congenital  and  persistent;  it  involves 
one  or  both  legs  and  is  dense  and  inelastic.  It  shows  no  disposition  to 
increase  and  is  unattended  bj^  special  inconvenience. 

The  oedema  which  occurs  in  trichinosis  is  of  diagnostic  importance. 
It  appears  in  the  face  and  over  the  affected  muscles,  and  undergoes 
remarkable  fluctuations  in  degree  during  the  course  of  the  disease. 

General  oedema  in  the  absence  of  nephritis  is  not  infrequently  observed 
in  certain  of  the  infectious  diseases,  as  scarlet  fever  and  diphtheria;  it  may 
follow  the  therapeutic  injection  of  the  different  sera  and  in  some  instances 
the  administration  of  potassium  iodide.  Slight  oedema  of  the  feet  and 
ankles — a  mere  puffiness — is  not  uncommon  in  individuals  otherwise 
healthy,  after  prolonged  standing  or  walking  or  after  forced  marches. 

Lymphcedema. — The  transudation  of  lymph  through  the  walls  of  the 
lymphatic  vessels,  or  distention  of  the  lymph  spaces  from  mechanical 
obstruction,  may  cause  great  swelling,  which  is  usually  local  or  confined  to 
a  single  Hmb.  It  results  from  pressure  upon,  or  internal  occlusion  of,  a 
lymph-vessel  and  is  seen  in  the  lymph  scrotum  and  certain  forms  of  elephan- 
tiasis caused  by  the  Filaria  sanguinis  hominis  and  accompanied  by  chyluria. 
Lymphoedema  involving  a  member — 7?iacrom6'/{a— sometimes  occurs  in 
lymphadenoma.  This  form  differs  from  ordinary  oedema  by  its  greater 
firmness  and  brawniness — a  very  important  point  in  differential  diagnosis. 

It  is  of  diagnostic  importance  to  recognize  the  distinction  between 
the  various  forms  of  oedema  and  myxoedema — an  affection  of  the  thyroid 
gland  characterized  by  swelling  of  the  skin,  eyelids,  and  other  parts  of  the 
body,  due  to  the  deposition  in  the  skin  and  subcutaneous  tissues  of  a  mucin- 
ous material.  The  skin  is  dry,  rough,  and  swollen,  but  firm  and  inelastic, 
and  does  not  pit  on  pressure. 

Certain  connective-tissue  dystrophies  present  a  superficial  resemblance 
to  localized  oedema.  The  swellings  usualh'  involve  the  outer  or  posterior 
aspect  of  the  extremities,  but  may  appear  at  various  parts  of  the  trunk. 
They  are  to  be  differentiated  from  oedema  by  their  localization,  the  absence 
of  pitting  upon  pressure,  and  by  other  appearances  of  the  skin  characteristic 
of  oedema. 

Scleroderma,  a  brawny  induration  of  the  skin,  in  some  instances 
suggests  chronic  oedema.  Two  forms  are  recognized,  the  circumscribed 
and  the  diffuse  in  which  large  areas  are  involved.  The  skin  is  brawny, 
hard,  and  inelastic.  When  circumscribed  the  patches  are  irregularly  oval 
and  vary  in  diameter;  they  may  be  as  large  as  the  hand.  They  are  preceded 
by  hypersemia  of  the  skin.  The  disease  is  more  common  in  women  than  in 
men  and  frequently  shows  itself  about  the  neck  and  breasts.  The  diffuse 
form  involves  the  extremities  and  face.  The  skin  is  hard  and  firm  with 
stiffness  and  tension.  It  is  adherent  to  the  underlying  tissues  and  cannot 
be  pinched  up  into  folds.  There  is  impairment  of  movement.  Very  often 
there  are  vasomotor  disturbances  with  cyanosis.  Pigment  alterations  are 
frequent — both  melanoderma  and  leucoderma. 


542  MEDICAL  DIAGNOSIS. 

Sclerema  neonatorum  is  a  rare  disease  of  the  new-born  in  which  the 
skin  rapidly  assumes  the  cHnical  appearance  of  scleroderma.  It  is  usually 
fatal.  It  presents  superficial  points  of  resemblance  to  oedema  neonatorum^ 
from  which  it  is  to  be  distinguished  by  the  complete  absence  of  the 
ordinary  signs  of  anasarca. 

Scurvy  sclerosis — a  deep  brawny  infiltration  of  the  subcutaneous  tissues 
and  muscles,  with  hemorrhagic  discoloration  of  the  overlying  skin — fre- 
quently seen  on  the  calves  of  the  legs,  is  not  to  be  confounded  with  oedema,, 
although  it  is  very  often  associated  with  it. 

Subcutaneous  Emphysema. — The  presence  of  gas,  usually  air,  in  the 
meshes  of  the  subcutaneous  tissue  gives  rise  to  swelling  and  puffiness  of 
the  surface  which  may  be  either  general  or  local.  The  appearance  is  not 
unlike  that  of  oedema,  but  upon  palpation  a  peculiar  crackling  is  to  be  felt 
and  heard,  due  to  the  displacement  of  bubbles  of  air  in  the  tissues.  The 
surface  resistance  is  lower  than  normal  and  pitting  from  pressure  does  not 
occur.  Upon  percussion  the  sound  is  tympanitic.  The  skin  is  pale  and  has. 
a  distended  appearance.  In  very  rare  cases  subcutaneous  emphysema  is 
due  to  the  presence  of  aerogenous  bacteria — Bacillus  aerogenes  capsulatus — 
and  allied  organisms.  This  gaseous  and  necrotic  oedema  occurs  in  serious 
wound  infection  and  may  extensively  involve  the  subcutaneous  tissues  of 
the  body.  The  infection  may  proceed  from  the  uterus,  gastro-intestinal 
canal,  or  respiratory  tract.  Analogous  to  this  condition  is  the  subcutaneous 
emphysema  of  malignant  oedema.    It  is  sometimes  associated  with  tetanus. 

In  the  greater  number  of  cases  the  air  finds  its  way  under  the  skin 
through  an  external  wound  or  through  the  ulceration  or  laceration  of  some 
air-containing  organ.  Subcutaneous  emphysema  is,  therefore,  an  accident 
of  carcinomatous  or  other  ulceration  of  the  oesophagus,  of  diseases  attended 
by  violent  paroxysmal  cough  by  which  the  alveolar  tissue  is  mechanically 
torn,  or  occasionally  of  the  after-treatment  of  tracheotomy,  the  air  being 
forced  into  the  subcutaneous  tissues  by  efforts  of  cough.  The  air  usually 
accumulates  about  the  root  of  the  neck  and  over  the  manubrium.  It  may 
invade  the  tissues  underlying  the  skin  very  extensively  and  sometimes  in- 
volves the  greater  part  of  the  body.    As  a  rule  it  undergoes  rapid  resorption. 

Cutaneous  hemorrhages  appear  as  spots  or  streaks  of  varying  size^ 
at  first  red,  but  quickly  becoming  darker.  Small  hemorrhages — petechioe — 
frequently  have  their  origin  in  the  hair  follicles.  Larger  hemorrhages — 
ecchymoses — are  diffuse.  Hemorrhages  arranged  in  the  skin  in  the  form 
of  lines  and  streaks  are  called  vibices.  The  term  suggillation  is  sometimes 
used  to  describe  the  ecchymosis  following  a  bruise.  Hceniatoma  is  a  tumor 
containing  effused  blood.  Cutaneous  hemorrhages  may  occur  upon  any 
part  of  the  body,  but  when  due  to  constitutional  disease  they  are  more 
abundant  upon  the  lower  extremities.  In  consequence  of  transformations 
in  the  haemoglobin  the  color  during  resorption  undergoes  progressive  changes 
to  blue,  green,  and  yellow,  and  gradually  fades.  The  appearance  and  dis- 
tribution of  petechiae  is  characteristic  of  cutaneous  hemorrhage.  They  are 
not  usually  elevated  above  the  skin.  Occasionally  in  purpura  there  are 
vesicular  points  distended  with  blood.  In  doubtful  cases  cutaneous  hem- 
orrhages may  be  distinguished  from  local  hypersemia  or  erythema  by  the 
fact  that  they  do  not  disappear  when  the  skin  is  made  tense  by  traction 


SYMPTOMS  AND  SIGNS:   SKIN.  543 

upon  it  of  the  thumb  and  finger  or  by  pressure  with  a  glass  sHde.  In 
local  hyperaeniia  the  spot  of  redness  disappears;  in  hemorrhage,  owing  to 
the  expression  of  the  blood  from  the  surrounding  capillaries,  it  becomes 
more  distinct.  Affections  characterized  by  the  extravasation  of  blood  into 
the  skin  are  collectively  described  under  the  term  purpura. 

Cutaneous  hemorrhage  is  in  all  cases  of  diagnostic  importance.  The 
more  important  conditions  with  which  it  is  associated  are  traumatism, 
intense  venous  stasis,  the  severe  and  especially  the  malignant  infections^ 
sepsis  of  various  kinds,  deep  jaundice,  and  cachectic  and  ansemic  states. 
It  is  a  characteristic  phenomenon  of  the  action  of  certain  snake  venoms 
and  under  exceptional  circumstances  follows  the  administration  of 
copaiba,  quinine,  ergot,  iodine,  and  other  drugs. 

Hemorrhage  into  the  skin  occasionally  occurs  in  acute  myelitis, 
severe  neuralgia,  and  in  tabes.  In  the  last  it  is  very  often  transient.  The 
bleeding  points  or  stigmata  that  have  attracted  so  much  attention  in  rare 
cases  of  hysteria  are  of  nervous  origin. 

It  is  frequently  associated  with  arthritis.  The  relationship  of  these 
conditions  has  been  regarded  without  adequate  reason  as  rheumatic. 

Other  changes  in  the  skin  of  diagnostic  importance  are:  striations, 
desquamation,  furunculosis,  cicatrices,  and  glossy  skin. 

Striations. — The  striae  of  the  skin  of  the  abdomen  and  those  occur- 
ring in  oedema  and  peritoneal  effusion,  which  resemble  the  striations  of 
pregnancy,  have  already  been  described.  They  frequently  disappear  after 
resorption  of  the  fluid,  but  may  persist  for  a  long  time.  Similar  striations 
may  attend  the  rapid  development  and  equally  rapid  resorption  of  a 
thick  panniculus  adiposus.  They  are  encountered  in  cases  of  great  abdomi- 
nal distention  from  rapidly  developing  tumors  or  other  cause. 

Desquamation. — Shedding  of  the  epidermis  is  of  diagnostic  impor- 
tance. A  diffuse  desquamation  of  the  trunk  and  extremities,  usually  in  the 
form  of  fine  scales,  occurs  in  the  cachexia  associated  with  emaciation.  A 
similar  fine-scaled  desquamation  follows  measles.  A  coarser  desquamation, 
sometimes  lamellar,  is  almost  constant  after  scarlet  fever.  A  coarse  des- 
quamation follows  erysipelas.  The  decrustation  of  the  variolous  diseases 
may  be  mentioned  in  this  connection. 

Furunculosis. — Boils  or  furuncles  are  the  expression  of  an  acute 
inflammation  of  a  hair  follicle  and  its  sebaceous  gland  and  the  connective 
tissue  immediately  surrounding  them.  It  is  a  local  process  due  to  an  infec- 
tion through  the  folhcle  by  pus-producing  organisms,  usually  the  Staphy- 
lococcus aureus.  Furunculosis  occurs  in  conditions  of  lowered  vitality, 
as  during  the  convalescence  from  infectious  diseases,  especially  enteric 
fever.  The  occurrence  of  furuncles  in  crops,  or  their  persistent  recurrence, 
is  a  common  event  in  diabetes  mellitus  and  should  always  lead  to  an 
examination  of  the  urine  for  the  presence  of  sugar. 

Cicatrices  or  Scars. — These,  whether  recent  or  old,  constitute 
important  diagnostic  signs.  In  doubtful  cases  special  significance  attaches 
to  the  presence  or  absence  of  the  scars  of  vaccination  and  their  characters 
and  to  the  scars  of  smallpox.  The  scars  of  furuncles  and  carbuncles,  of 
lupus,  of  inguinal  buboes,  and  those  left  by  tuberculous  glands  whicli  have 
healed  spontaneously  or  been  removed  are  very  suggestive  in  doubtful 


544 


MEDICAL  DIAGNOSIS. 


cases.  The  scars  left  by  tuberculous  disease  of  the  glands  or  bones  are 
usually  retracted  and  adherent.  The  presence  or  absence  of  scars  upon  the 
genitalia  following  the  primary  syphilitic  infection  is  of  great  importance. 
They  are  usually  difficult  to  discover  in  the  female  and  are  not  always 
persistent.  The  serpiginous  cicatrices  of  late  syphilis  cannot  be  mistaken. 
Cicatrices  produced  by  therapeutic  measures,  such  as  cupping,  venesection, 

leeching,  the  application  of  croton  oil  and 
tartar  emetic  ointment,  and  those  left  by 
surgical  operations  are  of  importance  in 
the  anamnesis.  Occasionally  scars  upon 
the  head  or  elsewhere  constitute  sugges- 
tive diagnostic  evidence  in  obscure  nervous 
diseases.  Scars  upon  the  tongue,  the  result 
of  laceration  during  the  epileptic  par- 
oxj^sm,  may  serve  to  clear  up  any  doubt 
as  to  the  character  of  convulsive  seizures. 
Glossy  Skin.  —  The  appearance  is 
characteristic.  The  skin  is  atrophied  and 
attached  to  the  subjacent  structures.  It  is 
smooth,  tense,  and  hairless  and  occurs  most 
frequently  and  is  more  pronounced  in  the 
hands  and  fingers.  It  may  develop  else- 
where. The  condition  is  the  result  of  the 
trophic  disturbance  caused  by  traumatic  or 
other  lesions  of  the  nerves.  It  is  encoun- 
tered in  extremities  that  have  been  splinted 
after  fracture,  forms  of  neuritis,  in  condi- 
tions giving  rise  to  the  claw  hand,  in  long- 
standing oedema,  and  in  some  advanced 
cases  of  arthritis  deformans.  It  is  not 
often  seen  in  young  persons. 

Collateral  Circulation    in   the   Skin. 
— Dilatation  of  the  superficial  vessels  fre- 
quently sheds  light  on  symptoms  dependent 
upon  deeper  circulatory  derangements.    In 
aged  persons  the  overfilled  veins  of  the  ex- 
tremities, showing  prominently  through  the 
translucent  atrophic  skin,  are  an  indication 
of  the  diminished  cardiac  power  associated 
with   general  involution   of   the   muscular 
system.     The  veins  are  darker  in  color  than  the  blood  which  they  contain 
— a  phenomenon  doubtless  due  to  intensification  of  the  color  in  transmission 
through  the  skin. 

In  tumors  of  the  mediastinum  which  compress  the  great  veins  of  the 
thorax,  especially  the  venae  cavse  superior  and  inferior,  the  venous  collat- 
erals upon  the  anterior  surface  of  the  chest  may  be  greatly  enlarged.  The 
blood  is  transferred  from  the  compressed  vena  cava  inferior  by  way  of  the 
intercostal  veins  and  the  internal  mammary  vein  to  the  superior  vena  cava, 
or  the  reverse. 


Fig.  204. —  Distended  veins  of  the  leg 
and  abdomen  in  a  case  of  mediastinal 
tumor. — Jefferson  Hospital. 


SYMPTOMS  AND  SIGNS:   SKIN. 


545 


Thrombosis  of  the -vena  cava  ascendens  or  of  both  common  iliac  veins 
results  in  the  development  upon  the  surface  of  the  abdomen  and  antero- 
lateral aspects  of  the  chest  of  prominent  sinuous  venous  enlargements, 
sometimes  reaching  the  thickness  of  a  finger,  by  which  the  blood  from  the 
lower  extremities  and  the  kidneys  is  conveyed  to  the  veins  of  the  thorax. 
In  cirrhosis  of  the  liver  and  portal  thrombosis  the  compensatory  circula- 
tion is  often  by  way  of  the  superficial  veins.  Occasionally  a  greatly  enlarged 
para-umbilical  vein  passes  from  the  hilus  of  the  liver  along  the  course 
of  the  round  ligament  and  joins  the 
epigastric  veins  at  the  navel,  produc- 
ing a  large  varix  with  wavy  radial 
distribution  of  the  veins  known  as 
the  caput  Medusce.  More  commonly 
branches  pass  in  the  round  and  sus- 
pensory ligaments  and  unite  with  the 
epigastric  and  mammary  systems. 
The  vessels  are  numerous  and  of  no 
great  size.  An  important  point  of 
difference  between  the  enlargement 
of  the  superficial  collateral  veins  in 
obstruction  of  the  vena  cava  and 
portal  obstruction  is  to  be  found  in 
their  distribution.  In  the  former  the 
enlarged  collaterals  usually  occupy 
the  anterolateral  aspect  of  the  chest; 
in  the  latter  the  region  around  the 
navel  and  ensiform  cartilage.  It  is 
important  to'  determine  in  which 
direction  the  blood  in  the  distended 
vein  flows.  This  is  done  by  empty- 
ing the  vein  by  stroking  it  between 
two  fingers  and  determining  by  re- 
moval of  the  pressure  of  the  fingers 
alternately  from  which  direction  the 
blood  stream  comes.  In  great  disten- 
tion of  the  veins  the  valves  become 
inadequate  and  this  investigation  is 
without  result.     The  small  vascular 

dendrites  so  often  seen  in  irregular  arrangement  at  the  base  of  the  thorax  in 
chronic  affections  of  the  lungs  and  pleura  indicate  local  areas  in  which  col- 
lateral circulation  has  been  established  between  the  lungs  and  skin.  They 
are  especially  common  in  pleural  adhesions  and  are  frequently  seen  upon 
the  upper  part  of  the  back  in  chronic  pulmonary  tuberculosis  with  great 
pleural  thickening.  In  many  cases  these  minute  dendritic  enlargements  at 
the  base  of  the  chest  and  the  borders  of  the  area  of  superficial  cardiac  dul- 
ness  are  without  pathological  significance,  since  they  occur  in  healthy  indi- 
viduals. They  have  a  certain  clinical  interest,  however,  since  by  their 
distribution  they  indicate  upon  inspection  the  position  of  the  borders  of  the 
lung.    Enlargement  of  the  veins  of  the  legs  may  be  due  to  changes  in  their 

35 


Fig.  205. — Varicose  veins. — German  Hospital. 


546  MEDICAL  DIAGNOSIS. 

walls  on  the  one  hand  or  to  thrombosis  or  pressure  pn  the  other.  Enlarge- 
ment of  the  veins  of  both  legs  is  caused  by  the  obstruction  of  the  vena  cava 
or  both  iliacs.  Great  enlargement  of  the  veins  of  the  legs,  with  the  formation 
of  varices,  sometimes  occurs  after  repeated  pregnancies,  and  enormous  vari- 
cosity of  one  leg,  with  great  dilatation,  frequently  results  from  venous 
thrombosis  following  pregnancy  or  the  infectious  diseases,  especially  enteric 
fever.  The  varicosities  which  occur  in  the  absence  of  pressure  or  throm- 
bosis are  largely  due  to  changes  in  the  walls  of  the  veins  themselves. 

THE   NAILS. 

The  appearance  of  the  nails  is  to  some  extent  indicative  of  the  state 
of  nutrition  and  habits.  The  deformity  arising  from  biting  the  nails  is 
characteristic  and  consists  in  shortening  of  the  nail  with  projection  of  the 
tip  of  the  finger,  into  which  the  edge  of  the  nail  tends  to  bury  itself.  Coarse 
longitudinal  striae  associated  with  brittleness  are  said  to  indicate  gouty 
tendencies.  Small  white  flecks — leucopathia  unguis — are  the  result  of 
trifling  knocks;  the  color  is  due  to  the  presence  of  air  among  the  cells. 
Transverse  arched  bands,  dull  and  opaque,  contrasting  with  the  normal 
glistening  surface,  are  seen  after  severe  acute  illness  and  indicate  a  period 
of  malnutrition.  They  appear  at  the  root  of  the  nail  and  gradually  advance. 
They  are  often  seen  after  enteric  fever  and  sometimes,  in  the  case  of  relapse, 
there  is  a  corresponding  secondary  band.  Pressure  upon  the  nails  drives 
blood  from  the  capillaries  of  the  bed.  The  blanching  is  marked  and  some- 
what prolonged  in  anaemic  states.  The  nail  is  normally  of  a  pink  tint. 
Cyanosis  shows  itself  early  in  the  nails  and  their  blueness  is  a  measure  of 
its  intensity.  When  the  capillary  pulse  is  present  it  may  be  seen  in  the 
nail-beds,  especially  after  slight  pressure.  The  nutrition  of  the  nails  is 
affected  in  various  skin  diseases.  They  become  dry,  fragile,  and  malformed 
in  neuritis,  syringomyelia,  Raynaud's  disease,  and  scleroderma.  Destruc- 
tion of  the  nails  occurs  in  the  neuritis  of  Morvan's  disease  and  leprosy. 
In  hemiplegia  and  infantile  palsy  the  growth  of  the  nails  upon  the  paralyzed 
side  is  retarded.  Oriychia  is  ulceration  of  the  nail  matrix.  It  may  be  due 
to  syphilis  or  tuberculosis.  In  chronic  disease  of  the  chest  the  nails  become 
hypertrophied  and  incurvated  and  the  terminal  phalanges  clubbed — the 
Hippocratic  fingers.  These  changes  are  seen  most  frequently  in  bronchi- 
ectasis and  empyema,  less  often  in  phthisis.  The  deformity  may  develop 
very  rapidly.  Trifling  lesions  at  the  root  of  the  nail — a  mere  splitting  of 
the  fold  of  epidermis  at  the  side  of  the  finger-nail,  may  be  the  point  of 
serious  infection.  Malignant  endocarditis  and  tetanus  have  arisen  from 
this  cause,  and  such  sores  upon  the  finger  of  the  surgeon  are  frequently 
the  seat  of  the  initial  lesion  of  syphilis.  Congenital  absence  and  deformities 
of  the  nails  are  not  common.  They  may  be  hereditary  and  are  usually 
associated  with  defects  in  development  of  the  hair  and  teeth. 

Shedding  of  the  nails  sometimes  occurs  in  syphilis,  alopecia  areata, 
saccharine  diabetes,  hysteria,  and  other  neurotic  conditions.  Extravasa- 
tion of  the  blood  beneath  the  nails  may  occur  from  injury  or  very  rarely 
in  purpuric  affections.  The  blood-clot  brings  about  a  separation  of  the 
nail  from  its  bed  and  its  ultimate  detachment. 


SYMPTOMS  AND  SIGNS:   HAIR.  547 

THE   HAIR. 

Wide  variations  in  color,  texture,  and  abundance  occur  in  different 
individuals.     Certain  changes  are  of  diagnostic  importance. 

Color. — Grayness  or  canities  may  begin  early  in  life.  It  is  a  sign  of 
old  age  but  there  are  people  who  grow  old  without  growing  gray.  Gray 
hair  in  young  people  is  sometimes  hereditary.  It  is  often  associated  with 
early  arteriocapillary  sclerosis.  In  a  family  in  which  nearly  every  member 
for  three  generations  was  the  victim  of  chronic  nephritis  it  was  characteristic 
for  the  hair  to  turn  gray  before  thirty.  Early  grayness,  however,  is  not 
incompatible  with  excellent  health.  In  rare  instances  rapid  whitening  of 
the  hair  has  been  attributed  to  extreme  terror  or  anxiety.  Circumscribed 
patches  of  gray  hair  are  occasionally  seen  in  healthy  individuals.  Their 
development  sometimes  appears  to  depend  upon  severe  neuralgia  involv- 
ing the  distribution  of  the  supra-orbital  branch  of  the  fifth  nerve.  It  is 
easy  for  the  close  observer  to  detect  bleached  or  dyed  hair.  To  the  physician 
the  former  is  suggestive  of  an  undisciplined  life,  the  latter  of  chronic  lead 
poisoning  as  the  cause  of  nervous  symptoms  otherwise  obscure.  Discolor- 
ation of  the  hair  occurs  in  workers  in  copper,  cobalt,  indigo,  and  from  local 
contact  with  dyes.  Change  in  color  may  occur  after  severe  illness  with 
temporary  loss  of  hair  or  after  frequently  repeated  excessive  sweating 
such  as  follows  the  hypodermic  use  of  pilocarpine. 

Hypertrichosis. — A  growth  of  hair  that  is  abnormal  in  quantity  or  in  loca- 
tion may  be  congenital  or  acquired.  It  is  a  deformity  rather  than  a  disease. 
Very  rare  instances  have  been  reported  in  which  a  growth  of  hair  has  covered 
the  entire  body  except  the  palms,  soles,  terminal  phalanges,  upper  eyelids, 
borders  of  the  lips,  prepuce,  and  glans  penis.  Hirsuties  is  more  commonly 
localized.  The  causes  of  this  condition  are  obscure.  Among  them  heredity 
and  irregularities  or  arrest  of  the  sexual  functions  are  prominent.  A  luxuri- 
ant growth  of  deeply  pigmented  hair  has  been  observed  in  Addison's  disease. 

Atrophy  of  the  hair  occurs  as  the  result  of  systemic  conditions  inter- 
fering with  nutrition.  The  hair  becomes  dry  and  lustreless  and  splits  at 
the  end.  It  may  undergo  atrophy  in  local  diseases  of  the  scalp  and  in 
general  conditions,  as  extreme  emaciation  and  cachexia.  Imperfect  nutri- 
tion of  the  hair  is  conspicuous  in  myxcedema  and  occurs  in  advanced  cases 
of  pulmonary  consumption. 

Alopecia  may  involve  the  scalp  or  other  hairy  parts  of  the  body.  It  may 
be  congenital  and  is  usually  accompanied  by  defects  in  the  teeth  and  nails. 
This  form  is  very  often  hereditary.  The  hair  does  not  usually  grow  in  scars 
upon  the  scalp.  Alopecia  senilis  accompanies  other  senile  changes.  Prema- 
ture falling  of  the  hair  sometimes  appears  to  be  an  idiopathic  condition.  It 
occurs  in  various  local  and  systemic  diseases.  Among  the  latter  are  acute 
febrile  infections,  syphilis,  and  erysipelas.     As  a  rule  the  hair  grows  again. 

Alopecia  areata  or  circumscribed  patches  of  baldness  appears  in  some 
instances  to  be  a  trophoneurosis  occurring  after  shock  or  injury  to  the 
nervous  system.     In  others  it  appears  to  be  a  local  parasitic  disease. 

Diseases  of  the  skin  as  such  do  not  fall  within  the  scope  of  this  work. 
The  cutaneous  manifestations  of  the  individual  constitutional  and  organic 
diseases  are  considered  elsewhere  (see  Part  IV). 


548  MEDICAL  DIAGNOSIS. 


XII. 
GENITO-URINARY  SYSTEM;    MICTURITION;    THE    REPRODUC- 
TIVE ORGANS. 

The  diagnostic  significance  of  the  results  of  examination  of  the  urine 
by  laboratory  methods  is  set  forth  in  a  previous  chapter.  The  clinical 
facts  may  properly  be  considered  separately. 

MICTURITION— URINATION. 

The  urine  is  secreted  continuously  and  conveyed  by  the  ureters  to  the 
bladder,  from  which  it  is  ejected  at  intervals  through  the  urethra  by  the 
act  of  micturition.  The  urine  accumulating  in  the  bladder  is  prevented 
from  escaping  by  the  elasticity  of  the  parts  surrounding  the  internal  ure- 
thral orifice  and  the  contraction  of  the  internal  sphincter.  When  the 
accumulation  reaches  a  certain  point  the  desire  to  pass  water  is  aroused. 
The  external  sphincter  may  be  controlled  by  voluntary  effort.  The  act  of 
micturition  consists  in  strong  contraction  of  the  bladder  with  the  simul- 
taneous relaxation  of  the  sphincters  and  the  contraction  of  the  abdominal 
muscles,  especially  toward  the  close  of  the  act.  The  contraction  of  these 
muscles  with  closure  of  the  glottis  and  fixation  of  the  diaphragm  increases 
the  pressure  upon  the  contents  of  the  abdominal  and  pelvic  cavities  and 
favors  the  complete  emptying  of  the  bladder.  The  peculiar  sensation 
caused  by  the  accumulation  of  urine  in  the  bladder  is  followed  by  the 
reflex  muscular  contractions  which  constitute  the  act  of  micturition. 
Not  only  is  this  act  largely  under  the  control  of  the  will,  but  the  ability  to 
void  small  quantities  is  also  to  some  extent  voluntary. 

The  average  total  daily  quantity  of  urine  in  healthy  men  is  1200  to 
1700  c.c;  in  women  the  amount  is  less  by  200-300  c.c.  This  represents 
the  water  excreted  by  the  kidneys,  but  there  is  in  health  as  well  as  in  disease 
a  vicarious  relationship  between  the  function  of  those  organs  and  the  skin 
and  lungs,  so  that  during  increased  cutaneous  and  respiratory  activity,  as 
in  prolonged  exercise  or  in  warm  weather,  the  quantity  of  urine  may  be 
reduced  to  400-500  c.c.  in  twenty-four  hours. 

The  quantity  is  diminished  in  disease  in  a  corresponding  manner. 
Thus,  the  loss  of  fluid  by  pathological  sweating,  profuse  vomiting,  colliqua- 
tive diarrhoea,  and  hemorrhage  is  attended  by  more  or  less  marked  reduc- 
tion in  the  urine.  The  quantity  is  also  reduced  in  acute  nephritis,  in 
lowering  of  the  blood-pressure  from  any  cause,  in  many  febrile  conditions, 
and  in  dropsies  and  effusions  into  the  serous  sacs.  Suppression  of  urine 
more  or  less  complete  is  designated  anuria — to  a  less  extent  oliguria. 

An  abnormal  and  continued  increase  of  the  daily  quantity  of  urine, 
not  accounted  for  by  increased  ingestion  of  fluid,  constitutes  the  patho- 
logical condition  designated  polyuria.  This  condition  occurs  in  diabetes 
insipidus  and  mellitus,  in  emotional  states,  in  hysteria,  during  the  epileptic 
paroxysm,  in  irritable  lesions  of  the  floor  of  the  fourth  ventricle,  under  the 


SYMPTOMS  AND  SIGNS:   MICTURITION.  549 

influence  of  diuretics,  in  contracted  kidneys,  in  chronic  parenchymatous 
nephritis,  in  lardaceous  renal  disease,  from  increased  blood-pressure,  and 
as  a  result  of  the  resorption  of  transudates  and  exudates. 

The  daily  quantity  is  voided  in  several  acts  of  micturition,  usually 
about  five,  but  the  number  within  normal  limits  is  largely  determined  by 
the  habits  and  circumstances  of  the  individual. 

The  following  abnormal  conditions  are  of  diagnostic  importance: 
(a)   Dysuria. — This  term  is  comprehensively  employed  to  designate 
difficult,  slow,  and  frequent  micturition,  and,  since  these  symptoms  are 
mostly  though  not  always  attended  with  distress  which  is  often  urgent, 
it  includes  painful  micturition. 

1.  Vesical  tenesmus  constitutes  the  most  severe  form  of  dysuria. 
It  consists  of  painful  spasm  of  the  bladder  and  is  often  associated  with 
rectal  tenesmus.  The  spasm  is  often  so  urgent  that  the  patient  is  unable 
to  remain  at  rest,  but  returns  at  short  intervals  to  the  ineffectual  and 
agonizing  attempt  to  pass  water,  with  the  result  that  a  few  drops  at  most 
are  voided  with  violent  bearing  down  and  burning  pain  in  the  urethra. 

2.  Strangury.— Not  rarely  a  few  drops  of  blood  or  bloody  mucus  are 
discharged  in  the  spasmodic  efforts  at  urination,  and  the  condition  is  de- 
scribed as  strangury.  This  term  is,  however,  frequently  employed  inter- 
changeably with  tenesmus. 

'  Very  concentrated  and  acid  urine  is  a  cause  of  dysuria  and  the  ingestion 
of  certain  condiments  in  excess,  as  mustard,  pepper,  and  horseradish,  may 
produce  similar  inconvenience.  The  absorption  of  cantharides  and  turpen- 
tine applied  to  the  surface,  or  overdoses  of  these  substances,  may  be 
followed  by  strangury.  A  sudden  attack  of  vesical  tenesmus  for  which  no 
obvious  cause  is  discoverable  may  be  found  upon  investigation  of  the 
facts  of  the  case  to  be  a  tabetic  crisis. 

Dysuria,  especially  these  more  intense  forms,  is  liable  to  occur  in  al- 
most all  acute  inflammatory  diseases  of  the  urinary  tract.  They  are 
encountered  therefore  in  posterior  gonorrhoea  and  in  gonorrhoeal  inflam- 
mation of  the  neck  of  the  bladder,  and  in  acute  cystitis,  prostatitis,  and  pye- 
litis. Dysuria  also  accompanies  the  chronic  forms  of  these  affections  but 
is  much  less  urgent  and  distressing.  Tenesmus  is  also  symptomatic  of 
direct  irritation  of  the  bladder,  as  by  stone,  gravel,  foreign  bodies,  parasites, 
and  local  ulceration.  Reflex  dysuria  with  tenesmus  is  sometimes  present 
in  renal  colic. 

Dysuria  is  a  symptom  of  incomplete  retention.  When  after  the  act 
of  micturition  there  is  residual  urine,  it  is  evident  that  the  capacity  of  the 
organ  will  be  more  speedily  reached  than  when  it  is  emptied  normally. 
Urination  becomes  more  frequent  and  more  difficult.  This  form  of  dysuria 
occurs  in  paresis  of  the  bladder,  as  in  tabes,  hypertrophied  prostate,  tumor 
involving  the  neck  of  the  bladder,  stricture  and  phimosis,  prostatic  abscess, 
arteriosclerosis  of  the  vesical  arteries,  spasm  of  the  neck  of  the  bladder, 
and  oedematous  swelling  of  the  urethral  mucosa  in  acute  gonorrhoea.  A 
chancre  of  the  urethra  may  act  in  the  same  way,  and  in  the  variolous  dis- 
eases pocks  in  the  meatus  may  occasion  similar  symptoms. 

Dysuria  frequently  attends  general  peritonitis,  acute  inflammatory 
diseases  of  the  pelvic  organs,  and  may  occur  in  dysmenorrhoea. 


550  MEDICAL  DIAGNOSIS. 

(b)  Frequent  Micturition. — This  occurs  in  polyuria.  It  is  obvious 
that  in  the  absence  of  dilatation  of  the  bladder  an  increase  in  the  quantity 
of  urine  must  be  followed  by  an  increase  in  the  frequency  with  which  it  is 
voided.  Hence  in  diabetes  insipidus  and  diabetes  mellitus,  in  contracted 
Iddneys  and  in  some  forms  of  pyelitis  the  frequenc}^  of  urination  is  greatly 
increased.  A  diabetic  who  voids  6  litres  of  urine  in  twenty-four  hours, 
with  an  average  vesical  capacity  of  about  300  c.c,  would  be  obliged  to  pass 
water  at  least  twenty  times  in  the  course  of  the  day — a  requirement  which 
is  slightly  diminished  by  a  gradual  increase  in  the  size  of  the  bladder.  When, 
on  the  other  hand,  the  bladder  has  undergone  concentric  hypertrophy  in 
consequence  of  chronic  cystitis  and  its  capacity  is  greatly  diminished,  the 
necessity  to  void  urine  at  short  intervals  becomes  imperative.  If  the  call 
be  not  obeyed,  as  in  deep  sleep,  the  urine  may  be  involuntarily  discharged. 

Frequent  micturition  is  often  due  to  psychical  causes,  among  them 
fright  and  excitement.  Soldiers  in  battle  and  students  awaiting  examina- 
tion constitute  oft-quoted  examples.  The  urine  is  voided  at  short  intervals 
and  in  small  amounts  and  often  involuntarily.  It  is  also  a  common  symp- 
tom in  hysteria  and  neurasthenia. 

(c)  Slow  Micturition. — The  act  is  slow,  prolonged,  and  difficult  in  all 
conditions  characterized  by  mechanical  obstruction  to  the  outflow  and  in 
nervous  affections  attended  by  paresis  of  the  vesical  wall.  Hence  the  form 
of  dysuria  encountered  in  incomplete  urinary  retention  from  any  cause  is 
characterized  by  slow  or  prolonged  micturition.  Stillicidium  urinoe.  or  the 
slow  discharge  of  urine  drop  b}^  drop  has  been  described  under  the  term 
"incontinence  of  retention."  It  occurs  in  the  low  fevers  and  in  soporose 
and  comatose  conditions,  when,  because  of  the  neglect  of  a  routine  physical 
examination  and  of  the  use  of  the  catheter,  the  bladder  has  been  allowed 
to  become  overdistended. 

(d)  Incontinence  of  Urine. — This  condition  is  due  to  mechanical  and 
nervous  causes. 

1.  Mechanical  causes  are  chiefly  operative  in  women.  Laceration  of 
the  perineum  or  injuries  to  the  urethra  sustained  in  parturition,  relaxation  of 
the  floor  of  the  pelvis,  and  cystocele  are  common  causes  of  urinary  inconti- 
nence. The  urine  may  dribble  constantly  or  be  discharged  in  gushes  upon 
any  muscular  effort  which  increases  the  pelvic  pressure,  as  lifting,  stooping," 
or  coughing.  Violent  sudden  cough,  as  in  pertussis,  may  cause  incontinence 
in  depressed  or  asthenic  conditions  with  relaxation  of  the  sphincter  muscles. 

2.  The  nervous  causes  of  incontinence  are  much  more  common. 
They  may  be  cerebral,  as  in  coma  and  shock,  idiocy  and  dementia,  or  the 
stuporous  states  of  the  profound  infections;  spinal,  as  in  traumatism, 
hemorrhage,  and  tumors  of  the  cord,  transverse  myelitis,  meningitis,  and 
tabes;  or  reflex  in  consequence  of  the  local  irritation  of  ascarides,  phimosis, 
contracted  urinary  meatus,  stone  in  the  bladder,  cystitis,  or  highly  con- 
centrated or  acid  urine.  To  the  last  of  these  causes  miay  be  referred  enuresis 
nocturna,  which  occurs  in  neurotic  children  and  acquires  the  force  of  a 
morbid  habit,  the  urine  being  voided  involuntarily,  as  a  rule  during  sleep, 
but  frequently  during  the  waking  hours  under  excitement  or  preoccupation. 
If  the  vesical  centre  in  the  lumbar  cord  is  destroyed,  complete  paralysis 
will  ensue,  with  retention  or  the  dribbling  incontinence  of  retention. 


SYMPTOMS  AND  SIGNS:   MICTURITION.  551 

(e)  Retention  of  Urine. — Retention  and  incontinence  are  very  con- 
stantly associated,  and  are  due  in  many  instances  to  the  same  causes. 
Thus,  retention  may  occur  in  coma  from  any  cause,  in  the  soporose  states 
incident  to  profound  toxasmia,  as  in  the  graver  forms  of  the  infectious 
diseases  and  especially  in  the  terminal  infections,  in  peritonitis,  in  acute 
pelvic  inflammations,  and  in  injuries  and  diseases  of  the  spinal  cord. 

Temporary  loss  of  vesical  power  sometimes  results  from  overdisten- 
tion  in  consequence  of  prolonged  voluntary  retention.  Mechanical  causes 
of  retention  are  stricture,  urethritis,  the  arrest  of  a  calculus  in  the  urethra, 
prostatic  enlargement,  and  the  pressure  of  the  head  in  parturition.  Remark- 
able retention  of  urine  is  sometimes  observed  in  hysterical  persons. 

In  infants  this  condition  may  occur  from  phimosis,  inflammation  of 
the  prepuce,  or  highly  concentrated  or  acid  urine.  These  causes  may  act 
reflexly,  by  producing  spasm  of  the  sphincters,  or  mechanically.  The  pas- 
sage of  a  renal  calculus  through  the  ureter  may,  by  reflex  irritation,  give 
rise  to  frequent  micturition  on  the  one  hand  or  to  spasm  of  the  sphincters 
and  retention  on  the  other. 

(f )  Suppression  of  Urine — Anuria. — This  condition  may  be  mechani- 
cal, renal  or  general,  partial  or  complete. 

1.  Mechanical  causes  of  complete  anuria  are  renal  calculi  blocking 
both  ureters  simultaneously  or  the  ureter  when  only  one  exists.  The  symp- 
toms are  those  of  ura?mia.-  The  condition  is  extremely  rare.  Life  may 
be  prolonged  several  days  with  complete  anuria;  in  Polk's  case  in  which 
a  solitary  kidney  was  removed,  the  patient  lived  eleven  days.  Partial 
anuria — oliguria — may  be  caused  by  the  presence  of  an  abdominal  aneurism 
or  tumor  upon  one  or  both  ureters,  or  by  a  kink  in  the  ureter  in  the  case 
of  an  ectopic  kidney,  or  by  malignant  disease  of  the  wall  of  the  bladder 
involving  one  or  both  urethral  orifices.  In  any  of  these  conditions  hydrone- 
phrosis may  occur. 

2.  Renal  lesions  leading  to  suppression  of  urine  are  acute  congestion, 
acute  nephritis;  the  acute  exacerbations  of  chronic  nephritis,  pyelitis, 
abscess  of  the  kidney,  perinephric  abscess,  and  hydro-  and  pyonephrosis. 
Among  the  rare  causes  of  suppression  is  thrombosis  of  the  inferior  vena 
cava  or  of  the  renal  vein, 

3.  General  conditions  accompanied  by  suppression  of  urine  are  extreme 
lowering  of  the  blood-pressure  such  as  occurs  in  profuse  hemorrhage  from 
any  cause;  collapse  or  shock  from  injuries,  surgical  operations;  the  per- 
foration of  hollow  viscera,  as  in  peptic  ulcer,  empyema  of  the  gall-bladder, 
enteric  fever,  or  rupture  of  the  uterus;  the  stage  of  collapse  in  cholera 
Asiatica,  cholera  nostras,  or  yellow  fever,  the  pernicious  malarial  fevers, 
and  acute  peritonitis.  Operations  upon  the  urinary  tract — even  so  trifling 
a  procedure  as  catheterization — may  in  elderly  men  be  followed  by  urinary 
suppression. 

This  symptom  also  occurs  in  acute  poisoning  by  phosphorus,  lead,  and 
turpentine,  in  acute  yellow  atrophy  of  the  liver,  and  in  sunstroke. 

Anuria,  more  or  less  complete,  and  prolonged  for  daj^s,  is  occasionally 
observed  in  hysterical  girls.  In  rare  cases  there  are  sj'^mptoms  of  ursemia, 
but  as  a  rule  there  are  no  associated  symptoms  other  than  those  due  to 
the  hysteria.     In  such  cases,  in  order  to  avoid  deception,  the  patient  must 


552  MEDICAL  DIAGNOSIS. 

be  isolated  and  carefully  and  continuously  watched,  and  the  catheter  used 
at  unexpected  and  irregular  periods.  Anuria  may  result  from  reflex  irri- 
tation and  functional  arrest  in  a  normal  kidney,  the  ureter  of  the  opposite 
side  being  blocked  by  a  calculus,  or  the  opposite  kidney  having  been 
removed  by  operation. 

Haematuria. — When  small  amounts  of  blood  are  present  the  color  of 
the  urine  is  smoky.  With  larger  quantities  it  is  bright  red  or  even  dark 
brown  and  opaque  like  porter.  Erythrocytes  are  present,  usually  crenated 
or  as  rounded  shadowy  disks.  The  haemoglobin  is  soon  dissolved,  especially 
in  ammoniacal  urines  and  those  of  low  specific  gravity.  Blood  from  the 
kidneys  is  intimately  mixed  with  the  urine,  which  is  discolored  both  at 
the  beginning  and  at  the  end  of  the  act  of  micturition.  Clots  are  often 
present  and  they  may  be  in  the  form  of  casts  of  the  pelvis  or  ureters.  Blood 
from  the  bladder  may  not  appear  until  toward  the  end  of  micturition  or  at 
its  close.  Upon  washing  out  the  bladder  the  water  returns  tinged  if  the 
source  of  the  hemorrhage  be  in  the  bladder  but  clear  if  it  be  in  the  kidneys. 
The  differential  diagnosis  of  the  source  of  the  bleeding,  however,  is  often 
attended  with  difficulty  and  can  be  made  only  by  means  of  the  cystoscope 
or  a  differentiator  by  which  the  urine  from  each  ureter  may  be  obtained 
separatel}^ 

Hsematuria  may  be  symptomatic  of  the  following  conditions: 

1.  The  hemorrhagic  varieties  of  the  acute  febrile  infections,  forms 
of  purpura,  haemophilia,  very  severe  cases  of  scurvy,  and  leukaemia.  A 
special  form  of  haematuria  or  haemoglobinuria — black  water  fever — prevails 
in  certain  malarious  districts. 

2.  Diseases  of  the  Urinary  Passages. — Sarcoma  or  tuberculosis 
of  the  kidney,  calculus  in  the  ureter,  tumor,  ulceration  or  calculus  in  the 
bladder,  parasites  of  the  bladder — Bilharzia  haematobia,  psorospermiasis — 
or  rupture  of  veins  in  its  wall  may  be  the  cause  of  haematuria.  In  rare- 
instances  this  condition  is  due  to  disease  of  the  prostate.  The  arrest  of  a 
calculus  in  the  urethra  or  acute  gonorrhoeal  urethritis  is  sometimes  attended 
by  the  passing  of  blood.  This  symptom  occurs  in  strangury  and  there  are 
cases  of  persistent  haematuria  in  which  no  adequate  lesion  has  been  found. 

3.  Traumatism. — Haematuria  follows  operations  upon  the  kidney. 
Gun-shot  wounds  or  stabs  involving  the  kidney,  laceration  of  the  organ 
from  blows  upon  the  back,  falls  or  crushing  accidents  cause  profuse  bleed- 
ing. Similar  injuries  involving  the  bladder  or  prostate,  falls  or  kicks 
resulting  in  severe  contusion  of  the  perineum  and  laceration  of  the  urethra 
are  also  followed  by  hemorrhage,  and  this  symptom  frequently  follows 
the  use  of  the  catheter. 

(g)  Haemoglobinuria. — The  urine  is  discolored  by  haemoglobin,  chiefly 
methaemoglobin.  Red  corpuscles  are  absent  or  few  in  number.  The 
urine  is  smoky  or  brownish-red,  even  black,  and  upon  standing  deposits  a 
dense,  dirty  brown  sediment  made  up  of  granular  pigment,  the  detritus  of 
blood-corpuscles,  epitheliimi,  and  pigmented  urates. 

Three  forms  are  recognized:  the  toxic,  the  paroxysmal,  and  haemo- 
globinuria of  the  new-born. 

1.  Toxic  Haemoglobinuria. — This  variety  is  encountered  in  poison- 
ing by  those  agents  which  produce  rapid  destruction  of  the  erythrocytes. 


SYMPTOMS  AND  SIGNS:    REPRODUCTIVE  ORGANS.        553 

Important  among  these  are  potassium  chlorate,  pyrogalhc  acid,  carbolic 
acid,  arseniureted  hydrogen,  carbon  monoxide,  naphthol,  and  muscarine. 
It  is  also  produced  by  the  transfusion  of  blood  from  one  mammal  into 
another,  by  exposure  to  intense  cold  and  violent  exertion,  and  occurs 
after  extensive  burns.  In  malarial  subjects  it  may  follow  the  administra- 
tion of  quinine — black  water  fever. 

2.  Paroxysmal  H.emoglobinuria.  —  An  affection  characterized  by 
the  occasional  passage  of  urine  colored  by  hsemoglobin.  It  occurs  in  adults 
and  is  more  common  in  males  than  in  females.  The  paroxysms  are  excited 
by  cold  and  exertion  and  last  from  a  few  hours  to  a  day  or  two.  It  is  thought 
by  some  observers  to  have  an  essential  relationship  to  Raynaud's  disease; 
by  others  to  malaria.  Pain  in  the  lumbar  region  is  common.  The  attacks 
may  be  ushered  in  by  chills  followed  by  fever;  more  commonly  the  tem- 
perature is  normal  or  slightly  subnormal.  They  recur  at  irregular  intervals 
for  an  indefinite  time. 

3.  Epidemic  Hemoglobinuria  op  the  New-born. — The  disease 
develops  about  the  fourth  day  and  attacks  a  large  proportion  of  the  infants 
in  the  maternity  institution  where  it  appears.  There  is  bloody  urine  with 
vomiting  and  purging,  jaundice,  hurried  breathing,  and  cyanosis.  It  is 
rapidly  fatal.  Post-mortem  examination  reveals  enlargement  of  the  spleen 
with  punctiform  hemorrhages  upon  the  surface  and  in  the  parenchyma  of 
the  viscera.  This  disease  is  to  be  differentiated  from  icterus  neonatorum 
to  which  it  bears  only  a  superficial  resemblance. 

THE   REPRODUCTIVE   ORGANS. 

In  both  men  and  women  sexual  neurasthenia,  hypochondriasis,  and 
perversion  frequently  occur.  Ungratified  desire,  excessive  venery,  and 
unnatural  sexual  acts  are  more  commonly  the  alleged  than  the  actual 
causes  of  various  nervous  and  mental  diseases.  The  two  latter  are  prob- 
ably manifestations  more  often  than  causes  of  such  forms  of  disease. 
Irregular  manifestations  may  be  on  the  one  hand  psychical,  on  the  other 
physical;  frequently  they  are  both.  The  field  is  a  large  one  and  the  extent 
to  which  it  is  to  be  investigated  in  individual  cases  may  be  left  to  the  judg- 
ment of  the  clinician. 

The  history  or  the  actual  manifestations  of  venereal  disease  in  a 
patient,  or  in  an  individual  with  whom  the  patient  has  had  sexual  relations, 
are  often  of  great  importance  in  the  diagnosis  of  an  otherwise  obscure  case. 
A  gonorrhoeal  discharge  may  solve  the  problem  of  an  obscure  and  intract- 
able arthritis  or  indicate  the  nature  of  serious  tubal  or  other  pelvic  disease, 
and  explain  an  unlooked  for  ophthalmia  in  the  new-born.  Syphilitic  lesions 
or  the  scar  of  a  chancre  in  the  husband  may  be  the  key  to  the  solution  of 
obscure  nervous  symptoms  in  the  wife,  or  nutiitional  disorders  and  lesions 
of  the  organs  of  special  sense  in  the  child. 

In  the  male,  priapism,  impotence,  and  spermatorrhoea  occur  as  impor- 
tant manifestations  of  disease. 

(a)  Priapism. — This  term  is  used  to  designate  abnormally  frequent 
and  prolonged  erection.  The  condition  is  not  associated  with  libido  scxualis 
but  with  distress  and  pain  and  constitutes  a  morbid  s3anptom. 


554  MEDICAL  DIAGNOSIS. 

It  is  often  manifest  in  a  mild  degree  in  young  boys.  Even  at  the  age 
of  one  or  two  years  it  may  be  painful  and  distressing  and  often  leads  to 
enuresis  nocturna.  It  may  be  due  to  phimosis  and  disappear  after  circum- 
cision. In  the  adult  it  may  result  from  inflammatory  irritation  of  the  ure- 
thral mucosa.  It  may  follow  the  passing  of  a  bougie  and  is  very  common  in 
gonorrhoea  and  in  the  chronic  inflammation  of  the  prostatic  portion  of  the 
urethra  in  those  who  have  practised  masturbation  or  indulged  in  sexual 
excesses  or  irregularities.  The  condition  may  be  due  to  excessive  stimula- 
tion of  the  centre  in  the  lumbar  cord.  The  latter  form  comes  on  during 
sleep.  The  patient  awakes  with  intensely  painful  priapism  unattended  by 
the  slightest  libido  sexualis.  This  presently  subsides  only  to  return  when, 
under  the  influence  of  deep  sleep,  the  inhibition  of  the  special  spinal  centre 
is  withdrawn.  In  severe  cases  sleep  is  seriously  interrupted  and  the  annoy- 
ance of  the  patient  is  increased  by  the  discharge  of  a  thin  mucus  from 
Cowper's  glands  and  painful  neuralgia  in  various  parts  of  the  body.  This 
form  of  priapism  is  often  accompanied  by  impotence. 

Priapism  may  be  the  result  of  stone  in  the  bladder,  inflammation  of 
the  prostate,  a  perineal  abscess,  proctitis  or  periproctitis,  inflamed  hemor- 
rhoids, or  poisoning  by  cantharides.  It  is  said  to  be  symptomatic  of  certain 
forms  of  neurasthenia  and  hysteria.  It  is  a  common  symptom  in  fractures 
of  the  spine,  especially  when  the  cervical  portion  is  involved.  It  may  occur 
in  myelitis,  spinal  meningitis,  and  in  lesions  of  the  pons  and  cerebellum. 
It  occurs  in  hydrophobia  and  tetanus  and  has  frequently  been  observed 
in  leukaemia. 

(b)  Impotence— Impotentia  Coeundi — This  symptom  may  be  me- 
chanical, psychical,  irritative,  or  paralytic. 

1.  Mechanical  impotence  arises  from  congenital  or  acquired  deformi- 
ties; loss  of  substance  from  ulceration,  gangrene,  or  operation;  the  presence 
of  tumors,  as  Iwdrocele,  enormous  hernia,  elephantiasis  of  the  scrotum,  and 
the  like.  To  this  li^t  must  be  added  hypertrophy  of  the  organ,  tumior  of 
the  glands,  preputial  or  urethral  calculi  and  defect,  atrophy  or  destruction 
of  the  testicles.  To  this  group  of  causes  is  to  be  added  deviation  of  the 
erect  penis  from  abnormally  short  frsenum  and  various  infiltrations  and 
indurations  in  its  tissues.  A  rare  cause  of  impotence  is  deformity  due  to 
ossification  of  the  fibrous  tissue  in  the  organ. 

2.  Psychical. — This  form  of  imi3otence  arises  from  apprehension, 
shame,  or  self-distrust.  It  may  occur  alike  in  those  who  have  made  too 
great  experience  and  in  those  who  have  made  none,  and  the  fear  of  it  fre- 
quently leads  men  about  to  marrj^  to  take  medical  advice.  It  is  sometimes 
due  to  indifference,  aversion,  or  dislike  towards  a  particular  person  and  in 
rare  instances  to  constitutional  lack  of  sexual  feeling. 

3.  Irritative. — There  is  premature  ejaculation  or  even  ejaculation  in 
the  absence  of  sexual  approach.  This  may  occur  in  healthy  individuals  after 
long  abstinence.  It  is  very  often  due  to  local  irritation,  to  lesions  resulting 
from  urethritis,  or  to  excesses.  The  subjects  ai-e  usually  neurasthenic, 
the  nervous  condition  being  the  cause  in  some  cases,  in  others  the  effect 
of  the  sexual  irregularity. 

4.  Paralytic. — Under  this  heading  are  to  be  grouped  those  forms  of 
impotence  caused  by  the  loss  of  power  to  react  to  physiological  stimuli  on 


SYMPTOMS  AND  SIGNS:    REPRODUCTIVE  ORGANS.        555 

the  part  of  the  sexual  nerves  or  their  centres.  In  the  atonic  cases  anaimia 
and  relaxation  of  the  parts  are  present  and  the  patients  are  neurasthenic. 
Sexual  irregularities  and  excesses,  immoderate  indulgence  in  alcohol  and 
tobacco  are  causes.  Certain  drugs,  as  opium  and  its  derivatives,  nitre, 
the  salicylates  and  the  bromides,  taken  in  large  doses  or  for  long  periods 
of  time,  lead  to  this  form  of  impotence. 

Diseases  of  the  brain  and  spinal  cord  may  be  the  cause  of  paralytic 
impotence.  Tabes  dorsalis  and  other  affections,  characterized  by  im- 
paired function  of  the  bladder  or  rectum  or  by  local  anaesthesia,  are  espe- 
cially to  be  considered.  This  condition  is  also  symptomatic  of  diabetes 
mellitus,  obesity,  and  cachectic  states. 

(c)  Spermatorrhoea.  —  This  term  is  used  to  designate  the  patho- 
logical discharge  of  seminal  fluid  which  takes  place  without  erection  or 
sexual  sensation  during  the  act  of  micturition  or  defecation.  The  emissions 
which  occur  at  intervals  of  two  or  more  weeks  in  continent  young  men 
during  sleep,  and  which  are  accompanied  by  lascivious  dreams,  are  physio- 
logical rather  than  pathological  and  are  not  to  be  considered  under  this 
heading.  When,  however,  these  emissions  recur  at  short  intervals,  or 
every  night,  they  become  symptomatic  of  disease  and  the  border-line 
between  such  nocturnal  pollution  and  spermatorrhoea  is  no  longer  clearly 
defined.  Gonorrhoea,  onanism  and  sexual  excesses  are  liable  to  be  followed 
by  spermatorrhoea.  Constipation,  nervous  diarrhoea,  fissure  of  the  anus, 
seat-wormS;  and  proctitis  may  act  as  accidental  causes.  The  patients  are 
neurasthenic  and  depressed,  complain  of  headache,  backache,  and  loss  of 
energy,  are  much  given  to  the  reading  of  advertisements  upon  loss  of  man- 
hood and  are  the  easy  pre 3^  of  quacks.  A  large  proportion  of  those  who 
think  they  are  victims  of  this  disease  do  not  have  it,  but  suffer  from  chronic 
gonorrhoea,  prostatorrhcea,  urethrorrhcea,  and  forms  of  phosphaturia. 
The  microscope  is  essential  to  the  diagnosis,  and  it  is  necessary  when  sper- 
matozoids  are  present  to  ascertain  whether  or  not  a  sexual  act  has  preceded 
the  emission  of  the  fluid  in  question.  If  not,  and  especially  if  spermato- 
zoids  are  present  upon  repeated  examination,  the  diagnosis  becomes  posi- 
tive. These  bodies  are  present  in  the  urine,  which  may  be  acid,  of  high 
specific  gravity,  and  contain  oxalates,  or  alkaline  with  phosphates. 

In  the  female  pruritus  vulvae,  leucorrhoea,  and  disorders  of  menstrua- 
tion may  be  symptomatic  of  various  local  and  general  conditions. 

(a)  Pruritus  Vulvge. — This  condition  is  a  common  result  of  inflam- 
matory affections  and  displacements  of  the  womb,  ovarian  disease,  and 
affections  of  the  urethra,  bladder,  and  kidneys.  It  is,  especially  in  children, 
a  common  manifestation  of  seat-worms  and  is  very  often  the  first  symp- 
tom of  the  diabetic  woman  to  attract  her  attention  to  her  condition.  This 
condition  on  the  one  hand  frequently  leads  to  masturbation;  on  the  other 
is  not  rarely  the  result  of  it. 

(b)  Leucorrhoea. — Vaginal  discharge  is  an  important  sign  of  many 
pelvic  diseases.  It  is  associated,  very  often  in  connection  with  pelvic 
inflammations  of  mild  grade,  with  the  anaemias,  especially  when  intense, 
with  conditions  of  debility  and  the  later  stages  of  chronic  diseases  when 
they  occur  in  early  life  and  in  particular  with  pulmonary  tuberculosis.  In 
young  children  a  purulent  discharge  indicates  vulvitis  or  vaginitis,  which 


556  MEDICAL  DIAGNOSIS. 

may  be  due  to  trauma,  filth,  ascarides,  or  gonorrhoea.  In  middle  life  an  offen- 
sive sanguinolent  discharge  may  be  the  earliest  sign  of  carcinoma  uteri. 
(c)  Menstrual  Derangements. — The  normal  menstrual  function  may 
be  deranged  in  various  ways.  It  maj^  be  absent  for  a  time  or  cease  alto- 
gether— amenorrhoea;  abnormally  profuse — menorrhagia;  or  attended  with 
much  distress  and  pain— dysmenorrhoea.  These  derangements  are  due  to 
local  and  to  constitutional  conditions. 

1.  Amenorrhoea. — Failure  in  the  function  may  be  a  manifestation  of 
arrested  development  of  the  ovaries  and  uterus.  The  interruption  of 
menstruation  may  be  physiological  or  pathological. 

Physiological  amenorrhoea  is  a  characteristic  sign  of  pregnancy  and 
usually  persists  during  lactation.  There  are  important  exceptions  to  both 
these  rules.  In  very  rare  instances  there  is  a  shght  menstrual  discharge 
during  the  first  two  or  three  months  of  gestation  and  many  women  men- 
struate regularly  during  the  period  of  nursing.  Amenorrhoea  occurs  in 
extra-uterine  foetation. 

Pathological  amenorrhoea  is  observed  in  conditions  of  malnutrition, 
as  in  overworked  school-girls,  in  those  suffering  from  chlorosis,  and  in 
wasting  diseases,  as  enteric  fever,  tuberculosis,  diabetes,  and  exophthalmic 
goitre.  It  may  be  symptomatic  of  powerful  depressing  psychical  states, 
as  anxiety,  worry,,  or  grief,  and  of  nervous  affections,  as  hysteria,  or  of 
melancholia  or  other  forms  of  insanity,  and  not  infrequently  occurs  in  young 
immigrants.  It  is  common  in  morphinism  and  other  drug  habits  and  in 
cachectic  states,  whether  due  to  chronic  intoxication,  as  by  mercury  or 
lead,  or  to  malaria,  cancer,  nephritis,  leukaemia,  or  profound  anaemia  from 
any  cause.  The  retention  of  the  flow  which  takes  place  in  cases  of  imper- 
forate hymen,  atresia  vaginae,  and  analogous  conditions  cannot  be  regarded 
as  a  form  of  amenorrhoea. 

Delay  in  the  estabhshment  of  menstruation  is  in  some  girls  consti- 
tutional and  often  hereditary;  its  early  cessation  may  in  some  instances  be 
accounted  for  upon  similar  grounds.  There  are  healthy  women  who  cease 
to  menstruate  at  thirty  or  thirty-five.  Premature  menopause  may  be  due 
to  atrophy  of  the  ovaries  following  disease  or  their  operative  removal. 

So-called  vicarious  menstruation,  namely,  the  monthly  discharge  of 
blood  from  the  nose,  lungs,  stomach,  from  hemorrhoids,  ulcers  or  wounds, 
in  the  absence  of  the  normal  flow,  is  described.  There  is  no  physiological 
basis  for  such  a  phenomenon  and  it  is  probable  that  in  the- cases  described 
the  conditions  causing  amenorrhoea  have  also  caused  hemorrhages,  the 
regular  periodicity  and  duration  of  which  have  corresponded  to  the  men- 
strual period  less  in  fact  than  in  fancy. 

2.  Menorrhagia. — Abnormally  profuse  menstruation  may  be  symp- 
tomatic of  disorders  of  the  pelvic  organs  or  of  constitutional  disease.  It 
occurs  in  a  great  variety  of  local  diseases  but  especially  in  chronic  endo- 
metritis, submucous  myomata,  polypi,  and  uterine  displacements.  Menor- 
rhagia is  an  occasional  symptom  in  haemophilia,  scurvy,  purpura  haemor- 
rhagica,  and  leukaemia.  When  menstruation  takes  place  in  the  course  of 
the  acute  infectious  diseases,  for  example  influenza,  enteric  fever,  or  variola, 
it  frequently  amounts  to  menorrhagia.  Other  conditions  in  which  this 
symptom  is  occasionally  observed  are  intense  jaundice,  phosphorus  poison- 


SYMPTOMS  AND  SIGNS:    REPRODUCTIVE  ORGANS.        557 

ing,  alcoholism,  cirrhosis  of  the  liver,  and  valvular  disease  of  the  heart. 
The  administration  of  certain  drugs,  as  ergot,  gossypium,  aloes,  and  the  oil 
of  savine,  is  sometimes  followed  by  menorrhagia.  Irregular  menstruation, 
sometimes  profuse,  not  infrequently  precedes  the  menopause. 

3.  Dysmenorrhcea. — This  term  is  used  to  designate  collectively  the 
symptom-complex  in  difficult  menstruation  of  which  pain  is  the  chief 
element.  The  morbid  conditions  in  which  it  occurs  may  be  arranged  under 
two  headings,  affections  of  the  sexual  system  and  general  diseases. 

Under  the  first  heading  are  to  be  included  those  diseases  in  which  there 
is  an  obstruction  to  the  outflow  of  the  menstrual  fluid,  as  in  contraction  of 
the  internal  or  external  os  uteri,  congenital  narrowing  of  the  cervical  canal 
or  a  narrowing  acquired  as  the  result  of  flexions  of  the  uterus,  the  presence 
of  tumors  or  cicatricial  contractions  following  unwise  treatment.  This 
form  is  spoken  of  as  mechanical  dysmenorrhcea.  Here  also  are  to  be  con- 
sidered the  dysmenorrhoeas  caused  by  irritable  or  inflamed  conditions  of 
the  mucosa  secondary  to  chronic  metritis,  displacements,  tumors  and 
disease  of  the  ovaries. 

Under  the  second  heading  we  include  the  dysmenorrhcea  of  neurotic 
persons — neuralgic  or  nervous  dysmenorrhcea.  This  form  is  common  alike 
in  badly-nourished,  anaemic,  unmarried  women  and  in  women  who  have 
borne  children.  Very  frequently  no  adequate  lesions  of  the  pelvic  viscera 
can  be  discovered;  more  commonly  trifling  abnormalities  such  as  cause 
insignificant  symptoms  in  otherwise  well-nourished  and  healthy  women. 
The  patients  are  neurasthenic  and  frequently  hysterical.  The  symptoms 
vary  greatly.  In  many  cases  they  amount  merely  to  an  intensification  of 
the  ordinary  discomforts  which  attend  the  periodical  sickness;  in  others 
the  patient  may  writhe  with  anguish  or  manifest  the  most  intense  reflex 
phenomena  as  nausea,  vomiting,  headache,  or  convulsions.  Usually  these 
symptoms  subside  upon  the  establishment  of  the  flow;  sometimes  they 
continue  with  remissions  and  exacerbations  throughout  the  whole  period, 
and  in  some  cases  they  cease  entirely  only  to  recur  toward  the  close  of  the 
process. 

Membranous  d^-smenorrhoea — decidua  menstrualis — a  form  of  dys- 
menorrhcea in  which,  with  recurring  menstruation,  hollow  membranous 
casts  of  the  uterus  are  expelled  with  great  pain.  These  casts  consist  of  a 
thickened  menstrual  decidua.  They  vary  from  membranous  fragments  to 
complete  triangular  casts  of  the  interior  of  the  womb,  showing  the  openings 
of  the  tubes  and  the  internal  os.  They  are  usually  expelled  upon  the  second 
or  third  day,  sometimes  later.  The  pains  are  paroxysmal  and  very  intense 
and  cease  immediately  upon  the  expulsion  of  the  membranes  from  the 
womb.  This  form  of  dysmenorrhcea  is  sometimes  encountered  in  women 
suffering  from  chronic  metritis  or  endometritis.  It  is  very  chronic,  some- 
times continuing  throughout  the  entire  menstrual  life  of  the  individual. 
There  is  complete  relief  during  the  intermenstrual  periods.  The  condition 
is  to  be  differentiated  from  early  abortion  and  extra-uterine  pregnancy. 

4.  Metrorrhagia. — An  abnormal  uterine  hemorrhage  is  to  be  distin- 
guished from  an  excessive  menstrual  discharge  or  menorrhagia,  with  which 
it  is,  however,  very  commonly  associated.  It  may  occur  in  diseases  of  the 
reproductive  organs  or  in  certain  general  affections.     Metrorrhagia  due  to 


558  MEDICAL  DIAGNOSIS. 

local  disease  usually  indicates  disease  of  the  uterus  and  mostly  the  presence 
of  new  growths,  namely,  carcinoma,  sarcoma,  or  fibroid  tumors.  The 
bleeding  in  carcinoma  at  first  takes  the  form  of  an  increased  menstrual 
flow  usually  more  and  more  prolonged  and  frequently  accompanied  by  a 
more  or  less  abundant  watery  discharge.  The  bloody  discharge  after  a 
time  persists  during  the  intermenstrual  periods  and  becomes  wholly  atyp- 
ical. The  occurrence  of  bleeding  in  women  who  have  passed  the  meno- 
pause is  very  suggestive  and  renders  an  examination  per  vaginam  at  once 
imperative.  The  metrorrhagia  of  sarcoma  and  in  particular  of  sarcoma 
involving  the  uterine  mucosa  presents  similar  characters.  Subserous 
fibromata  do  not  bleed.  Those  situated  in  the  substance  of  the  uterus,  if 
near  the  serous  surface,  bleed  little  or  not  at  all.  Submucous  fibromata 
bleed  more  or  less  freely.  Necrotic  changes  in  uterine  neoplasm ata  are 
attended  by  a  foul-smelling  discharge  in  which  shreds  of  broken-down 
tissue  are  present.  The  atypical  bleedings  which  attend  inflammatory 
affections  are  less  frequent  and  less  profuse.  Those  which  are  caused  by 
mucous  polypi  are  often  profuse  and  continuous. 

Exceptionally  metrorrhagia  occurs  in  valvular  disease  of  the  heart, 
especially  mitral  stenosis,  and  is  said  to  have  been  observed  in  cirrhosis 
of  the  liver.  This  symptom  occurs  infrequently  in  the  acute  infectious 
febrile  diseases,  as  enteric  fever,  measles,  scarlet  fever,  variola,  cholera, 
and  malaria,  and  in  phosphorus  poisoning  and  scurvy.  In  the  last  the 
blood  loss  is  sometimes  copious.  Difficulties  arise  in  the  differential  diag- 
nosis of  the  cause  of  the  bleeding  when  the  patient  suffering  from  the 
foregoing  diseases  has  also  local  conditions  in  themselves  capable  of  caus- 
ing metrorrhagia  or  when,  during  the  acute  illness  or  shortly  before  its 
onset,  an  abortion  or  miscarriage  has  taken  place. 


XIII. 

GENERAL  SYMPTOMATIC  DISORDERS  OF  THE 

NERVOUS  SYSTEM. 

PAIN. 

Pain  is  a  symptomatic  sensory  neurosis.  The  pain  sense  is  to  be  dis- 
tinguished from  the  tactile  sense,  the  pressure  sense,  and  the  thermal  sense. 
It  is,  however,  so  closely  associated  with  the  last  two  that  a  considerable 
degree  of  pressure,  unusual  heat,  or  intense  cold  is  accompanied  by  pain. 
Pain  is  in  the  strictest  sense  a  symptom.  It  is  purely  subjective,  hence  its 
value  in  diagnosis  is  to  a  large  degree  dependent  upon  the  individual 
peculiarities  of  the  sufferer,  the  nature  of  the  primary  lesion  or  disease,  and 
concomitant  phenomena,  many  of  which  are  objective.  Judged  by  these 
standards  pain  is  a  symptom  of  the  most  varied  intensity,  from  a  trifling 
discomfort  without  direct  diagnostic  significance  to  agony  so  extreme  as 
to  cause  death.  The  pain  sense  is  universally  distributed  throughout  the 
body,  the  only  structures  in  which  it  is  wholly  lacking  being  the  hair  and 


SYMPTOMS  AND  SIGNS:    PAIN.  559 

nails.  Variations  in  the  pain  sense  in  different  localities,  probably  due  to 
modifications  in  the  sensory  nerve  supply,  must  be  invoked  in  explanation 
of  the  different  kinds  of  pain  in  the  various  viscera  and  other  anatomical 
structures.  Etiological  factors  of  the  most  diverse  kind  have  to  do  with 
pain  in  its  relation  to  time,  as  shown  in  its  onset,  course,  and  decline. 

Pain  is  dependent  upon  consciousness.  In  profound  coma,  as  that  of 
surgical  anaesthesia,  consciousness  and  pain  are  alike  wholly  abolished. 
When  consciousness  is  less  completely  impaired  there  are  objective  mani- 
festations of  painful  impressions,  though  the  patient,  upon  recovering, 
may  have  no  recollection  of  pain.  Pain  may  be  absent  in  shock.  Individ- 
uals usually  make  no  complaint  of  pain  during  the  period  of  shock  follow- 
ing gun-shot  wounds  or  other  severe  traumatism.  Under  these  circum- 
stances pain  comes  on  as  shock  subsides. 

Etiology. — Pain  is  functional  or  organic.  The  temporary  pain  in  over- 
worked muscles  is  functional.  The  pain  in  pleurisy  and  gastric  ulcer  is 
organic.  Pain  occurs  as  a  more  or  less  prominent  symptom  under  the 
following  conditions: 

1.  Excessive  or  unduly  prolonged  physiological  activity,  either 
physical,  as  in  muscular  strain  or  fatigue,  or  psychical,  as  in  the  head- 
ache which  follows  undue  intellectual  effort.  The  pains  of  parturition 
are  physiological. 

2.  Traumatism  of  all  kinds. 

3.  Circulatory  disturbances,  (a)  Passive  congestion.  An  example  of 
pain  thus  caused  is  to  be  found  in  thrombosis  of  the  crural  vein,  formerly 
known  as  phlegmasia  alba  dolens.  (b)  Active  hyperemia,  for  example,  the 
cutaneous  pain  of  local  irritants,  as  heat,  cold,  mustard  and  the  like.  Pain 
in  the  region  of  the  spleen  after  running  is  an  example  of  visceral  pain  due 
to  this  cause,  (c)  Ana3mia.  Examples  of  this  form  of  pain  are  headache 
upon  exertion  and  the  neuralgias. 

4.  Inflammation.  Pain  is  a  prominent  symptom  in  all  forms  of 
inflammation. 

5.  Toxsemia.  The  offending  substance  or  substances  in  the  blood 
may  be  the  result  of  (a)  infection,  as  in  the  acute  specific  fevers  and  malaria; 
(b)  incomplete  or  perverted  physiologicochemical  processes  or  the  defec- 
tive elimination  of  waste,  as  in  the  headache  of  uraemia  and  diabetes  and 
the  pains  of  gout,  rheumatism,  and  lithsemia;  (c)  the  action  of  drugs  or 
poisons.  Pain  due  to  this  cause  may  be  hypersemic,  as  in  the  head  pain 
produced  by  amyl  nitrite  and  quinine;  inflammatory,  as  in  the  later  stages 
of  narcotic  poisoning;  purely  nervous,  as  an  abstinence  symptom  in  mor- 
phinism and  the  pains  of  the  chloral  habit  and  lead  colic. 

6.  Changes  in  the  arteries.  Examples  of  pain  due  to  this  cause  are 
found  in  syphilis,  chronic  alcoholism,  chronic  lead  poisoning,  migraine, 
and  aneurism.  To  this  general  topic  must  also  be  referred  the  pain  in 
intermittent  claudication  and  angina  pectoris. 

7.  All  organic  painful  diseases,  abscess,  tumor,  both  benign  and 
malignant,  and  various  diseases  of  the  viscera,  whether  the  pain  be  due  to 
changes  in  the  organ  itself  or  disturbance  of  adjacent  structures  by  pres- 
sure or  displacement. 

8.  Caries  and  other  diseases  of  the  bones. 


560  MEDICAL  DIAGNOSIS. 

9.  Neuropathic  conditions,  for  example,  neurasthenia,  hysteria,  tabes, 
dysmenorrhoea,  and  tetanus. 

10.  Reflex  irritation,  as  the  supra-orbital  pain  in  indigestion  and  the 
various  locaHzed  head  pains  of  eye-strain,  pain  in  the  external  auditory 
meatus  in  dental  irritation,  and  coccygodynia  in  uterine  disease.  Anal- 
ogous are  the  pains  in  the  knee  which  occur  in  hip-disease  and  painful 
sensations  due  to  the  irritation  of  the  nerve  stump  referred  to  the  hand  or 
foot,  as  the  case  may  be,  in  an  amputated  limb. 

The  cause  of  pain  is  very  often  simple.  In  many  cases,  however,  it  is 
complex,  two  or  moi-e  of  the  foregoing  factors  being  operative. 

Mode  of  Expression  of  Pain. — Pain  must  be  studied  subjectively, 
as  we  experience  it  in  our  own  person,  and  objectively,  as  manifested  by 
the  movements,  attitudes,  and  verbal  descriptions  of  the  sufferer. 

Subjectively  we  know  that  certain  external  impressions  give  rise  to 
the  sensation  of  pain  and  that  this  sensation  is  accompanied  by  movements 
of  withdrawal  from  the  object  causing  the  pain,  by  particular  attitudes  of 
the  body  and  contortions  of  the  facial  muscles.  Under  certain  circumstances 
there  are  inarticulate  sounds,  cries  or  groans  expressive  of  pain;  these 
phenomena  are  varied  according  to  the  suddenness  and  the  intensity  of  the 
pain  and  its  character. 

Objectively  we  recognize  in  these  phenomena  a  manifestation  of  pain 
in  others.  The  gestures  that  are  characteristic  of  different  varieties  of  pain 
have  been  described  by  W.  H.  Thomson.  In  pains  due  to  inflammation 
the  patient  avoids  touching  the  painful  part,  or  approaches  it  very  cau- 
tiously. Thus  the  hand  passes  over  an  inflamed  joint  with  a  hovering 
gesture.  If  the  pain  be  deeper  seated  the  gestures  are  indicative  of  its 
distribution  and  the  character  of  the  inflamed  tissue.  Thus  the  substernal 
pain  of  bronchitis  as  indicated  by  the  whole  hand  laid  upon  the  sternum 
and  passed  over  the  chest.  In  pleurisy  the  location  of  the  pain  is  indicated 
by  the  tips  of  the  straightened  fingers,  the  natural  gesture  expressive  of 
the  stabbing  or  lancinating  character  of  the  pain.  Precordial  pain,  if 
severe,  is  indicated  by  the  tips  of  the  bent  fingers.  The  gestures  by  which 
abdominal  pain  is  indicated  are  equally  significant.  In  pains  associated 
with  lesions  of  the  intestines  the  open  hand  is  passed  over  the  abdomen 
with  a  rotary  movement.  In  the  localized  pain  of  appendicitis  the  open 
hand  is  held  over  the  affected  area  with  the  fingers  lightly  flexed.  In  peri- 
tonitis the  tips  of  the  fingers  are  used  but  they  touch  the  surface  very  gently 
and  cautiously.  Local  pains  resulting  from  visceral  disease  or  colic  are 
indicated  by  less  guarded  gestures;  radiating  pains  by  a  repeated  sweep 
of  the  hand  in  the  same  direction;  distention  pains  and  colic  by  a  firm 
pressure  upon  the  abdomen;  neuralgic  pains  by  repeated  firm  pressing 
movements  of  the  hand  in  the  direction  of  the  involved  nerve.  The  light- 
ning pains  of  tabes  are  often  indicated  by  a  quick  sweep  of  the  tips  of  the 
fingers  along  the  limb. 

The  shrinking  of  the  whole  body  or  of  a  member  from  an  object  ca- 
pable of  causing  or  increasing  pain  is  a  characteristic  gesture;  so  also  is  the 
limping  gait  in  painful  conditions  of  a  lower  extremity.  For  diagnostic 
purposes  it  is  important  to  bear  in  mind  the  fact  that  limping  is  frequently 
due  to  restricted  movement  not  necessarily  accompanied  by  pain.     Very 


SYMPTOMS  AND  SIGNS:  Px\IN.  561 

characteristic  are  the  attitudes  in  certain  painful  affections:  retraction 
of  the  head  in  meningitis,  the  shallow  breathing  and  flexion  of  the  trunk 
toward  the  affected  side  in  plastic  pleurisy,  the  strong  bending  forward  in 
colic,  the  rigid  trunk  and  flexed  thighs  in  peritonitis,  the  semiflexion  and 
immobilization  of  inflamed  joints. 

Sudden  immobility  of  the  whole  body  is  diagnostic  of  angina  pectoris. 

The  facies  of  pain  constitutes  a  most  important  objective  manifesta- 
tion, whether  it  be  the  contorted,  dusky  pale  face  of  sudden  agony  or  the 
drawn  and  pallid  countenance  of  prolonged  and  repeated  suffering.  Severe 
pain,  especially  when  paroxysmal,  is  frequently  accompanied  by  dilatation 
of  the  pupils,  rapid  respiration,  flushing  or  pallor,  free  sweating,  increased 
arterial  tension,  and  sensations  of  faintness.  Inarticulate  sounds  and  invol- 
untary exclamations  are  familiar  objective  manifestations  of  sudden  and 
intense  pain. 

Some  of  the  objective  manifestations  of  pain  are  involuntary  and 
cannot  be  simulated;  others  may,  with  or  without  the  conscious  intention 
to  deceive,  be  feigned  or  exaggerated.  By  the  verbal  description  we  gain 
information  as  to  the  location,  character,  intensity,  and  duration  of  pain, 
and  the  patient's  opinion  as  to  its  cause.  The  accounts  are  much  modified 
by  the  temperament,  power  of  expression,  and  general  experience  of  the 
sufferer. 

Not  only  the  ability  to  express  the  subjective  sensation  of  pain  varies 
greatly  but  also  the  susceptibility.  There  are  on  the  one  hand  individuals 
in  whom  the  pain  sense  is  but  slightly  developed;  on  the  other  those  in 
whom  it  is  present  to  an  abnormal  and  excessive  degree. 

There  are  racial  differences  in  the  susceptibility  to  pain  and  the  mode 
of  expressing  painful  sensations.  The  Latin  races  manifest  a  greater  sus- 
ceptibility to  pain  than  the  Anglo-Saxons.  Oriental  apathy  is  proverbial. 
On  the  other  hand  Hebrews  appear  to  have  a  peculiar  susceptibility  to  pain. 

The  individual  susceptibility  is  much  modified  by  temperament. 
Phlegmatic  persons  suffer  less  and  show  such  sufferings  as  they  experience 
much  less  forcibly  than  those  of  sanguine  or  nervous  temperament.  The 
neurotic  individual  suffers  in  proportion  to  the  instability  of  his  nervous 
organization.  The  pains  of  hypochondria  and  hysteria  are  probably  of 
central  origin.  They  are  of  irregular  distribution,  inconstant,  and  occur 
independently  of  the  recognized  causes  of  pain.  They  are  probably  none 
the  less  real.  They  diminish  in  intensity  or  disappear  when  the  patient's 
attention  is  diverted  from  them  and  are  aggravated  by  suggestion.  The 
painful  aura  of  epilepsy  is  also  of  central  origin.  Fright,  expectation,  and 
dread  intensify  painful  impressions. 

Somewhat  analogous  to  the  influence  of  temperament  is  that  of  the 
power  of  expression.  The  manifestations  of  pain  are  sometimes  much  less 
marked  in  the  rude  and  uneducated  than  those  in  the  higher  walks  of  life. 
Apathy  is  a  striking  mental  condition  in  hospital  patients. 

Experience  is  not  less  important.  Habitual  exposure  to  hardship 
benumbs  the  pain  sense.  On  the  other  hand  a  life  of  refinement  and  luxury 
exalts  it.  Prolonged  suffering  or  frequent  recurrence  of  painful  sensations 
augments  the  sensibility  and  each  recurrence  becomes  less  endurable. 
There  is  a  popular  phrase  to  the  effect  that  the  patient  is  worn  out  with  pain, 

36 


562  MEDICAL  DIAGNOSIS. 

The  manifestations  of  painful  sensations  are  much  influenced  by  cir- 
cumstance and  motive.  Consciousness  of  pain  is  greatly  diminished  during 
intense  religious  or  other  excitement  and  upon  the  field  of  battle.  When 
the  excitement  subsides  pain  asserts  itself.  The  repression  of  the  mani- 
festations of  pain  by  religious  fanatics,  the  stoicism  of  captives  under  tor- 
ture, and  the  fortitude  with  which  the  brave  endure  suffering  set  common 
experience  at  naught  and  emphasize  the  purely  subjective  nature  of  pain 
as  a  S3miptom.  Not  uncommonly  patients  understate  their  sufferings 
either  from  motives  of  pride  or  reserve  or  in  order  to  avoid  operation  or 
treatment.  On  the  other  hand  patients  frequently  appear  to  overstate 
their  sufferings  in  order  to  secure  sympathy  or  for  other  obvious  motives. 
Women  are  more  susceptible  to  pain  than  men  and  according  to  circum- 
stances manifest  it  with  greater  intensity  or  endure  it  with  greater  fortitude. 

The  patient's  description  of  his  sufferings,  the  character  of  the  con- 
comitant phenomena,  and  the  presence  of  an  obvious  cause  will  enable  the 
physician  to  form  an  estimate  of  the  significance  of  pain.  In  young  chil- 
dren, in  certain  forms  of  insanity,  and  under  other  circumstances  in  which 
patients  are  unable  to  describe  their  sensations  the  ol:)jective  manifestations 
of  pain  are  of  diagnostic  value  in  determining  its  seat  and  intensity.  The 
physician  must  be  on  his  guard  in  any  particular  case  against  under-esti- 
mating the  importance  of  pain  or  being  deceived  by  its  unintentional  or 
purposeful  exaggeration. 

Varieties  of  Pain. — Pain  in  the  broadest  sense  may  be  considered  as 
parenchymatous  or  neuralgic.  In  the  former  the  terminal  sensory  fila- 
ments are  irritated;  in  the  latter  the  nerve-trunks,  the  sensory  roots,  or  the 
sensory  centres.  Parenchymatous  pain  is  as  a  rule  less  intense  than  neu- 
ralgic pain  and  the  spontaneous  remissions  are  less  marked.  In  the  former 
the  pain  in  the  whole  affected  region  is  increased  by  pressure,  while  in  the 
latter,  though  in  some  cases  the  entire  region  is  tender  under  pressure^ 
the  general  rule  is  that  the  tenderness  is  localized  to  the  course  of  the  nerve- 
trunk,  especially  when  it  is  superficial  or  overlies  a  bone  or  makes  its  exit 
through  dense  fasciae — so-called  tender  points.  An  example  of  parenchym- 
atous pain  is  that  which  occurs  in  visceral  diseases  and  the  diffuse  head- 
aches; examples  of  neuralgic  pains  are  the  various  actual  neuralgias  which 
occur  as  primary  affections  in  persons  otherwise  in  fair  health,  in  the  ca- 
chectic and  broken-down,  and  as  secondary  affections  in  gout,  syphilis,  and 
diabetes,  and  the  lightning  pains  of  spinal  disease,  especially  tabes.  The 
pains  originating  from  suggestion  and  autosuggestion  and  many  of  the 
forms  of  hysterical  pain  are  of  central  origin  and  may  be  regarded  as 
parenchymatous. 

Pain  has  been  described  as  acute,  sharp,  lancinating,  dull,  throbbing, 
grinding,  shooting,  burning,  chilling,  shivering,  boring,  creepy,  griping  or 
colicky,  itching  and  formicating.  These  descriptive  adjectives  indicate  not 
so  much  distinct  variations  in  the  quality  of  pain  as  the  simultaneous 
recognition  of  other  associated  sensations;  hence,  the  descriptions  of  pain 
are  often  complex  or  picturesque  in  proportion  to  the  vividness  of  the 
patient's  imagination  and  his  powers  of  expression. 

(a)  Acute  Pain — Sharp,  Lancinating,  or  Stabbino. — These  adjec- 
tives are  employed  to  describe  the  pain  which  attends  acute  inflammations 


SYMPTOMS  AND  SIGNS:    PAIN,  563 

of  serous  membranes,  as  pleurisy,  pericarditis,  and  peritonitis;  the  pains 
of  acute  arthritis;  acute  neuralgias;  the  painful  forms  of  neuritis;  acute 
phlegmonous  inflammation,  and  the  pains  of  thoracic  aneurism.  The 
lightning  pains  of  tabes  belong  to  this  group  and  are  characterized  by 
their  suddenness,  brief  duration,  and  intensity.  They  are  sometimes  spoken 
of  as  shooting  pains. 

(b)  Dull  pain  is  symptomatic  of  inflammation  of  the  mucous  mem- 
branes and  the  viscera.     It  occurs  also  in  chronic  inflammations. 

(c)  Throbbing  or  pulsating  pain  is  encountered  in  acute  superficial 
phlegmonous  inflammations.     This  is  the  pain  of  whitlow — paronychia. 

(d)  Grinding,  burning,  or  gnawing  are  adjectives  used  to  describe 
the  pain  which  occurs  in  diseases  of  the  bones  and  periosteum,  in  aneurism 
of  the  thoracic  and  abdominal  aorta,  in  carcinoma  of  the  viscera  and  of 
the  breast.  Pain  of  this  kind  sometimes  occurs  in  lithsemic  conditions  and 
in  the  later  stages  of  acute  gout.  The  localized  neuralgic  pain  in  the  head, 
known  as  clavus,  and  the  persistent  local  pains  which  occur  in  some  forms 
of  tabes  are  described  as  boring. 

(e)  Aching  pains  are  not  unlike  the  preceding.  They  are  usually 
persistent  and  intense  and,  when  severe,  throbbing.  Aching  is  a  term 
used  to  describe  pains  in  the  head,  those  resulting  from  dental  caries 
and  forms  of  neuritis  and  myalgia,  especially  lumbago — hence,  cephalalgia, 
odontalgia,  rhachialgia.  The  pains  which  occur  in  the  initial  period  of 
acute  infectious  diseases,  as,  for  example,  variola,  influenza,  and  dengue, 
and  are  referred  to  the  bones  and  muscles,  are  of  this  character.  They 
are  frequently  associated  with  painful  sensations  of  chilling  or  shiver- 
ing and,  since  they  spread  from  one  part  to  another,  are  often  described 
as  creeping. 

(f)  Burning  pain  occurs  in  the  superficial  cutaneous  lesions  caused 
by  intense  heat  or  the  action  of  the  sun's  rays,  and  caustic  applications. 
It  is  characteristic  of  certain  forms  of  neuritis.  Circumscribed  neuralgias 
are  frequently  associated  with  the  sensation  of  burning  pain — causalgia. 

(g)  Itching  pain  occurs  in  irritable  states  of  the  mucous  membranes, 
stich  as  attend  certain  forms  of  conjunctivitis,  some  acute  diseases  of  the 
upper  air-passages,  and  hay  fever  and  some  forms  of  inflamed  hemorrhoids. 
Formication  is  a  term  used  to  describe  a  sensation  like  that  of  ants  or  other 
insects  crawling  over  the  skin.     It  is  occasionally  painful. 

(h)  Griping  or  colicky  pains  are  those  which  attend  the  overaction 
of  the  muscular  walls  of  tubal  structures.  Flatulent  or  other  distention 
of  the  stomach  or  intestines  induces  pain  of  this  kind — popularly  gripes 
or  belly-ache.  The  pains  upon  overaction  of  the  muscular  wall  of  the  intes- 
tines caused  by  indigestible  food,  cathartic  drugs,  irritant  poisons,  and 
certain  infections,  as  those  of  cholera  morbus  and  cholera  Asiatica,  are 
colicky.  To  this  group  belong  also  the  intense  paroxysmal  pains  which 
attend  the  passage  of  hepatic  and  renal  calculi — biliary  colic;  renal  colic. 
These  pains  are  frequently  spoken  of  as  cramp,  a  term  also  applied  to 
painful  contraction  of  the  skeletal  muscles,  as  those  of  the  calf,  toes,  fin- 
gers, the  pains  of  tetanus  and  strychnine  poisoning  and  those  which  occur 
in  habitually  over-used  muscles  in  certain  occupations — writer's  cramp, 
piano-player's  cramp. 


564  MEDICAL  DIAGNOSIS. 

(i)  Tenesmus  is  the  term  used  to  describe  the  painful  bearing-down  or 
straining  sensations  which  accompany  expulsive  efforts  from  the  outlets 
of  the  pelvic  organs  under  certain  abnormal  conditions,  as  urination  when 
there  is  acute  inflammation  of  the  bladder,  urethra,  or  prostate  gland,  or 
stricture;  defecation  in  proctitis  or  inflamed  piles  or  hydatid  or  other 
tumors  compressing  the  rectum.  The  bearing-down  pains  of  labor  are 
tenesmic. 

Pain  is  modified  by  physical  and  psychical  influences.  Among  the 
former  are  pressure,  mechanical  irritation,  movement,  and  rest. 

Modifications  by  Physical  Causes. — The  pain  which  is  caused  by 
pressure  and  the  increase  of  pain  upon  pressure  are  described  as  tenderness. 
This  will  be  discussed  later  under  a  separate  heading. 

Mechanical  irritation  causes  pain  or  aggravates  it  in  inflammation 
and  ulceration  of  mucous  membranes,  as  in  aphthous  and  other  forms  of 
stomatitis,  angina  tonsillaris,  peptic  ulcer  and  fissure  of  the  anus,  inflamed 
hemorrhoids,  and  in  various  lesions  of  the  tegumentary  structures.  Even 
slight  mechanical  irritation  of  the  normal  mucous  membrane  of  the  orifices 
of  the  body  causes  pain,  as  the  presence  of  a  minute  foreign  body  under 
the  eyeHd,  the  introduction  of  a  probe  into  the  nasal  chambers,  or  the 
passing  of  an  urethral  bougie. 

Movement  aggravates  the  pain  of  wounds,  fractures,  and  inflammations. 
The  pain  which  attends  acute  inflammation  of  serous  membranes  is  espe- 
cially increased  upon  movement,  as  is  to  be  observed  upon  full  inspiration 
in  pleurisy  and  upon  flexion  and  extension  of  the  thigh  in  peritonitis. 
Movement  intensifies  the  pain  of  arthritis,  hence  the  involuntary  immobili- 
zation of  the  joints  and  the  rehef  afforded  by  splints.  Movement  also  greatly 
increases  the  pains  of  vertebral  disease  and  neuritis.  The  pains  of  myalgia 
and  of  all  acute  inflammations  involving  the  muscles  are  augmented  by 
movement  of  the  affected  part.  In  many  instances  the  pains  of  inflamma- 
tory conditions  and  of  visceral  disease  are  increased  by  the  motion  of  the 
body  in  transportation. 

Rest,  upon  the  contrary,  is  commonly  attended  with  remission  of  pain; 
functional  rest,  by  its  temporary  disappearance,  as  in  myalgia,  the  headache 
of  eye-strain,  headache  from  prolonged  study,  and  the  pain  of  gastric  ulcer. 
The  foregoing  facts  indicate  the  value  of  attitude,  posture,  and  movement 
in  determining  the  diagnostic  significance  of  pain. 

Cold  and  heat  modify  pain.  Hot  apphcations  are  usually  soothing; 
cold  apphcations  only  occasionally  afford  rehef.  The  apphcation  of  heat 
or  cold  to  the  spine  may  indicate  the  level  of  disease  by  local  intensification 
of  pain.  Apphcations  of  heat  or  cold  frequently  enable  the  dentist  to 
locate  the  offending  tooth  in  diffuse  pain  involving  the  distribution  of  the 
dental  branches  of  the  fifth  nerve. 

Seasonal  influences  modify  habitual  tendencies  to  pain.  The  pains  of 
chronic  arthritis,  gout,  and  neuralgia  are  worse  in  cold  and  damp  weather, 
better  when  it  is  warm  and  dry.  The  influence  of  climate  upon  such  chronic 
painful  affections  is  similar;  dry,  equable,  warm,  inland  chmates  being 
more  favorable  than  those  of  the  opposite  characteristics. 

Modifications  by  Psychical  Causes. — Among  the  psychical  influences 
which  modify  pain  and  its  manifestations,  intense  emotion,  excitement, 
pride,  and  fortitude  have  already  been  mentioned.     Other  influences  of 


SYMPTOMS  AND  SIGNS:    PAIN.  565 

more  importance  in  diagnosis  are  diversion,  preoccupation,  expectant 
attention,  suggestion,  and  autosuggestion.  They  may  be  active  under 
certain  circumstances  and  to  some  extent  in  almost  any  kind  of  pain;  but 
they  are  agencies  of  especial  importance  in  neurotic  persons  and  in  those 
suffering  from  hysteria,  neurasthenia,  and  hypochondriasis.  Not  only  are 
the  pains  for  which  there  are  no  obvious  physical  causes  augmented  or 
diminished,  or  made  to  disappear  or  shift  to  other  parts,  by  purely  psychical 
influences,  but  even  those  which  attend  actual  injury  and  manifest  disease 
ma}^  be  greatly  modified  for  a  brief  period  of  time.  In  the  hypnotic  state 
pre-existing  pain  may  be  made  to  disappear  and  definite  pain  aroused 
with  readiness.  It  is  evident  that  persons  of  great  determination  may 
inhibit  the  manifestation  of  pain  under  the  stress  of  powerful  motives. 
There  are  also  rare  individuals  who  appear  to  be  able  to  inhibit  the 
sensation  of  pain. 

Time. — Pain  in  relation  to  time  may  be  occasional,  constant,  persistent, 
intermittent,  recurrent,  or  paroxysmal.  Pain  that  continues  for  any  length 
of  time  shows  marked  remissions  and  exacerbations.  The  remissions  are 
due  to  functional  exhaustion  of  the  pain  sense. 

Distribution. — Pain  may  be  (a)  diffuse  or  general,  or  (b)  circum- 
scribed or  local. 

Diffuse  pain  is  symptomatic  of  the  stage  of  onset  in  the  majority 
of  the  acute  febrile  infections.  It  varies  in  intensity  from  a  mere  sense  of 
malaise  or  general  soreness,  as  in  enteric  fever,  to  the  severe  aching  of 
influenza,  dengue,  or  variola.  It  occurs  also  in  angina  tonsillaris,  partic- 
ularly the  lacunar  form,  and  in  trichiniasis.  Diffuse  pains  attend  certain 
stages  of  some  chronic  diseases,  as  syphilis,  lithsemia,  and  saturnine  and 
mercurial  intoxication.  They  are  sometimes  described  as  vague  and  are 
often  shifting.  They  are  probably  peripheral  in  origin  and  due  to  the 
action  upon  the  nervous  system  of  toxic  substances  in  the  blood. 

Circumscribed  or  local  pain  occurs  as  a  symptom  in  the  greatest 
variety  of  morbid  conditions.  It  is  in  fact  the  most  common  and  most 
important  of  the  subjective  manifestations  of  disease.  Its  value  in  diag- 
nosis depends  largely  upon  the  ability  of  the  physician  to  estimate  the  ac- 
curacy of  the  verbal  description,  the  spontaneity  of  the  accompanying 
objective  phenomena,  the  anatomical  relationships  of  the  pain  itself,  the 
underlying  pathological  process,  and  the  importance  of  alleged  or  manifest 
causes.  Pain,  and  in  particular  local  pain,  may  be  a  danger  signal,  a  sign 
post,  a  gauge  of  the  progress  or  extension  of  disease,  a  counter  check  to 
objective  phenomena,  or  it  may  be  to  the  unwary  or  ill-informed  physician 
a  delusion  and  a  snare. 

Feigned  Pain. — The  simulation  of  pain  is  common  enough  in  malinger- 
ing, neurasthenia,  and  hysteria.  The  motives  of  malingering  are  innumer- 
able. In  neurasthenia  and  hysteria  they  usually  consist  of  a  morbid  crav- 
ing for  sympathy.  The  detection  of  simulated  pain  is  in  some  cases 
attended  with  difficulties  that  are  insurmountable.  In  malingering  the 
simulation  of  pain  is  usually  overdone.  The  distribution  of  the  pain  does 
not  conform  to  known  anatomical  rules.  Suggestion  is  of  importance.  The 
objective  phenomena  commonly  associated  with  intense  pain  are  wanting 
or  incongruous. 


566  MEDICAL  DIAGNOSIS. 

To  properly  estimate  the  value  of  pain  in  an  obscure  case  it  is  some- 
times desirable  to  have  the  patient  under  the  close  observation  of  an  experi- 
enced nurse  or  attendant  or  in  a  hospital  for  some  days. 

Significance  of  Pain. — In  general  terms  local  pain  is  symptomatic  of 
disease  of  the  part  to  which  it  is  referred.  Organic  headache,  angina  ton- 
sillaris, the  pain  in  the  side  in  pleurisy,  in  the  abdomen  in  peritonitis,  in 
the  joints  in  arthritis,  and  various  forms  of  pain  due  to  traumatism,  are 
examples  of  the  relationship  of  local  pain  to  local  disease.  As  regards  the 
anatomical  structure  involved  pain  may  be  tegumentary,  muscular,  osseous, 
visceral,  or  neural.  Very  commonly  the  pain  is  also  Hmited  to  the  region  or 
organ  affected.  But  there  are  numerous  exceptions  to  these  statements, 
and  we  find  local  pain  frequently  symptomatic  of  a  pathological  process  in 
a  distant  part,  or  local  disease  causing  pain  in  an  extended  area.  The 
recognition  of  these  facts  is  of  cardinal  importance  in  estimating  the  value 
of  local  pain  in  diagnosis. 

Referred  Pain. — A  familiar  example  is  the  intense  pain  over  the  supra- 
orbital notch  sometimes  felt  upon  eating  an  ice.  The  organ  affected  is 
probably  the  stomach,  the  location  of  the  pain  being  determined  by  the 
association  of  sensory  nerves  from  that  organ  with  the  trifacial.  Very 
curious  instances  of  referred  pain  have  been  reported — a  case  in  which 
rubbing  the  forearm  caused  pain  in  the  chest;  another  in  which  rubbing 
or  pinching  a  mole  on  the  leg  was  attended  by  sharp  pain  in  the  chin. 

Referred  pains  manifest  themselves  in: 

1.  Symmetrical  Areas. — A  case  is  reported  by  Mitchell  in  which  a 
shell-wound  of  the  right  foot  at  once  gave  rise  to  burning  pain  in  both  feet. 
A  shell-wound  of  the  left  thigh  caused  an  immediate  reference  of  pain  to 
the  same  area  on  both  sides,  so  that  the  patient  supposed  he  was  shot 
through  both  thighs.  Again,  an  injury  to  the  median  and  ulnar  nerves  was 
attended  by  pain  in  the  opposite  hand. 

Allochiria  is  the  name  given  to  the  phenomenon  of  pain  or  other  sen- 
sation referred  to  a  symmetrical  area.  It  has  been  observed  in  tabes  and 
in  postdiphtheritic  neuritis. 

2.  Functionally  Associated  Organs.  —  Pain  in  the  mammae  is 
common  in  congestion  of  the  pelvic  organs  and  dysmenorrhoea;  pain  in 
the  glans  penis  or  testicle  in  renal  colic;  diffuse  pain  in  the  abdomen  in  the 
early  stage  of  appendicitis. 

3.  Segmental  Areas.  —  Visceral  disease  is  frequently  attended  by 
pain  and  tenderness  referred  to  areas  corresponding  to  the  nerve  supply 
of  a  given  spinal  segment.  The  affected  organs  receive  their  sensory  nerve- 
fibres  from  the  same  segment  of  the  spinal  cord  from  which  arise  the  fibres 
of  the  sensory  areas  to  which  the  pain  is  referred.  In  the  words  of  Head: 
"  As  the  sensory  and  localizing  power  of  the  surface  of  the  body  is  enor- 
mously in  excess  of  that  of  the  surface  of  the  viscera,  an  error  of  judgment 
occurs,  the  diffusion  area  being  accepted  by  consciousness  and  the  pain 
referred  to  the  surface  of  the  body  instead  of  to  the  organ  actually  affected." 
Hence  the  pain  in  intestinal  colic  is  referred  to  the  whole  abdomen;  that  of 
hepatic  colic  to  the  epigastric  zone,  and  that  of  renal  colic  to  the  lumbar 
region.  So  also  pain  in  the  heart,  lungs,  liver,  and  stomach  may  be  referred 
to  areas  innervated  by  the  cranial  nerves  and  nerves  given  off  from  the 


SYMPTOMS  AND  SIGNS:    PAIN.  567 

cervical  plexus,  and  the  pain  in  disease  of  the  pelvic  organs  is  very  com- 
monly referred  to  the  back.  A  striking  example  of  this  kind  of  pain-refer- 
ence is  seen  in  the  pam  and  exquisite  tenderness  of  the  right  hypochondrium 
sometimes  encountered  in  diaphragmatic  pleurisy. 

4.  Longitudinally  Related  Areas. — Pain  arising  in  the  course  of 
a  nerve  may  be  referred  to  its  terminal  distribution.  The  pain  in  the  stump, 
which  appears  to  be  in  the  amputated  foot,  is  a  familiar  example.  The 
lightning  pains  of  tabes,  the  thigh  pains  in  mahgnant  disease  of  the  rectum 
and  in  psoas  abscess,  and  the  pain  around  the  umbilicus  in  vertebral  caries 
are  further  illustrations.  Sometimes  the  areas  are  not  so  directly  related, 
as  in  the  knee  pain  in  hip-joint  disease,  the  shoulder  pain  in  disease  of  the 
liver,  and  the  pain  in  the  distribution  of  the  ulnar  nerve  in  angina  pectoris. 

Peripheral  pain  may  be  an  early  and  suggestive  symptom  in  organic 
disease  of  the  brain  and  spinal  cord.  In  meningitis  the  pains  in  the  back 
and  limbs  may  be  very  severe.  The  joints  are  frequently  the  seat  of  pain, 
which  may  be  more  or  less  constant  or  lancinating  and  paroxysmal. 

Painful  Crises. — Severe  and  prolonged  attacks  of  pain,  associated  with 
functional  disturbances  and  wholly  independent  of  local  organic  disease, 
occur  in  some  cases  of  locomotor  ataxia  and  are  known  as  the  tabetic  crises. 
They  are  (a)  cardiac — intense  precordial  pain  accompanied  by  a  feeling  of 
oppression  and  rapid  and  irregular  pulse;  (b)  gastric,  the  most  common — 
sudden  severe  pain  in  the  epigastrium,  with  vomiting,  rapid  and  irregular 
pulse,  sometimes  symptoms  of  collapse;  there  may  be  vomiting  without 
pain  or  pain  without  vomiting;  (c)  laryngeal,  which  is  comparatively 
rare — pain  in  the  larynx  with  paroxysmal  cough,  inspiratory  stridor  and 
sensations  of  choking;  (d)  pharyngeal,  also  rare — painful  acts  of  degluti- 
tion following  one  another  at  short  intervals  and  lasting  from  some  minutes 
to  half  an  hour.  Intestinal,  rectal,  urinary,  and  genital  crises  have  also 
been  described.  Suddenness  of  onset,  intensity,  paroxysmal  character, 
and  abrupt  termination  are  characteristic  of  these  attacks.  The  absence 
of  lesions  in  the  affected  viscera  either  during  the  attacks  or  in  the  intervals 
between  them  is  of  diagnostic  importance.    Errors  in  diagnosis  are  common. 

Localization  of  Pain. 

Superficial  pains  are  mostly  symptomatic  of  diseases  of  the  under- 
lying parts,  but  they  may  be  referred. 

Deep-seated  pain  attends  inflammatory  and  ulcerative  diseases  of 
the  viscera,  mediastinal  tumor,  aortic  aneurism,  visceral  cancer,  and  dis- 
ease of  the  bones. 

Pain  may  be  unilateral  or  bilateral.  The  former  usually  attends  mor- 
bid processes  confined  to  the  affected  side;  the  latter  those  involving  both 
sides  or  of  central  origin.  This  rule  is  far  from  being  absolute.  The  pain 
caused  by  floating  kidney  is  occasionally  referred  to  the  opposite  side  of 
the  abdomen. 

The  more  important  local  pains  and  their  diagnostic  significance  are 
now  to  be  considered. 

Pain  in  the  Head. — (a)  Headache  is  a  term  used  to  designate  pain 
referred  to  various  regions  of  the  head.     It  may  be  paroxysmal  or  con- 


568  MEDICAL  DIAGNOSIS. 

tinuous.  The  term  cephalalgia  was  applied  by  the  ancients  to  slight, 
limited,  or  transitory  headaches;  the  term  cephala^a  to  severe,  deep-seated, 
and  chronic  pains  in  the  head.  Headache  is  in  many  cases  a  symptom  of 
such  importance  and  prominence  that  it  overshadows  all  others  and  lends 
to  the  clinical  picture  its  most  characteristic  feature,  often  at  first  sight  its 
only  obvious  feature.  Headache  is  a  symptom  very  often  significant 
when  other  phenomena  are  obscure.  It  thus  acquires  a  high  degree  of 
diagnostic  importance. 

Organic  and  Functional  Headaches. — Headaches  due  to  lesions  of 
the  skull  or  intracranial  disease  are  organic;  those  due  to  other  causes  are 
functional.  In  general  terms  headache  is  the  manifestation  of  the  irrita- 
tion of  sensory  nerve-fibres  caused  by  derangement  of  pressure  or  tension, 
inflammation,  toxaemia,  and  reflex  disturbances.  It  is  probable  that  the 
meninges  are  chiefly  concerned  in  the  causation  of  headache.  The  sub- 
stance of  the  brain  in  the  lower  animals  does  not  respond  to  direct  irrita- 
tion by  the  manifestations  of  pain;  and  lesions  of  cerebral  tissue  not  directly 
or  indirectly  involving  the  membranes  may  exist  without  causing  headache. 
The  meninges  and  especially  the  dura,  on  the  other  hand,  are  directly  or 
indirectly  implicated  in  those  pathological  processes  which  give  rise  to 
headache.  The  sensory  nerve  supply  of  the  dura  in  the  anterior  three- 
fourths  of  its  extent,  that  of  the  falx  and  probably  that  of  the  tentorium 
are  derived  from  the  trigeminus,  while  the  dura  mater  of  the  posterior  fossa 
is  supplied  with  sensory  fibres  from  the  vagus.  The  trigeminus  is  the  nerve 
of  sensation  to  the  scalp  as  far  back  as  the  vertex,  while  the  posterior 
branches  of  the  upper  four  cervical  nerves  supply  the  muscles  and  the  skin 
of  the  back  of  the  neck  and  the  occiput.  Sometimes  headache  is  referred 
to  the  scalp;  usually  the  pain  is  deep-seated  and  intracranial.  In  rare 
cases  superficial  headaches  are  essentially  myalgic,  the  pathological  condi- 
tion involving  the  occipitofrontal,  temporal,  or  sternomastoid  muscles. 

The  following  clinical  considerations  in  regard  to  headache  are 
important: 

Distribution  of  Headache. — This  pain  is  usually  bilateral.  It  may 
be  frontal,  occipital,  parietal,  and  temporal,  vertical  or  diffuse.  The  area 
most  commonly  involved  is  frontal,  next  in  order  of  frequency  is  diffuse 
headache,  then  follow  in  the  order  named  vertical,  occipital,  and  temporal. 
Headache  often  shifts  from  one  part  of  the  head  to  another  and  is  not 
always  confined  to  regions  limited  by  anatomical  boundaries. 

Varieties  of  Headache. — Headache,  according  to  the  character  of  the 
pain,  may  be:  1.  Pulsating  or  throbbing.  Headache  of  this  kind  is  symp- 
tomatic of  circulatory  disturbances;  it  is  often  diffuse.  2.  Dull,  heavy. 
This  is  the  headache  due  to  toxaemia;  it  is  usually  frontal,  sometimes 
occipital.  3.  Binding  or  constrictive;  the  sensation  is  often  described  as 
that  of  a  tight  band  around  the  head;  the  focus  of  intensity  is  referred  to 
the  parietal  regions.  This  is  the  headache  of  hysteria  and  neurasthenia. 
4.  Burning  or  sore;  forms  of  headache  diagnostic  of  anaemia,  rheumatism, 
and  lithaemia.  5.  Boring  or  sharp.  These  headaches  are  symptomatic  of 
hysteria  and  allied  conditions;  they  are  usually  localized;  one  form  is 
known  as  "clavus" — the  sensation  as  if  a  nail  were  being  driven  into 
the  head. 


SYMPTOMS  AND  SIGNS:    PAIN.  569 

Headache  may  be  transient  or  persistent.  In  the  latter  case  there  may 
be  exacerbations  and  remissions,  or  occasional  intermissions  which  may 
last  for  days  or  weeks.  There  may  be  slight,  continuous  headache  with 
exacerbations  of  yarying  intensity.  Headache  of  this  kind  is  symptomatic 
of  forms  of  reflex  irritation,  especially  those  arising  from  defects  of  accom- 
modation. Persistency  is  characteristic  of  organic  headaches  such  as  occur 
in  cerebral  tumor  or  abscess  or  pachymeningitis,  or  those  which  result  from 
excesses  in  tobacco  or  alcohol,  syphilis,  and  uraemia.  The  headaches  which 
occur  after  sunstroke  are  persistent,  with  brief  and  irregular  periods  of 
remission. 

The  headache  following  cerebral  concussion  is  severe  and  protracted. 
It  may  be  circumscribed  and  limited  to  a  region  corresponding  to  the  seat 
of  the  injury  or  to  the  opposite  side  of  the  head.  It  is  commonly  associated 
with  tenderness  on  light  percussion.  The  headache  following  injury  may 
be,  on  the  other  hand,  diffuse.  It  is  apt  to  be  associated  with  vertigo, 
lassitude,  and  indisposition  to  mental  effort. 

Significance  of  Headache.  —  Congestion.  —  Headache  may  result 
from  mechanical  interference  with  the  return  of  venous  blood  from  the 
head.  When  produced  by  improper  clothing  it  is  slight  and  ceases  upon 
removal  of  the  cause;  when  due  to  venous  obstruction  from  the  pressure  of 
tumors  it  is  not  usually  severe.  The  headache  caused  by  violent  paroxysmal 
or  frequently  repeated  cough  is  congestive. 

Hypercemia. — Headache  is  symptomatic  of  active  cerebral  hyperaemia 
such  as  follows  excessive  and  prolonged  mental  effort,  and  results  from  the 
action  of  vasodilator  drugs,  as  alcohol  and  the  nitrites.  This  form  of 
headache  occurs  in  the  initial  stage  of  acute  meningitis.  The  headache  of 
cerebral  hyperaemia,  whether  passive  or  active,  is  usually  frontal  or  diffuse, 
often  pulsating  or  throbbing. 

Anmmia. — Headache  occurs  in  the  ana?mia  due  to  blood  loss  or  other 
cause.  It  is  a  common  symptom  in  chlorosis.  Anaemic  headache  is  com- 
monly severe,  usually  frontal  or  diffuse,  often  attended  by  sensations  of 
pressure  and  not  rarely  associated  with  vertigo  and  tinnitus  aurium.  The 
headache  of  anaemia  is  intensified  by  effort. 

Inflammation. — Headache  is  characteristic  of  all  forms  of  cerebral 
meningitis,  both  acute  and  chronic.  It  is  usually  at  first  localized,  a  fact 
of  importance  in  the  diagnosis  of  meningitis  due  to  mastoid  or  ethmoid 
disease  or  disease  or  injury  of  the  cranial  bones.  It,  however,  rapidly 
becomes  diffuse.  Meningeal  headache  is  usually  continuous  with  exacer- 
bations of  great  severity.  Headache  in  exceptional  cases  is  absent  in 
the  early  stages  of  gradually  developing  leptomeningitis.  Sudden  intense 
headache  with  painful  rigidity  of  the  muscles  of  the  back  of  the  neck  and 
vomiting  are  early  symptoms  of  epidemic  cerebrospinal  fever.  Intense 
paroxysmal  headache  is  a  symptom  of  tuberculous  meningitis.  The  head- 
ache of  pachymeningitis  is  local  at  first,  but  later  becomes  generalized. 
Severe  frontal  headache,  usually  unilateral,  is  symptomatic  of  disease  of 
the  frontal  sinuses. 

Infection. — Headache  is  a  common  manifestation  of  infection.  This 
headache  is  usually  frontal,  it  may  be  occipital  or  general,  is  often  neuralgic 
or  superficial,  soon  becoming  dull,  deep-seated,  and  severe.     Headache  is 


570  MEDICAL  DIAGNOSIS. 

an  important  symptom  of  the  stage  of  onset  of  the  acute  febrile  infections. 
It  is  early  and  severe  in  typhus  and  associated  with  pain  in  the  back  and 
limbs.  After  a  time  it  is  followed  by  stupor.  It  is  a  constant  symptom  in 
the  early  stages  of  enteric  fever  but  subsides  spontaneously  during  the 
second  week  of  the  disease.  It  occurs  at  the  onset  of  relapsing  fever  and 
persists  until  the  crisis,  when  it  commonly  ceases  altogether.  The  head- 
ache of  influenza  is  diffuse  with  points  of  intensity  in  the  region  of  the 
frontal  sinuses  and  behind  the  eyeballs.  It  may  be  a  troublesome  sequel. 
Intense  headache  characterizes  the  period  of  invasion  of  smallpox  and 
is  usually  accompanied  by  excruciating  pains  in  the  back  and  joints. 

Headache  occurs  in  early  syphilis.  The  headaches  of  late  syphilis  are 
usually  symptomatic  of  arterial  changes,  gummata,  or  meningitis.  Head- 
ache is  common  in  hereditary  S3^philis.  Paroxysmal  headache  is  symp- 
tomatic of  malaria.  It  occurs  in  the  hot  stage  of  the  paroxysm.  It  is 
persistent  and  intense  in  estivo-autumnal  fever.  Periodical  headache  may 
be  the  chief  symptom  in  estivo-autumnal  infection. 

Toxaemia. — Some  intractable  headaches  are  symptomatic  of  chronic 
ursemia.  They  are  frontal  or  temporal,  intense,  usually  continuous,  with 
irregular  exacerbations.  Headaches  of  the  same  general  character  occur  in 
diabetes  and  in  those  suffering  from  the  gouty  diathesis.  To  this  group  we 
may  refer  the  headaches  of  chronic  lead  poisoning,  those  occurring  in  gastro- 
hepatic  derangements,  and  constipation.  These  headaches  are  intensified 
by  alcoholic  })everages  and  relieved  by  free  purgation.  Certain  drugs  cause 
headache.  Full  doses  of  quinine  or  the  salicylates  produce  headache  and 
tinnitus  aurium.  Opium  causes  distressing  headache  with  floating  sensa- 
tions, nausea,  and  vomiting.  All  these  symptoms  are  increased  when  the 
patient  assumes  the  upright  posture.  Tense,  vertiginous  headache  follows 
the  administration  of  the  nitrites  in  full  doses.  Headache  is  a  significant 
symptom  in  chronic  poisoning  by  lead,  tobacco,  alcohol,  opium,  and  chloral. 
In  the  case  of  lead  and  of  alcohol  arterio-capillary  sclerosis  is  cooperative. 
Opium  and  chloral  headaches  are  often  abstinence  symptoms,  occurring  upon 
the  withdrawal  of  the  drug.  Intense  headache  not  unlike  that  of  migraine 
frequently  follows  excesses  in  alcohol — the  acute  alcoholism  of  debauch. 

Cerebral  Abscess. — Headache  is  often  very  severe  and  persistent  in 
cerebral  abscess.  It  is  apt  to  be  associated  with  vertigo  and  pronounced 
mental  dulness  and  irritation.  Vomiting  is  common  but  not  constant. 
Chronic  brain  abscess  may  present  no  other  symptom  than  headache,  vertigo, 
mental  dulness,  irritability,  and  physical  depression.  The  pain  is  usually 
related  to  the  region  of  the  lesion;  in  ear  disease  it  is  referred  to  the  parietal 
or  the  occipital  region  of  the  affected  side.  In  abscess  following  disease  of 
the  nasal  or  ethmoid  bones  the  pain  is  referred  to  the  brow.  In  abscess 
from  traumatism  the  focus  of  pain  is  located  in  the  region  of  the  injury. 

Tumor. — Headache  may  be  said  to  be  a  constant  symptom  of  brain 
tumor.  Its  frequency  and  intensity  vary  according  to  the  location  of  the 
new  growth,  the  rapidity  of  its  development,  and  in  some  degree  to  its 
character.  Headache  is  more  persistent  and  severe  in  cerebellar  than  in 
cerebral  tumors;  in  those  of  the  cerebral  hemispheres  than  in  those  of  the 
base  and  in  those  directly  implicating  the  meninges.  It  is  more  prominent 
in  tumors  of  rapid  than  in  those  of  slow  growth,  without  regard  to  the  nature 


SYMPTOMS  AND  SIGNS:    PAIN.  571 

of  the  pathological  process.  In  general  terms  the  nature  of  the  tumor 
formation  has  no  direct  relation  to  the  intensity  of  the  headache,  the 
exception  to  this  rule  being  that  gliomata  are  less  painful  than  other  forms 
of  coarse  intracranial  new  growths.  Headache  in  brain  tumor  is  sometimes 
dull  and  boring,  sometimes  lancinating,  usually  intense,  often  agonizing. 
It  is  commonly  continuous  with  periods  of  intensification,  but  sometimes 
recurs  with  a  regular  periodicity  suggestive  of  malaria.  The  fact  that  it  is 
commonly  worse  at  night  has  some  diagnostic  value.  The  focus  of  the 
headache  in  cerebral  tumor  may  be  in  the  region  involved,  in  the  brow  or 
in  the  occiput,  or  the  pain  may  be  diffuse.  The  headache  of  brain  tumor 
may  be  localized  when  of  moderate  degree,  diffuse  during  periods  of  inten- 
sification. Light  percussion  with  the  finger-tips  may  elicit  tenderness  in 
a  region  corresponding  to  the  tumor.  The  headache  of  pachymeningitis 
interna  haemorrhagica  is  usually  at  first  referred  to  the  vertex;  later  it 
becomes  generalized. 

Aneurism. — Headache,  either  continuous  or  paroxysmal,  is  the  most 
common  symptom  of  intracranial  aneurism  affecting  the  larger  arteries 
at  the  base.  The  location  of  the  headache  has  in  general  no  definite 
relation  to  the  position  of  the  aneurism,  though  aneurisms  of  the  basilar 
artery  usually  occasion  occipital  headache.  Headache  occurs  in  caries 
of  the  bones  of  the  skull. 

Neurotic  States. — Headache  is  a  very  common  symptom  in  neuro- 
pathic conditions.  In  neurasthenia  it  is  frontal,  occipital,  or  diffuse;  it  is 
apt  to  be  continuous  and  is  aggravated  by  mental  application  and  physical 
effort.  Its  intensity  is  moderate  and  it  is  attended  by  sensations  of  pres- 
sure in  the  head,  aching  in  the  back  of  the  neck,  and  spinal  pains.  Head- 
ache is  very  common  in  the  interparoxysmal  periods  of  hysteria.  It  is 
often  referred  to  the  vertex  and  may  be  severe  and  persistent.  Headache 
is  common  in  emotional  and  precocious  children.  It  is  frequently  associated 
with  brow  pains,  pains  in  the  back  of  the  neck,  and  intolerance  of  bright 
light.  Headaches  of  this  kind  are  allied  to  the  headaches  of  hysteria. 
Headache  frequently  enters  into  the  symptom-complex  of  the  epileptic 
paroxysm.  It  may  precede  or  follow  the  convulsive  attack.  In  the  latter 
case  it  is  associated  with  drowsiness  and  hebetude.  Headache  is  common 
in  petit  mal.  In  many  cases  of  epilepsy  it  constitutes  an  important  symp- 
tom in  the  interparoxysmal  state. 

He/lex  Headache. — This  form  is  often  troublesome  and  persistent. 
This  is  sometimes  the  case  when  the  direct  s3"mptoms  of  the  local  disease 
are  slight  or  absent.  Errors  of  refraction  constitute  a  common  cause  of 
reflex  headache.  The  pain  is  usually  frontal,  sometimes  temporal,  often 
occipital.  The  patient  is  frequently  unaware  of  any  defect  in  visual  accom- 
modation. The  headache  is  usually  aggravated  by  close  or  prolonged 
use  of  the  eyes.  Reflex  headache  may  occur  as  a  symptom  in  chronic  nasal 
disease  especially  in  affections  of  the  accessory  sinuses.  It  usually  involves 
the  temporal  region  or  the  vertex.  It  is  associated  with  sensitiveness  of 
the  nasal  wall  of  the  orbit  and  hyperaesthetic  areas  on  the  mucous  mem- 
brane of  the  middle  turbinate  bone.  Headache  is  an  important  symptom 
of  adenoid  vegetations  in  the  nasopharynx.  It  constitutes  one  of  the 
forms  included  under  such  terms  as  "school  headaches,"  "headaches  of 


572  MEDICAL  DIAGNOSIS. 

the  period  of  growth/'  and  the  like.  Associated  symptoms  are  mouth- 
breathing,  mental  dulness,  and  irritabihty.  Carious  teeth  and  exposure 
of  the  pulp  not  only  cause  toothache  but  occasionally  also  cause  reflex 
headache.  Disease  of  the  auditory  apparatus  may  be  the  unsuspected 
cause  of  persistent  headache. 

The  headache  of  acute  indigestion  and  gastro-intestinal  catarrh  is 
probably  rather  toxsemic  than  reflex. 

The  importance  of  headache  as  a  disease  of  the  sexual  organs  is  prob- 
ably over-estimated;  yet  this  symptom  is  very  common  in  those  of  both 
sexes  who  suffer  from  actual  disease  of  the  reproductive  apparatus  or  are 
the  victims  of  psychical  processes  concerning  such  diseases.  Very  often 
these  headaches  are  due  rather  to  the  attendant  neuropathic  condition 
than  to  reflex  irritation. 

Associated  Symptoms. — Vertigo,  nausea,  vomiting,  drowsiness,  irrita- 
bility, and  hebetude  are  associated  with  headache  with  such  frequency  as 
to  indicate  a  common  causation.  These  symptoms  are  as  a  rule  less  con- 
stant and  less  severe  in  symptomatic  than  in  organic  headaches.  Vertigo 
is  a  frequent  attendant  upon  headache  due  to  gastro-intestinal  disorder; 
nausea  and  vomiting  in  acute  toxaemia;  somnolence  in  malaria,  anaemia, 
and  syphilis.  In  organic  headaches  the  presence  of  this  group  of  symptoms 
and  their  persistence  are  important  and  suggestive. 

Headache  is  essentially  a  symptom  and  a  careful  examination  and 
inquiry  will  reveal  some  general  or  local  cause.  Headache  is  to  be  differen- 
tiated from   migraine — a  paroxysmal  neurosis. 

Neuralgia  differs  from  headache  in  the  following  points:  The  pain 
involves  the  trunk  or  branches  of  the  nerve  rather  than  its  peripheral 
distribution.  It  is  unilateral,  localized,  sharp,  paroxysmal,  and  there  are 
present  the  characteristic  tender  points  of  Valleix.  Neuralgia  affecting 
the  first  branch  of  the  fifth  nerve  is  sometimes  attended  with  suffusion  of 
the  eye  and  oedema  of  the  lids. 

Functional  and  Organic  Headaches. — The  differential  diagnosis 
between  functional  and  organic  headaches  is  of  fundamental  importance. 
Organic  headache  is  commonly  persistent,  varying  from  time  to  time  in 
intensity,  som.etimes  undergoing  violent  exacerbations  but  rarely  wholly 
absent.  It  often  interferes  with  sleep.  It  is  aggravated  by  mental  or 
physical  effort,  by  excitement,  alcohol,  and  all  conditions  that  increase 
intracranial  hyperaemia.  It  yields  less  readily  than  functional  headache 
to  symptomatic  treatment.  It  tends  to  progressively  increase  in  severity 
and  is  in  many  cases  ultimately  replaced  by  the  stupor,  drowsiness  or  coma 
of  the  terminal  stage  of  the  disease.  Associated  symptoms,  such  as  vomit- 
ing, vertigo,  hebetude,  and  irritability,  are  of  diagnostic  importance,  and 
double  optic  neuritis,  convulsions,  and  localizing  symptoms,  as  monospasm, 
cranial  nerve  paralysis,  cerebellar  titubation,  forced  movement,  and  hemi- 
anopsia, render  the  differential  diagnosis  between  organic  headaches  and 
functional  headaches  in  most  cases  an  easy  matter. 

(b)  Pains  in  the  Scalp. — Myalgic  pains  have  been  already  spoken  of. 
They  are  usually  frontal  or  occipital,  increased  by  voluntary  movements 
of  the  scalp  and  by  pressure.  Various  affections  of  the  skin  are  attended 
by  itching  and  burning  pains  of  moderate  degree.    Local  dermatitis  attended 


SYMPTOMS  AND  SIGNS:    PAIN.  573 

with  pain  sometimes  results  from  the  injudicious  application  of  hair  washes 
containing  excess  of  cantharides  and  sometimes  from  the  action  of  pediculi; 
also  from  burns  and  scalds,  from  erysipelas,  and  from  traumatism. 

Diffuse  wandering  pains  are  often  experienced  in  various  parts  of  the 
scalp  and  are  associated  with  tenderness  of  the  skin.  These  pains  are  not 
confined  to  the  ramification  of  nerve-trunks  and  cannot  be  strictly  regarded 
as  neuralgic,  but  they  very  frequently  alternate  with  true  neuralgia.  A 
patient  under  my  observation  compared  these  pains  to  sheet  lightning. 

(c)  Pains  in  the  Face. — The  most  important  is  trigeminal  or  facial 
neuralgia,  known  also  as  tic  douloureux  and  pTosopalgia.  Neuralgia  of  the 
fifth  nerve  is  much  more  frequent  than  all  other  forms  of  neuralgia. 
The  pain  is  spontaneous,  paroxysmal,  and  unilateral.  Neuralgic  pains  in^- 
volving  the  ophthalmic  division  usually  affect  the  supra-orbital  branch 
and  are  known  as  brow  ague  or  supra-orbital  neuralgia.  The  pain 
radiates  over  the  front  of  the  head  from  the  supra-orbital  notch.  It  may 
be  felt  in  the  eyelid  or  the  eyeball  or  at  the  side  of  the  nose.  Tender 
points  are  found  at  or  above  the  supra-orbital  notch,  in  the  upper  eyehd, 
and  on  the  side  of  the  nose. 

The  neuralgic  pain  may  be  referred  to  the  eyeball  itself.  It  may  occur 
spontaneously  or  as  the  result  of  over-use  of  the  eyes.  It  is  attended  with 
dimness  of  vision  and  lachrymation  and  may  occur  alone  or  in  connection 
with  other  neuralgic  pain  in  the  region  of  the  fifth. 

Neuralgia  of  the  superior  maxillary  division  of  the  fifth  nerve  is  referred 
to  the  region  between  the  orbit  and  the  mouth  and  the  side  of  the  nose. 
Areas  of  special  intensity  are  upon  the  side  of  the  nose,  over  the  prominent 
part  of  the  upper  jaw  and  along  the  gum.  Paroxysms  are  frequently  induced 
by  the  use  of  the  tooth-brush.  When  the  inferior  maxillary  division  is 
involved  a  focus  of  pain  is  frequently  found  just  in  front  of  the  ear,  or  in 
the  temple  or  opposite  the  point  of  emergence  of  the  nerve  from  the  fora- 
men, or  in  the  region  of  the  parietal  eminence,  and  sometimes  a  point  at 
the  side  of  the  tongue. 

In  intense  paroxysms  of  trifacial  neuralgia  the  whole  side  of  the  face 
and  brow  is  involved  and  there  is  reflex  facial  spasm — tic  convulsif.  Supra- 
orbital neuralgias  are  occasionally  attended  with  vasomotor  disturbance. 
In  other  instances  a  herpetic  eruption  occurs  which  is  probably  the  mani- 
festation of  an  actual  neuritis.  Intractable  neuralgias  of  the  fifth  nerve 
occurring  late  in  life  are  known  as  degenerative  neuralgias  and  are  asso- 
ciated with  changes  in  the  ganglion  of  Gasser. 

Severe  pains  in  the  distribution  of  the  fifth  nerve  accompany  cancer  of 
the  tongue,  lingual  ulcer,  and  caries  of  the  inferior  maxilla.  Caries  of  the 
teeth  and  exposure  of  the  pulp  may  give  rise  to  pain  referred  to  the  ear. 

(d)  Pain  in  the  Eye. — Inflammatory  diseases  of  the  eye  cause  local  pain. 
In  acute  conjunctivitis  there  is  pain  in  the  eyelids,  accompanied  by  photo- 
phobia and  lachrymation;  in  iritis  pain  in  the  eyeball  and  intense  supra- 
orbital pain,  which  may  radiate  in  the  distribution  of  the  ophthalmic  division. 

The  pain  of  glaucoma  involves  the  distribution  of  the  trigeminus, 
having  its  focus  of  intensity  in  the  eyeball  or  at  the  supra-orbital  notch. 
In  the  acute  cases  it  is  agonizing  and  associated  with  depression,  pallor, 
nausea,  and  vomiting.     In  the  chronic  form  it  may  be  subacute  with  par- 


574  MEDICAL  DIAGNOSIS. 

oxysms  of  great  severity.  As  the  disease  begins  with  great  frequency  on 
one  side  there  is  a  misleading  resemblance  to  migraine.  Increase  of  the  intra- 
ocular tension,  irregular  or  dilated  pupil,  with  inactive  iris,  haziness,  anaesthe- 
sia of  the  cornea,  and  various  visual  derangements  are  suggestive  symptoms. 

(e)  Pain  in  the  Ear. — The  pain  of  acute  middle-ear  disease  is  intense, 
throbbing,  increased  by  pressure  in  front  of  the  tragus  and  by  gentle  trac- 
tion of  the  ear.  It  is  subject  to  exacerbations  and  remissions  and  often 
radiates  to  the  side  of  the  face.  Upon  spontaneous  or  surgical  perforation 
of  the  tympanic  membrane  the  distressing  feeling  of  tension  is  followed  by 
immediate  relief.  Tinnitus  is  a  common  accompaniment.  Pain  referred 
to  the  ear  and  the  side  of  the  head  is  a  prominent  symptom  in  mastoid  dis- 
ease.   It  is  accompanied  by  tenderness  upon  pressure  and  localized  oedema. 

(f)  Pain  Referred  to  the  Mouth. — Pain  is  a  symptom  of  various  forms 
of  stomatitis.  It  is  intense  in  aphthous  stomatitis,  a  very  trifling  affection, 
and  often  wholly  absent  in  cancrum  oris,  one  of  the  gravest  of  diseases. 
In  mucous  patches  and  syphilitic  ulceration  pain  is  less  conspicuous  than 
in  tuberculous  ulceration.  In  carcinomata  pain  is  a  persistent  and  distress- 
ing symptom.  In  inflammatory  and  ulcerative  conditions  of  the  pharynx 
pain  is  a  prominent  symptom.  It  is  excited  by  mechanical  irritation  and 
by  the  contraction  of  the  pharyngeal  muscles  in  deglutition.  Pain  is  not 
a  prominent  symptom  in  epidemic  parotitis  and  parotid  bubo.  It  is  excited^ 
however,  by  the  movements  of  the  parts  involved  and  accompanied  by 
great  tenderness  upon  pressure. 

(g)  Sinus  Pain. — Pain  is  a  prominent  symptom  in  disease  of  the  acces- 
sory sinuses  of  the  nose,  especially  in  those  cases  in  which  there  is  an  obstruc- 
tion to  the  outlet.  Under  these  circumstances  the  pain  may  be  extremely 
severe  and  accompanied  by  marked  systemic  disturbance,  as  fever,  chilli- 
ness, headache,  and  malaise.  The  sinuses  usually  involved  are  the  antrum 
of  Highmore  and  the  frontal  sinuses.  Free  discharge  of  mucus  or  pus  is 
usually  followed  by  immediate  relief,  but  there  are  chronic  forms  in  which 
the  pain  is  apt  to  be  of  a  dull  character  and  constant,  with  exacerbations 
in  damp  weather  and  after  exposure  to  cold.  The  diagnosis  of  antrum 
disease  may  be  confirmed  by  transillumination  with  an  electric  light. 

Pain  in  the  Body. — (a)  Pain  in  the  Back — Backache;  Rhachialgia. — 
Pain  may  occur  in  any  part  of  the  back.  It  is  more  common  in  the 
lumbar  and  sacral  regions  than  elsewhere.  Pain  in  the  back  of  the  neck 
extending  between  the  shoulder-blades  is  a  common  symptom  in  neuras- 
thenia and  hysteria. 

Acute  pain  in  the  small  of  the  back  attends  the  period  of  onset  of  many 
of  the  infectious  febrile  diseases,  especially  influenza,  dengue,  variola,  and 
cerebrospinal  fever.  It  occurs  also  in  angina  tonsillaris  and  acute  nephritis. 
Acute  pain  in  the  back,  much  aggravated  upon  movements  of  extension, 
as  in  rising  after  lacing  one's  shoes,  is  characteristic  of  lumbago.  Unilateral, 
deep-seated  lumbar  pain  of  great  severity  is  symptomatic  of  renal  colic. 
Persistent  pain  of  this  kind  attends  renal  calculus.  This  pain  is  aggravated 
by  pressure  over  the  kidney  or  sudden  jarring  of  the  body.  Pain  in  the  back 
is  often  present  in  floating  kidney.  Sacral  pains  are  symptomatic  of  disease 
of  the  pelvic  organs,  especially  uterine  flexions  and  displacements,  ovarian 
disease,  disease  of  the  colon  and  rectum,  hemorrhoids,  and  urethral  stric- 


SYMPTOMS  AND  SIGNS:    PAIN.  575 

ture.  Many  of  the  pains  in  the  lower  part  of  the  back  are  myalgic.  Pains 
of  this  kind  result  from  occasional  or  habitual  overwork  of  the  muscles  or 
from  traumatism  in  the  form  of  contusion  or  strain,  or  finally  from  expos- 
ure to  cold  or  damp,  especially  in  lithamic  individuals.  The  pain  of  myalgia 
is  increased  by  movement,  cold,  and  pressure;  it  is  relieved  by  rest  in  the 
recumbent  posture  and  by  hot  applications. 

Pain  in  the  spine  occurs  in  disease  of  the  vertebrae.  Traumatism, 
syphilis,  tuberculosis,  and  caries  from  pressure,  as  in  aneurism  of  the  aorta, 
are  common  causes.  The  pain  is  local  and  corresponds  to  the  segment  of 
the  column  involved.  It  is  increased  by  sudden  pressure  upon  the  head 
or  shoulders,  by  jarring,  by  the  application  of  heat,  cold,  and  faradism,  and 
is  relieved  by  the  recumbent  posture  and  in  some  cases  by  suspension  and 
a  properly  applied  spinal  jacket.  Rigidity  results  from  muscular  spasm  in 
the  earlier  stages  and  from  ankylosis  in  the  later.  Various  deformities 
occur.  Pain  is  present  in  that  form  of  arthritis  deformans  which  involves 
the  vertebra? — spondylitis  deformans — spondylose  rhizomelique.  There  are 
associated  nerve-root  symptoms,  as  anaesthesia  and  muscular  atrophy. 

Pain  attends  various  diseases  of  the  spinal  meninges.  It  is  local  and 
often  intense.  There  are  symptoms  of  irritation  in  the  course  of  the  nerves. 
The  more  common  causes  are  hemorrhage  into  the  spinal  membranes  and 
meningitis.     Muscular  spasm  and  rigidity  are  present. 

Diseases  of  the  cord  are  more  apt  to  cause  radiating  and  referred  pains 
than  pain  in  the  spine  itself.  The  latter  is  felt  in  the  lumbar  region;  the 
former,  as  nerve-root  irritation,  as  girdle  pains,  and  in  the  lightning  pains 
of  tabes. 

(b)  Pain  in  the  Side. — 1.  The  pain  may  be  symptomatic  of  injury 
or  inflammation  of  the  skin,  as  abrasion,  contusion,  local  dermatitis,  or 
furunculosis.  The  last  is  common  in  the  axillary  region.  In  rare  instances 
phlegmon  or  subcutaneous  extravasations  of  blood  may  be  the  cause  of 
severe  pain.    An  inspection  of  the  parts  is  necessary  in  all  cases. 

2.  Myalgic  pains  are  not  uncommon.  Pleurodynia  affects  the  muscles 
on  one  side,  usually  the  intercostals,  sometimes  the  pectorals  and  the 
serratus  magnus.  It  is  more  common  on  the  left  than  on  the  right  side. 
It  is  especially  distressing  since  the  muscles  are  in  constant  use  in  respira- 
tion. The  movements  are  restricted  on  the  affected  side,  but  deep  breath- 
ing, coughing,  and  forced  lateral  movements  increase  the  pain.  Tenderness 
is  present  often  in  a  limited  area.  This  affection  may  suggest  intercostal 
neuralgia,  from  which  it  is  to  be  distinguished  by  the  more  circumscribed 
area  involved,  the  paroxysmal  character  of  neuralgic  pain,  and  the  well- 
defined  tender  points.  It  is  sometimes  mistaken  for  pleurisy,  but  the 
absence  of  friction  sounds  is  of  diagnostic  importance.  Violent  spasmodic 
flexion  to  one  side  is  an  occasional  though  rare  manifestation  of  tetanus 
and  is  attended  with  great  pain  in  the  affected  muscles.  Side  pains  refer- 
able to  the  muscles  are  observed  in  some  cases  of  trichiniasis, 

3,  Pains  due  to  injury  or  disease  of  the  bones  may  be  referred  to  the 
side.  Fracture  of  the  ribs,  periostitis,  osteosarcoma,  rickets,  and  some  cases 
of  osteitis  deformans  are  to  be  considered.  The  diagnosis  demands  a  care- 
ful examination  of  the  area  involved  by  inspection,  palj^ation,  ausculta- 
tion, and  in  obscure  cases  by  the  Rontgen  rays. 


576  MEDICAL  DIAGNOSIS. 

4.  The  pain  of  plastic  pleurisy  is  referred  to  the  inframammary 
region  or  the  side.  It  is  sharp  or  stabbing, — the  stitch  in  the  side, — 
increased  on  deep  breathing  and  accompanied  by  friction  sounds,  in  some 
cases  friction  fremitus  and  a  dry  cough.  It  may  occur  in  previously 
healthy  individuals,  or  be  accompanied  by  slight  fever  and  presently  dis- 
appear; it  is  a  secondary  process  in  croupous  pneumonia  and  develops 
during  cancer,  abscess,  and  gangrene  when  the  surface  of  the  lung  is 
involved.  It  is  a  very  common  phenomenon  in  tuberculosis  of  the  lungs 
and  may  be  basic  or  apical. 

5.  Pain  in  the  side  may  be  due  to  visceral  disease.  Sudden  tension  of 
the  spleen,  as  often  occurs  in  boys  after  running,  is  accompanied  by  intense 
pain  in  the  infra-axillary  region  of  the  left  side.  Heavy,  dull,  dragging 
pains  are  symptomatic  of  the  splenic  tumor  of  leukaemia  and  the  malarial 
cachexia — ague  cake.  Renal  colic  is  characterized  by  an  extension  of  the 
pain  from  the  lumbar  region  to  the  affected  side  and  thence  downward 
toward  the  groin.  In  biliary  colic  the  pain  frequently  extends  to  the  right 
side  of  the  chest.  A  dull  heavy  pain  in  the  side  sometimes  attends  up- 
ward pressure  upon  the  diaphragm  such  as  occurs  in  an  overloaded  stom- 
ach or  distended  colon,  rapidly  developing  ascites,  or  an  enormous  abdom- 
inal tumor.  Pain,  paroxysmal  in  character  but  not  extremely  intense, 
occurs  in  the  early  stage  of  some  cases  of  pyelitis.  Intense  pain  in  the 
lumbar  region,  aggravated  by  pressure,  is  a  symptom  of  perinephritic 
abscess.  It  is  often  referred  to  the  hip-joint  or  the  adjacent  region  or  the 
inner  aspect  of  the  thigh.  This  pain  is  attended  with  fixation  of  the  thigh, 
which  is  flexed  to  relax  the  psoas  muscle,  and  the  patient  in  walking  stoops 
and  throws  his  weight  upon  the  sound  side.  The  pain  of  hepatic  abscess 
is  usually  referred  to  the  back  or  shoulders;  it  may  be  most  severe  in  the 
right  h3^pochondrium.  A  duller,  dragging  pain  is  felt  in  the  right  side  when 
the  patient  turns  upon  the  left.  The  pain  of  angina  pectoris  is  occasionally 
referred  to  the  left  side — fifth,  sixth  and  seventh  and  even  eighth  and  ninth 
dorsal  areas. 

6.  Pain  in  the  side  is  very  often  the  manifestation  of  disease  of  the 
nerves  themselves.  Neuralgia  may  be  the  result  of  nutritional  changes  in 
the  sensory  nerve-roots,  the  course  of  the  nerve,  or  its  peripheral  distribu- 
tion. Intercostal  neuralgia  is  very  common.  Women  are  more  liable  than 
men;  adults  far  more  liable  than  children.  The  left  side  is  more  frequently 
involved  than  the  right.  Neuropathic  individuals  especially  suffer.  Inter- 
costal neuralgia  is  encountered  in  ansemic  conditions,  general  malnutrition, 
gout,  lead  poisoning,  malaria,  cachexia,  and  chronic  nephritis.  The  attack 
may  follow  exposure  to  cold.  The  pain  is  paroxysmal  and  burning  or 
lancinating  and  there  are  characteristic  "points  douloureux.  Trophic  or 
vasomotor  phenomena  may  occur,  as  local  cedema  or  erythema.  The 
Jjosterior  branches  of  the  lumbar  plexus  may  be  involved  with  pain  in 
advance  of  the  crest  of  the  ilium  extending  along  the  inguinal  canal  and 
spermatic  cord  to  the  scrotum — irritable  testis — or  the  labium  majus. 
The  pain  of  herpes  zoster  is  intense  and  often  persistent.  It  corresponds 
to  the  distribution  of  the  eruption.  The  pain  in  caries  of  the  vertebrae 
and  aneurism  of  the  descending  aorta  is  referred  to  the  distribution  of  the 
intercostal  nerves. 


SYMPTOMS  AND  SIGNS:    PAIN.  577 

(c)  Pain  in  the  Chest  and  Abdomen. — 1.  The  skin  may  be  the  seat 
of  pain  in  inflammatory  diseases,  burns,  severe  eruptions,  and  herpes  zoster. 
Painful  burns  sometimes  result  from  the  unguarded  use  of  sinapisms  or 
hot-water  bags.     An  inspection  of  the  part  is  necessary. 

2.  Myalgia  of  the  abdominal  muscles  may  result  from  continuous 
cough.  The  epigastric  pain  in  children  suffering  from  measles  is  due  to  the 
cough.  Muscular  pain  attends  tetanus  and  some  cases  of  strychnia  poison- 
ing.    Trichiniasis  is  to  be  considered. 

3.  Periostitis  and  necrosis  of  the  sternum,  costal  cartilages,  and  ribs 
cause  pain  in  the  anterior  wall  of  the  thorax.  Resorption  and  ulceration 
from  aneurism,  malignant  disease,  syphilis,  and  enteric  fever  are  common 
causes  of  painful  lesions  in  these  structures.  Contusions,  fractures,  and 
dislocations  cause  pain. 

4.  Many  visceral  diseases  cause  pain  in  the  chest  and  abdomen.  It  is 
an  important  sign  of  aneurism  of  the  aorta.  It  is  usually  dull  and  persistent 
with  frequent  paroxysms  in  which  it  is  sharp  and  lancinating.  It  is  fre- 
quently severe  when  erosion  of  the  chest  wall  or  vertebrae  is  taking  place. 
Anginose  attacks  may  occur.  Pain  may  be  absent.  Broadbent  has  spoken 
of  aneurism  of  the  ascending  arch  as  the  aneurism  of  physical  signs;  of  the 
transverse  arch  as  the  aneurism  of  symptoms.  Pain  is  the  chief  symptom 
in  aneurism  of  the  abdominal  aorta.  It  is  epigastric,  paroxysmal,  and  radi- 
ates to  the  back  and  sides.  Severe  epigastric  pain  occurs  in  aneurism  of 
the  coeliac  axis  and  the  splenic  artery.  Pain  may  occur  in  mediastinal 
tumor,  but  it  is  much  less  common  than  in  aneurism  and  does  not  have  the 
radiating  character  so  common  in  the  latter  affection.  The  pain  of 
mediastinal  abscess  is  substernal,  throbbing,  and  usuall}^  associated  with 
chilliness  and  profuse  sweating.  In  plastic  pericarditis  pain  may  be 
absent.  When  present  it  is  variable  in  intensity,  usually  mild,  exception- 
ally severe,  and  frequently  intensified  by  the  pressure  of  the  stethoscope. 
It  is  felt  in  the  precordia  or  at  the  base  of  the  ensiform  cartilage.  The  pain 
of  pericarditis  with  effusion  is  sharp  and  lancinating  and  intensified  by 
pressure  over  the  ensiform  cartilage.  It  may  be  dull  and  dragging.  Pain 
is  not  a  symptom  of  endocarditis.  It  occurs  in  chronic  valvular  disease, 
especially  aortic  insufficiency,  in  which  it  is  sometimes  persistent  and 
distressing.  It  is  usually  precordial,  dull,  and  aching;  sometimes  sharp  and 
radiating  to  the  neck  and  down  the  left  arm.  Pain  is  much  less  common  in 
aortic  stenosis  and  is  not  a  prominent  symptom  in  mitral  disease  so  long  as 
compensation  is  maintained.  Angina  pectoris  is  characterized  by  par- 
oxysmal, agonizing  pain  in  the  region  of  the  heart,  radiating  into  the  neck 
and  arms,  especially  into  the  ulnar  distribution  of  the  left  arm,  and  often 
attended  with  the  fear  of  impending  death.  Chest  pain  is  common  and 
severe  in  croupous  pneumonia,  pleurisy,  and  pulmonary  abscess.  It  may 
occur  in  any  part  of  the  chest  but  is  most  common  in  the  inframammary 
and  mammary  regions.  In  some  cases  of  severe  acute  bronchitis  substernal 
pain  is  a  distressing  symptom.  Pain  may  be  absent  in  diseases  of  the 
liver.  It  occurs  in  acute  infectious  cholecystitis  and  is  paroxysmal  and 
severe.  It  is  referred  to  the  region  of  the  liver  but  may  have  its  focus  of 
intensity  as  low  as  the  appendix  or  in  the  epigastrium.  Intense  paroxysmal 
pain  is  met  with  in  cancer  of  the  bile  passages.     Biliary  colic  is  of  common 

37 


578  MEDICAL  DIAGNOSIS. 

occurrence  in  gall-stone  disease.  There  is  agonizing  pain  in  the  region  of 
the  gall-bladder,  extending  into  the  lower  thoracic,  epigastric,  and  upper 
abdominal  zones  and  radiating  to  the  right  shoulder.  Dull  dragging 
pain  with  intense  exacerbations  associated  with  nausea  or  vomiting  is 
encountered  in  so-called  hj^pertrophic  cirrhosis.  Pain  of  a  dull,  aching 
character  and  radiating  to  the  back  and  right  shoulder  occurs  in  hepatic 
abscess.  Pain  and  uneasiness  in  the  right  hypochondrium  are  present  in 
some  cases  of  cancer  of  the  Hver.  In  pancreatic  disease  pain  may  be  a 
prominent  and  suggestive  symptom.  It  occurs  in  hemorrhage,  acute 
pancreatitis,  and  abscess  and  is  referred  to  the  upper  zone  of  the  abdomen. 
It  is  intense  and  persistent  with  agonizing  paroxysms.  Painful  coHcky 
attacks  with  nausea  and  vomiting  have  been  noted  in  pancreatic  cysts  and 
the  passage  of  calculi  has  caused  pancreatic  colic.  A  dull  pain  under  the 
sternum  is  present  in  inflammation  and  in  spasm  of  the  oesophagus.  In 
cancer  it  may  be  persistent  or  only  present  upon  attempts  to  swallow  food. 
The  pain  of  gastralgia  is  usually  deeply  seated;  that  of  gastritis  more 
superficial.  Cardialgia  is  a  term  used  to  designate  the  uneasy  and  painful 
sensations  in  chronic  gastritis,  sometimes  caused  by  the  taking  of  food, 
sometimes  present  when  the  stomach  is  empty.  Pain  is  a  distinctive  symp- 
tom of  gastric  ulcer.  It  is  gnawing,  burning,  paroxysmal,  induced  by  tak- 
ing food,  and  referred  to  the  epigastrium.  It  is  also  in  some  cases  felt  in  the 
back  at  the  level  of  the  tenth  dorsal  vertebra.  In  peptic  ulcer  of  the  duo- 
denum the  pain  is  sometimes  located  in  the  right  hypochondrium  and  may 
come  on  two  or  three  hours  after  eating.  Pain  is  an  early  symptom  in 
cancer  of  the  stomach  and  occurs  at  some  period  in  almost  all  cases.  It  is 
usually  epigastric  but  may  be  felt  in  the  back  or  loins.  It  is  usually  burn- 
ing or  gnawing  and  rather  continuous  than  paroxysmal,  though  it  is  aggra- 
vated after  food.  The  gastric  crises  of  tabes  consist  of  intense  paroxysmal 
pain  in  the  stomach  accompanied  with  vomiting  and  an  excess  of  intensely 
acid  gastric  fluid.  Intestinal  diseases  are  accompanied  by  pain  which  may 
be  colicky  when  the  small  intestine  is  involved  and  bearing-down  when  the 
colon  is  affected — the  tormina  and  tenesmus  of  the  older  physicians. 
Abdominal  pain  of  variable  intensity  occurs  in  acute  and  chronic  catarrh, 
ileocolitis,  proctitis,  malignant  disease  of  the  intestines,  obstruction,  intus- 
susception, ileus,  and  appendicitis.  It  is  the  first  and  most  distinctive  symp- 
tom of  peritonitis.  Inframammary  pain  upon  the  left  side  is  a  common 
symptom  of  fecal  accumulations  in  the  sigmoid  flexure  of  the  colon  in 
women,  and  is  relieved  by  free  purgation.  Renal  cohc  may  extend  well  into 
the  abdomen  upon  the  affected  side.  Pyelitis  may  cause  suprapubic  pain. 
Displaced  kidney  is  usually  a  source  of  much  discomfort;  often  of  distressing 
pain.  The  paroxysmal  pains  known  as  DietVs  crises  occur  in  this  condition. 
5.  Lead  colic,  the  referred  pain  of  diaphragmatic  pleurisy  felt  in  the 
right  hypochondrium,  and  the  girdle  sensations  of  disease  of  the  spinal 
cord  are  abdominal  pains  of  purely  nervous  origin.  The  last  may  be  a 
mere  sensation  of  a  cord  or  belt  around  the  waist  or  it  may  constitute  an 
actual  pain.  It  is  usually  upon  the  level  of  the  umbilicus  or  higher  but  may 
be  lower.  The  pain  is  sometimes  much  less  marked  upon  one  side  than 
upon  the  other  and  may  suggest  a  unilateral  new  growth  or  other  form  of 
one-sided  abdominal  disease. 


SYMPTOMS  AND  SIGNS:    PAIN.  579 

Pains  in  the  Extremities. — In  general  terms  the  diagnostic  significance 
is  the  same  for  the  arms  and  hands  and  for  the  legs  and  feet.  The  excep- 
tions are  mainly  as  follows:  The  pain  of  angina  pectoris  extends  to  the 
arms  and  especially  to  the  left  arm  and  involves  the  ulnar  distribution. 
The  pain  in  writer's  spasm  and  other  occupation  neuroses  involves  the 
forearms  and  hands.  It  consists  of  irregular  darting  pains  in  the  affected 
muscles  and  the  usual  pains  attending  the  spasm  upon  effort.  The  pains 
of  dactylitis,  onychia,  and  paronychia  involve  the  fingers.  Gout  occa- 
sionally affects  the  fingers,  but  usually  the  foot  and  especially  the  great  toe. 
A  group  of  painful  affections  are  due  to  improper  foot  wear — ingrowing  toe- 
nail, corns,  bunions  and  metatarsalgia.  The  pains  of  flat-foot,  varicose  veins 
and  varicose  ulcer  are  to  be  considered  in  regard  to  the  habitually  erect 
posture.  The  especial  liability  of  the  knee  and  ankle  to  troublesome  painful 
affections  and  the  greater  frequency  of  venous  thrombosis  in  the  lower 
extremity  are  due  to  postural  conditions  and  the  greater  distance  of  the 
blood-vessels  from  the  heart.  .Referred  pains  are  common  in  the  lower 
extremities.  The  pain  in  hip-joint  disease  and  obturator  hernia  is  often 
referred  to  the  inner  side  of  the  knee;  that  of  ovarian  and  uterine  disease, 
fecal  impaction,  aneurism,  and  other  abdominal  tumors,  to  the  inner  sur- 
face of  the  corresponding  thigh,  and  in  rare  instances  that  of  acute  disease 
of  the  prostate  gland  to  the  sole  of  the  foot.  Pains  in  the  hmbs  associated 
with  numbness  and  tingling  have  occasionally  been  observed  in  the  pre- 
hemiplegic  stage  of  cerebral  hemorrhage.  Pain  in  the  toes,  due  to  periph- 
eral neuritis,  is  an  occasional  affection  after  enteric  fever.  The  aflfection 
is  not  attended  by  the  signs  of  inflammation  and  passes  away  in  the  course 
of  some  days.  Painful  muscular  cramps  in  the  post-dormitium  usually 
involve  the  lower  extremities  and  in  particular  the  muscles  of  the  calf  of 
the  leg.  They  occur  in  pregnancy,  in  gouty  subjects,  and  in  persons  oth- 
erwise in  good  health.  Similar  painful  cramps  may  attend  violent  exer- 
tion and  exposure  to  cold,  as  in  swimmers. 

The  painful  affections  common  to  the  upper  and  lower  extremities,, 
aside  from  traumatism  and  the  action  of  cold,  as  in  frost-bite,  involve  the 
muscles,  nerves,  blood-vessels,  articulations,  and  bones. 

1.  Pain  is  symptomatic  of  myalgia  from  unaccustomed  or  habitual 
overwork.  It  shows  itself  in  athletes,  dancers,  horseback  riders,  pedestrians 
and  soldiers  after  forced  marches  and  is  without  diagnostic  significance. 
Muscular  pain  occurs  in  various  forms  of  myositis  and  especially  in  trich- 
iniasis.  General  muscular  pain  is  a  symptom  of  rickets:  It  occurs  in  scurvy 
and  is  distinctive  of  infantile  scorbutus,  in  which  it  is  a  prominent  symp- 
tom upon  both  voluntary  and  passive  movement  of  the  legs.  Painful 
cramp  upon  muscular  effort — intermittent  claudication — occurs  in  throm- 
bosis and  arteriosclerosis  of  the  lower  extremities. 

2.  Nervous  pain  is  symptomatic  of  neuralgia — tender  points;  par- 
oxysms, pressure  aggravation;  neuritis  either  intrinsic  or  from  pressure; 
peripheral  neuritis  or  neuromata.  Diffuse  pain  below  the  knees  is  especially 
common  in  alcoholic  neuritis.  Sciatica,  as  well  as  brachial  neuritis,  which  is 
the  same  thing  in  the  upper  extremity,  is  in  some  instances  a  neuralgia; 
in  others  a  neuritis  of  the  nerve  or  its  plexus.  It  is  almost  always  unilateral. 
Lightning  pains  occur  in  spinal  disease,  especially  tabes.     They  are  more 


580  MEDICAL  DIAGNOSIS. 

common  in  the  legs  than  in  the  arms.  They  are  sometimes  locahzed. 
Bilateral  neuralgic  pains  in  the  arms  and  legs  are  due  to  spinal  cord  disease 
as  sclerosis,  to  general  toxic  conditions  as  lead  or  arsenic,  to  vertebral 
disease,  or  in  the  lower  extremities  to  pressure  upon  the  nerve-roots  of  the 
Cauda  equina. 

3.  Venous  thrombosis  —  milk-leg,  phlegmasia  alba  dolens  —  is  often 
extremely  painful.  It  occurs  in  lying-in  women  and  as  a  sequel  to  enteric 
fever  and  other  infectious  diseases.  A  similar  condition  may  occur  in 
consequence  of  local  pressure  in  the  upper  extremity.  Pain,  usually  tin- 
gling or  burning  in  character,  occurs  in  the  early  stages  of  local  gangrene, 
in  ergotismus,  diabetes,  and  Raynaud's  disease. 

4.  The  joints  are  especially  liable  to  pain.  Exquisite  pain  is  experienced 
in  the  joint  affection  of  rheumatic  fever.  The  wrists,  elbows,  knees,  and 
ankles  are  especially  liable  to  involvement.  Another  exquisitely  painful 
joint  affection  is  gout.  Arthritis  deformans  is  attended  by  occasional 
outbreaks  of  pain,  each  of  which  results  in  an  increase  of  the  previously 
existing  deformity  of  the  joints.  Many  of  the  cases  described  under  the 
term  chronic  rheumatism  belong  to  this  category.  The  pain  in  gonorrhoeal 
arthritis  is  persistent  and  rebellious  to  treatment.  That  of  ordinary  syno- 
vitis is  of  moderate  intensity.  Pysemic  joints  are  usually  exquisitely  painful. 
Postfebrile  arthritis  closely  resembles  the  joint  affection  of  rheumatic 
fever.  In  spinal  arthropathies — Charcot's  joints — and  in  tuberculous  joints 
pain  is  not  always  a  conspicuous  symptom. 

5.  All  forms  of  periostitis  are  accompanied  by  pain.  The  subperi- 
osteal hemorrhages  of  scurvy  are  attended  with  pain,  which  is  also  a  com- 
mon symptom  in  osteomyelitis  and  a  group  of  cases  of  osteitis  deformans. 

TENDERNESS. 

Tenderness  is  pain  upon  pressure.  It  usually  but  not  invariably  accom- 
panies spontaneous  pain.  Intestinal  colic  and  some  forms  of  neuralgia  are 
relieved  by  pressure.  Tenderness  may  be  present  in  the  absence  of  spon- 
taneous pain.  This  symptom  is  often  of  considerable  diagnostic  value, 
but  being  purely  subjective  it  is  liable  to  the  uncertainties  which  modify 
the  diagnostic  significance  of  spontaneous  pain.  It  is  attended  by  objec- 
tive manifestations,  as  wincing,  flinching,  exclamations  of  suffering,  and  the 
like.  As  in  the  case  of  spontaneous  pain  the  allegations  of  the  patient  can- 
not always  be  depended  upon.  In  certain  cases  tenderness  may  disappear 
when  his  attention  is  directed  to  other  objects,  or  it  may  be  present  under 
the  influence  of  suggestion  or  expectant  attention,  or  finally  it  may  be 
simulated  in  malingering. 

A  distinction  is  to  be  made  between  tenderness,  which  is  pain  upon 
pressure,  and  hyperesthesia,  which  is  an  exaggeration  of  the  sensibility 
of  the  skin.  Tenderness  is  (a)  superficial,  namely,  pain  upon  a  very  hght 
touch;  or  (b)  deep,  that  is,  pain  excited  by  pressure  sufficiently  firm  to 
extend  to  underlying  parts.  Superficial  tenderness  is  closely  allied  to 
hyperesthesia  and  is  usually  coupled  with  a  diminution  of  the  power  to 
recognize  the  nature  of  the  agent  by  which  the  impression  is  caused — loss 
of  tactile  sensibility. 


SYMPTOMS  AND  SIGNS:   TENDERNESS.  581 " 

For  practical  purposes  tenderness,  like  pain,  may  be  best  studied  in 
relation  to  the  parts  in  which  it  is  localized  and  the  anatomical  structures 
involved. 

The  Head. — Tenderness  of  the  scalp  occurs  during  and  after  the 
attack  in  migraine,  occipital  neuralgia,  and  in  hysterical  conditions.  Light 
pressure  or  the  use  of  the  comb  or  brush  may  excite  pain.  Local  tenderness 
is  present  in  traumatism,  especially  contusions,  and  subcutaneous  effusions 
of  blood.  Diffuse  tenderness  may  be  elicited  in  myalgia  of  the  occipito- 
frontalis  muscle.  Tenderness  attends  periostitis  and  caries  of  the  skull. 
It  is  present  also  in  gumma.  Tenderness  with  or  without  local  oedema  is 
symptomatic  of  infection  of  the  mastoid  sinuses — suppurative  mastoiditis. 
Localized  pain  is  produced  by  tapping  upon  the  skull  in  some  cases  of 
meningitis,  tumor,  and  abscess  of  the  brain — a  symptom  of  minor  impor- 
tance. 

The  Face. — Tenderness  immediately  in  front  of  the  tragus  is  pres- 
ent in  acute  inflammation  of  the  middle  ear.  Tenderness  over  the  malar 
bone  is  symptomatic  of  abscess  and  malignant  disease  of  the  antrum 
of  Highmore.  The  tender  points  in  trifacial  neuralgia  are  found  at  the 
emergence  of  the  branches  from  the  bony  foramina  and  their  pene- 
tration of  fasciae.  There  is  occasionally  also  sympathetic  tenderness  at 
the  occipital  protuberance  and  over  the  ujsper  cervical  spines.  Exqui- 
site hj^persesthesia  is  encountered  in  some  cases  of  neuralgia  of  the 
fifth  nerve. 

The  Neck. — Localized  tenderness  is  found  in  acute  inflammatoiy 
conditions,  as  mumps,  cellulitis— angina  Ludorici — acute  adenitis;  in 
myalgia,  the  spastic  rigidity  of  meningitis;  in  caries  of  the  cervical  verte- 
brae and  in  cervico-occipital  and  cervicobrachial  neuralgia. 

The  Thorax. — Tenderness  in  the  course  of  the  spine  occurs  in  men- 
ingitis, spondylitis,  arthritis  deformans  involving  the  spine,  periostitis, 
and  in  some  cases  of  myelitis.  It  is  a  symptom  of  importance  in  neuras- 
thenia, hysteria,  and  spinal  irritation,  and  in  lumbago.  Pressure  upon  the 
tender  points  produces  not  only  pain  but  also  marked  acceleration  of  the 
pulse — Mannkopfs  symptom.  Thoracic  aneurism  causing  erosion  of  the 
vertebrae  is  a  cause  of  tenderness  in  the  dorsal  or  lumbar  spine.  Spinal 
tenderness  may  frequently  be  found  in  lumbar,  subphrenic,  and  perinephric 
abscess,  and  has  been  observed  in  acute  inflammation  of  the  bronchial 
glands  and  in  some  cases  of  tumor  of  the  mediastinum.  In  these  condi- 
tions pain  may  be  also  called  forth  by  sudden  pressure  upon  the  shoulders 
of  the  patient  or  by  jarring  the  body,  as  by  a  misstep. 

Tenderness  attends  periostitis  and  caries  of  the  clavicles,  sternum, 
ribs,  and  cartilages.  It  may  be  present  in  these  structures  in  the  painful 
form  of  osteitis  deformans,  especially  early  in  the  course  of  the  disease. 
It  is  found  in  abscess  of  the  wall  of  the  thorax,  perforating  empyema,  and 
eroding  aneurism.  Tender  points  are  present  in  intercostal  nem-algia. 
Tenderness  upon  percussion  is  not  uncommon  in  the  infraclavicular  regions 
in  phthisis.  The  mammae  sometimes  are  tender  at  the  menstrual  period, 
in  early  pregnane}^  in  the  condition  known  as  irritable  breast,  which  is  a 
syndrome  of  hysteria,  and  in  adenoma  and  malignant  tumor.  Tender- 
ness is  a  symptom  of  pericarditis. 


582  MEDICAL  DIAGNOSIS. 

Abdominal  tenderness  is  a  very  common  symptom.  It  may  be 
general,  as  in  peritonitis,  or  local.  The  latter  is  usually  present  in  a  limited 
area,  as  the  epigastric,  hypochondriac,  umbilical,  hypogastric,  or  iliac 
regions;  or  the  tenderness  may  be  found  in  one  of  the  quadrants  of  the 
abdomen.  Sometimes  the  tenderness  is  distinctly  focal,  as  in  peptic  ulcer, 
the  McBurney  point  in  appendicitis,  the  region  of  the  gall-bladder,  or 
pyosalpinx.  In  other  cases  it  is  diffused,  with  or  without  circumscribed 
areas  of  intensit3^ 

Epigastric  tenderness  is  a  symptom  in  acute  and  some  cases  of  chronic 
gastritis,  pancreatitis,  pericarditis,  acute  yellow  atrophy  of  the  liver,  and 
disease  of  the  gall-bladder  and  bile  passages.  It  may  be  found  in  some  cases 
of  Addison's  disease.  One  or  more  tender  points  are  present  in  peptic 
ulcer.  Tenderness  in  this  region  attends  the  myalgia  of  persistent  cough 
and  may  be  observed  in  hysteria  and  hypochondriasis. 

Tenderness  in  the  right  hypochondrium  is  encountered  in  various 
diseases  of  the  liver,  as  perihepatitis,  congestion,  acute  hepatitis,  abscess, 
cancer,  acute  yellow  atrophy,  and  in  diseases  of  the  gall-bladder  and  bile- 
ducts,  including  cholelithiasis.  In  the  last  group  of  cases  the  tenderness 
may  be  confined  to  the  region  of  the  gall-bladder,  or  diffused  over  the 
hepatic  area  or  even  more  widely;  in  the  left  hypochondrium  in  acute 
distention  of  the  spleen,  infarct,  perisplenitis,  pancreatitis,  and  fecal 
impaction;  in  either  hypochondrium  in  diaphragmatic  pleurisy;  in  both 
in  influenza,  relapsing  fever,  and  the  gastrohepatic  form  of  estivo- 
autumnal  malarial  fever.  Tenderness  in  the  umbilical  region  may  be 
ehcited  in  peritonitis,  enteritis>  and  enteric  fever;  in  the  right  iliac  region 
in  enteric  fever,  appendicitis,  renal  calculus,  fecal  accumulations  in  the 
hepatic  flexure  of  the  colon,  and  in  cancer;  in  the  left  iliac  region  in  can- 
cer of  the  sigmoid  flexure  and  in  some  cases  of  membranous  colitis;  in 
either  in  pelvic  inflammations  and  diseases  of  the  tubes  and  ovaries;  in 
both  when  any  of  these  conditions  are  bilateral,  and  in  hysteria.  Hypo- 
gastric tenderness  may  be  symptomatic  of  cystitis,  inflammation  of  the 
pelvic  organs,  dysmenorrhoea,  and  hysteria. 

The  Extremities. — Cutaneous  hypersesthesia  may  be  due  to  peripheral 
neuritis,  especially  the  alcohoHc  form,  neuritis  involving  a  nerve-trunk 
in  the  course  of  which  there  are  tenderness  upon  pressure  and  points  dou- 
loureux, crural  thrombosis,  varicose  veins;  to  periostitis,  osteitis,  osteo- 
sarcoma, arthritis,  myalgia,  myositis,  rickets,  scurvy,  trichiniasis,  or  tetanus. 
Forms  of  arthritis  especially  characterized  by  pain  and  tenderness  are 
encountered  in  rheumatic  fever,  the  acute  process  in  arthritis  deformans, 
the  gonorrhoeal  joint  infection,  gout,  sprain,  and  tuberculosis.  The  hyster- 
ical knee  is  usually  exquisitely  painful  upon  pressure. 

PARiESTHESIA. 

Parsesthesia  is  a  condition  of  modification  of  normal  sensibility.  The 
phenomena  are  due  to  irritation  of  the  sensory  nerves  in  their  course  or 
distribution.  They  depend  upon  nutritive  disturbances  of  the  nervous 
system  or  the  action  of  toxic  or  irritating  substances  in  the  blood.  The 
itching  of  mild  morphine  intoxication  is  an  example.     Similar  symptoms 


SYMPTOMS  AND  SIGNS:   PAR.ESTHESIA.  583 

occur  in  gout  and  lithsemia  and  are  met  with  in  neurasthenia  and  hysteria. 
Sensations  of  numbness,  burning,  stinging,  itching,  and  formication  are 
common.  Coldness,  weight,  tenesmus,  the  girdle  sensation,  precordial 
constriction,  tightness,  throbbing,  sinking,  faintness,  and  debility  also 
belong  to  this  group  of  symptoms.  The  sensations  are  closely  allied  to  pain 
and  are  often  described  as  painful  by  the  patients.  They  are  wholly  sub- 
jective and  their  value  in  diagnosis  rests  entirely  upon  the  ability  of  the  phy- 
sician to  estimate  the  patient's  accuracy  of  expression  and  desire  to  com- 
municate the  truth.    There  is  no  objective  method  of  testing  his  statements. 

These  perversions  of  sensibility  are  very  common  and  in  many  instances 
constitute  the  principal  if  not  indeed  the  only  symptom  of  which  patients 
complain.  They  are  much  more  common  in  women  than  in  men  and  in 
the  well-to-do  than  in  the  poor.  Common  associated  conditions  are  defec- 
tive digestion,  constipation,  anaemia,  and  general  malnutrition.  Impor- 
tant etiological  factors  are  overwork,  worry,  irregular  or  indifferent  meals, 
the  stress  of  life,  too  frequent  child-bearing,  prolonged  lactation,  and  enter- 
optosis.  Remarkable  forms  and  combinations  are  described  by  women 
passing  through  the  grand  climacteric.  Forms  of  general  and  local  paraes- 
thesia  constitute  important  epiphenomena  of  many  chronic  morbid  states. 

Cerebral  Parsesthesias. — Sensations  of  heat,  fulness,  pressure,  and 
other  abnormal  sensations  in  the  head — the  so-called  cerebral  parcesthesice — 
occur  in  neurotic  individuals  and  over-taxed  brain  workers.  These  abnor- 
mal sensations  do  not  amount  to  actual  pain,  though  they  frequently  alter- 
nate with  it.  The.y  are  often  distressing  and  sometimes  intense.  They 
occur  in  adolescence  and  early  adult  life  and  are  especially  common  in  women 
about  the  time  of  the  grand  climacteric.  They  are,  however,  more  com- 
mon in  men  than  in  women  and  in  those  given  to  intellectual  pursuits  and 
of  sedentary  habits  than  among  the  laboring  classes.  They  occur  with 
great  frequency  in  lithsemic  and  gouty  individuals.  These  sensations  are 
sometimes  general,  sometimes  localized  to  the  vertex,  occiput,  or  forehead. 
They  frequently  persist  for  long  periods  of  time,  in  some  cases  preserving 
the  same  character,  in  others  varying.  They  are  augmented  by  mental 
effort  and  by  disagreeable  emotions  and  intensified  by  introspection  and 
attempts  on  the  part  of  the  patient  to  explain  them  to  his  physician. 
They  are,  on  the  other  hand,  minimized  by  diversion  and  suggestion. 

Forms  of  Paraesthesia. — The  parsesthesise  may  be  best  studied  in 
respect  of  their  character,  since  almost  any  of  them  may  be  referred  to 
various  parts  of  the  body  and  all  parts  at  different  times.  They  are  de- 
scribed in  the  most  varied  combinations,  so  that  numbness  and  tingling, 
itching  and  formication,  burning  and  stinging,  coldness  and  tension,  tight- 
ness and  throbbing,  and  many  others  occur. 

Numbness. — This  is  a  common  symptom  in  superficial  injuries  of  the 
skin  from  cold  or  heat;  the  action  of  corrosive  substances,  as  the  mineral 
acids  and  carbolic  acid;  overdoses  of  certain  drugs,  as  aconite  and  the 
bromides;  injuries  of  nerves,  neuritis,  neuralgia  in  the  stage  of  access  and 
decline  and  in  the  remissions  of  pain;  herpes  zoster;  peripheral  neuritis 
from  any  cause  and  in  the  endemic  form  of  the  tropics,  beriberi;  hysteria, 
neurasthenia,  tetany,  tabes,  the  early  stages  of  myelitis,  and  in  cerebro- 
spinal fever.     Numbness  may  be  a  localizing  symptom  in  coarse  lesions  of 


584  MEDICAL  DIAGNOSIS. 

the  brain,  as  tumor  or  abscess.  It  may  occur  as  a  premonitory  symptom 
in  apoplexy  and  as  the  aura  in  epilepsy.  The  sensation  is  sometimes  de- 
scribed as  like  that  produced  by  a  very  mild  faradic  current.  It  is  common 
and  distressing  in  myxoedema  and  may  be  a  troublesome  symptom  affect- 
ing the  hands  and  feet  in  arthritis  deformans.  Numbness  in  the  hands  and 
feet  constitutes  the  condition  known  as  acroparcesthesia.  Waking  numb- 
ness occurs  at  or  about  the  menopause.  It  involves  the  extremities  and 
usually  passes  off  as  the  day  goes  on  and  ceases  when  the  patient  becomes 
adjusted  to  the  non-menstrual  life.  Numbness  is  sometimes  associated 
with  or  alternates  with  burning  and  tingHng. 

Itching  or  Pruritus. — This  form  of  para3sthesia  is  frequently  asso- 
ciated with  formication  and  is  sometimes  so  severe  as  to  be  described  as 
pain.  It  is  also  associated  with  burning,  especially  in  inflam.mations  of 
the  skin  such  as  occur  in  the  exanthemata,  as  measles  and  scarlet  fever. 
Itching  of  the  scalp  is  a  symptom  of  seborrhoea;  of  the  lips  and  nose  a 
symptom  of  herpes;  of  the  eyeHds  a  symptom  of  beginning  conjunctivitis; 
of  the  anal  region  a  symptom  of  hemorrhoids  or  ascarides;  of  the  external 
genitaha  in  both  sexes  a  symptom  of  saccharine  diabetes,  in  the  female  of 
leucorrhoea  and  neurotic  states.  Itching  of  the  whole  surface  is  a  trouble- 
some symptom  in  aged  persons,  in  certain  subjects  in  winter,  in  others 
who  are  lithaemic  or  gouty,  in  hysteria,  neurasthenia,  and  many  organic 
diseases  of  the  nervous  system.  It  is  a  symptom  of  jaundice,  and  some- 
times follows  the  administration  of  morphine,  copaiba,  and  other  drugs. 
Pruritus  is  an  occasional  symptom  in  chronic  interstitial  nephritis  and 
chronic  lead  poisoning. 

Coldness. — A  common  form  of  paraesthesia.  It  is  often  general,  as 
in  the  chill,  rigor,  or  shivering  which  marks  the  onset  of  an  acute  febrile 
infection  as  pneumonia,  or  constitutes  the  initial  stage  of  ague.  Under 
these  circumstances  the  internal  temperature  is  elevated.  Sensations  of 
coldness  with  a  normal  or  subnormal  temperature  occur  in  myxoedema, 
profound  asthenia  from  any  cause,  especially  after  hemorrhage,  hysteria, 
neurasthenia,  and  in  some  forms  of  spinal  cord  disease,  as  tabes,  lateral 
sclerosis,  and  syringomyelia.  Coldness  in  the  back  is  often  experienced 
by  persons  who  are  suffering  from  pulmonary  tuberculosis  in  the  period 
of  incipiency.  Subjective  sensations  of  coldness  in  the  extremities  are 
usually  associated  with  actual  low  temperature  and  often  with  some  degree 
of  cyanosis.  In  other  cases  the  sensation  of  coldness  is  referred  to  a  cir- 
cumscribed area,  usually  in  the  leg  or  thigh.  The  affected  region  feels  as 
though  in  contact  with  a  piece  of  cold  metal  or  even  a  piece  of  ice.  This 
symptom  occurs  in  neuropathic  persons  usually  in  middle  Hfe  and  com- 
monly in  men.  It  has  been  observed  in  local  injury  to  a  nerve-trunk  and 
in  spinal  diseases. 

Heat. — Heat  as  a  subjective  sensation  not  dependent  upon  general 
or  local  elevation  of  temperature  constitutes  a  common  and  distressing 
paresthesia.  When  it  amounts  to  pain  it  is  known  as  causalgia.  It  is 
mostly  locaHzed.  Flushing  is  accompanied  by  the  sensation  of  heat. 
Flushes  of  heat  are  common  in  stout  women  at  middle  life,  at  or  about 
the  menopause,  and  in  nervous  persons  with  weak  heart.  Subjective 
sensations  of  heat  are  sometimes  associated  with  the  girdle  sensation. 


SYMPTOMS  AND  SIGNS:    PARiESTHESIA.  585 

Weight. — This  parsesthesia  is  likewise  of  common  occurrence.  It 
occurs  in  the  chest  as  a  symptom  in  severe  acute  bronchitis,  asthma,  pleural 
and  pericardial  effusion,  and  mediastinal  tumor;  also  in  great  cardiac  hyper- 
trophy and  dilatation  and  in  valvular  disease  upon  rupture  of  compensa- 
tion. Substernal  weight  and  oppression  may  be  a  symptom  of  acute  indi- 
gestion or  of  an  overloaded  stomach  and  may  precede  haematemesis.  The 
sensation  may  be  referred  to  the  epigastrium.  Weight  upon  the  chest 
occurs  in  hysteria  and  neurasthenia  and  constitutes  the  incubus  in  night- 
mare. It  is  symptomatic  of  enteroptosis  and  splanchnoptosis,  ascites,  and 
abdominal  and  pelvic  tumors. 

Tenesmus  or  Bearing  Down. — This  form  is  frequently  so  distress- 
ing as  to  amount  to  actual  pain.  The  milder  forms  are  encountered  in 
over-distention  of  the  bladder,  straining  at  stool,  and  some  varieties  of 
dysmenorrhoea. 

Precordial  constriction  or  stenocardia  accompanies  the  pain  of 
angina  pectoris.  Similar  sensations  but  much  less  intense  are  sometimes  ex- 
perienced in  cardiac  asthenia^  myocarditis,  fatty  heart,  pericarditis,  and  when 
the  heart  is  displaced  upward  by  large  ascites  or  abdominal  tympany. 
It  belongs  also  to  the  wide  group  of  sensations  in  hysteria  and  neurasthenia. 

Throbbing. — Sensations  of  throbbing  are  felt  in  conditions  charac- 
terized by  vascular  relaxation  and  nervous  excitement.  Among  these  are 
aortic  regurgitation,  anaemia,  and  paroxysmal  states  in  hysteria  and  nevu'as- 
thenia.  Almost  every  part  of  the  body  may  be  the  seat  of  these  sensations. 
They  affect  the  head  in  migraine  and  other  intense  headaches;  the  neck 
in  front  and  laterally  in  cardiac  hypertrophy  and  exophthalmic  goitre; 
the  precordia  in  palpitation;  the  epigastrium  in  the  pulsating  aorta  of 
neurasthenia;  and  constitute  a  local  symptom  in  phlegmon  and  aneurism. 
Throbbing  is  commonly  associated  with  objective  pulsations.  Purely 
subjective  sensations  of  fluttering  are  described  by  nervous  women.  They 
are  often  referred  to  the  left  inframammary  region. 

Faintness. — Faintness  is  a  sensation  attendant  upon  enfeeblement 
of  the  heart's  action,  whether  due  to  physical  or  emotional  causes.  Hence 
it  occurs  in  dilated  heart,  myocarditis,  fatty  heart,  and  all  forms  of  anaemia, 
especially  upon  exertion;  in  hemorrhage,  shock,  collapse,  and  upon  the  too 
sudden  withdrawal  of  fluid  by  the  trocar  or  aspiration;  and  finally  in 
fatigue,  excessive  heat,  and  intense  pain.  Faintness  attends  sudden  depress- 
ing emotion  and  mental  shock.  Weakness  and  debility  are  attended  by 
subjective  sensations  which  are  characteristic  and  important,  since  they 
are  often  danger  signals  in  the  absence  of  the  objective  phenomena  of 
oncoming  disease.  Sudden  sensations  of  weariness  out  of  all  proportion  to 
effort — fatigue  symptoms — are  suggestive  of  neurasthenia. 


586  MEDICAL  DIAGNOSIS. 


XIV. 

GENERAL    SYMPTOMATIC   DISORDERS   OF  THE   NERVOUS 

SYSTEM  (CONTINUED):    VERTIGO;   CONVULSIONS; 

TREMOR;    FIBRILLARY  TWITCHINGS. 

VERTIGO. 

Vertigo — literally  a  turning — is  a  symptomatic  derangement  of  the 
nervous  system  governing  the  relationship  of  the  body  to  external  objects. 
It  is  of  two  kinds:  objective  vertigo,  characterized  by  sensations  of  move- 
ment on  the  part  of  surrounding  objects  which  are  really  at  rest,  and 
subjective  vertigo,  characterized  by  sensations  of  movement  on  the  part  of 
the  individual  himself.  It  is  popularly  known  as  dizziness  or  giddiness. 
This  symptom  attends  organic  intracranial  disease,  but  is  more  common  in 
peripheral  or  functional  disturbance.  Vertigo  in  which  no  underlying 
pathological  condition  is  discoverable  is  known  as  essential.  Vertigo  is  a 
common  nervous  symptom.  It  is  often  associated  with  headache.  It  may 
occur  (1)  in  mild  cerebral  concussion;  (2)  circulatory  disturbances,  as 
cerebral  anemia  and  hyperaemia;  (3)  local  nerve  irritation,  as  mechanical 
irritation  of  the  external  auditory  meatus,  inflammation  of  the  middle  ear, 
or  the  application  of  electrical  currents  to  the  head.  A  special  form  of 
vertigo — true  auditory  vertigo — occurs  in  labyrinthine  disease.  (4)  Vertigo 
is  a  common  symptom  in  toxiemic  conditions  and  is  associated  with  head- 
ache in  the  period  of  onset  of  the  acute  infections,  in  many  cases  of  acute 
and  subacute  gastrohepatic  derangements,  and  in  lithsemia.  It  is  symp- 
tomatic of  narcotic  poisoning,  especially  that  produced  by  alcohol,  tobacco, 
opium,  and  the  nitrites.  It  occurs  also  in  aniline  poisoning,  (5)  It  is  a 
common  S5miptom  iv  arteriosclerosis  and  (6)  in  valvular  disease  of  the 
heart,  especially  aortic  insufficiency,  and  in  forms  of  degenerative  myo- 
carditis; (7)  in  neuropathic  conditions,  especially  neurasthenia  and  epi- 
lepsy; (8)  in  reflex  disturbances,  such  especially  as  arise  from  diseases  of 
the  visual  apparatus  or  the  stomach;  (9)  in  organic  disease  of  the  brain, 
especially  in  tumor,  cerebellar  disease,  in  meningeal  irritation  and  menin- 
gitis, and  in  brain  syphilis.  Finally,  (10)  vertigo  results  from  mechanical 
causes,  such  as  swinging,  certain  unusual  postures,  rapid  rotary  move- 
ments, and  sea-sickness. 

Vertigo  varies  in  intensity  from  a  trifling  sensation  of  imperfect 
equilibrium — mere  swimming  of  the  head — to  the  most  active  and  dis- 
tressing sensations  of  rapid  or  irregular  movement  or  whirling  of  the  body 
or  of  surrounding  objects. 

The  equilibrium  of  the  body  is  maintained  by  muscular  action.  The 
nicely  adjusted  and  constantly  varying  motor  impulses  necessary  to  equi- 
hbrium  are  determined  in  cerebral  centres  in  response  to  sensory  impres- 
sions which  are  as  continuous  as  the  motor  impulses  which  respond  to  them. 
These  sensory  impulses  are  visual,  aural,  muscular,  articular,  cutaneous. 


SYMPTOMS  AND  SIGNS:   VERTIGO.  587 

and  visceral.  Anything  which  suddenly  deranges  the  continuous  and 
systematized  though  unconscious  sensory  impulses  from  these  structures 
causes  a  derangement  of  the  nervous  mechanism  by  which  the  body  is 
maintained  in  its  relation  to  external  objects.  This  derangement  mani- 
fests itself  as  vertigo.  These  sensory  impressions  are  not  felt  in  normal 
consciousness,  but  when  they  are  interrupted  or  when  the  cortical  processes 
by  which  they  are  converted  into  motor  impulses  are  deranged  consciousness 
in  regard  to  them  is  perverted  and  vertigo  results.  For  this  reason  vertigo 
implies  a  disturbance,  not  a  loss  of  consciousness.  In  true  vertigo  con- 
sciousness is  always  retained. 

Vertigo  comes  on  suddenly  and  is  commonly  of  short  duration.  In 
the  objective  form  the  floor  or  the  bed  on  which  the  patient  is  lying  appears 
to  rise  and  sink  and  objects  whirl  around,  usually  in  a  definite  direction. 
In  subjective  vertigo  the  patient  himself  appears  to  be  whirling  around  or 
rising  and  sinking  in  space.  These  sensations  are  often  accompanied  by 
compensatory  movements  on  the  part  of  the  patient  which  may  result  in 
a  fall.  Mental  confusion,  faintness,  a  sense  of  alarm,  and  nausea  or  vomit- 
ing are  associated  symptoms,  which  vaiy  in  intensity  but  are  almost  al- 
ways present.  When  the  vertigo  is  severe  consciousness  is  impaired  but 
not  lost.  The  attacks  continue  to  recur  whilst  the  causal  condition  per- 
sists.    The  term  status  veriiginosis  has  been  applied  to  persistent  vertigo. 

The  following  forms  of  vertigo  demand  separate  consideration: 

Aural  Vertigo. —  This  symptom  frequently  arises  from  the  pressure 
of  accumulated  cerumen  in  the  external  auditory  canal  or  from  the  pres- 
sure of  air  against  the  tympanic  membrane  by  a  blow  upon  the  ear,  or  the 
entrance  of  water  in  diving  or  surf  bathing,  or  the  too  forcible  use  of  the 
ear  syringe.  It  may  also  occur,  though  it  is  not  a  common  symptom,  in 
cases  of  middle-ear  disease  or  from  the  use  of  the  Eustachian  catheter. 
Vertigo  occurring  under  the  above  circumstances  is  usually  slight  and 
transitory.    Labyrinthine  vertigo  is  the  chief  symptom  in  Meniere's  disease. 

Toxic  Vertigo. — Vertigo  which  attends  the  onset  of  the  acute  infec- 
tions is  of  no  great  importance  and  usually  quickly  passes  away.  That 
which  occurs  in  gastrohepatic  catarrh  is  commonly  annoying  on  rising  in 
the  morning  in  persons  of  bilious  temperament  and  sedentary  lives,  espe- 
cially if  they  be  addicted  to  the  pleasures  of  the  table.  This  symptom 
occurs  also  in  acute  indigestion  and  in  lithiemic  conditions.  Vertigo  is 
a  very  common  drug  symptom,  which  is,  however,  much  influenced  by 
habit  and  idiosyncrasy. 

Cardiovascular  Vertigo. — Vertigo  is  a  symptom  of  cerebral  anaemia. 
It  occurs  in  sudden  blood  loss,  cardiac  asthenia,  excitement,  or  sudden 
effort  during  digestion,  upon  sudden  effort  in  myocarditis,  valvular  disease, 
and  in  particular  aortic  insufficiency.  It  occurs  also  in  pernicious  and  other 
forms  of  anaemia,  chlorosis,  and  leukaemia.  Associated  with  tinnitus  aurium 
it  is  very  common  in  sclerotic  changes  in  the  branches  of  the  cerebral 
arteries. 

Neurotic  Vertigo. — Vertigo  sometimes  occurs  in  epilepsy  as  an  aura. 
It  is  not  rare  in  petit  mal.  Vertigo  is  a  common  and  distressing  symptom 
in  neurasthenia.  The  attacks  are  frequent  but  not  commonly  severe  or 
prolonged.     They  are  attended  with  nausea,  though  vomiting  is  not  com- 


588  MEDICAL  DIAGNOSIS. 

mon.  It  is  usually  subjective  and  frequently  reflex.  Stumbling  or  para- 
lyzing vertigo  has  been  observed  in  exophthalmic  goitre  and  as  an  endemic 
condition  in  certain  cantons  of  Switzerland  during  the  summer.  There  is 
a  sudden  loss  of  power  in  the  legs  with  impairment  of  consciousness.  Par- 
oxysmal vertigo  may  occur  in  nervous  individuals  after  excitement  or 
fatigue.  It  is  very  distressing,  occurring  suddenly,  accompanied  with 
nausea  and  vomiting,  and  lasting  sometimes  for  hours. 

Reflex  vertigo  may  be  associated  with  the  brow  pains  and  other  forms 
of  headache  which  are  symptomatic  of  errors  in  refraction  or  want  of 
harmonious  action  in  the  ocular  muscles. 

Mechanical  Vertigo. — This  symptom  attends  sudden  lowering  of 
the  head,  whirling  around,  or  swinging  in  individuals  not  accustomed  to  it,. 
and  is  a  very  important  part  of  the  symptom-complex  in  sea-sickness  and 
car-sickness.     Mild  persistent  vertigo  has  been  observed  in  elevator  boys. 

Vertigo  op  Intracranial  Disease. — This  is  a  very  common  symp- 
tom in  diseases  of  the  brain  and  its  meninges.  It  is  sometimes  distressing 
but  as  a  rule  is  of  secondary  importance  to  the  headache,  vomiting,  and 
mental  dulness  with  which  it  is  commonly  associated.  It  occurs  at  some 
time  during  the  course  of  meningitis,  cerebral  abscess,  thrombotic  soften- 
ing, tumor  of  the  brain,  and  cerebellar  disease.  This  form  is  of  considerable 
importance  in  the  diagnosis  of  cerebral  syphilis. 

Laryngeal  vertigo,  better  called  laryngeal  epilepsy,  usually  mani- 
fests itself  in  neurotic  adults.  The  paroxysm  begins  with  tickling  or  irrita- 
tion in  the  larynx,  cough,  partial  loss  of  consciousness,  and  dyspnoea.  Light 
tonic  or  clonic  movements  occur.  The  patients  suffer  from  laryngitis, 
bronchitis,  asthma,  or  pulmonary  phthisis.  The  attacks  recur  as  often  as 
once  a  day  or  at  longer  intervals. 

CONVULSIONS. 

The  term  convulsion  is  used  to  designate  a  paroxysm  of  involuntary 
and  more  or  less  violent  muscular  contractions  involving  the  voluntary 
muscles  in  general.  The  word  spasm  is  frequently  used  in  a  more  limited 
sense  to  indicate  similar  involuntary  contractions  of  the  -muscles  of  partic- 
ular parts  of  the  body.  We  speak  of  general  convulsions  and  local  spasms^ 
This  distinction  is,  however,  not  always  observed. 

General  Convulsions. — Convulsions  are  tonic  and  clonic.  A  tonic 
convulsion  is  an  involuntary  muscular  contraction  which  is  continuous 
and  intense.  It  may  be  of  brief  duration,  as  in  the  beginning  of  the  epileptic 
paroxysm;  or  prolonged,  as  in  tetanus.  A  clonic  convulsion  is  character- 
ized by  the  rapid  alternation  of  contraction  and  relaxation,  as  in  the  second 
stage  of  the  epileptic  paroxysm  or  in  infantile  eclampsia.  The  posture  in 
tonic  convulsions  is  forced  and  immovable;  in  clonic  convulsions  it  is  con- 
stantly changed.  The  arms  and  legs  are  alternately  flexed  and  extended 
with  more  force  than  in  ordinary  movements,  the  body  is  violently  tossed, 
and  the  muscles  of  the  face  contorted.  The  chief  centre  for  convulsions  is 
the  cerebral  cortex.  Tonic  and  clonic  convulsions  may  succeed  each  other, 
as  in  epilepsy,  or  may  alternate,  as  in  hysteria.  Consciousness  is  often  pre- 
served in  general  convulsions  of  the  tonic  type,  as  strychnine  poisoning  and 


SYMPTOMS  AND  SIGNS:   CONVULSIONS.  589 

tetanus,  and  usually  lost  in  those  of  clonic  type,  as  epilepsy  and  ursemia. 
A  spasm  may  be  confined  to  a  muscle  or  a  group  of  muscles;  or  it  may  ex- 
tend to  an  entire  limb  or  the  whole  of  the  body.  A  cramp  is  a  painful 
tonic  spasm  affecting  a  single  muscle  or  group  of  muscles,  as  the  well- 
known  cramp  in  the  calves  of  the  legs. 

Etiology. — From  the  standpoint  of  etiology  convulsions  are  symp- 
tomatic of  (1)  local  irritation;  (2)  general  cortical  irritation,  (a)  from 
causes  wholly  unknown,  (b)  from  the  toxaemia  of  infection,  (c)  from  va- 
rious intoxications;  (3)  circulatory  derangements;  (4)  inflammatory  and 
degenerative  processes  involving  the  cerebral  cortex;  (5)  convulsions  are 
very  often  of  reflex  origin. 

Convulsions  are  essentially  paroxysmal.  Even  though  the  cause  is 
persistent,  the  motor  centres  become  exhausted  and  there  are  intermis- 
sions, as  in  uraemia.  Again  the  paroxysms  occur  as  storms,  the  cause 
exhausting  itself  in  a  single  paroxysm  or  series  of  paroxysms  and  only 
again  asserting  itself  after  an  interval  more  or  less  prolonged,  as  in  ordi- 
nary epilepsy.  In  infancy,  in  the  children  of  neurotic  parents,  and  in  neuro- 
pathic individuals  convulsions  frequently  arise  from  the  action  of  causes  not 
capable  of  producing  them  at  a  later  age  or  in  normal  individuals. 

1.  Local  Irritation. — The  motor  areas  may  be  directly  involved 
in  fracture,  hemorrhage,  cicatrix,  or  neoplasm,  as  in  focal  or  Jacksonian 
epilepsy.  The  initial  symptom  may  be  a  local  spasm,  involving  the  leg, 
arm,  or  face,  the  convulsion  becoming  generalized  in  the  course  of  a  few 
seconds  or  longer.  Again  the  local  irritation  may  be  transmitted  from  a 
distance,  as  in  tumor,  abscess,  or  sclerosis. 

2.  The  irritation  may  be  general,  (a)  from  causes  wholly  unknown, 
as  in  epilepsy.  The  paroxysm  is  frequently  preceded  by  an  aura;  it  begins 
with  tonic  spasm  and  loss  of  consciousness  and  is  characterized  by  clonic 
convulsions.  So  characteristic  is  the  latter  stage,  that  general  convulsions 
due  to  other  causes  are  described  as  epileptiform  or  epileptoid.  The  par- 
oxysm is  followed  by  hebetude,  drowsiness,  or  stupor,  and  may  be  replaced 
by  a  maniacal  outbreak  or  other  mental  disturbance — the  psychical  epi- 
leptic equivalent,  (b)  The  toxaemias  of  infection.  General  convulsions  very 
commonly  attend  the  onset  of  the  infectious  diseases  in  childhood.  They 
occur  at  this  period  of  life  as  the  equivalent  of  the  initial  chill  in  the  adult 
and  are  frequently  seen  at  the  onset  of  scarlet  fever,  measles,  and  pneumonia, 
and  in  other  not  well  defined  infections.  They  are  frequent  in  rickets, 
which  is  the  most  important  predisposing  cause  of  infantile  convulsions. 
They  are  early  symptoms  of  that  disease,  and  when  convulsions  occur  in 
infancy  without  manifest  cause  rickets  is  to  be  considered.  The  convul- 
sions of  tetanus,  strychnine  poisoning,  and  hydrophobia  are  to  be  considered 
under  this  heading,  (c)  General  convulsions  occur  in  poisoning  from 
aconite,  prussic  acid,  and  veratrum  viride,  and  in  chronic  alcoholism  and 
lead  poisoning.  Under  this  heading  are  to  be  included  the  convulsions  of 
uraemia,  puerperal  eclampsia,  and  asphyxia. 

3.  Circulatory  derangements  are  sometimes  the  cause  of  general 
convulsions  which  occur  after  profuse  hemorrhages,  and  in  the  cerebral 
anaemia  which  immediately  precedes  dissolution.  Violent  general  convul- 
sions occasionally  occur  during  the  coma  following  sunstroke. 


590  MEDICAL  DIAGNOSIS. 

4.  Inflammatory  and  degenerative  processes  involving  the  cere- 
bral cortex  give  rise  to  general  convulsions.  Under  this  heading  are  to 
be  considered  the  convulsions  of  cerebrospinal  fever  and  other  forms  of 
meningitis,  cerebral  syphilis,  general  paresis,  and  pachymeningitis  hsemor- 
rhagica. 

5.  Convulsions  are  very  often  of  reflex  origin.  Painful  affections  and 
excitation  in  the  region  of  a  sensory  nerve  may  produce  spasms.  Exam- 
ples of  reflex  convulsions  are  those  following  severe  injuries,  burns,  those 
associated  with  renal  or  intestinal  colic,  a  foreign  body  in  the  ear,  intestinal 
strangulation,  retention  of  urine,  and  phimosis.  Dentition  and  intestinal 
worms  are  less  common  causes  of  convulsions  than  is  generally  supposed. 
Indigestion  is  a  cause  of  convulsions  in  infants  and  older  children.  In 
whooping-cough  convulsions"  are  very  common.  They  result  from  the 
asphyxia  attendant  upon  a  prolonged  paroxysm,  cerebral  congestion,  or 
hemorrhage  resulting  from  such  a  paroxysm.  In  other  cases  they  are  to 
be  attributed  to  the  depressed  condition  of  the  nervous  system  caused  by 
the  disease  itself.  General  convulsions  have  been  attributed  to  enlarge- 
ment of  the  thymus  gland  as  a  result  of  pressure  either  upon  the  pneumo- 
gastric  or  upon  the  trachea.  They  frequently  occur  in  children  in  whom  no 
cause  can  be  discovered  and  may  in  such  cases  be  regarded  as  idiopathic.  In 
infants  in  whom  an  attack  of  convulsions  has  once  occurred  a  predisposition 
seems  to  be  established,  so  that  similar  attacks  occur  from  indifferent  or  not 
recognizable  causes.  In  infantile  convulsions  the  attack  is  commonly  pre- 
ceded by  restlessness,  fretfulness,  grinding  of  the  teeth,  and  slight  twitching. 
It  may  occur  suddenly  without  premonitory  symptoms.  The  initial  cry  so 
common  in  epilepsy  is  usually  absent,  nor  are  the  successive  stages  so  well 
defined.  The  spasm  begins  in  the  hands;  the  eyes  are  fixed  and  staring 
or  strongly  turned  upward;  the  body  rigid,  and  the  face  congested.  The 
convulsion  is  at  first  tonic,  so  that  respiration  is  suspended,  but  presently 
clonic  convulsions  set  in,  the  eyes  are  moved  from  side  to  side,  there  are 
violent  twitchings  or  alternate  flexions  and  extensions  of  the  limbs,  contor- 
tion of  the  face,  and  retraction  of  the  head.  There  is  spastic  flexion  of  the 
fingers,  the  thumb  being  against  the  palm — clenched  fingers.  These  move- 
ments gradually  cease  and  the  child  passes  into  a  condition  of  stupor. 
There  is  usually  slight  elevation  of  temperature.  Convulsions  arising  from 
indigestion  and  those  which  usher  in  an  infectious  disease  are  commonly 
single,  but  those  due  to  rickets  recur  in  series.  In  some  instances  one 
attack  succeeds  another  until  death  ensues. 

When  the  attack  occurs  in  a  healthy  child,  it  may  be  due  to  acute 
indigestion  or  some  form  of  peripheral  irritation;  when  accompanied  by 
high  fever  and  vomiting  it  may  be  the  forerunner  of  an  acute  infection,  as 
scarlet  fever,  or  of  infantile  hemiplegia;  when  it  occurs  in  badly  nourished 
or  rickety  children  it  is  apt  to  be  incomplete  and  to  recur.  The  convulsions 
of  infancy  do  not  of  necessity  run  on  into  epilepsy,  but  general  convulsions 
occurring  without  apparent  cause  at  irregular  intervals  in  young  children 
otherwise  healthy  are  in  a  limited  proportion  of  the  cases  epileptic  from  the 
beginning. 

Ursemic  convulsions  may  be  preceded  by  headache  and  restlessness. 
Sometimes  they  come  on  without  warning.     The  epileptic  cry  does  not 


SYMPTOMS  AND  SIGNS:   CONVULSIONS.  591 

occur,  but  in  other  respects  the  attack  may  resemble  true  epilepsy.  The 
convulsions  are  often  recurrent  and  prolonged,  the  seizures  being  separated 
by  periods  of  coma  or  deep  stupor.  The  temperature  is  usually  subnormal; 
exceptionally  it  is  elevated.  The  condition  is  recognized  by  the  characters 
of  the  urine,  the  presence  of  oedema,  the  condition  of  the  heart  and  arteries, 
a  urinous  odor,  and  the  history  of  the  case. 

Puerperal  convulsions  present  the  same  clinical  picture  as  those  which 
occur  in  ordinary  nephritis. 

Hysterical  convulsions  are  to  be  distinguished  from  epilepsy  by  the 
emotional  state  which  precedes  the  attack,  the  globus  hystericus,  the  diffi- 
cult respiration,  the  alternating  laughter  and  tears.  Sensations  may  be 
described  which  suggest  the  epileptic  aura,  as  precordial,  abdominal,  or 
pelvic  uneasiness  or  distress.  The  patient  does  not  fall  to  the  floor  in  instant 
and  complete  unconsciousness  as  in  epilepsy,  but  gently  or  by  preference 
upon  a  sofa  or  couch  in  such  a  way  as  to  do  herself  no  harm.  The  move- 
ments are  irregular  and  clonic  but  usually  much  less  violent  than  in  epi- 
lepsy. The  tongue  is  not  bitten.  The  attack  gradually  subsides  and  the 
patient  becomes  conscious  and  emotional  again.  At  the  close  of  the  attack 
a  large  amount  of  light-colored  urine  of  low  specific  gravity  is  often  voided. 
The  more  violent  convulsions,  manifestations  of  hystero-epilepsy,  include 
grinding  of  the  teeth,  tonic  spasm,  opisthotonus,  and  other  forced  attitudes, 
clonic  spasms,  and  more  or  less  profound  unconsciousness.  The  attack  is 
more  prolonged  than  in  epilepsy  and  is  followed  by  contortions  and  cata- 
leptic poses  and  in  some  instances  by  attitudinizing  suggestive  of  various 
passionate  states. 

In  tetanus  the  earliest  symptoms  are  slight  stiffness  of  the  neck  and 
some  embarrassment  in  mastication.  These  symptoms  gradually  increase 
until  the  condition  of  trismus  or  lockjaw  develops.  The  spasm  extends 
and  involves  the  muscles  of  the  body,  causing  the  rigid  attitudes  known  as 
opisthotonus,  orthotonus,  pleurotonus,  and  emprosthotonus.  Respiration 
is  interfered  with  by  the  muscular  spasm  and  asphyxia  may  threaten  from 
closure  of  the  glottis.  The  convulsive  paroxysms  are  excited  by  the  slight- 
est irritation  and  are  of  variable  duration.  Complete  relaxation  may  not 
occur  during  the  intervals.    There  is  usually  a  history  of  trauma. 

The  resemblance  of  strychnine  poisoning  to  tetanus  is  close.  Trismus 
is  absent  as  a  rule  and  the  relaxation  between  the  convulsive  paroxysms 
is  complete.     There  is  a  history  of  the  ingestion  of  the  poison. 

Tetany  is  characterized  by  the  peculiar  position  of  the  hands  and  feet, 
the  involvement  of  the  extremities,  less  often  the  face  and  neck,  and  the 
presence  of  Trousseau's  symptom — the  reproduction  of  the  paroxysm  by 
compression  of  the  affected  part  either  in  the  direction  of  the  principal 
nerve-trunks  or  over  the  blood-vessels;  or  of  Chvostek's  symptom — an 
increase  in  the  mechanical  irritability  of  the  motor  nerves,  a  slight  tap 
over  the  nerve-trunk  being  sufficient  to  throw  the  muscles  into  active  spasm. 
The  history  of  the  case  is  quite  different  from  that  of  both  tetanus  and 
strychnine  poisoning. 


592  MEDICAL  DIAGNOSIS. 

TREMOR. 

Tremor  is  a  rhythmical  to-and-fro  movement  of  limited  range  due  to 
the  alternate  contraction  and  relaxation  of  opposing  muscles.  The  move- 
ments are  involuntary  and  differ  from  fibrillation  in  that  they  cause  loco- 
motion of  the  parts  involved.  It  is  due  to  nutritive  alterations  in  the  motor 
neurons  both  of  the  cortex  and  spinal  cord.  A  distinction  is  made  between 
intention  or  volitional  tremor,  which  shows  itself  only  upon  intentional  move- 
ments, and  passive  tremor,  which  occurs  when  the  parts  are  at  rest.  The 
former  is  sometimes  spoken  of  as  paralytic;  the  latter  as  spastic  tremor. 
In  the  examination  the  patient  is  to  be  observed  at  rest,  in  intentional 
movement,  and  in  attitudes  which  require  sustained  tonic  contraction  of 
the  muscles,  as  horizontal  extension  of  the  arms  and  hands,  separation  of 
the  fingers,  or  protrusion  of  the  tongue. 

The  following  forms  of  tremor  are  of  diagnostic  importance: 

1.  The  Intention  Tremor  of  Multiple  Sclerosis. — This  form  of 
tremor  does  not  occur  during  rest,  but  shows  itself  upon  intentional  move- 
ment, usually  at  first  slight,  then  progressively  more  rapid  and  with  wider 
oscillations,  so  that  the  intended  movement  is  greatly  hindered.  The 
movements  in  some  cases  are  so  great  and  so  irregular  as  to  suggest  ataxia. 
The  rate  of  the  tremor  in  disseminated  sclerosis  is  given  by  Peterson  at 
7.9  to  8.1  per  second  for  the  earlier  stages  and  4.6  to  6.3  for  the  later  stages. 

2.  The  tremor  of  paralysis  agitans  is  distinctly  slower.  It  con- 
tinues during  rest,  becomes  less  marked  upon  movement,  and  upon  deter- 
mined impulse  of  the  will  may  disappear  for  a  brief  period.  The  rate  is 
from  3  to  6  per  second.  This  form  of  tremor  disappears  during  sleep.  It 
usually  first  appears  in  the  hands  and  is  characterized  by  rhythmical 
movements  of  the  index  finger  against  the  thumb  which  suggest  pill  rolling. 
The  tremor  of  paralysis  agitans  very  seldom  affects  the  head. 

3.  Senile  tremor  is  in  its  more  moderate  forms  an  intention  tremor; 
in  well  developed  forms  a  tremor  of  rest.  The  hands  and  arms  are  more 
commonly  involved,  but  the  head  is  often  affected  and  the  under  jaw  and 
lips.    The  rate  is  from  4  to  6  oscillations  per  second. 

4.  The  tremor  op  exophthalmic  goitre  is  best  manifested  in  the 
hands  when  extended  and  the  fingers  separated.  It  sometimes  affects  the 
head.  The  rate  is  rapid — 8  or  more  per  second — and  the  excursion  limited. 
Upon  intentional  movements  the  tremor  is  sometimes  increased.  This 
form  of  tremor  is  common  in  hysteria,  in  which,  however,  every  form 
may  be  encountered.  It  is  seen  also  in  tuberculous  meningitis,  in 
lesions  of  the  corpora  quadrigemina,  and  rarely  in  disease  of  the  cere- 
bellum. Similar  tremors  occur  in  the  acute  febrile  diseases.  The 
tremor  of  enteric  fever  is  an  example.  It  occurs  even  in  mild  cases  and  is 
most  noticeable  in  the  tongue  when  it  is  protruded  for  examination.  At 
first  fine,  it  becomes  coarser  as  the  exhaustion  increases.  The  lips  are 
affected  and  in  severe  cases  the  hands.  It  is  more  marked  in  persons  who 
are  addicted  to  alcohol.  Murchison  regarded  excessive  tremor  as  one  of 
the  signs  of  deep  ulceration  of  Peyer's  patches. 

5.  The  toxic  tremors  are  usually  fine.  They  are  intensified  upon 
intentional  movement.     The  more  common  causes  are  alcohol,  tobacco, 


SYMPTOMS  AND  SIGNS:   FIBRILLATION.  593 

morphine,  and  mercury.  In  alcoholic  tremor  first  the  hands  and  then  the 
lips  are  affected,  and  it  is  temporarily  intensified  upon  the  withdrawal  of 
alcohol  and  diminished  by  its  administration  in  increased  doses. 

6.  Tremor  due  to  miscellaneous  causes,  as  intense  emotion,  exces- 
sive or  prolonged  muscular  effort  and  extreme  cold  may  occur  in  healthy 
persons  and  is  without  diagnostic  importance.  Popular  phrases  are  trem- 
bling with  anger  ov  fear  or  cold,  and  buck  fever,  in  the  inexperienced  hunter. 

FIBRILLARY  TWITCHING  OR  FIBRILLATION. 

This  is  an  involuntary,  brief,  sluggish  contraction  of  groups  of  muscular 
fibres  rather  than  of  an  entire  muscle.  It  is  manifested  as  a  wave-like 
movement  of  feeble  intensity  just  under  the  skin,  not  involving  the  muscle 
as  a  whole  and  producing  no  movement  of  the  parts  to  which  the  muscle 
is  attached.  It  may  occur  in  a  limited  number  of  fibres  at  long  intervals, 
or  in  successive  groups  of  fibres  in  rapid  succession.  There  are  cases  in 
which  fibrillary  contractions  do  not  occur  spontaneously  but  can  be  excited 
by  tapping  the  skin  overlying  the  muscle  with  the  finger,  and  in  those  cases 
in  which  they  occur  infrequently  they  may  be  produced  in  the  intervals  by 
the  same  manoeuvre.  They  often  occur  in  healthy  persons  upon  exposure 
of  the  surface  of  the  body  to  cold  air.  Fibrillation  is  probably  caused  by 
a  lesion  which  at  once  weakens  and  irritates  the  cell-body  of  the  peripheral 
motor  neuron  in  the  anterior  horn  of  the  spinal  cord  (Lloyd).  It  is,  there- 
fore, symptomatic  of  progressive  degenerative  processes  involving  and  gradu- 
ally destroying  the  large  ganglionic  motor  cells,  and  occurs  in  paretic 
and  atrophic  muscles  when  those  changes  are  of  nuclear  origin.  This  phe- 
nomenon is  especially  seen  in  anterior  poliomyelitis  and  in  bulbar  paralysis. 
It  may  be  present  in  traumatic  neuroses  without  paresis  or  atrophy. 

Other  morbid  motor  phenomena  are  discussed  in  the  chapter  upon 
the  Examination  of  the  Nervous  System. 


XV. 

PSYCHICAL  CONDITIONS,  EMOTIONAL  STATES,  DERANGE- 
MENTS OF  CONSCIOUSNESS,  INSOMNIA  AND 
OTHER  DISORDERS  OF  SLEEP. 

PSYCHICAL  CONDITIONS. 

The  consideration  of  abnormal  mental  phenomena  comes  properly 
within  the  scope  of  psychiatry.  Mental  derangements  constitute  at  times, 
however,  important  symptoms  in  almost  every  department  of  internal 
medicine.  The  degree  of  intelhgence,  defects  of  memory,  emotional 
states,  and  irritative  and  depressive  derangements  of  consciousness  are 
to  be  considered.     Closely  allied  are  insomnia  and  other  disorders  of  sleep. 

Intelligence. — The  age,  education,  and  social  surroundings  of  the 
patient  are  to  be  considered.  Derangements  of  intelligence  are  frequently 
38 


594  MEDICAL  DIAGNOSIS. 

associated  with  impaired  consciousness  but  may  occur  independently  of  it. 
Both  vary  greatly  in  degree.  Slight  intellectual  defects  often  not  recognized 
in  the  ordinary  demeanor  and  conversation  of  the  patient  become  apparent 
upon  further  knowledge  or  upon  taking  a  careful  clinical  history.  The 
lower  grades,  designated  by  such  terms  as  dulness  and  stupidity,  or  an 
extreme  degree,  as  idiocy  and  demientia,  are  immediately  apparent  in  the 
facial  expression  and  behavior  of  the  individual.  Not  infrequently  a  fall- 
ing off  in  intelligence  is  manifest  in  persons  suffering  from  chronic  incurable 
affections,  as  valvular  disease  of  the  heart,  nephritis,  tuberculosis,  and  cancer. 
Not  only  is  the  nutrition  of  the  cerebral  cortex  impaired  but  the  patient's 
range  of  thought  becomes  progressivelj*  more  circumscribed.  His  interest 
in  general  affairs  or  the  particular  objects  of  his  previous  intellectual  activity 
diminish  in  proportion  as  his  interest  in  his  sj^mptoms  and  in  the  narrow 
life  of  the  sick-room  increase.  Graver  derangements  amounting  to  abso- 
lute indifference,  stupidity,  or  dementia  are  on  the  other  hand  observed 
in  cerebral  diseases,  especially  in  tumors  of  the  brain,  progressive  bulbar 
paralysis,  multiple  sclerosis,  hemorrhage,  thrombosis,  embolism,  and  soften- 
ing. In  other  cases  stupidity  or  dementia  may  be  the  expression  of  a 
developmental  anomaly  of  the  brain,  as  in  idiocy  and  cretinism.  Of  special 
interest  is  the  derangement  of  intelhgence  which  occurs  in  myxoedema, 
both  that  form  which  develops  spontaneously  and  in  the  cachexia  struma- 
priva.  In  this  condition,  w^hich  is  closely  allied  to  cretinism  or  indeed 
practically  identical  with  it,  the  derangements  of  intelligence  vary  in  degree 
from  moderate  apathy  and  indifference  with  slowness  of  thought  associated 
with  slowness  of  speech  to  a  state  bordering  upon  dementia.  A  transient 
abnormal  exaltation  in  mental  activity  with  a  rapid  flow  of  ideas  and  un- 
usual facility  of  expression  may  attend  hectic  fever,  the  action  of  alcohol, 
and  excitement  due  to  other  causes.  A  corresponding  depression  in  mental 
activity  is  observed  in  the  period  of  reaction.  The  patient  who  has  been 
restless  and  talkative  in  the  febrile  period  is  depressed  and  silent  during  the 
sweating  that  attends  the  defervescence;  the  exhilaration  of  alcohol  is 
followed  by  the  depression  of  a  physical  if  not  a  moral  remorse;  fervor  of 
speech  and  energetic  action  give  place  to  dulness  and  abstraction. 

Mental  dulness  or  confusion  occurs  independently  of  derangements  of 
consciousness.  Confusion  of  thought  attends  grave  neurasthenia,  cerebral 
tumor,  arteriocapillary  sclerosis,  old  age,  and  profound  malnutrition. 
Slowness  of  apprehension  and  unreadiness  in  expression  are  usually  char- 
acteristic of  defective  intelligence,  but  may  indicate  lesions  of  the  nervous 
mechanism  by  which  ideas  are  received  and  expressed,  as  in  forms  of  aphasia. 

Memory. — As  age  increases  the  memory  becomes  less  accurate  and 
retentive.  In  many  old  people  in  other  respects  in  good  health  and  intelli- 
gence failure  of  memory  becomes  pronounced.  At  earlier  periods  of  life 
the  integrity  of  the  memory  is  dependent  upon  the  same  conditions  of 
general  good  health  as  that  of  the  intelligence.  We  find  therefore  very  often 
impairment  or  loss  of  memory  in  local  lesions  of  the  brain  such  as  result 
from  hemorrhage  or  softening,  which  are  not,  however,  necessarily  asso- 
ciated with  enfeeblement  of  intelligence.  Weakness  of  memory  is  very 
often  observed  in  the  traumatic  neuroses — a  fact  demanding  attention 
since  frequently  this  condition  is  attributed  to  malingering.     Individuals 


SYMPTOMS  AND  SIGNS:   EMOTIONAL  STATES.  595 

.  recovered  from  severe  traumatic  neurasthenia  very  often  have  but  faint 
recollection  of  the  events  associated  with  and  following  the  injury.  Loss 
of  memory  occurs  in  epilepsy,  bromidism,  and  chronic  alcoholism,  is 
common  in  insanity,  and  often  complete  in  terminal  dementia. 

EMOTIONAL    STATES. 

Mental  depression  is  very  common  in  chronic  and  incurable  diseases. 
It  is  sometimes  purely  symptomatic.  More  commonly  it  arises  from  pain 
and  suffering  or  from  apprehension  in  regard  to  the  future.  A  high  grade 
of  depression  characterizes  hypochondriasis  and  melancholia.  In  deep 
jaundice,  especially  when  chronic,  depression  is  very  common.  Mental 
depression  frequently  attends  diseases  of  the  stomach,  particularly  those 
in  which  pain  is  prominent.  Periods  of  depression  occur  during  the  meno- 
pause and  in  pronounced  neurasthenia,  hysteria,  and  in  cerebral  disease. 

Emotional  exaltation  characterizes  acute  and  chronic  mania  and  is 
an  important  element  in  active  delirium.  During  anaesthesia  by  chloro- 
form, ether,  and  nitrous  oxide  the  early  derangement  of  consciousness  is 
manifest  by  emotional  excitement  which  is  often  intense.  A  similar  condi- 
tion is  characteristic  of  alcoholic  intoxication. 

Instability  of  temper,  irritability,  and  sensitiveness  are  very  common 
in  invalids.  The  testiness  and  outbursts  of  anger  which  occur  in  gout 
and  the  fretfulness  and  impatience  of  uterine  disease  are  well  known. 
Emotional  instabihty  and  similar  changes  in  disposition  are  frequently 
observed  in  pregnancy. 

DERANGEMENTS   OF   CONSCIOUSNESS. 

These  may  be  irritative  or  depressive.  Irritative  derangements  of 
consciousness  vary  in  degree  from  mild  emotional  excitement  to  furious 
homicidal  mania;  in  extent  from  perversion  in  a  limited  region  of  con- 
sciousness relating  to  a  single  idea  or  group  of  ideas  to  systematized  delu- 
sions influencing  the  whole  life  of  the  patient.  Irritative  frequently  alter- 
nate with  depressive  derangements  of  consciousness.  Delusions,  illusions, 
and  hallucinations  are  irritative  derangements  of  consciousness. 

A  delusion  is  an  unfounded  conviction  or  belief.  It  is  very  often  ab- 
surd or  ridiculous.  Delusions  that  are  persistent  and  based  upon  false 
ideas  having  a  logical  interdependence  or  sequence  are  known  as  organized. 
An  expansive  delusion  is  an  insane  behef  in  the  individual's  own  greatness, 
power,  or  goodness.  No  evidence  or  demonstration  is  sufficient  to  convince 
a  person  of  the  falsity  of  his  delusions.  Examples  of  delusions  that  are 
common  are  the  belief  that  individuals,  almost  always  unknown,  are  con- 
spiring to  do  the  patient  a  serious  harm,  or  that  the  patient  is  the  Christ 
or  Solomon  or  Queen  Victoria. 

An  illusion  is  a  false  or  misinterpreted  sensory  perception.  The  phe- 
nomena upon  which  it  is  based  actually  exist.  A  patient  who  mistakes  the 
nurse  for  an  officer  of  the  law,  or  a  bundle  of  rags  for  her  baby,  or  ordinary 
household  sounds  for  the  voice  of  God  is  the  subject  of  an  illusion.  Illu- 
siDns  are  very  often  transient  or  momentary. 


596  MEDICAL  DIAGNOSIS. 

An  hallucination  is  a  sense  perception  not  founded  on  objective  reality. 
Hallucinations  may  relate  to  any  of  the  senses.  The  patient  who  sees  the 
figures  of  bystanders  or  hears  whispering  voices,  or  perceives  a  disagreeable 
odor  or  unpleasant  taste,  or  feels  upon  his  shoulder  the  pressure  of  a  hand 
when  none  of  these  objects  exist,  suffers  from  an  hallucination.  Hallucina- 
tions are  frequently  persistent  and  distressing. 

The  Obsessions. — An  obsession  is  an  idea  which  dominates  conscious- 
ness often  to  the  exclusion  of  other  thoughts  and  ideas.  It  comes  unbidden 
and  cannot  be  dismissed  by  any  effort  of  the  will.  Nevertheless  its  nature 
and  unreasonableness  are  usually  fully  understood  by  the  subject. 

Obsessions  very  commonly  take  the  form  of  definite  systematized 
fears  relating  to  certain  objects  or  conditions.  These  constitute  the 
so-called  phobias,  as  kenophobia,  the  dread  of  large  or  open  spaces; 
claustrophobia,  the  fear  of  closed  or  narrow  spaces;  agoraphobia  {ayopd, 
a  market  place),  the  fear  of  a  crowd;  aichmo phobia,  the  fear  of  pointed 
instruments  or  weapons  or  the  dread  of  being  touched  by  anything; 
metallo phobia,  a  terror  of  touching  or  handling  a  metallic  object;  pyrho- 
phobia,  a  morbid  dread  of  fire;  and  many  other  forms  of  persistent  and 
dominating  fear. 

Doubt  constitutes  a  common  form  of  obsession.  The  mental  uncer- 
tainty may  be  restricted  to  a  single  subject  or  set  of  subjects  or  embrace 
almost  every  affair  of  life  from  the  simplest  to  the  most  important,  recur- 
ring with  intolerable  insistence  and  refusing  to  be  allayed  by  the  demon- 
stration of  the  actual  conditions  to  which  they  relate. 

Another  group  of  obsessions  consists  in  a  morbid  exaggeration  of  the 
activities  of  life.  Those  who  are  subject  to  them  are  possessed  of  a  demon 
of  unrest  and  are  irresistibly  impelled  to  be  continually  doing  something  or 
going  somewhere,  usually  aimlessly  and  without  fixed  purpose,  and  always 
ready  without  adequate  motive  to  change  from  one  occupation  to  another 
or  from  the  selected  course  to  a  different  pne. 

Closely  allied  to  this  group  of  obsessions  are  those  which  consist,  in  an 
irritable  impulse  to  touch  a  spot  or  an  object — folie  de  toucher — or  to  repeat 
certain  movements,  as  returning  to  pass  through  a  door  two  or  three  times 
before  departing  from  it,  and  the  like. 

Fixed  ideas  are  closely  allied  to  obsessions  and  the  terms  are  often  used 
interchangeably.  There  are  those,  however,  who  distinguish  between  these 
two  derangements  of  consciousness,  namely,  that  an  obsession  is  recog- 
nized by  the  patient  as  an  abnormal  train  of  ideas  without  basis  in  fact, 
while  the  subject  of  a  fixed  idea  is  convinced  that  it  is  based  upon  the 
conditions  as  they  exist  and  perfectly  normal  under  the  circumstances. 

The  foregoing  derangements  of  consciousness  are  permanent  symp- 
toms in  insanity.  They  occur  also  in  hysteria  and  neurasthenia  and  con- 
stitute important  elements  of  delirium. 

Delirium  is  an  irritative  derangement  of  consciousness  characterized 
by  restlessness,  excitement,  and  incoherence.  Periods  of  delirium  may 
alternate  with  somnolence,  stupor,  or  convulsions.  There  are  two  forms  of 
delirium.  In  the  active  or  maniacal  the  patient  is  wild  and  noisy.  He 
sings,  screams,  shouts,  tries  to  get  out  of  bed,  struggles  with  his  attendants, 
and  has  to  be  restrained  bv  force.     His  face  is  congested,  his  eyes  bright, 


SYMPTOMS  AND  SIGNS:   DELIRIUM.  597 

his  expression  alert,  excited,  even  fierce.  The  second  form  is  low  or  mutter- 
ing. The  patient  Hes  quiet,  murmuring  in  a  low  tone,  holding  incoherent 
and  often  whispered  conversation  with  imaginary  persons,  or  occupied  with 
vague  fancies  and  taking  no  notice  of  what  goes  on  around  him.  If  aroused 
he  may  give  a  rational  but  brief  reply  to  questions,  quickly  relapsing  into 
his  wandering  dreams.  This  form  of  delirium  is  sometimes  associated  with 
restlessness.  The  patient  moves  in  bed,  may  even  try  to  get  up,  but  is 
easily  restrained.  Between  these  two  there  are  transitional  forms  attended 
with  moderate  restlessness  and  excitement.  The  patients  are  irritable, 
disturbed  by  trifles,  and  at  times  incoherent,  though  not  boisterous. 

Delirium  develops  very  readily  in  persons  of  neurotic  temperament 
and  in  early  life.  It  may  occur  in  any  severe  illness.  It  is  especially  com- 
mon in  fever  and  usuaHy  indicates  a  grave  infection.  In  febrile  diseases 
children  are  more  Hable  to  dehrium  than  adults,  just  as  they  are  more 
liable  to  high  temperature.  In  general  terms,  there  is  no  constant  relation 
between  particular  diseases  and  forms  of  dehrium.  Active  dehrium  is, 
however,  frequently  associated  with  the  acute  infectious  fevers.  The 
delirium  of  pneumonia  is  sometimes  violent;  in  inflammatory  diseases  of 
the  brain  and  in  acute  mania  it  is  often  furious.  In  fevers  of  ordinary 
intensity  the  delirium  is  of  moderate  type.  It  is  muttering  or  wandering  m 
the  exhaustion  of  the  low  fevers  and  in  the  later  stages  of  other  acute  dis- 
eases. Delirium  may  be  present  in  uraemia  and  in  poisoning  by  belladonna, 
cannabis  indica,  hyoscyamus,  and  opium,  and  a  loud  and  boisterous  delirium 
quite  different  from  delirium  tremens  sometimes  occurs  in  acute  alcoholism. 
In  enteric  fever  the  headache  usually  ceases  as  delirium  develops. 

The  onset  of  dehrium  may  be  abrupt  or  gradual.  An  outbreak  of 
maniacal  delirium  has  in  rare  instances  been  the  first  manifestation  of  an 
acute  infectious  disease,  as  enteric  fever,  typhus,  or  pneumonia.  Cases  have 
occurred  in  which  under  these  circumstances  individuals  have  been  regarded 
as  insane  and  placed  in  an  asylum.  Much  more  commonly  dehrium  de- 
velops gradually,  showing  itself  first  in  a  certain  confusion  of  thought  upon 
awaking  from  sleep.  In  some  cases  delirium  is  absent  during  the  day, 
coming  on  again  and  increasing  as  night  approaches.  Mild  nocturnal 
delirium  is  sometimes  seen  during  convalescence  from  pneumonia,  enteric 
fever,  and  septic  conditions. 

The  delirium  of  inanition  occurs  in  wasting  diseases  and  in  starvation. 
It  is  not  very  rare  in  malignant  disease  of  the  oesophagus  or  stomach  and 
occurs  in  cases  characterized  by  intractable  vomiting.  The  delirium  of 
convalescence  is  probably  a  delirium  of  inanition.  In  this  form  of  dehrium 
the  outbreak  is  sudden,  usually  in  the  early  morning.  There  is  feebleness 
of  pulse  and  a  relaxed  and  sweating  skin  with  cold  hands  and  feet.  It  is 
very  often  of  brief  duration,  yielding  in  the  course  of  some  hours  or  a  day 
or  two  to  the  proper  administration  of  nourishment  and  stimulants.  Mani- 
acal delirium  not  uncommonly  follows  the  epileptic  paroxysm — postepileptic 
mania — or  may  develop  as  the  psychical  equivalent  of  the  paroxysm. 

The  delirium  of  alcohohsm — delirium  tremens — is  very  characteristic. 
It  is  almost  always  associated  with  hallucinations  which  take  the  form  of 
large  numbers  of  small  objects,  as  mice,  bugs,  serpents.,  which  continually 
approach  the  patient  and  inspire  abject  and  pitiable  terror,  or  there  are 
animals  running  around  his  bed  or  crawling  upon  the  walls.    The  delirium 


598  MEDICAL  DIAGNOSIS. 

is  busy.  The  patient  is  restless,  his  hands  are  constantly  moving,  he  tries 
to  get  out  of  bed,  but  is  usually  tractable.  Associated  symptoms  of  diag- 
nostic importance  are  tremor  and  sleeplessness,  which  are  almost  constantly 
present.  A  condition  not  unlike  delirium  tremens  may  develop  in  other 
drug  habits.  It  has  been  observed  after  prolonged  excesses  in  morphine, 
chloral,  and  paraldehyde. 

Carphologia,  literally  a  gathering  of  chaff,  the  picking  at  the  bed- 
clothes, seen  in  the  wandering  delirium  of  grave  fevers  and  profound 
exhaustion,  is  of  unfavorable  prognostic  significance.  The  patients  lie 
quiet,  wholly  oblivious  of  their  surroundings,  plucking  with  feeble  hands 
at  the  bed-covering  or  grasping  at  imaginary  objects  in  the  air.  These 
movements  are  dependent  upon  hallucinations. 

Delirium  is  sometimes  simulated  by  malingerers.  Feigned  delirium 
is  to  be  recognized  by  the  absence  of  other  signs  of  illness,  the  want  of  the 
characteristic  incoherence,  and  by  the  continuing  sameness  and  limited 
range  of  the  manifestations. 

Depressive  derangements  of  consciousness  vary  in  degree  from  simple 
clouding  of  the  ordinary  consciousness  to  complete  unconsciousness.  They 
affect  the  entire  field  of  consciousness.  Loss  of  consciousness  may  be  sud- 
den or  gradual,  and  is  a  symptom  of  great  diagnostic  importance. 

Somnolence  is  the  term  used  to  describe  the  mildest  degree.  The 
individual  is  dull,  drowsy,  and  indifferent,  but  retains  an  appreciation  of 
his  surroundings  and  can  respond  more  or  less  intelligently  when  addressed. 
Naturally  there  is  no  sharp  line  of  demarcation  between  this  and  the  fol- 
lowing progressive  conditions. 

Sopor,  literally  a  sound  or  deep  sleep,  constitutes  a  more  profound 
impairment  of  consciousness.  The  individual  lies  deeply  drowsy  and  indif- 
ferent to  his  surroundings  but  can  be  aroused.  To  questions  he  rephes  in 
monosyllables  and  when  aroused  can  move  himself  about  and  has  a  con- 
fused notion  of  his  surroundings.  Left  to  himself  he  sinks  again  into  an 
abnormal  drowsiness  attended  with  muttering  or  snoring. 

Stupor  is  partial  or  nearly  complete  un-consciousness.  The  patient 
cannot  be  aroused  except  with  difficulty  and  then  rephes  reluctantly  and 
briefly  to  questions,  relapsing  at  once  into  his  previous  condition.  The  ex- 
pression of  the  face  is  dull  and  "  stupid. "  He  is  still  capable  of  swallowing. 
Coma  is  complete  loss  of  consciousness.  The  patient  cannot  be  aroused 
from  his  insensibility.  Perception  and  vohtion  are  whohy  suspended. 
The  face  is  expressionless,  the  respiration  stertorous,  the  mouth  open,  the 
tongue  dry.  Swallowing  is  impossible,  the  sphincter  ani  is  relaxed,  there 
is  urinary  incontinence  or  retention.  The  breathing  is  frequently  irregular. 
It  may  be  irregularly  interrupted  or  show  the  Cheyne-Stokes  modification. 
Coma  vigil  is  a  condition  of  profound  unconsciousness  attended  by 
muttering  delirium  and  carphologia.  It  is  characteristic  of  this  condition 
that  the  eyes  are  open  and  appear  to  follow  the  movements  of  the  attend- 
ants.   The  prognosis  is  ominous. 

Syncope — a  swoon  or  fainting — is  a  sudden  loss  of  consciousness, 
usually  complete  and  transient,  associated  with  pallor,  coolness  of  the  skin, 
and  muscular  prostration.  It  is  a  manifestation  of  acute  anaemia  of  the 
brain  resulting  from  failure  of  the  heart's  action.  It  may  be  caused  in 
neurotic  persons  by  sudden  violent  depressing  emotions,  as  fear  or  horror, 


SYMPTOMS  AND  SIGNS:   COMA.  599 

or  follow  intense  or  prolonged  muscular  effort,  or  accompany  hemorrhage 
or  shock.  It  is  important  in  all  cases  to  make  the  differential  diagnosis 
between  suddenly  on-coming  coma  and  syncope. 

Lethargy  or  trance  is  a  condition  of  unconsciousness,  more  or  less 
complete,  which  occurs  in  hysteria.  It  has  been  observed  in  rare  instances 
after  excessive  mental  application  or  exhausting  disease  and  cases  have 
been  noted  in  which  it  has  occurred  in  individuals  otherwise  apparently 
in  good  health.  It  differs  from  coma  in  resembling  a  deep  and  protracted 
sleep  from  which  the  patient  in  some  instances  may  be  partially  aroused. 
The  patient  is  usually  pallid,  the  extremities  relaxed,  the  eyelids  closed, 
the  eyes  turned  upward  or  to  one  side.  The  pupils  vary  in  size  but  react 
to  light.  Respiration  and  circulation  are  greatly  enfeebled.  The  tem- 
perature is  subnormal.  The  attack  varies  in  duration  from  some  hours  to 
several  weeks.     Cataleptic  rigidity,  or  convulsions,  may  develop. 

Catalepsy  is  a  condition  of  impaired  consciousness  characterized  by 
rigidity  affecting  the  voluntary  muscles.  A  limb  or  the  body  of  the  patient 
may  be  maintained  continuously  for  some  time  in  the  same  posture.  The 
position  of  the  limb  may  be  passively  changed  with  slight  resistance, 
remaining  in  the  posture  in  which  it  has  been  placed.  This  condition  of 
increased  muscular  tonus  has  been  termed  "waxy  flexibility."  The  attack 
may  last  for  a  few  minutes  or  for  several  hours.  It  is  attended  with  com- 
plete anaesthesia  of  the  skin  and  deeper  tissues.  The  rhythm  of  the 
respiration  is  disturbed,  the  circulation  feeble,  the  surface  temperature 
depressed,  and  the  reflexes  impaired.  The  eyes  are  usually  open ;  the  pupils 
are  dilated  but  react  to  light.  The  attitudes  are  sometimes  bizarre  and 
grotesque.  As  the  attack  passes  away  the  power  of  muscular  movement 
is  fully  regained.  Catalepsy  is  a  rare  symptomatic  disorder.  It  is  encoun- 
tered in  hysteria,  occurs  in  hypnotic  states,  and  has  been  observed  in  cerebral 
disease,  as  tumor  and  meningitis,  and  in  forms  of  insanity,  as  melancholia. 

Coma  may  be  easily  recognized.  Its  diagnostic  significance  is  often 
obscure.  It  occurs  not  only  in  cerebral  disease  but  in  the  most  varied 
constitutional  conditions.     It  may  be  symptomatic  of  the  following: 

(a)  Organic  disease  of  the  brain,  either  general,  as  acute  encephalitis, 
cerebral  syphilis,  multiple  sclerosis,  and  general  paresis;  focal,  as  intra- 
cranial hemorrhage,  embolism,  thrombosis  or  softening,  tumor,  abscess 
and  thrombosis  of  the  cerebral  sinuses;  disease  of  the  meninges,  as  inflam- 
mation, the  pressure  from  exudate,  and  subdural  hemorrhage  or  tumor; 
or,  finally,  it  may  occur  in  the  course  of  disease  of  the  cranial  bones,  (b) 
Traumatism  of  the  head,  producing  cerebral  commotion  or  compression, 
(c)  The  pre-agonistic  state  in  all  diseases  terminating  fatally,  (d)  The  fully 
developed  febrile  infectious  diseases.  Only  exceptionally  is  coma  under 
these  circumstances  complete.  Early  and  complete  coma  occurs  in  the 
malignant  forms,  (e)  Uraemia,  in  which  it  commonly  alternates  with  con- 
vulsions, (f)  The  last  stage  of  diabetes,  (g)  Forms  of  auto-intoxication 
analogous  to  diabetic  coma  in  which  /?-oxybutyric  acid  or  its  derivatives  arc 
present  in  the  blood,  (h)  Rare  cases  of  septicaemia,  pyaemia,  carcinoma,  and 
acute  yellow  atrophy  of  the  liver,  (i)  Narcotic  poisoning,  especially  by  alco- 
hol, morphine,  chloral,  and  various  poisonous  gases,  and  the  surgical  anaes- 
thesia produced  by  the  administration  of  ether,  chloroform,  nitrous  oxide, 
etc.      (j)  General  convulsions,  infantile  eclampsia,  and  the  epileptic  par- 


600  MEDICAL  DIAGNOSIS. 

oxysm.  (k)  Drowning  and  asphyxia  from  other  causes.  (1)  Sunstroke  and 
similar  conditions  produced  by  exposure  to  excessive  heat,     (m)  Hysteria. 

The  Associated  Phenomena  in  Different  Morbid  States  Characterized  by 
Coma. — The  diagnosis  of  the  underlying  condition  is  always  important, 
often  difficult,  sometimes  impossible.  When  the  previous  history  can  be 
obtained  from  the  patient's  friends  the  diagnosis  is  simplified.  A  child  is 
seized  with  convulsions  and  vomiting  and  falls  presently  into  coma.  The 
fact  that  other  children  in  the  family  suffer  from  scarlet  fever  justifies  a 
provisional  diagnosis  of  malignant  scarlet  fever.  A  man  in  middle  life 
complains  of  headache  and  becomes  comatose,  with  twitching  of  the  face 
and  general  convulsions.  Information  to  the  effect  that  he  has  had  poly- 
uria with  low  specific  gravity,  small  amounts  of  albumin,  and  casts,  war- 
rants a  diagnosis  of  uraemia.  A  girl  is  found  unconscious,  pallid,  with 
irregular  respiration  and  occasional  twitching  of  the  face  or  extremities. 
It  is  of  diagnostic  importance  to  learn  that  she  has  been  a  highly  nervous 
person  who  has  just  passed  through  some  emotional  stress  and  that  the 
coma  was  preceded  by  tears  and  outbreaks  of  laughter — phenomena, 
characteristic  of  hysteria. 

The  anamnesis  is  not  always  conclusive.  It  frequently  happens  that 
a  patient  suffering  from  chronic  nephritis  becomes  comatose  from  cerebral 
hemorrhage  and  that  a  man  who  has  been  drinking  falls  into  a  coma  not 
the  manifestation  of  alcoholic  intoxication  but  of  fracture  of  the  skull.. 
The  causal  diagnosis  of  coma  is  attended  with  increased  difficulty  in  am- 
bulance cases  and  patients  concerning  whom  no  history  can  be  obtained^ 
seen  for  the  first  time  in  a  comatose  condition. 

Cerebral  Disease. — Coma  occurring  in  the  course  of  organic  disease 
of  the  brain  is  usually  preceded  by  such  general  symptoms  as  headache,, 
vomiting,  delirium,  and  somnolence,  with  varied  local  symptoms  which 
depend  upon  the  position  and  extent  of  the  lesions  and  may  be  either 
irritative  or  paralytic. 

Apoplexy — the  Apoplectic  Insult. — Premonitory  symptoms  are 
rare.  Headache,  ocular  derangements,  and  paraesthesia  of  the  extremi- 
ties may  occur  but  are  not  characteristic.  The  coma  usually  is  sudden 
and  complete  and  the  condition  is  popularly  spoken  of  as  a  ''stroke." 
In  other  cases  the  coma  develops  gradually — ingravescent  apoplexy. 

Traumatism  of  the  Head. — The  history  of  an  accident  or  injury  is 
important.  A  careful  examination  should  be  made  for  contusion,  lacera- 
tion, or  depression  of  the  skull.  If  necessary  the  head  should  be  shaved. 
Bleeding  from  one  or  both  ears  may  occur  in  fracture  of  the  base  of  the  skulL 

Infectious  Diseases. — The  antecedent  conditions  leading  up  to  the 
coma  are  usually  known.  Coma  under  these  circumstances  may  be  a 
manifestation  of  the  intensity  of  the  primary  infection  or  of  some  second- 
ary process.  Occasionally  in  grave  enteric  fever,  very  commonly  in  severe 
typhus  and  cerebrospinal  fever,  coma  develops  in  the  course  of  the  disease 
and  is  not  necessarily  the  sign  of  impending  dissolution.  Coma  may  occur 
under  similar  circumstances  from  an  intercurrent  nephritis  with  uraemia  or 
from  intercurrent  cerebral  hemorrhage,  sinus  thrombosis,  or  in  the  rheu- 
matic fever  attended  with  endocarditis  from  embolism.  Coma  occurs 
early  in,  or  may  even  mark  the  onset  of,  the  malignant  forms  of  the  infec- 
tious diseases,  particularly  scarlet,  enteric,  and  cerebrospinal  fever  and  the 


SYMPTOMS  AND  SIGNS:   COMA.  601 

pernicious  forms  of  malarial  infection.  In  the  last  there  is  the  history 
of  exposure  in  intensely  malarial  localities  and  of  one  or  two  recent  well 
characterized  paroxysms  of  ague. 

Uremia. — Ursemic  coma  may  occur  in  acute  or  chronic  nephritis. 

Diabetes. — In  saccharine  diabetes  coma  very  often  attends  the  ter- 
minal condition,  particularly  in  the  young.  Three  forms  of  diabetic  coma 
are  recognized:  (a)  The  patient  after  exertion  is  seized  with  sudden  weak- 
ness, syncope,  and  somnolence  which  gradually  deepens  to  coma  and  is 
followed  in  a  few  hours  by  death,  (b)  The  early  symptoms  are  due  to  pul- 
monary or  gastric  derangement  or  there  may  be  some  local  affection,  as 
pharyngitis,  phlegmon,  or  carbuncle.  The  attack  begins  with  nausea  and 
vomiting.  The  breath  has  the  peculiar  sweetish,  fruity  odor  of  acetone. 
The  onset  of  coma  is  gradual.  Death  occurs  in  the  course  of  one  to  five  days. 
(c)  The  patient  without  special  previous  symptoms  is  suddenly  seized 
with  violent  headache  and  the  sensation  of  profound  illness  and  rapidly 
falls  into  deep  and  fatal  coma.  There  are  cases  of  diabetes  in  which  the 
coma  is  due  to  some  accidental  cause,  as  uraemia,  apoplexy,  or  meningitis. 

Narcotic  Poisoning. — In  coma  from  opium  and  its  derivatives  the 
face  is  pallid,  dusky,  and  slightly  cyanotic,  respirations  and  pulse  slow^ 
pupils  equal  and  contracted,  skin  natural,  and  temperature  normal. 

In  alcoholic  coma  the  face  is  commonly  flushed,  sometimes  pallid,, 
occasionally  cyanotic.  The  respirations  are  usually  normal  in  depth  and 
frequency.  They  are  sometimes  stertorous.  The  odor  of  the  breath  is 
characteristic,  the  pulse  is  at  first  frequent  and  full,  later  small  and  feeble. 
The  pupils  are  equal,  sometimes  normal,  more  frequently  dilated.  The 
skin  is  usually  cool  and  moist  and  the  surface  temperature  lowered,  espe- 
cially under  circumstances  of  exposure  to  cold  or  damp,  when  heat  dissipa- 
tion is  favored.    Convulsions  are  not  common. 

Poisonous  Gases. — Coma  develops  under  circumstances  that  make 
the  diagnosis  clear.  It  may  result  from  the  inhalation  of  carbon  dioxide, 
as  in  disused  wells,  and  carbon  monoxide — illuminating  gas,  charcoal  fire — 
a  very  common  cause  of  accidental  death  and  suicide.  There  can  be  no 
question  about  the  coma  of  surgical  anaesthesia.  During  this  state  various 
accidents  may  occur.  Asphyxia  has  resulted  from  the  falling  back  of  the 
base  of  the  tongue  and  from  pulmonary  oedema.  Progressively  deepening 
coma  may  terminate  in  death  from  failure  of  the  cardiac  or  respiratory 
centres,  and  apoplexy  may  occur. 

Convulsions. — Coma  is  very  often  preceded  by  general  convulsions 
or  alternates  with  them.  It  is  frequently  preceded  by  convulsions  in  the 
malignant  forms  of  the  infectious  diseases,  especially  in  children,  and 
sometimes  in  dentition  and  the  digestive  disorders  in  young  infants — 
infantile  eclampsia.  It  follows  the  general  convulsions  of  epilepsy.  Coma 
and  convulsions  may  alternate  in  cerebral  syphilis,  general  paresis,  and 
some  forms  of  alcoholism.  The  alternation  of  coma  and  convulsions  is 
characteristic  of  uraemia. 

The  coma  of  sunstroke  is  very  often  preceded  by  convulsions.  The 
skin  is  excessively  hot  and  dry,  the  face  flushed,  the  respiration  labored, 
the  pulse  frequent  and  full.  The  temperature  ranges  extremely  high  and 
may  become  that  of  hyperpyrexia.  Upon  venesection  the  blood  is  dark, 
thick,  and  flows  slowly  from  the  vein.    The  diagnosis  is  usually  easy. 


602  MEDICAL  DIAGNOSIS. 

Epilepsy. — The  diagnosis  of  postepileptic  coma  rests  upon  the  history 
of  the  case,  the  convulsive  seizure,  the  bitten  tongue,  the  foam  upon  the 
lips,  and  the  sudden  profound  loss  of  consciousness  of  no  very  long  dura- 
tion. The  congestion  of  the  face,  stertorous  breathing,  urinary  incon- 
tinence, and  general  muscular  relaxation  may  suggest  apoplexy,  but  the 
signs  of  hemiplegia  are  lacking. 

Hysteria. — The  unconsciousness  of  hysteria  is  commonly  incomplete 
— lethargy  or  its  intensification,  trance.  Its  duration  may  extend  over 
several  days  or  weeks.  True  hysterical  coma  which  is  a  further  intensifica- 
tion of  the  foregoing  is  very  rare.  A  condition  of  impaired  consciousness 
suggestive  of  coma  not  infrequently  enters  into  the  symptom-complex  in 
the  grand  attack  of  hysteria.  It  is  usually  preceded  by  the  ordinary 
phenomena  of  the  hysterical  paroxysm:  laughing,  crying,  convulsions, 
extravagant  muscular  movements,  and  the  like. 

For  practical  purposes  the  differential  diagnosis  between  the  coma 
resulting  from  opium,  traumatism,  alcohol,  apoplexy,  and  uraemia  is  of 
imperative  importance.  Only  in  a  correct  diagnosis  are  to  be  found  the 
indications  for  treatment.  These  are  often  immediate  and  urgent.  Further- 
more the  diagnosis  may  have  to  do  with  questions  of  medico-legal  interest. 
Definite  diagnostic  phenomena  are  to  be  systematically  sought  for. 

Such  points  in  the  anamnesis  as  are  available  are  to  be  obtained  from 
the  patient's  friends  or  the  bystanders.  The  immediate  investigation  de- 
mands an  examination  of  the  scalp  and  head  for  evidences  of  traumatism; 
of  the  eyes  with  reference  to  pupillary  conditions  and  reactions,  strabismus, 
and  conjugate  deviation;  the  face  for  blood  extravasations,  flushing, 
pallor,  cyanosis,  oedema,  puffing  of  the  cheeks,  the  presence  of  foam  upon 
the  lips,  a  bitten  tongue,  relaxation  of  the  jaw,  the  odor  of  the  breath, 
and  the  presence  upon  the  lips  or  face  of  the  stains  of  corrosive  or  other 
poisons.  The  character  of  the  respiration  is  to  be  studied,  the  frequency, 
volume,  and  tension  of  the  pulse,  the  sounds  of  the  heart.  The  occurrence 
of  fecal  or  urinary  incontinence  is  to  be  noted,  catheterization  should  be 
performed,  and  the  urine  examined  for  the  presence  of  albumin,  blood, 
sugar,  acetone,  etc.  The  signs  of  hemiplegia  are  to  be  sought  in  the  posi- 
tion of  the  head  and  eyes — conjugate  deviation — in  the  greater  relaxation 
of  the  mouth  and  cheek  upon  one  side  and  the  complete  loss  of  muscular 
tonus  in  the  arm  and  leg.  The  temperature  must  be  taken  in  the  axilla, 
and  if  found  to  be  very  low,  in  the  rectum  also.  The  signs  of  antecedent 
disease,  general  anasarca,  great  emaciation,  various  specific  and  other 
eruptions  and  scars,  and  the  general  condition  of  the  viscera  as  determined 
by  the  methods  of  physical  examination,  such  as  the  presence  of  effusions 
in  the  serous  sacs,  great  enlargement  of  the  liver  or  spleen,  and  the  like,  are 
to  be  in  turn  rapidly  investigated.  The  stomach  pump  is  often  necessary 
for  the  diagnosis.  If  the  conditions  suggest  the  possibility  of  pernicious 
malarial  fever  an  examination  of  the  blood  should  be  made  for  Laveran's 
bodies. 

Not  every  case  demands  such  comprehensive  and  elaborate  investi- 
gation. Very  often  the  condition  underlying  the  coma  is  obvious  at  a 
glance.  In  other  cases  it  is  speedily  revealed.  Once  in  a  while  the  true 
condition  is  not  discovered  without  careful  and  prolonged  study,  and  there 
are  obscure  cases  which  tax  the  resources  of  clinical  medicine. 


SYMPTOMS  AND  SIGNS:   INSOMNIA.  603 

INSOMNIA  AND  OTHER  DISORDERS  OF  SLEEP. 

Insomnia — Abnormal  Wakefulness. — These  terms  are  used  to  desig- 
nate a  disturbance  of  the  nervous  system  characterized  by  habitual  incom- 
plete sleep  or  periods  of  entire  absence  of  normal  sleep.  Sleep  varies  with  age, 
sex,  and  individual  peculiarity.  In  very  young  babies  sleep  is  practically 
continuous;  a  healthy  child  two  years  old  passes  half  its  time  in  slumber; 
the  adult  requires  from  seven  to  eight  hours  out  of  twenty-four;  and  aged 
persons  not  more  than  five  or  six  hours.  Women  need  more  sleep  than 
men.  Workers  in  the  open  air  require  longer  hours  of  sleep  than  those  of 
sedentary  habits.  Insomnia  may  be  functional  or  symptomatic.  Func- 
tional insomnia  occurs  in  neurotic  individuals  and  over-taxed  brain  workers. 
Symptomatic  insomnia  is  an  important  element  in  the  symptom-complex 
of  a  great  variety  of  morbid  conditions.  It  occurs  in  painful  diseases,  as 
cancer,  aneurism,  and  the  intractable  neuralgias.  It  is  common  in  acro- 
megaly. Insomnia  is  a  very  troublesome  symptom  in  neurasthenia  and 
various  forms  of  insanity.  It  is  an  important  element  in  acute  delirium. 
Advanced  disease  of  the  heart  is  very  often  attended  by  sleeplessness  due 
in  part  to  cerebral  anaemia,  in  part  to  the  condition  of  the  blood,  but 
chiefly  to  the  inability  of  the  patient  to  lie  down.  As  the  condition  pro- 
gresses wakefulness  gives  way  to  somnolence  and  stupor.  Tea  and  coffee 
have  in  many  persons  the  power  of  inhibiting  sleep.  Complete  insomnia 
is  a  conspicuous  phenomenon  in  delirium  tremens  and  alcoholic  mania. 
Insomnia  occurs  with  some  degree  of  frequency  also  in  the  early  stage  of 
enteric  fever,  influenza,  and  croupous  pneumonia.  It  is  met  with  in  cases 
of  malaria  and  is  a  troublesome  symptom  in  trichiniasis.  It  is  not  un- 
common during  the  convalescence  from  acute  disease.  Insomnia  may 
take  the  form  of  troubled  and  unrefreshing  sleep  of  short  duration  or 
broken  by  intervals  of  distressing  wakefulness,  or  sleep  may  be  absent  for 
days  together.  The  patient  may  fall  asleep  upon  going  to  bed  but  awakes 
in  the  course  of  two  or  three  hours  and  lies  absolutely  awake  or  lightly 
dozes  until  morning.  There  is  often  great  and  irregular  mental  activity, 
especially  in  neurasthenia,  and  the  cares,  anxieties,  and  worries  of  the  day 
are  rehearsed  with  torturing  iteration.  Such  insomnia  is  associated  with 
restlessness,  which  is  also  present  in  the  insomnia  of  insanity.  Insomnia 
is  rare  in  children  but  when  present  significant  of  profound  disturbance  of 
the  nervous  system.  The  sleeplessness  of  the  aged  is  usually  tranquil  and 
unaccompanied  by  excitement  or  irritability. 

Dreams  usually  have  their  starting-point  in  some  sensory  impression 
arising  from  local  causes,  as  an  uncomfortable  posture,  a  sound  which  is 
perceived  but  which  does  not  arouse,  an  over  loaded  stomach,  a  distended 
bladder  or  rectum,  or  a  condition  which  interferes  with  the  action  of  the 
heart  and  lungs.  Nightmare  is  a  frightful  dream  accompanied  by  sensa- 
tions of  oppressive  weight  upon  the  chest,  intense  fear,  horror,  or  anxiety, 
and  inability  to  move  or  cry  out.  The  attack  ends  in  a  groan  and  the 
recovery  of  consciousness.     It  is  mostly  symptomatic  of  indigestion. 

Night  Terrors — Payor  Nocturnus. — This  condition,  which  presents 
points  of  resemblance  to  nightmare  and  somnambulism,  is  a  paroxysmal 
disturbance  of  sleep  in  young  children.      It  differs  from  nightmare  in  the 


604  MEDICAL  DIAGNOSIS. 

gradual  subsidence  of  the  attack  and  the  persistence  of  terror  and  distress 
after  waking.  It  differs  from  somnambulism  in  the  gradual  waking,  the  less 
complete  automatism,  and  the  terror.  The  child  starts  up  in  bed  screaming 
with  fear  and  seeks  protection,  trembling  and  sobbing.  The  dream  images 
are  often  indefinite,  sometimes  the  creatures  of  imagination,  suggested  by 
the  tales  of  the  nursery.  Night  terrors  occur  commonly  in  neurotic  and 
badly  nourished  children.  They  are  sometimes  symptomatic  of  eye-strain, 
the  cutting  of  the  second  teeth,  intestinal  parasites,  or  indigestion. 

Sleep  drunkenness  is  a  rare  condition  resembling  maniacal  delirium 
which  appears  upon  waking  from  profound  sleep.  There  are  delusions  of 
immediate  danger  to  life  or  liberty.  The  sufferer  fails  to  recognize  his 
surroundings.  He  is  excited,  incoherent,  and  boisterous.  The  attack  is 
usually  of  short  duration. 

Somnambulism — sleep=walking — is  a  disorder  of  sleep  in  which  con- 
sciousness and  volition  are  suspended  but  the  activity  of  certain  nerve- 
centres  is  exerted  and  coordinated  movements  are  automatically  per- 
formed. It  occurs  in  adolescents  and  young  adults  of  neurotic  tempera- 
ment and  is  more  common  in  females.  It  is  due  to  causes  which  ordinarily 
give  rise  to  dreams,  including  indigestion,  faulty  attitude  during  sleep, 
intense  excitement,  or  violent  distressing  emotion  during  the  period  preced- 
ing sleep.  The  attacks  are  frequently  recurrent  and  may  become  habitual. 
They  are  of  brief  duration  but  may  continue  an  hour  or  two,  during  which 
time  difficult  and  compHcated  actions  are  performed,  apparently  with 
conscious  intention.  The  eyes  are  closed  or,  if  open,  are  staring  and  fixed. 
There  is  complete  indifference  to  sound  and  the  expression  is  blank  and 
impassive.     The  patient  on  waking  has  no  recollection  of  his  wanderings. 

Morbid  Sleep. — Drowsiness  may  be  symptomatic  of  cerebral  malnutri- 
tion or  toxaemia.  It  is  common  in  aged  persons  with  feeble  heart  and  dis- 
eased blood-vessels,  in  the  obese,  and  in  malaria,  anaemia,  and  diabetes.  It 
is  caused  by  the  impure  air  of  crowded  assemblies.  Cases  have  been 
reported  in  which  prolonged  deep  sleep  has  ceased  after  the  discharge  of 
lumbricoid  worms.  Morbid  sleep  is  a  symptom  by  no  means  uncommon  in 
organic  cerebral  disease,  as  syphihs,  tumor,  and  arteriosclerosis.  It  is 
common  in  insanity,  both  in  the  prodromal  period  and  the  developed  state. 

Narcolepsy  is  abnormal  deep  sleep  occurring  in  spells  which  may  be 
of  short  duration  or  prolonged  and  continuous.  The  cause  is  unknown.  In 
some  instances  the  sleep  has  progressively  advanced  to  deep  and  fatal  coma. 

Waking  numbness — sleep  palsy. — This  is  a  form  of  paraesthesia  occur- 
ring upon  waking.  There  is  a  sensation  of  numbness  and  tingling.  The  dis- 
tribution involves  one  or  more  extremities,  usually  the  hands  and  arms.  It 
is  commonly  of  brief  duration,  disappearing  in  an  hour  or  two.  It  resembles 
the  forms  of  paraesthesia  which  occur  about  the  grand  climacteric. 

Paroxysmal  disturbances  of  the  nervous  system,  both  physiological 
and  pathological,  are  common  during  sleep.  Seminal  emissions,  the  vene- 
real orgasm,  and  urinary  incontinence  are  accidents  of  sleep.  Epileptic 
seizures — nocturnal  epilepsy — are  not  uncommon,  and  the  paroxysms  of 
asthma  and  migraine  frequently  come  on  in  sleep. 


PART   IV. 

OF  THE   CLINICAL   APPLICATIONS. 


I. 
DIAGNOSIS  OF  THE  SPECIFIC  INFECTIONS. 

I.  ENTERIC  OR  TYPHOID  FEVER. 

Definition.  —  An  acute  general  infection  caused  by  the  Bacillus 
typhosus,  characterized  clinically  by  fever  of  prolonged  duration,  a 
scanty  rose-colored,  maculopapular  eruption,  enlargement  of  the  spleen, 
abdominal  tenderness,  diarrhoea  and  tympanites,  profound  asthenia,  and 
rapid  wasting;  anatomically  by  hyperplasia  and  ulceration  of  the  lymph 
follicles  of  the  intestines,  enlargement  of  the  mesenteric  glands,  and  diffuse 
parenchymatous  changes  in  the  viscera. 

Etiology.  —  Predisposing  Influences.  —  Enteric  fever  is  the  prevalent 
febrile  infection  of  the  present  historical  epoch,  just  as  typhus  was  that  of 
the  three  hundred  years  preceding  the  beginning  of  the  nineteenth  century 
and  the  plague  that  of  the  Middle  Ages.  It  owes  its  present  wide  distribution 
and  great  prevalence  to  faulty  disposal  of  sewage  and  neglect  of  the  simplest 
sanitary  laws.  Defective  drainage  and  contaminated  water  and  milk  con- 
stitute the  means  by  which  the  specific  infecting  organisms  are  distributed. 
Climate. — Enteric  fever  prevails  in  all  parts  of  the  world  but  is  especially 
common  in  temperate  climates.  Season. — It  is  most  common  in  the 
autumn  months  but  occurs  at  all  seasons  of  the  year.  Of  personal  causes: 
Sex. — Males  and  females  are  equally  liable  to  the  disease.  The  mode  of 
life  of  the  individual  exposes  males  to  the  infection  to  a  greater  extent 
than  females.  In  early  childhood  the  sexes  suffer  alike;  in  late  childhood 
and  adolescence,  boys  more  than  girls.  More  men  than  women  are  admitted 
to  hospitals.  The  conditions  of  camp  life  in  military  campaigns  especially 
favor  the  spread  of  the  infection.  In  the  Spanish-American  and  South 
African  wars  enteric  fever  prevailed  most  disastrously.  Age.  —  Enteric 
fever  is  especially  a  disease  of  youth  and  early  adult  life.  The  period  of 
greatest  liability  is  from  the  fifteenth  to  the  twenty-fifth  year.  Expos- 
ure and  immunity  are  to  be  considered  in  this  connection.  Exposure 
to  the  infection  is  probably  greater  after  adolescence  and  the  immu- 
nity acquired  by  the  attack  more  general  after  the  twenty-fifth  year. 
Cases  occasionally  occur  after  sixty.  Occupation  and  Social  State. — 
These  conditions  are  without  predisposing  influence.  Immunity. — Not  all 
who  are  exposed  contract  the  disease.  An  unrecognized  or  forgotten 
attack  in  childhood  may  have  conferred  immunity.  There  are  families 
which  show  in  successive  generations  an  especial  susceptibilit3^  The  im- 
munity acquired  by  the  attack  is  usually  life-long.     Second  attacks  have 

605 


606 


MEDICAL  DIAGNOSIS. 


Fig.  206. — Bacillus  typhosus. 


occurred  in  the  course  of  several  months  or  years  and  three  attacks  in 
the  same  person  have  been  noted  by  competent  observers. 

The  Exciting  Cause. — Bacillus  Typhosus. — This  organism,  the  ba- 
cillus of  Eberth,  is  constantly  present  in  enteric  fever.  It  is  a  short, 
thick,  flagellate,  motile  bacillus  with  rounded  ends,  growing  readily  on 
various  culture  media.  It  can  now  be  differentiated  from  certain  other 
bacteria,  to  which  it  bears  a  close  morphological  resemblance,  especially 
the  BL,cillus  coli  communis,  with  which  it  is  liable  to  be  confounded.  These 
organisms   colonize  with   preference  in  the   lymphoid   tissues.     They  are 

distributed  in  recent  infection  in  the 
solitary  follicles  and  Peyer's  patches 
of  the  intestines,  in  the  mesenteric 
glands,  spleen,  bone-marrow,  liver,  and 
in  the  bile.  They  have  been  isolated 
from  foci  of  suppuration  in  various 
parts  of  the  body,  from  meningeal  and 
pleural  exudates  and  vegetations  upon 
the  endocardium.  Their  presence  in 
the  blood  and  rose  spots  may  be 
demonstrated.  In  the  course  of  the 
second  week  and  afterwards  they  have 
been  isolated  by  culture  methods  from 
the  stools.  They  are  met  with  in  the 
urine  and  sputum  and  have  in  a  few 
instances  been  found  in  the  sweat. 
Outside  the  body  typhoid  bacilli  retain  their  vitality  in  water,  snow, 
ice,  the  superficial  layers  of  the  soil,  dust,  and  in  faeces  for  periods  varying 
according  to  circumstances  from  several  days  to  many  months.  In  milk 
they  undergo  rapid  growth  without  changing  its  appearance.  They  retain 
their  vitality  for  three  months  in  sour  milk  and  for  shorter  periods  in  butter 
made  from  infected  cream. 

The  above  facts  are  of  great  use  in  the  etiological  diagnosis  of  enteric 
fever,  especially  when  the  disease  occurs  in  local  outbreaks.  It  is  most 
important  in  this  connection  that  the  infecting  principle  is  discharged 
from  the  body  of  the  patient  in  the  urine  and  especially  in  the  faeces. 
Its  conveyance  by  means  of  water,  milk,  or  other  articles  of  food  contam- 
inated by  such  discharges  in  consequence  of  faulty  sanitation  is  the 
source  of  the  sporadic,  endemic,  and  epidemic  prevalence  of  the  disease. 
It  may  be  stated  positively  that  enteric  fever  is  not  contagious  in  the 
ordinary  sense,  i.e.,  transmissible  from  the  sick  to  others  by  contact  or  by 
the  exhalations  from  the  body,  when  the  introduction  of  bacilli-containing 
dejecta  or  secretions  does  not  take  place. 

Infected  water  is  the  ordinary  means  of  transmission.  By  means  of 
such  water  the  infection  of  milk,  uncooked  vegetables,  salads,  oysters,  and 
clams  occurs.  It  has  recently  been  shown  that  lobsters  also  may  become 
infected  when  kept  in  cages  in  sewage-contaminated  water  awaiting  a 
market.  Natural  ice  and  vegetables  grown  upon  soil  fertilized  by  sewage, 
eaten  raw,  may  convey  the  germs.  Flies  and  atmospheric  dust  play  an 
important  part  in  the  dissemination  of  the  disease.    The  open  latrines  on 


ENTERIC  OR  TYPHOID  FEVER.  607 

the  one  hand  and  the  unscreened  mess  table  on  the  other  were  largely 
responsible  for  the  terrible  epidemics  among  our  recruits  in  the  practice 
camps  at  the  time  of  the  Spanish-American  War. 

When  the  bacilli  find  their  way  into  the  intestinal  tract  the  evolution 
of  the  disease  is  as  follows:  Being  resistant  to  dilute  acids  they  are  by  no 
means  wholly  destroyed  by  the  hydrochloric  acid  of  the  gastric  secretion. 
If  acid  be  absent  or  the  water  or  other  fluid  containing  them  be  ingested 
when  hydrochloric  acid  is  not  secreted  they  pass  into  the  intestine  and 
colonize  and  multiply  in  the  lymph  structures,  finding  their  way  into  the 
mesenteric  glands  and  thence  by  means  of  the  blood  to  the  spleen,  liver, 
kidneys,  and  bone-marrow.  In  these  locations  and  elsewhere  they  form 
soluble  toxins  which,  circulating  in  the  blood,  exert  their  influence  espe- 
cially upon  the  nervous  system  and  the  nutrition  and  thus  give  rise  to  the 
fever  and  other  constitutional  symptoms.  Brieger  isolated  from  cultures 
a  toxin  belonging  to  the  ptomaine  group  to  which  he  gave  the  name  typho- 
toxin.  Later  with  Fraenkel  he  isolated  a  toxalbumin.  Of  greater  impor- 
tance is  the  poison  derived  from  the  bacilli — protein  toxin — by  R,  Pfeiffer. 

Period  of  Incubation. — The  duration  of  the  time  from  the  entrance 
of  the  pathogenic  principle  until  the  appearance  of  the  phenomena  of  the 
fever  varies  upon  the  average  between  two  and  three  weeks.  This  period 
runs  its  course  without  symptoms,  provided  prodromes  are  not  included. 

Stage  of  Prodromes. — The  onset  is  very  rarely  abrupt.  It  is  as  a 
rule  preceded  by  a  period  of  impaired  health  characterized  by  malaise, 
feebleness,  indisposition  to  bodily  or  mental  effort,  loss  of  appetite,  head- 
ache, vertigo,  and  disturbed  sleep.  Abdominal  uneasiness,  even  pain, 
and  diarrhoea  in  the  absence  of  laxatives  are  often  present  at  this  time. 
Slight  but  transient  rises  of  temperature  may  occur.  Bleeding  at  the 
nose  is  common. 

The  course  of  the  attack  varies  between  twenty-one  and  twenty- 
eight  days.  It  may  be  divided  into  the  stage  of  onset,  the  fastigium  or 
fully  developed  disease,  and  the  stage  of  decline  upon  which  supervenes 
the  convalescence.  As,  however,  there  are  anatomical  changes  in  the  lym- 
phoid structures  of  the  intestines  which  run  their  successive  courses  in 
periods  of  five  to  seven  days  and  correspond  to  changes  in  the  symptom- 
complex  of  similar  duration,  it  is  convenient  for  purposes  of  description  to 
divide  the  course  of  the  attack  into  four  periods  of  a  week  each. 

Course  of  the  Disease. — First  Week. — The  attack  of  enteric  fever 
begins  with  a  distinct  and  sustained  elevation  of  temperature.  This  rise 
is  frequently  attended  with  chilliness,  which  may  be  repeated,  but  rarely 
by  a  pronounced  chill.  The  patient  now  in  the  majority  of  instances  betakes 
himself  to  his  bed.  During  the  first  four  or  five  days  the  temperature 
rises  in  the  evening  from  one  to  two  degrees  higher  than  upon  the  previous 
evening  and  each  morning  a  degree  or  more  above  that  of  the  preceding 
morning.  At  the  end  of  this  time  the  temperature  has  reached  its  fastig- 
ium, 103°-105°  F.  (39.5°-40.5°  C),  and  with  slight  morning  remissions 
remains,  in  the  absence  of  complications,  at  this  level  until  the  end  of  the 
second  week.  During  this  period  there  are  lassitude,  headache,  anorexia, 
thirst,  a  hot,  dry  skin,  diminished  urine,  and  restless  sleep.  The  headache 
becomes  progressively  more  severe  and  is  attended  with  tinnitus   aurium 


608  MEDICAL  DIAGNOSIS. 

and  delirium,  at  first  mild  and  present  usually  upon  waking.  Epistaxis 
frequently  occurs.  It  is  usually  slight  but  may  be  free.  The  tongue  is 
coated  and  is  seen  to  be  of  a  bright  red  color  at  the  edges  and  tip — "red 
tongue  fever."  At  this  time  constipation  is  the  rule  but  laxatives  act 
with  unusual  energy.  Toward  the  end  of  the  first  week  spontaneous 
diarrhoea  often  occurs.  There  are  cases,  however,  in  which  constipation 
continues  throughout  the  attack.  The  spleen  is  found  upon  palpation  to 
"be  enlarged  toward  the  end  of  this  period;  there  is  slight  tympanitic 
distention  of  the  abdomen  and  tenderness  in  the  ileocaecal  region.  The 
gurgling  upon  pressure,  often  observed  in  this  region,  is  wholly  without 
diagnostic  value. 

A  few  scattered,  medium-sized,  dry  rales  may  usually  be  heard  upon 
auscultation  of  the  lungs.  The  pulse  is  rapid,  90-110,  but  less  so  in  pro- 
portion to  the  rise  of  temperature  than  in  many  other  acute  diseases. 
It  is  full  in  volume,  of  low  tension,  and  often  dicrotic. 

Second  Week. — The  fever  now  assumes  the  subcontinuous  type,  the 
range  between  the  evening  rises  and  morning  remissions  not  greatly  exceed- 
ing those  of  health.  The  symptoms  become  progressively  more  severe. 
The  pulse  is  rapid  and  gradually  loses  its  dicrotism.  About  the  tenth  day 
the  headache  spontaneously  ceases  and  is  replaced  by  somnolence  and 
stupor,  which  alternate  with  delirium  usually  wandering  but  sometimes 
noisy  and  active.  The  facies  is  dull,  faintly  flushed,  sometimes  slightly 
cyanotic.  The  lips  and  tongue  are  dry  and  there  is  a  tendency  for  sordes 
to  collect  upon  the  teeth  and  gums.  The  abdominal  symptoms,  diarrhoea 
and  tympanites,  are  aggravated;  there  is  decided  enlargement  of  the  spleen 
and  between  the  sixth  and  tenth  days  the  eruption  makes  its  appearance, 
commonly  upon  the  upper  abdominal  or  lower  thoracic  regions  anteriorly. 
Traces  of  albumin  are  now  to  be  found  in  many  of  the  cases.  The  signs  of 
bronchitis  are  more  pronounced.  Fine  subcrepitant  and  crepitant  rales 
are  heard  at  the  bases  posteriorly  and  slight  dulness  upon  percussion  may 
be  found  in  this  region. 

Third  Week. — The  temperature  assumes  the  remittent  type  showing 
morning  remissions  of  increasing  length.  The  pulse  becomes  more  feeble 
and  frequent,  110-140.  The  first  sound  of  the  heart  is  faint  and  may  be 
inaudible.  There  is  muscular  tremor.  Diarrhoea  and  tympanitic  disten- 
tion of  the  abdomen  may  increase  or,  if  previously  absent,  now  appear. 
There  is  often  retention  of  urine  and  sometimes  involuntary  discharges  of 
urine  and  faeces.  Weakness  is  most  marked  and  wasting  conspicuous. 
Stupor  and  delirium  continue.  The  rash,  which  has  continued  to  appear 
and  fade  in  successive  crops,  now  as  a  rule  gradually  diminishes  and  does 
not  in  most  cases  again  appear.  This  is  especially  the  period  of  severe 
complications,  hypostatic  pneumonias,  bed-sores,  parotitis,  hemorrhages, 
and  perforation. 

Fourth  Week. — The  type  of  the  fever  is  now  intermittent,  the  morning 
remissions  gradually  falhng  to  normal  or  slightly  subnormal  ranges  and 
the  evening  rises  progressively  diminishing  until  they  no  longer  transcend 
the  normal.  The  tongue  becomes  clean  and  moist,  the  diarrhoea  ceases, 
and  there  is  a  rapidly  increasing  and  urgent  desire  for  food.  The  spleen 
undergoes   involution.      The    tympanites    subsides.      The    pulse    becomes 


ENTERIC  OR  TYPHOID  FEVER. 


609 


stronger  and  fuller  and  the  first  sound  and  impulse  of  the  heart  more 
distinct.  The  convalescence  may  be  postponed  by  the  occurrence  of 
various  sequels  or  by  relapse,  and  in  some  instances  the  symptoms  of  the 
fourth  or  even  of  the  fifth  week  may  continue  to  be  the  same  which  were 
present  during  the  third — progressive  asthenia,  rapid  and  feeble  pulse, 
abdominal  distention,  involuntary  discharges,  dry  tongue,  muttering 
delirium,  stupor,   and  subsultus. 

The  foregoing  sketch  represents  a  severe  attack  of  enteric  fever  unmod- 
ified by  treatment  and  terminating  in  recovery.  But  from  this  typical 
picture  of  the  disease  there  are  many  variations.  The  problem  in  diagnosis 
is  to  determine  not  the  nature  of  a  well-defined  typical  case  of  enteric 


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Fig.  207.  — Temperature  range  in  enteric  fever. — Wunderlich. 

fever — that  any  tyro  in  medicine  can  readily  do — but  to  recognize  the 
atypical  cases  and  to  differentiate  them  from  the  affections  to  which  they 
present  features  of  resemblance  and  to  do  this  successfully  at  the  earliest 
possible  moment,  since  failure  in  this  respect  leads  to  indifference  in  regard 
to  the  search  for  the  cause  of  the  attack  on  the  one  hand  and  neglect  in 
the  proper  treatment  and  disposal  of  the  evacuations  on  the  other. 

Symptoms  of  Especial  Importance  in  Diagnosis. — Before  entering 
upon  the  consideration  of  the  varieties  of  enteric  fever  it  is  important  to 
give  our  attention  in  greater  detail  to  certain  of  the  principal  symptoms 
the  association  of  which  is  of  cardinal  importance  in  diagnosis.  These 
symptoms  relate  to  (a)  the  fever,  (b)  the  pulse,  (c)  the  rash,  (d)  the 
abdominal  organs,  and  (e)  the  nervous  system. 

(a)  Tlie  Fever.  —  1.  Regular,  so-called  Typical  Course,  —  The 
temperature  rises  by  regular  step-like  gradations,  with  marked  evening 
exacerbations  and  slight  morning  remissions,  until  it  reaches  a  range  of 

39 


610  MEDICAL  DIAGNOSIS. 

103°-105°  F.  (39.5°-40.5°  C.)  by  the  fourth  or  fifth  day.  From  this  period 
to  the  end  of  the  second  week  its  range  is  subcontinuous,  the  oscillations 
between  the  morning  minima  and  the  evening  maxima  but  Httle  exceed- 
ing those  of  health.  During  this  time  the  temperature  is  scarcely  modified 
by  ordinary  antipyretic  measures  and  only  gradually  yields  to  systematic 
cold  batliing.  Toward  the  end  of  the  second  and  throughout  the  third 
week  the  type  becomes  remittent  with  diurnal  oscillations  of  gradually 
increasing  length  until  in  the  fourth  week  the  type  is  distinctly  inter- 
mittent, the  diurnal  oscillations  progressively  diminishing  at  the  expense 
of  the  evening  rises  until  subnormal  ranges  are  reached.  The  defervescence 
is  by  lysis.  From  this  level  the  temperature  again  in  the  course  of  a  few 
days  rises  to  normal,  but  it  remains  for  a  time  unstable  and  is  liable 
to  recrudescences  of  l°-3°  F.,  extending  over  a  day  or  two,  from  the 
action  of  sh'ght  causes, — physical  or  mental  effort,  the  visits  of  friends, 
constipation,  the  eating  of  solid  food, — fehris  carnis. 

This  typical  temperature  range  is  much  less  common  than  it  was 
formerly  thought  to  be  and  numerous  modifications  occur  in  cases  that  in 
other  respects  must  be  regarded  as  typical. 

2.  Variatioxs  IX  THE  TEMPERATURE  Range. — The  fact  that  most  of 
the  cases  do  not  come  under  observation  until  some  days  have  elapsed  and 
the  temperature  has  attained  its  fastigium  throws  some  obscurity  upon  the 
frequency  of  the  gradual  step-like  ascent  of  the  first  week.  In  cases  seen 
from  the  onset  it  is  often  absent  and  the  temperature  may  reach  104°-105° 
F.  in  the  course  of  twenty-four  or  forty-eight  hours.  This  is  especially 
common  in  the  cases  which  begin  abruptly  with  chills  or  in  children  with 
convulsions.  Not  rarely  the  temperature  range  is  remittent  throughout — 
infantile  type,  seen  sometimes  also  in  the  adult.  Not  very  rarely  the 
temperature  falls  rapidly  about  the  end  of  the  second  week, — defervescence 
by- rapid  lysis,  or  by  crisis, — an  event  more  common  in  the  cases  which  be- 
gin abruptly  than  in  those  of  gradual  onset.  Inverse  temperature  is 
observed  very  rarely  in  enteric  fever  and  is  without  diagnostic  significance 
other  than  that  which  arises  from  its  occasional  occurrence  in  tuberculosis. 

The  course  of  the  temperature  is  sometimes  interrupted  by  sudden 
falls.  These  declines  may  amount  to  8°  or  10°  F.  in  the  course  of  a  few  hours. 
They  occur  from  hemorrhage  from  any  cause  and  especially  accompany 
intestinal  hemorrhage.  As  a  rule  they  are  followed  in  the  course  of  several 
hours,  when  the  bleeding  has  ceased,  by  a  rise  to  the  former  range,  but  the 
temperature  often  remains  unstable;  exceptionally  the  temperature  stays 
low  and  the  patient  enters  upon  an  early  convalescence.  Hyperpyrexia  is 
not  common  in  enteric  fever.  In  very  rare  instances  collapse  may  occur 
in  the  absence  of  hemorrhage  or  perforation. 

Recrudescences  of  fever  from  trifling  causes,  occurring  as  a  manifesta- 
tion of  the  instabilit}^  of  the  heat-regulating  mechanism  which  follows  the 
infection,  are  of  no  great  importance.  They  are,  however,  to  be  differen- 
tiated from  the  symptomatic  fever  of  an  inflammatory  complication,  as 
pneumonia  or  pleurisy  or  venous  thrombosis.  In  this  connection  the 
local  phenomena  and  an  increase  of  the  leucocytes  are  of  importance. 

Suhfehrile  States  in  Convalescence. — In  children  and  neurotic  individ- 
uals there  may  be  evening  fever,  100.5°-102°  F.  (.3S°-39°  C),  for  weeks  after 


ENTERIC  OR  TYPHOID  FEVER. 


611 


1-05° 


Fig.  208. — Collapse  in  enteric  fever,  14th  day.   No 
hemorrhage.     Ultimate  recovery. 


C. 

420 


the  symptoms  of  the  disease  have  disappeared  and  convalescence  is  in 
other  respects  fully  established.  I  have  several  times  seen  this  condition 
in  laboring  men  in  hospital  wards.  It  has  been  described  as  bed-fever. 
It  disappears  when  the  patient  is  allowed  to  sit  up.  A  similar  evening  rise 
may  be  the  sign  of  a  latent  complication. 

The  subnormal   temperature  of  early   convalescence  is   not   important. 
It  is  especially  liable  to  occur  in  feeble  or  greatly  emaciated  individuals 
but  may  be  encountered  in  persons  making  a  good  recovery.    In  the  course 
of  a  week  or  ten  days  the  tempera- 
ture rises  to  normal  and  regains  its 
stability.     The  hypothermia  of  hem- 
orrhage and  the  morning  remissions 
of  the  later  stages  have  been  already 
described.       That    of    cold    bathing 
and  other   antipyretic   treatment   is 
transient     and     without     diagnostic 
importance. 

Relapses  are  characterized  by  a 
febrile  range  like  that  of  the  primary 
attack,  except  that  the  respective 
periods  are  shorter  just  as  the  re- 
lapse is  shorter — ten  days  to  two 
weeks.  The  gradual  ascent,  subcon- 
tinuous  fastigium,  and  defervescence 
by  lysis  with  remittent  and  inter- 
mittent curves  are  important  from 
the  standpoint  of  diagnosis. 

Afebrile  Typhoid.  —  Cases  have 
been  described  in  which  the  general 
constitutional  symptoms  and  the 
duration  of  the  case  together  with 
the  eruption,  enlargement  of  the 
spleen,  dicrotism,  and  the  diazo  re- 
action have  been  present  without 
fever  or  at  most  with  only  a  trifling 
elevation  of  the  evening  tempera- 
ture to  subnormal  ranges,  and  in  which  the  etiology  of  the  disease  and  the 
existence  of  a  local  epidemic  have  rendered  the  diagnosis  of  enteric  fever 
in  the  highest  degree  probable.  The  diagnosis  will  become  positive  in  the 
event  of  the  occurrence  of  intestinal  hemorrhage  or  upon  post-mortem 
examination  resulting  in  the  demonstration  of  the  characteristic  intestinal 
lesions.  In  the  absence  of  those  events  the  diagnosis  may  then  be  made 
by  the  finding  of  the  bacilli  in  the  urine  and  stools  or  in  blood  cultures. 

3.  Chills. — Chilliness  is  not  uncommon  in  the  period  of  onset,  but  rigors 
are  rare  in  enteric  fever.  Chills  occasionally,  however,  occur  with  the  initial 
rise  of  temperature;  at  irregular  intervals  during  the  course  of  the  attack, 
followed  by  profuse  sweating;  sometimes  upon  the  development  of  compli  • 
cations;  after  the  administration  of  internal  antipyretics,  and  in  septic  con- 
ditions.    Chilliness  and  shivering  are  frequent  at  the  end   of  tub-baths. 


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612  MEDICAL  DIAGNOSIS. 

(b)  The  Pulse. — The  characters  and  frequency  of  the  pulse  in  relation 
to  the  fever  are  of  diagnostic  importance.  The  pulse  is  commonly  full  and 
of  low  tension  in  the  beginning  of  the  attack.  Dicrotism  appears  early 
and  is  not  only  more  common  but  also  more  marked  than  in  any  other 
acute  disease.  The  frequency  is  increased  but  not  proportionately  to  the 
elevation  of  the  temperature.  A  pulse  of  100-120  may  within  the  second 
week  be  associated  with  a  temperature  of  104°-105°  F.  (40°-40.5°  C). 
Later  the  pulse  becomes  more  frequent  and  feeble  and  its  volume  is  much 
diminished.  In  grave  cases  with  great  prostration  it  may  reach  160  and 
such  a  degree  of  enfeeblement  as  to  be  scarcely  countable. 

(c)  The  Rash. — The  eruption  occurs  in  at  least  four-fifths  of  the 
cases.  It  consists  of  lenticular,  hypersemic  papules,  slightly  elevated  above 
the  surface  of  the  skin,  of  a  pale  rose  color,  one  to  four  mm.  in  diameter 
and  disappearing  upon  pressure  or  when  the  skin  is  made  tense.  These 
roseolous  maculopapules  may  be  felt  by  the  finger.  They  must  not  be 
confounded  with  the  dense  papules  or  small  pustules  of  acne  which  are 
common  upon  the  trunk,  especially  the  back,  of  young  persons.  They 
appear  in  successive  crops  and  vary  in  number  from  two  or  three,  found 
only  upon  careful  search,  to  a  somewhat  copious  roseola  distributed  upon 
the  surface  of  the  trunk  and  extremities.  Contrary  to  the  general  opinion, 
I  am  now  of  the  belief  that  cases  characterized  by  an  abundant  rash 
frequently  run  a  severe  course.  The  eruption  first  makes  its  appearance 
between  the  end  of  the  first  and  the  middle  of  the  second  week  and  commonly 
in  the  epigastric  zone  upon  the  anterior  surface  of  the  body.  It  is  also  fre- 
quently noted  upon  the  back,  between  the  shoulder-blades.  It  may  in  rare 
instances  be  seen  upon  the  face,  especially  in  young  persons  of  fair  skin. 
The  spots  are  circular  or  oval  with  well-defined  borders.  They  gradually 
fade  in  two  or  three  days,  leaving  an  area  of  pigmentation  the  degree  of  which 
varies  according  to  the  complexion  of  the  individual.  In  the  majority  of 
cases  no  new  crops  appear  after  the  defervescence  begins,  but  exceptionally 
the  spots  continue  to  appear  after  the  temperature  has  fallen  to  normal. 

Other  points  of  value  in  diagnosis  in  connection  with  the  skin  are  the 
out-cropping  of  sudamina  as  the  fever  begins  to  decline;  the  occasional 
occurrence  of  purpura;  an  infrequent  erythematous  eruption  at  the  outset, 
resembling  that  of  scarlet  fever;  a  fine  branny  desquamation  in  children;  the 
presence  of  the  tache  cerebrals,  and  the  great  infrequency  of  herpes  labialis 
in  comparison  with  malaria,  croupous  pneumonia,  and  cerebrospinal  fever. 

(d)  The  Symptoms  Relating  to  the  Abdominal  Organs. — Splenic  en- 
largement may  be  made  out  upon  palpation,  the  border  of  the  organ 
extending  below  the  ribs,  especially  on  deep  inspiration.  The  results  of 
percussion  are  obscured  by  the  meteorism  which  is  common  after  the 
beginning  of  the  second  week.  A  splenic  tumor  is  demonstrable  in  more 
than  eighty  per  cent,  of  the  cases. 

Diarrhoea  is  a  variable  symptom.  It  is  present  at  some  time  in  the 
course  of  the  majority  of  the  cases,  often  alternating  with  constipation. 
There  are,  however,  epidemics  in  which  constipation  throughout  is  the  rule. 
Diarrhoea  is  more  common  in  the  later  course  of  the  attack.  It  is  caused 
by  the  associated  catarrh  rather  than  by  the  ulcers  and  is  indicative  of 
extensive  rather  than  of  deep  ulceration.    The  number  of  the  stools  varies 


ENTERIC  OR  TYPHOID  FEVER. 


613 


from  two  or  three  to  eight  or  ten  in  twenty-four  hours.  They  are  usually 
large,  thin,  grayish-yellow  in  color  and  of  a  granular  composition.  They 
very  often  contain  one  or  more  soft  scybalous  masses  of  the  size  of  a  walnut. 
The  reaction  is  alkaline  and  the  odor  foul.  On  standing,  the  fluid  and 
solid  constituents  separate  into  two  layers,  the  upper  containing  albumin, 
salts,  and  coloring  matter,  the  lower  epithelial  debris,  cellular  elements, 
fat  crystals,  triple  phosphates,  and  later  in  the  disease  sloughs  from  the 
necrotic  Peyer's  patches,  and  microscopic  blood.  In  many  cases  the  bacilli 
of  Eberth  may  be  found  after  the  middle  of  the  second  week.  This  separa- 
tion of  the  stools  into  layers  is 
not  often  seen  in  other  forms 
of  diarrhoea,  but  cannot  be 
regarded  as  pathognomonic. 
In  truth  it  cannot  be  said  that 
the  stools  of  enteric  fever  are 
characteristic  in  any  diagnostic 
sense.  The  familiar  compari- 
son with  pea-soup  is  inexact 
and  misleading  and  might  well 
be  discarded  with  a  multitude 
of  other  unscientific,  tradi- 
tional, false  phrases  from 
the  language  of  descriptive 
medicine. 

Tenderness  and  Pain. — 
Tenderness  in  the  ileocsecal  re- 
gion is  common  in  the  early 
course  of  the  attack  and  im- 
portant in  the  differential  diag- 
nosis between  enteric  fever  and 
appendicitis.  The  tenderness  is 
in  some  instances  confined  to 
the  umbilical  region;  less  often 
it  may  be  elicited  upon  pres- 
sure over  almost  any  part  of 
the  abdomen.  Tenderness  and 
pain  in  the  abdomen  may  be 
symptomatic  of  an  over-distended  bladder,  pleurisy,  crural  phlebitis,  or 
other  acute  affection.  In  a  large  proportion  of  the  cases  no  definite  cause 
for  these  symptoms  can  be  discovered.  Pain  and  tenderness  are  occasion- 
ally associated  with  intestinal  hemorrhage  but  are  present  and  intense 
in  almost  all  cases  of  perforation. 

Intestinal  Hemorrhage. — Hemorrhage  from  the  bowel  is  a  serious 
accident,  occurring  in  from  three  to  ten  per  cent,  of  all  cases.  It  varies 
in  amount  from  a  trace  of  blood  in  the  stools  to  a  profuse  and  fatal  blood 
loss.  Large  hemorrhages  most  commonly  occur  about  the  time  of  the 
separation  of  the  sloughs,  namely,  between  the  close  of  the  second  and  the 
beginning  of  the  fourth  week.  The  slighter  hemorrhages  which  take  place 
earlier  than  this  period  are  due  to  oozing  from  the  hyperaemic  Peyer's 


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Fig.  209. — Enteric  Fever.     Hemorrhage  on  the  13th  day; 
recovery.    Woman,  aged  23. 


614 


MEDICAL  DIAGNOSIS. 


patches;  those  which  occur  after  it  are  to  be  ascribed  to  the  mechanical 
disturbance  of  unhealed  ulcers  by  the  peristaltic  movement  of  the  bowel 
and  the  contact  of  the  intestinal  contents.  Intestinal  hemorrhage 
usually  comes  on  without  premonitory  symptoms.  It  may  reveal  itself 
at  once  by  the  discharge  of  blood  from  the  anus,  with  faintness, 
feeble  pulse,  pallor,  and  a  rapid  fall  of  temperature  to  the  extent  of 
several  degrees,  or  by  collapse  symptoms  which  may  terminate  in 
death  before  the  blood  appears  in  the  stools — concealed  hemorrhage. 
Intestinal  bleeding  may  be  symptomatic  of  a  general  hemorrhagic  con- 
dition manifested  also  by  pe- 
techise  and  hsematuria  or  ooz- 
ing from  other  mucous  surfaces. 
Perforation.  —  Intestinal 
perforation  is  the  gravest  acci- 
dent that  occurs  in  enteric 
fever.  Its  frequency  is  about 
three  per  cent,  of  all  cases.  It 
may  happen  in  otherwise  ap- 
parently mild  cases  but  is  more 
common  in  severe  cases  in 
which  diarrhcEa  and  meteorism 
are  marked  or  in  which  hemor- 
rhage has  occurred.  Nearly 
fifty  per  cent,  of  the  cases 
occur  in  the  third  or  fourth 
week.  The  symptoms  are  first 
those  caused  by  the  perforation 
itself  and  the  escape  of  the  con- 
tents of  the  bowel  into  the  per- 
itoneum, and  second,  those  of 
the  resulting  peritonitis.  Of 
the  first  group,  sudden,  sharp 
pain  in  the  right  lower  quad- 
rant of  the  abdomen,  increasing 
in  severity,  attended  by  general 
or  local  tenderness,  is  the  most 
significant.  Next  in  order  of 
importance  is  rigidity  of  the  abdominal  muscles,  which  become  spastic 
upon  palpation.  Irritabihty  of  the  bladder  and  frequent  micturition  are 
not  uncommon.  Much  less  frequent  are  collapse  symptoms,  fall  in  temper- 
ature, increase  in  pulse-frequency,  and  coldness  of  the  surface  with  sweat- 
ing. In  grave  toxemia  with  stupor  the  symptoms  of  perforation  may 
be  obscured. 

The  second  group  comprises  the  symptoms  of  the  consecutive  peri- 
tonitis. The  local  symptoms  are  of  great  importance  since  the  life  of  the 
patient  may  depend  upon  their  early  recognition.  They  consist  of  muscular 
rigidity  with  pain  upon  pressure  and  deep  breathing,  limitation  of  the  respir-, 
atory  movements,  obliteration  of  the  lower  border  of  the  liver  and  splenic 
dulness  from  the  presence  of  free  air  in  the  peritoneal  cavity,  fulness  and 


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Fig.  210. — Enteric  fever.    Signs  of  perforation,  14th  day; 
operation  refused;   death  two  days  later. 


ENTERIC  OR  TYPHOID  FEVER.  615 

tenderness  upon  digital  examination  per  rectum;  absence  of  the  peris- 
taltic murmur  upon  auscultation,  friction  sounds  in  the  upper  hepatic 
area  or  elsewhere,  and  in  the  majority  of  the  cases  a  rapidly  progressive 
leucocytosis.  These  phenomena  are  not  all  present  in  every  case  but  the 
presence  of  several  of  them  justifies  the  diagnosis  of  typhoid  peritonitis  in 
its  early  stage.  Their  progressive  development  is  soon  followed  by  the 
occurrence  of  more  ominous  signs.  The  spastic  contraction  of  the  muscles 
of  the  abdominal  wall  is  replaced  by  tympanitic  distention  which  pro- 
gressively increases.  Percussion  in  the  flanks  reveals  flatness  in  the  most 
dependent  region,  the  sign  of  an  accumulating  exudate.  The  pain  is  less 
urgent;  the  tenderness  less  acute.  Further  displacement  of  the  liver  and 
splenic  dulness  in  an  upward  direction  is  noted  and  the  impulse  of  the  heart 
may  be  found  as  high  as  the  fourth  interspace.  In  a  small  number  of  the 
cases  perforation  and  peritonitis  occur  with  a  flat  or  even  retracted  abdomen. 

The  general  symptoms  indicate  the  gravity  of  the  condition.  They 
consist  of  pallor,  an  expression  indicative  of  pain,  which  develops  later  into 
the  facies  Hippocratica,  profuse  clammy  sweating,  a  feeble,  thready,  fre- 
quent pulse,  hiccough,  and  vomiting.  The  respiration  is  shallow,  the  heart 
sounds  indistinct,  the  temperature,  which  may  have  fallen  upon  the  occur- 
rence of  perforation,  rises  again,  and  the  kidneys  secrete  little  or  no  urine. 
This  formidable  array  of  symptoms,  the  forerunners  of  the  approaching  fatal 
issue,  may  be  masked  by  those  of  an  antecedent  overwhelming  toxaemia. 

Perforative  peritonitis  without  the  escape  of  air  into  the  peritoneal 
sac  may  arise  from  the  rupture  of  a  pseudo-abscess,  softened  mesenteric 
gland,  or  a  splenic  or  hepatic  abscess.  A  general  or  local  peritonitis  may 
occur  in  consequence  of  infection  through  the  thinned  base  of  a  deep  ulcer 
without  rupture. 

(e)  The  Nervous  System. — There  is  nothing  characteristic  in  the 
nervous  symptoms  of  enteric  fever;  yet  their  association  with  the  phe- 
nomena mentioned  in  the  foregoing  pages  constitutes  a  symptom-complex 
that  is  in  the  highest  degree  significant. 

Headache,  sleeplessness,  and  a  condition  of  the  nervous  system  which 
renders  physical  and  mental  effort  alike  difficult  characterize  the  period 
of  prodromes.  The  headache  may  involve  any  part  of  the  head  or  be  gen- 
eral. Its  most  constant  peculiarity  is  that  it  becomes  worse  toward 
night.  It  usually  ceases  spontaneously  about  the  middle  of  the  second 
week  and  is  replaced  by  somnolence  and  stupor — a  change  which  is  of  diag- 
nostic value.  Tinnitus  aurium  frequently  accompanies  the  headache  and 
deafness  develops  with  the  progress  of  the  disease. 

Delirium  sometimes  begins  early  and  is  usually  of  mild  character. 
The  patient  can  be  roused,  his  attention  fixed  and  his  replies  become  ap- 
parently rational.  The  delirium  is  at  first  nocturnal.  Later  it  becomes 
continuous  and  marked.  It  may  not  appear  until  the  second  or  even  the 
third  week.  In  other  cases  it  is  noisy  and  restless  and  attended  with  efforts 
to  get  out  of  bed.  In  hard  drinkers  it  may  be  associated  with  tremor  and 
the  hallucinations  peculiar  to  delirium  tremens.  Abrupt  changes  in  the 
form  of  delirium  occur.  The  patient  who  has  been  apathetic  and  wander- 
ing may  without  warning  develop  an  active  and  purposeful  delirium  with 
suicidal  tendencies.     The  enteric  fever  patient  who  has  become  delirious 


616  MEDICAL  DIAGNOSIS. 

must  under  no  circumstances  be  left  alone.  Somnolence  and  hebetude 
are  common  and  in  the  severe  cases  these  symptoms  deepen  into  a  stupor 
from  which  the  patient  cannot  be  roused.  Coma  vigil,  tremor,  subsultus 
tendinum,  and  carphologia  are  among  the  most  ominous  symptoms  of 
the  disease. 

Convulsions  are  rare.  They  may  occur  in  children  at  the  onset.  In 
the  course  of  the  attack  and  especially  in  adults  they  may  be  hysterical, 
ursemic  or  symptomatic  of  some  nervous  complication,  as  encephalitis  or 
thrombosis  of  cerebral  arteries  or  veins. 

Varieties. — Enteric  fever  is  in  the  strictest  sense  a  disease  of  the 
whole  organism.  Scarcely  an  organ  escapes;  not  a  function  goes  on  nor- 
mally. The  duration  of  the  attack  with  profound  derangements  of  nutrition 
exposes  the  defenceless  tissues  to  the  secondary  invasions  of  pathogenic 
organisms  both  local  and  general.  In  different  cases  various  organs  bear 
the  brunt  of  the  attack  according  to  the  personal  predisposition  of  the 
individual.  Variations  in  the  intensity  of  the  infection, — virulence  of  the 
bacilli, — the  resistance  of  the  individual, — integrity  of  the  tissues,  degrees 
of  hereditary  or  acquired  immunity  or  predisposition, — complications, 
sequels,  relapse,  the  management  of  the  case  and  the  surroundings  likewise 
modify  the  severity  of  the  attack.  Hence  a  most  diverse  and  complex 
symptomatology.  A  full  account  of  enteric  fever  in  all  its  relations  would 
constitute  an  epitome  of  the  Practice  of  Medicine.  It  is  important  to 
remember  that  the  disease  presents  the  widest  variations  from  a  typical 
course  alike  in  its  mode  of  onset,  its  intensity,  the  prominence  of  certain 
symptoms,  and  in  its  duration.  Errors  in  diagnosis  in  doubtful  cases  are 
to  be  avoided  only  by  the  routine  employment  of  every  resource  of  clinical 
medicine  with  due  regard  to  the  teachings  of  the  clinical  laboratory  and 
the  post-mortem  room.  From  the  standpoint  of  the  infection  the  follow- 
ing varieties  may  be  recognized: 

(a)  Ordinary  Form  with  WelUdeveloped  Intestinal  Lesions. — This  group 
includes  the  great  majority  of  the  cases.  The  lesions  of  the  lymph 
structures  are  well  marked  and  more  or  less  extensive;  the  mesenteric 
glands  and  spleen  are  enlarged,  parenchymatous  changes  are  present 
in  the  viscera.  The  anatomical  diagnosis  can  be  made  in  the  absence  of 
a  history  of  the  symptoms. 

(b)  Cases  Characterized  by  Slight  Intestinal  Lesions. — The  changes 
in  the  lymphoid  structures  of  the  intestines  may  be  superficial  and  limited 
in  extent  and  therefore  readily  overlooked,  or  if  death  has  occurred  late 
in  the  attack  the  ulceration  may  have  already  healed.  The  symptom- 
complex  may  be  that  of  an  ordinary  attack  with  or  without  mild  intestinal 
symptoms,  of  a  general  sepsis  with  high  fever  and  marked  nervous  symp- 
toms,— so-called  typhoid  state — typhoid  septicaemia, — or  of  an  affection  of 
one  or  more  viscera  with  profound  constitutional  disturbance.  The  organs 
especially  involved  may  be  the  liver,  gall-bladder,  lungs,  pleura,  kidneys, 
endocardium,  or  meninges.  It  is  in  the  last  group  that  the  cases  are  found 
which  are  described  as  pneumotyphus,  in  which  the  attack  sets  in  with 
pulmonary  symptoms;  pleurotyphus,  beginning  with  an  acute  pleurisy; 
nephrotyphus,  in  which  the  general  symptoms  and  urinary  findings  of 
an  acute  nephritis  are  present  at  the  onset,  and  the  cerebrospinal  form  ia 


ENTERIC  OR  TYPHOID  FEVER.  617 

which  the  attack  begins  suddenly  with  urgent  symptoms  of  disturbance 
of  the  nervous  system.  In  all  of  these  unusual  forms  the  symptoms  which 
dominate  the  clinical  picture  at  the  onset  shortly,  and  mostly  in  the  course 
of  the  first  week,  become  subordinate  to  those  characteristic  of  enteric 
fever  and  the  attack  generally  runs  its  subsequent  course  in  the  usual  way 
and  time.  In  many  of  these  cases,  however,  the  intestinal  lesions  are 
well  developed.  To  elevate  these  groups  of  cases  into  separate  varieties 
is  to  increase  the  difficulties  of  the  student  and  teacher  alike  without  any 
compensatory  advantages  of  classification. 

(c)  Cases  Characterized  by  the  Absence  of  Intestinal  Lesions. — In 
some  of  the  cases  the  true  nature  of  the  affection  has  not  been  demon- 
strated; in  others  lesions  such  as  those  of  tuberculous  ulceration,  by  which 
the  bacilli  of  Eberth  may  have  found  access,  were  present.  There  remain, 
however,  a  limited  number  of  cases  in  which  the  Bacillus  typhosus  has  been 
demonstrated  in  the  organs,  the  symptoms  have  been  characteristic,  and 
death  has  occurred  at  a  time  when  the  lesions  of  the  gut  are  commonly 
conspicuous,  yet  none  have  been  discovered.  The  possibility  that  the 
bacilli  have  found  entrance  by  way  of  the  intestinal  wall  without  giving 
rise  to  demonstrable  lesions  has  been  suggested.  Infection  by  way  of  the 
respiratory  passages  has  not  been  demonstrated.  Even  in  the  cases  of 
pneumotyphus  the  absence  of  intestinal  lesions  to  which  the  early  lung 
affection  may  have  been  consecutive  has  not  been  established. 

(d)  Mixed  or  Secondary  Infections. — The  conditions  caused  by  the 
Bacillus  typhosus  impair  the  powers  of  resistance.  A  secondary  invasion 
of  colon  bacilli,  streptococci,  staphylococci,  or  the  pneumococci  may  occur 
with  the  development  of  consecutive  local  and  constitutional  phenomena. 
This  true  mixed  infection  may  take  place  in  any  disease  and  is  to  be  dis- 
criminated from  other  specific  infections  which  occur  as  complications  or 
intercurrent  affections,  as  infection  with  Bacillus  tuberculosis.  Bacillus 
diphtherise.  Streptococcus  Fehleisen  or,  the  malarial  parasite. 

(e)  Cases  Presenting  the  Symptoms  of  Enteric  Fever  but  due  to 
other  Organisms— Paratyphoid. — Researches  conducted  since  1896  have 
shown  that  a  symptom-complex  not  to  be  distinguished  from  enteric  fever 
may  be  caused  by  organisms  other  than  the  Bacillus  typhosus,  which  stand 
in  their  cultural  and  agglutinating  properties  between  B.  typhosus  and  B. 
coli  communis,  and  that  B.  coli  may  perhaps  play  the  same  etiologic  role. 
This  fact  does  not,  however,  impair  the  universal  belief  in  the  specific 
nature  of  B.  typhosus  and  enteric  fever. 

As  regards  intensity  the  following  forms  may  be  described: 

(a)  The  Mild  Form — Typhus  Levissimus. — The  fever  is  moderate, 
not  exceeding  102°- 103°  F.  (39°-39.5°  C.)  in  the  evening.  The  symptoms 
characteristic  of  the  ordinary  form  are  present  but  are  of  mild  intensity. 
Headache,  weakness,  epistaxis,  rose  spots,  and  the  signs  of  splenic  enlarge- 
ment are  present,  but  the  illness  is  so  slight  that  it  is  difficult  to  make  the 
patient  realize  its  true  nature.  Diarrhoea  is  not  common.  These  cases 
are  often  regarded  as  simple  continued  fever,  febricula,  or  gastric  fever. 
Their  duration  varies  from  eight  to  fourteen  days. 

(b)  The  Abortive  Form. — The  onset  is  abrupt  and  marked  by  shiver- 
ing or  a  chill.     The  temperature  rises  abruptly  and  ma}^  reach  104°  F. 


618  MEDICAL  DIAGNOSIS. 

(40°  C).  Rose  spots  appear  early,  often  before  the  fifth  day.  At  the  end 
of  the  first  week,  or  early  in  the  second,  the  temperature  falls  by  rapid 
lysis  or  even  by  crisis  with  profuse  sweating  and  the  patient  enters  upon 
convalescence.  These  cases  are  sometimes  seen  in  epidemics.  The  recog- 
nition of  the  true  nature  of  the  mild  and  abortive  cases  is  of  the  utmost 
importance  from  the  standpoint  of  prophylaxis. 

(c)  The  Latent  or  Ambulatory  Form — Walking  Typhoid. — The  symp- 
toms are  slight  and  the  patient  continues  to  attend  to  his  affairs  as 
usual.  There  is  feverishness  and  a  feehng  of  illness.  Diarrhoea  is  commonly 
present  but  not  urgent.  The  rose  spots  and  enlarged  spleen  are  often  found 
in  the  routine  examination  of  walking  typhoid  patients;  or  sudden  dehrium, 
hemorrhage,  or  perforation  may  occur.  Cases  belonging  to  this  group  are 
more  common  in  men  than  in  women  and  among  laboring  men,  tramps,  and 
others  who  habitually  give  little  attention  to  their  subjective  symptoms. 
They  are  also  encountered  with  some  frequency  among  school-boys. 

(d)  The  Grave  Form. — The  symptoms  may  at  first  be  of  moderate 
intensity.  More  commonly  they  are  severe  from  the  onset.  The  infection 
is  intense.  The  temperature  is  high,  105°-106°  F,  (40.5°-41°  C),  with  very 
trifling  remissions,  and  the  duration  of  the  fever  may  be  protracted  into 
the  fifth  or  sixth  week.  To  this  category  must  be  assigned  the  cases  of 
mixed  or  secondary  infection  and  the  cases  beginning  with  severe  symptoms 
referable  to  the  lungs,  kidneys,  and  nervous  system. 

Modifications  of  the  course  of  the  attack  as  determined  by  anatomical 
and  physiological  conditions  pecuHar  to  the  individual  give  rise  to  the 
following  forms : 

(a)  Enteric  Fever  in  Children. — This  disease  is  not  common  in  infancy.- 
The  nature  of  the  food  and  doubtless  the  presence  of  an  immuniz- 
ing substance  in  the  milk  of  the  mother  protects  sucklings.  Cases  have, 
however,  been  reported  in  the  first  week  of  life  and  occasionally  in  the  first 
year.  Enteric  fever  is  not  at  all  uncommon  after  the  second  year.  The 
onset  may  be  insidious;  commonly  it  is  abrupt  with  high  temperature. 
The  type  of  the  fever  in  a  majority  of  the  cases  is  remittent  throughout — 
infantile  remittent  of  the  early  writers.  Nose-bleeding  and  diarrhoea  are 
comparatively  infrequent  but  bronchial  catarrh  begins  early  and  is  often 
moderately  severe.  There  is  nothing  pecuHar  about  the  rash,  which  may 
be  sparse  or  plentiful.  Tympanites  is  commonly  sHght  and  intestinal 
hemorrhage  and  perforation  much  less  common  than  in  adults.  Nervous 
symptoms  are  often  prominent.  The  attack  may  begin  with  convulsions. 
Drowsiness  alternating  with  insomnia,  and  mild  delirium  interrupted  by 
sudden  outcries  and  spells  of  fretfulness  are  observed.  Aphasia,  usually 
transient,  and  noma  are  prominent  sequels.  The  mortality  is  much  lower 
among  children  than  in  older  persons.  The  marked  differences  in  the  course 
of  the  disease  in  childhood  and  after  puberty,  and  especially  the  very 
common  occurrence  of  fever  of  remittent  course  in  connection  with  the 
symptom-complex  just  described,  warrant  the  division  of  the  cases  of 
enteric  fever  into  two  great  groups,  those  of  the  Infantile  and  those  of 
the  Adult  Type.  Those  of  the  infantile  type  are  milder  than  those  of  the 
adult  type  and  the  prognosis  is  more  favorable.  Cases  of  the  former 
sometimes  occur  among  adults;    of  the  latter  among  children.     The  prog- 


ENTERIC  OR  TYPHOID  FEVER.  619 

nosis  is  less  favorable  in  an  attack  of  adult  type  in  a  child;  more  so  when 
the  infantile  type  occurs  in  later  life.  This  is  in  accordance  with  a  long 
recognized  fact,  namely,  that  in  the  absence  of  complications  the  prognosis 
is  more  favoral)le  in  proportion  as  the  morning  remissions  are  longer,  i.e., 
as  the  temperature  curve  conforms  to  the  remittent  type  of  fever.  It  has 
been  found  also  that  treatment  which  systematically  brings  about  large 
oscillations  between  the  morning  and  evening  temperatures,  as  the  cold 
bath  treatment,  also  renders  the  prognosis  more  favorable. 

(b)  Enteric  Fever  in  the  Aged. — The  course  of  the  disease  is  much 
modified  when  it  occurs  in  middle  life  or  in  elderly  persons.  The  tempera- 
ture range  is  irregular  and  not  so  high.  The  rose  rash  and  splenic  tumor 
are  often  absent.  Diarrhoea  and  tympany  are  often  troublesome  and 
there  is  a  marked  tendency  to  complications,  especially  those  affecting  the 
respiratory   tract — pneumonia,    bronchitis. 

(c)  Enteric  Fever  in  Pregnancy. — The  pregnant  woman  enjoys  no 
immunity  against  the  disease.  The  fever  may  develop  at  any  time,  but  is 
more  commonly  met  with  in  the  first  half  of  pregnancy.  Abortion  or  pre- 
mature labor  occurs  in  a  large  proportion  of  the  cases.  The  maternal 
mortality  is  high — sixteen  to  twenty  per  cent.  Infection  of  the  foetus 
does  not  always  follow,  but  when  it  occurs  the  child  dies  either  in  utero  or 
shortly  after  delivery.  Recent  investigations  have  shown  that  the  bacilli 
may  pass  by  way  of  the  placenta  to  the  child  and  cause  a  typhoid  septi- 
caemia without  intestinal  lesions.  The  positive  Widal  reaction  has  been 
observed  with  fetal  blood. 

Complications  and  Sequels. — Complications  and  sequels  are  more 
common  in  enteric  fever  than  in  any  other  acute  infectious  disease.  A 
recognition  of  this  fact  is  of  great  importance  in  diagnosis,  since  cases  occur 
in  which  the  prominence  of  a  complication  may  mask  the  sj^mptoms  of 
the  primary  disease. 

The  following  more  important  complications  are  to  be  considered: 

(a)  Complications  Involving  the  Digestive  and  Abdominal  Organs.  — 
Ulcerative  stomatitis  occasionally  occurs.  Phlegmonous  and  pseudo- 
membranous angina  is  a  rare  complication,  which  may  develop  in  the  third 
week  and  usually  proves  fatal.  Parotid  bubo,  usually  single,  sometimes 
double,  is  a  grave  but  not  necessarily  fatal  complication  in  severe  cases. 
It  may  be  followed  by  extensive  sloughing  or  by  angina  Ludovici,  venous 
thrombosis  or  pyaemia.  Hsematemesis  is  of  extremely  rare  occurrence  in 
enteric  fever.  It  may  result  from  the  specific  lesions  implicating  agminate 
follicles  present  in  the  gastric  mucous  membrane  or  from  a  peptic  ulcer. 

The  enlargement  of  the  spleen  may  attain  such  a  degree  that  the 
capsule  may  burst.  Rupture  of  this  organ  is  more  likely  to  be  the  result 
of  abscess  formation  following  infarct.  The  latter  condition  owes  its  occur- 
rence to  embolism  or  venous  thrombosis. 

The  liver  itself  is  rarely  the  seat  of  changes  which  attract  attention. 
Jaundice  is  of  very  infrequent  occurrence.  Hepatic  abscess  is  exceedingly 
rare.  Cholecystitis  is,  on  the  other  hand,  conmion.  Pain,  tenderness,  and 
muscular  rigidity  in  the  region  of  the  gall-bladder  may  be  noted  in  most 
of  the  cases.  Distention  of  the  viscus — gall-bladder  tumoi- — may  be  recog- 
nized upon  nice  palpation  and  percussion.     Perforation  may  occur  with 


620  MEDICAL  DIAGNOSIS. 

the  symptoms  of  intestinal  perforation — extreme  pain,  tenderness,  rigidity^ 
fall  of  temperature,  collapse  symptoms,  and  the  general  and  local  signs  of 
peritonitis.  A  suppurative  cholangitis  may  occur.  More  commonly  the 
symptoms  gradually  subside  and  recovery  follows.  There  may,  however, 
be  remote  consequences.  The  bacilli  frequently  give  rise  to  chronic  chole- 
cystitis with  recurrent  paroxysms  and  to  cholelithiasis. 

Persistence  of  B.  typhosus  After  Recovery. — In  by  far  the 
greater  number  of  cases  inflammation  of  the  bile-ducts  and  gall-bladder 
terminates  in  recovery,  but  in  about  2  per  cent,  it  persists,  especially  in. 
the  gall-bladder,  and  the  bacillus  continues  to  multiply  in  the  latter 
for  an  indefinite  period.  From  this  viscus  it  passes  from  time  to  time  in 
considerable  quantities  into  the  gut  and  may  be  recovered  from  the  faeces. 
These  cases  constitute  a  group  of  individuals  now  known  as  "typhoid 
carriers"  who  are  a  constant  source  of  danger  to  the  public,  since  they  may 
spread  the  infection  without  giving  rise  to  suspicion.  Many  of  the  sporadic 
cases,  the  origin  of  which  has  been  involved  in  obscurity,  are  now  attributed 
to  these  "carriers."  Many  of  them  are  women  and  the  subjects  of  chole- 
lithiasis. The  presence  of  Eberth's  bacilli  in  the  stools  is  frequently  asso- 
ciated with  a  remarkable  reduction  in  the  total  number  of  micro-organisms 
ordinarily  present  in  the  faeces. 

Intestinal  hemorrhage  and  perforation  have  already  been  considered. 
These  events  are  so  directly  due  to  the  specific  lesions  of  enteric  fever, 
they  occur  with  such  frequency,  and  require  such  a  degree  of  importance 
in  the  consideration  of  the  subject  that  it  seems  more  in  accordance  with 
the  facts  to  regard  them  not  as  complications,  but  rather  as  accidents  in 
the  disease. 

(b)  Complications  Affecting  the  Respiratory  Organs. — Laryngeal  ulcera- 
tion is  common  in  the  severe  cases.  It  may  consist  merely  of  superficial 
erosion  and  run  its  course  without  symptoms.  It  may,  on  the  other 
hand,  give  rise  to  hoarseness,  pain  and  difficulty  in  deglutition.  Finally, 
it  may  produce  perichondritis,  in  the  course  of  which  oedema  of  the  glottis 
may  occur.  Bronchitis  is  prominent  in  infancy  and  often  severe  in  old 
persons.  Hypostatic  pneumonia  and  deglutition  pneumonia  are  almost 
always  present  in  severe  cases  after  the  middle  of  the  second  week.  Pul- 
monary oedema  is  a  terminal  condition. 

Lobar  pneumonia  occurs,  (1)  as  an  initial  condition — pneumotyphus. 
The  onset  is  abrupt  with  chill,  high  temperature,  pain  in  the  sides.  Cough 
and  bloody  sputa  occur.  After  a  day  or  two  the  signs  of  consolidation  occur 
and  the  case  presents  the  complete  clinical  picture  of  an  ordinary  croup- 
ous pneumonia.  Crisis  does  not  occur  and  by  the  end  of  the  first  or  the 
middle  of  the  second  week  rose  spots  appear  and  the  symptoms  of  enteric 
.fever  are  unmistakable.  In  the  absence  of  rose  spots,  the  uncertainty  as 
to  whether  the  case  is  one  of  croupous  pneumonia  with  so-called  typhoid 
symptoms  resulting  from  secondary  infection  or  enteric  fever  with  early 
pulmonary  localization  can  only  be  cleared  up  by  a  bacteriological  diag- 
nosis— presence  or  absence  of  Eberth's  bacilli  in  the  sputum,  urine,  and 
pus,  blood  culture,  Gruber-Widal  test.  (2)  Croupous  pneumonia  is  a  com- 
mon and  serious  complication — intercurrent  disease — in  the  second  or 
third  week.     It  usually  occurs  in  cases  already  otherwise  severe.     The 


ENTERIC  OR  TYPHOID  FEVER.  621 

symptoms  are  not  usually  well  developed.  Cough  is  slight,  rusty  sputum 
may  be  absent,  and  the  presence  of  the  pulmonary  consolidation  may  only 
be  discovered  upon  routine  examination.  Secondary  gangrene  of  the  lung 
may  develop.  Pulmonary  gangrene  in  enteric  fever  is  more  frequently 
the  result  of  the  breaking  down  of  an  infarct.  Abscess  of  the  lung  con- 
stitutes one  of  the  less  common  complications. 

Pleurisy  is  by  no  means  rare.  It  may  be  fibrinous,  serofibrinous,  or 
purulent.  The  effusion  is  often  small  and  circumscribed.  It  may  follow 
the  signs  of  an  infarct — local  pain  and  dulness,  increased  fever,  and  hemor- 
rhagic sputa.  Typhoid  bacilli  have  frequently  been  found  in  both  the 
serous  and  purulent  pleural  exudates. 

Pulmonary  tuberculosis  is  not  rarely  an  associated  affection.  The 
patient  may  be  already  phthisical,  in  which  case  the  enteric  fever  plays 
the  role  of  an  intercurrent  disease,  or  a  latent  tuberculous  process  may 
become  active.  Haemoptysis  may  be  profuse,  even  fatal.  Pneumothorax 
has  been  observed.  It  may  result  from  the  rupture  of  a  peripheral  abscess 
of  the  lung. 

(c)  Complications  Affecting  the  Circulatory  Organs. — Pericarditis  is 
exceedingly  uncommon.  It  has  been  observed  in  children  and  in  con- 
nection with  pneumonia.    Endocarditis  is  likewise  rare. 

Myocardial  changes  are  on  the  other  hand  most  frequent.  They  begin 
early  and  are  often  well  established  by  the  end  of  the  second  week.  The 
heart  is  soft,  flabby,  and  of  a  pale  yellowish — faded-leaf — color.  Upon  the 
table  it  often  flattens  into  a  formless  mass.  Microscopically  the  changes 
are  those  of  parenchymatous  degeneration  and  interstitial  myocarditis. 
There  may  be  fatty  degeneration  of  high  grade.  Feebleness  of  the  pulse, 
faint,  even  inaudible  first  sound,  profound  asthenia,  fatal  collapse  may  be 
the  manifestations  of  the  changes  in  the  myocardium.  Acute  dilatation 
with  relative  insufficiency,  thrombus  formation  and  visceral  engorgements 
likewise  arise  and  are  attended  with  their  usual  symptoms  and  signs. 
There  is  a  direct  relationship  in  patients  who  recover  between  the  myo- 
cardial changes  of  enteric  fever  and  chronic  myocarditis,  the  symptoms  of 
which  develop  later  in  life,  as  can  be  learned  from  the  anamnesis. 

Vascular  occlusions  occur  both  in  the  veins  and  arteries.  They  may 
result  from  embolism  or  thrombosis.  Obliteration  of  the  femoral  artery 
may  occur  with  gangrene  of  the  foot  and  leg.  Obliteration  of  both  femorals 
with  extension  of  the  clot  into  the  aorta  has  been  observed.  The  condition 
has  been  ascribed  to  local  arteritis  with  thrombus  formation. 

Venous  thrombosis  is  of  comparatively  frequent  occurrence — two  to 
four  per  cent,  of  the  cases.  It  is  usually  unilateral,  sometimes  bilateral, 
the  left  side  being  first  affected,  the  right  later.  In  far  the  greater  number 
of  cases  the  femoral  vein  is  the  seat  of  the  occlusion;  less  frequently  the 
popliteal  or  the  long  saphenous.  The  clot  may  extend  along  the  vein  from 
the  point  of  formation.  The  greater  liability  of  the  left  femoral  vein  has 
been  attributed  to  the  relative  retardation  of  the  blood-flow  in  the  left 
common  iliac  vein  caused  by  the  pressure  of  the  right  iliac  artery  which 
crosses  it.  The  occurrence  of  venous  thrombosis  is  attended  by  elevation 
of  temperature,  pain,  tenderness,  enlargement,  and  tense  oedema  of  the  leg. 
It  may  come  on  later  in  the  attack  or  not  until  after  defervescence.    Eberth's 


622  MEDICAL  DIAGNOSIS. 

bacilli  have  been  found  in  the  clot  and  in  the  wall  of  the  vein.  Suppura- 
tion and  pyaemia  may  occur.  A  fragment  of  the  clot  swept  into  the  blood 
stream  may  cause  sudden  death  by  plugging  of  the  pulmonary  artery. 
Gangrene  does  not  result  from  venous  thrombosis.  As  the  collateral 
circulation  is  established  the  enlargement  of  the  leg  subsides,  but  many 
patients  are  obliged  to  wear  an  elastic  stocking  for  months  or  even  years. 

Thrombosis  of  the  cerebral  sinuses  is  a  rare  accident.  Infarction  of 
the  lungs,  spleen,  or  kidneys  occurs  as  the  result  of  arterial  occlusion,  due 
more  commonly  to  thrombosis  than  embolism. 

Gangrene  as  a  sequel  of  enteric  fever  most  commonly  affects  the 
feet  and  legs.  Gangrenous  areas  occur  less  frequently  upon  the  face, 
neck,  and  trunk.  The  genitalia,  especially  in  girls,  the  nose  and  ears 
may  also  be  affected. 

The  blood  undergoes  important  changes.  In  the  third  week  the 
erythrocytes  and  haemoglobin  are  reduced.  A  gradual  increase  to  normal 
takes  place  during  convalescence,  the  haemoglobin,  which  has  suffered  a 
relatively  greater  reduction  than  the  corpuscles,  regaining  the  normal 
more  slowly  than  the  latter.    These  changes  are  without  diagnostic  value. 

Very  important,  however,  is  the  fact  that  there  is  a  reduction  of  the 
leucocytes  during  the  whole  course  of  the  attack — leucopenia.  This  con- 
dition is  of  actual  diagnostic  value  in  the  differentiation  between  enteric 
fever  and  septic  states,  and  other  infectious  diseases  which  resemble  it 
more  or  less  closely.  A  leucocytosis  occurs  when  in  the  course  of  enteric 
fever  a  local  inflammation  arises  or  pneumonia  or  some  other  affection 
characterized  by  an  increase  in  the  number  of  the  leucocytes  occurs  as  an 
intercurrent  disease.  The  large  mononuclear  and  transitional  forms  are 
increased  and  the  polynuclear  neutrophiles  are  greatly  diminished.  In 
contrast  to  these  changes,  the  polynuclear  neutrophiles  are  increased  in 
inflammatory  conditions,  as  in  abscess  formation  or  perforation,  a  fact  of 
diagnostic  value. 

(d)  Complications  Affecting  the  Nervous  System. — The  nervous  sys- 
tem, as  has  been  pointed  out  above,  in  all  cases  manifests  to  a  greater 
or  less  degree  the  effects  of  the  intoxication.  These  effects  are  apparent 
at  the  onset  of  the  attack  and  vary  in  intensity  from  the  headache  and 
indisposition  to  mental  effort  seen  in  the  mildest  cases  to  the  furious  symp- 
toms of  meningitis.  The  latter  cases,  which  fortunately  are  extremely 
rare,  are  characterized  by  intense  headache,  photophobia,  painful  retrac- 
tion of  the  muscles  of  the  back  of  the  neck,  muscular  twitchings,  rigidity, 
and  in  some  cases  convulsions.  The  onset  is  abrupt  and  vomiting  may 
occur.  At  the  end  of  a  week  the  symptoms  become  less  intense,  in  a  con- 
siderable proportion  of  the  cases  almost  as  suddenly  as  they  appeared. 
The  headache  ceases,  rose  spots  appear,  there  is  palpable  enlargement  of 
the  spleen,  and  the  case  presents  the  clinical  features  of  an  ordinary  attack 
of  enteric  fever  which  runs  the  usual  course.  These  are  the  cases  described 
as  cerebrospinal  typhoid.  In  fatal  cases  of  this  group  the  lesions  of  menin- 
gitis are  not  found. 

Inflammation  of  the  meninges  of  the  brain  has  been  observed.  It  is 
an  extremely  rare  complication.  Typhoid  bacilli  have  been  isolated  from 
the  exudate  in  pure  culture.     Kernig's  sign  was  present  in  a  case  of  enteric 


ENTERIC  OR  TYPHOID  FEVER.  623 

fever  with  meningeal  symptoms  recently  observed.  Lumbar  puncture 
may  be  necessary  in  the  differential  diagnosis  between  this  form  of  enteric 
fever  and  cerebrospinal  fever. 

The  rare  cases  of  thrombosis  of  the  cerebral  veins  and  sinuses  are 
characterized  by  local  and  general  convulsive  movements,  active  delirium, 
and  rapidly  developing  coma. 

Neuritis  is  an  infrequent  complication.  It  is  usually  confined  to  a 
single  nerve;  sometimes  it  is  symmetrical.  Less  frequently  there  is  a 
general  peripheral  neuritis.  Neuritis  affecting  a  single  nerve  area  may 
develop  during  the  course  of  the  attack,  or,  as  is  more  commonly  the  case, 
after  convalescence  has  begun.  There  is  severe  pain  in  the  affected  limb 
with  exquisite  tenderness  over  the  trunk  of  the  nerve.  There  ma}^  be 
swelling  and  redness.  The  extensors  are  more  commonly  involved  and 
wrist-drop  or  foot-drop  may  occur. 

Tender  toes  constitute  the  manifestation  of  a  form  of  neuritis  not  very 
uncommon.  This  distressing  but  not  very  serious  condition  may  occur 
under  any  treatment  but  is  said  to  be  more  frec[uent  in  cases  treated  by 
systematic  cold  bathing.  The  tips  of  the  toes,  their  pads,  and  sometimes 
the  pads  at  their  bases  are  painful  and  exquisitely  sensitive  so  that  it  is 
impossible  for  the  patient  to  bear  the  weight  of  the  bedclothes.  There  is 
neither  redness  nor  swelling,  and  the  condition — which  begins  toward  the 
end  of  the  attack — usually  disappears  in  the  course  of  a  week  or  ten  days. 

Multiple  neuritis,  sometimes  giving  rise  to  paraplegia,  palsies  of 
individual  nerve-trunks  from  neuritis  and  poliomyelitis,  hemiplegia  from 
thrombosis  or  meningo-encephalitis,  and  tetany  may  develop  during 
convalescence.  These  sequels  are  of  extremely  rare  occurrence  and  of 
secondary  importance  in  the  diagnosis. 

Postfebrile  insanity  is  encountered  more  frequently  after  enteric 
fever  than  any  other  acute  infection.  It  belongs  to  the  group  of  confu- 
sional  insanities  and  is  the  manifestation  of  profound  nutritional  derange- 
ments in  neurotic  individuals.  It  has  occurred  in  my  experience  in  cases 
in  which  active  delirium  has  been  present  during  the  attack.  There  are 
persistent  hallucinations,  melancholia,  and  speech  derangements.  The 
prognosis  is  good.  A  majority  of  the  cases  recover  in  the  course  of  six  or 
eight  months.  After  that  period  the  outlook  becomes  progressively  less 
favorable,  though  I  have  seen  a  case  recover  at  the  end  of  a  year. 

Complications  relating  to  the  eye  are  exceedingly  rare..  Of  those 
affecting  the  ear,  otitis  media  is  common.  There  have  been  years  in  my 
service  in  the  Pennsylvania  Hospital  in  which  no  cases  of  this  complica- 
tion have  occurred,  and  years  in  which  it  has  been  extremely  frequent. 
The  otitis  commonly  develops  insidiously  but  it  sometimes  comes  on  with 
a  chill  and  increase  of  fever.  The  ears  should  be  examined  as  a  matter  of 
routine.     ^lastoid  disease  may  occur. 

(e)  Other  Complications. — Febrile — toxic  —  albuminuria  is  of  very 
frequent  occurrence  as  in  the  other  serious  infectious  diseases.  Hyaline 
and  granulohyaline  casts  may  be  found  in  the  centrifugated  urine.  This 
condition  passes  away  with  convalescence.  Eberth's  bacilli  are  demon- 
strable in  the  urine  in  a  large  proportion  of  the  cases.  In  some  cases  they 
have  been  found  in  the  urine  of  persons  months,  even  years,  after  the  attack. 


624 


MEDICAL  DIAGNOSIS. 


The  attack  may  begin  with  the  symptoms  of  an  acute  nephritis — 
nephro typhus.  The  toxic  albuminuria  occasionally  leads  to  the  develop- 
ment of  an  acute  nephritis  with  scanty  urine  of  high  specific  gravity,  a 
large  amount  of  albumin,  and  microscopical  blood.  This  complication  may 
be  the  cause  of  a  fatal  termination  of  the  case.  Otherwise  it  gradually 
subsides  and  complete  recovery  ensues.  Polyuria  during  the  course  of 
the  attack  is  an  extremely  rare  complication.  Chronic  nephritis  is  a 
rare  sequel.  The  multiple  foci  of  round-celled  infiltration — lymphom- 
atous  infiltration — which  may  lead  to  the  formation  of  miliary  abscess 
does  not  as  a  rule  give  rise  to  symptoms  and  is  rather  of  pa.thological 
than  of  clinical  interest. 

Pyelitis  is  occasionally  observed.  It  may  develop  in  the  later 
stages  of  the  attack  or  during  convalescence.  It  may  involve  one  or 
both  kidneys.      This  infection  reveals  itself  by  free  blood  together  with 


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.TEMPERATURE. 


Fig.  211. — Polyuria  in  enteric  fever. 

pus  and  later  by  a  condition  in  which  there  is  an  abundant  pyuria. 
If  one  kidney  only  is  affected  the  pyuria  may  be  intermittent,  with  an 
almost  pus-free  urine  in  the  intervals. 

Catarrh  of  the  bladder  or  an  acute  cystitis  may  be  the  cause  of  the 
urinary  pus.  These  conditions  are  somewhat  common  in  enteric  fever, 
especially  after  repeated  catheterization.  The  more  common  pyogenic 
micro-organisms  are  B.  coli,  B.  typhosus,  and  staphylococci.  Orchitis 
occasionally  occurs,  as  a  rule  in  association  with  a  purulent  urethritis. 
In  women  oedema  and  gangrene  of  the  vulva  and  acute  mastitis  are  very 
rare  complications.  Menstruation  is  not  likely  to  occur  during  the  attack. 
When  it  does  occur  it  is  usually  profuse. 

Hemorrhagic  cases  of  enteric  fever  have  been  reported.  Of  these  I 
have  seen  several.  Hemorrhages  into  the  skin  are  more  common  than  from 
mucous  surfaces.     The  general  symptoms  are  severe. 

Furunculosis,  local  gangrene  of  peripheral  parts,  periostitis,  caries, 
and  necrosis  with  abscess  and  sinus  formation  are  complications  and 
sequels  often  encountered.  The  bone  lesions  of  enteric  fever  are  notable 
for  their  persistence.     Typhoid  bacilli  are  present  in  a  majority  of  the 


ENTERIC  OR  TYPHOID  FEVER.  625 

cases.  The  tibiae,  ribs,  and  costal  cartilages  are  most  commonly  involved. 
Arthritis  involving  the  knee  and  hip  is  among  the  infrequent  comphca- 
tions.     It  is  usually  septic. 

Typhoid  Spine. — Spinal  symptoms  are  sometimes  observed  in  the 
later  course  of  severe  attacks  or  during  convalescence.  They  consist  of 
pain  in  the  lumbosacral  region,  aggravated  by  mx)vement,  tenderness  upon 
pressure,  stiffness,  and  inability  to  execute  movements  requiring  flexion, 
extension,  or  rotation  of  the  spine.  Nervous  symptoms  are  prominent  in 
some  cases.  There  is  no  rise  of  temperature  and  physical  signs  are  absent. 
The  condition  is  usually  a  neurosis — hysterical  spine — and  terminates  in 
recovery.  There  may  be  a  spondylitis.  I  have  seen  a  fatal  case  of  vertebral 
tuberculosis  following  enteric  fever  in  a  lad  of  seventeen,  which  for  a 
period  of  several  months  was  regarded  as  an  instance  of  typhoid  spine. 

Parenchymatous  degeneration  of  the  voluntary  muscles,  which  espe- 
cially affects  the  recti  abclominalis  and  the  adductors  of  the  thigh,  some- 
times leads  to  the  rupture  of  the  mass  of  the  muscle  and  may  also  lead  to 
hemorrhage  and  abscess  formation. 

The  Association  of  other  Diseases  with  Enteric  Fever. — The  fre- 
quency of  croupous  pneumonia  as  an  intercurrent  disease  has  been  noted 
above.  Erysipelas  occurs  in  about  two  per  cent,  of  the  cases,  more  com- 
monly in  the  period  of  convalescence.  The  exanthemata,  especially 
measles  and  varicella,  may  be  associated  with  enteric  fever. 

Malarial  fever  and  enteric  fever  may  coexist.  There  is  no  such  thing 
as  a  hybrid,  as  indicated  by  the  term  typhomalarial  fever.  Such  cases 
are  usually  enteric  fever  or  estivo-autumnal  fever  without  well-marked 
paroxysms. 

Tuberculosis  as  an  associated  disease  has  already  been  mentioned. 
The  various  phases  of  this  relation  will  be  fully  considered  later. 

The  Effect  of  Enteric  Fever  upon  Certain  Chronic  Diseases. — 
During  the  attack  of  enteric  fever  the  paroxysms  of  epilepsy  frequently  cease, 
the  irregular  movements  of  chorea  and  the  allied  affections  are  in  abeyance, 
and  sugar  frequently  wholly  disappears  from  the  urine  in  diabetic  subjects. 
In  all  these  conditions  the  effect  is  only  temporary  and  the  symptoms 
of  the  antecedent  disease  recur  with  convalescence  or  shortly  afterwards. 

Relapse.  —  The  frequency  of  relapse  varies,  according  to  different 
observers,  between  three  and  eighteen  or  twenty  per  cent.  Relapse  occurs 
with  greater  frequency  in  cases  treated  by  systematic  cold  bathing.  It  is 
obvious  that  a  therapeutic  method  which  reduces  the  mortality  will  increase 
the  number  of  convalescent  cases  in  which  relapse  may  occur. 

The  ordinary  form  of  relapse  begins  after  the  defervescence  is  com- 
plete and  presents  the  picture  of  a  repetition  of  the  primary  attack,  usually 
shortened  and  moderated  in  intensity.  The  onset  is  somewhat  more  rapid; 
sometimes  abrupt  with  a  chill.  At  times,  however,  the  relapse  is  even 
more  severe  than  the  original  disease  and  occasionally  it  terminates  in 
death.  The  interval  between  the  defervescence  and  the  relapse  varies 
from  two  or  three  to  twenty  days.  I  have  seen  a  case  in  which  it  was  five 
weeks.  The  question  as  to  whether  a  repetition  of  the  attack  after  a  pro- 
longed period  constitutes  a  late  relapse  or  an  early  second  attack  is  purely 
academic  and  without  practical  importance.     The  relapse  is  commonly 

40 


626 


MEDICAL  DIAGNOSIS. 


single;  occasionally  multiple:  two  are  by  no  means  rare;  three  are  infre- 
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and  other  factors  in  the  enteric  fever  symptom-complex.  It  is  to  be  dis- 
tinguished from  recrudescence — a  transient  fever  dependent  upon  the 
instability  of  the  heat-regulating  apparatus  during  convalescence  and  due 
to  trifling  causes;  from  so-called  bed-fever, — an  unimportant  clinical 
manifestation, — and  from  the  symptomatic  fever  which  may  be  the  first 


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Pig.  212. — Enteric  fever.  Relapse  beginning  in  abrupt  rise  of  temperature  on  the  29th  day  after 
the  onset  of  the  primary  attack  and  the  14th  after  complete  defervescence.  Duration  of  relapse  13  days» 
Recovery.    Girl,  aged  11  years. 

indication  of  some  sequel  or  fresh  infective  or  inflammatory  process,  to 
which  the  depraved  nutrition  of  the  organism  singularly  disposes  it. 

Intercurrent  Relapse. — This  form  of  relapse  receives  its  name  from  the 
fact  that  it  begins  before  the  primary  attack  comes  to  an  end.  The  patient 
seems  to  be  doing  well;  the  temperature  has  assumed  the  remittent,  even 
the  intermittent,  curve;  the  tongue  begins  to  clean  off;  the  nervous  symp- 
toms ameliorate,  and  convalescence  appears  assured,  when  the  fever  again 
rises  and  becomes  subcontinuous,  and  with  recurrence  of  the  symptoms 
the  attack  repeats  its  previous  course.  Relapses  of  this  form  are  often 
severe.     They  explain  a  large  proportion  of  the  protracted  cases. 

Theory  of  the  Relapse  in  Enteric  Fever. — In  a  majority  of  the 
cases  the  circumstances  under  which  relapses  occur  render  it  practically 


ENTERIC  OR  TYPHOID  FEVER.  627 

impossible  for  the  reinfection  to  have  come  from  outside.  Neither  the 
water  nor  the  food,  including  the  milk,  can  be  incriminated.  The  theory 
of  reinfection  from  within  the  organism  is  the  only  alternative.  Of  the 
actual  conditions  favoring  its  occurrence  little  is  known.  As  a  working 
hypothesis,  reinfection  from  the  gall-bladder  and  bile  passages  as  suggested 
by  Chiari  appears  to  meet  the  requirements  of  a  majority  of  the  cases. 
The  persistence  of  the  bacilli  in  the  mesenteric  glands,  the  spleen,  and  the 
gall-bladder,  and  their  presence  in  the  stools  for  a  long  time  after  deferves- 
cence favor  this  view.  The  immunity  conferred  by  the  attack  is  apparently 
of  slow  development.  The  fact  that  the  greater  number  of  relapses  occur 
within  a  week  or  ten  days  after  the  fever  has  subsided,  at  a  time  when  solid 
food  in  increasing  amounts  is  being  taken,  lends  support  to  this  hypothesis. 
It  is  at  least  possible  that  increased  peristalsis  may  cause  the  sudden  dis- 
charge of  large  quantities  of  bacilli-laden  bile  into  the  intestines  at  a  time 
when  immunity  is  not  yet  complete.  Too  much  food  and  unwholesome 
food  may  cause  recrudescences  of  fever,  but  that  they  can,  in  the  absence 
of  reinfection,  cause  relapse  is  a  proposition  not  to  be  considered.  The 
hypothesis  of  Durham,  that  groups  of  bacilli  of  similar  species  but  not 
identical  cause  the  attack,  and  that  the  antitoxin  formed  in  the  blood 
does  not  neutralize  all  these  groups,  those  remaining  active  giving  rise  to 
single  or  multiple  relapses,  is  highly  ingenious  but  lacks  proof. 

Diagnosis. — (1)  The  causal  or  etiological  diagnosis;  (2)  the  direct 
diagnosis;  (3)  the  differential  diagnosis;  (4)  diagnosis  by  exclusion;  and 
(5)  a  provisional  diagnosis  are  to  be  considered. 

The  diagnosis  is  a  simple  matter  in  well-characterized  cases  after  the 
first  week.  The  atypical  cases  are  obscure  and  the  more  widely  they 
depart  from  the  type  the  more  uncertain  does  the  diagnosis  become.  The 
remarkable  variations  in  the  disease  itself,  the  great  number  of  complica- 
tions and  seqiiels,  and  the  irregularity  of  its  course  add  to  the  difficulties. 
The  diagnostician  must  know  not  only  enteric  fever  but  he  must  also  know 
the  many  maladies  to  which  in  its  multiform  aspects  it  bears  a  close  or 
superficial  resemblance. 

1.  Causal  or  Etiological  Diagnosis. — In  sporadic  cases  in  which  the  true 
nature  of  the  attack  remains  obscure  and  the  association  of  cardinal 
symptoms  essential  to  a  clinical  diagnosis  is  lacking,  it  is  of  importance 
to  ascertain  whether  or  not  the  patient  has  visited  a  district  in  which  enteric 
fever  is  endemic  or  in  which  the  water  supply  is  tainted;  whether  he  has 
been  in  a  house  in  which  there  were  one  or  several  cases  or  he  is  a  newcomer, 
and  to  ascertain  the  length  of  time  since  such  probable  exposure.  The 
question  of  acquired  immunity  is  to  be  considered.  A  clear  history  of  a 
previous  attack  is  presumptive  but  not  positive  evidence  against  enteric 
fever  in  a  doubtful  case.  In  a  majority  of  sporadic  cases  the  source  of 
the  infection  cannot  be  traced. 

In  local  epidemics  every  effort  should  be  made  to  find  the  starting- 
point  of  the  outbreak.  Has  a  case  been  the  source  of  contamination? 
Has  a  sewer  burst  and  discharged  its  contents  into  a  water  reservoir?  Do 
the  cases  follow  the  distribution  of  the  milk  from  a  particular  dairy?  Are 
they  limited  to  those  who  have  eaten  oysters  or  other  shell-fish  from  beds 
in  sewage-defiled  waters  ?     If  in  a  standing  camp  is  the  water  to  be  incrimi- 


628  MEDICAL  DIAGNOSIS. 

nated,  or  badly  constructed  latrines  and  swarms  of  house-flies?  Upon  the 
answer  to  questions  like  these  often  depend  many  lives.  Diagnosis  and 
prophylaxis,  the  work  of  the  physician  and  of  the  sanitarian,  are  inseparably 
bound  together.  Bacteriologically,  the  presence  of  the  bacilli  in  the  blood 
or  discharges  is  of  conclusive  importance. 

The  isolation  of  B.  typhosus  from  the  blood  by  means  of  culture 
methods  has  become  in  recent  years  a  practical  diagnostic  procedure. 
The  quantity  of  blood  necessary  is  considerable  but  not  so  great  as  to  do 
harm  in  any  case.  Its  withdrawal  from  a  vein  is  almost  painless.  This 
method  yields  positive  results  early  in  the  attack,  even  before  the  appear- 
ance of  the  eruption.  It  is  especially  valuable  in  septic  cases.  A  recent 
method  is  that  of  Peabody,  and  consists  in  the  employment  of  ox-bile  as 
a  culture  medium  for  the  Bacillus  typhosus.  The  quantity  of  blood  required 
is  small — two  cubic  centimetres  being  sufficient.  The  blood  is  inoculated 
into  a  small  quantity  of  sterile  ox-bile  which  is  incubated  for  twenty-four 
hours.  A  portion  of  this  culture  is  then  transferred  to  Loffler's  blood- 
serum  medium  and  incubated  for  another  twenty-four  hours.  The  isola- 
tion of  a  motile  bacillus  may  be  regarded  as  presumptive  evidence  of  the 
existence  of  enteric  fever,  but  further  cultures  are  necessary  to  establish 
the  identity  of  the  organism. 

Blood  removed  from  the  rose  spots  contains  the  bacilli.  The  procedure 
is  attended  with  pain  and  is  useless  for  diagnostic  purposes,  since  the 
eruption  itself  constitutes  a  cardinal  diagnostic  criterion.  The  isolation 
of  the  bacilli  from  the  urine  is  now  a  practical  method  of  diagnosis.  Their 
demonstration  is  conclusive  as  regards  the  nature  of  the  disease.  Their 
presence  has  been  noted  in  some  cases  at  an  earlier  period  than  a  positive 
agglutination  test. 

The  isolation  of  the  bacilli  from  the  stools  has  been  rendered  practi- 
cable by  the  more  recent  culture  methods,  but  the  technical  difficulties  are 
considerable  and  the  results  uncertain. 

Of  the  foregoing  methods,  blood  cultures  and  the  examination  of  the 
urine  are  more  practical  than  the  others  and  are  in  use  when  the  necessary 
technical  skill  and  the  facilities  of  a  clinical  laboratory  are  at  hand. 
The  majority  of  practitioners  are  not,  however,  in  a  position  to  avail 
themselves  of  them. 

The  Agglutination  Test — Widal  Test. — This  diagnostic  procedure 
is  of  very  great  value.  It  depends  upon  the  property  of  the  blood-serum 
of  an  enteric  fever  patient,  when  added  to  a  fresh  culture  of  the  bacilli,  to 
cause  an  arrest  of  the  movement  of  the  latter  and  their  agglutination  in 
clumps.  The  test  requires  a  definite  dilution  of  the  serum  and  time  limit. 
The  microscopical  examination  is  made  by  means  of  the  hanging  drop. 
A  dilution  of  1-50  and  time  limit  of  an  hour  are  in  general  use.  The  result 
is  decisive  if  loss  of  motility  and  clumping  occur  within  this  period.  The 
dried  serum  is  convenient  but  its  use  does  not  permit  of  accurate  dilution. 
Small  glass  bulbs  may  be  used  for  the  collection  of  the  serum.  When  the 
test  yields  a  positive  result  an  equally  prompt  and  energetic  response  to  an 
increased  dilution  renders  the  diagnosis  even  more  certain. 

The  results  of  the  Widal  test  are  to  be  taken  into  consideration  in 
connection  with  the  following  facts: 


ENTERIC  OR  TYPHOID  FEVER.  629 

A  positive  result  has  been  obtained  some  time  in  the  course  of  the 
attack  or  convalescence  in  about  97  per  cent,  of  cases  in  which  the  clinical 
or  post-mortem  data  rendered  the  diagnosis  certain. 

A  positive  result  has  been  obtained  in  about  93  per  cent,  of  similar 
cases  in  which  the  test  was  made  before  the  eighth  day. 

In  a  limited  number  of  cases  the  diagnosis  has  been  negative  in  the 
early  course  of  the  attack  and  become  positive  in  the  third  or  fourth 
week,  or  not  until  after  the  defervescence  or  upon  the  occurrence  of  a 
relapse.  A  well-characterized  case  of  enteric  fever  with  enlarged  spleen, 
rose  spots,  diarrhoea,  even  intestinal  hemorrhage  may  give  a  negative 
result  throughout. 

The  agglutinating  power  is  retained  by  the  serum  for  an  indefinite 
time,  sometimes  months,  even  years,  after  the  attack.  A  positive  reaction 
may  be  therefore  misleading,  especially  in  a  patient  in  whom  the  disease 
has  run  its  course  in  an  irregular  manner  or  has  been  of  the  mildest  or  of 
the  ambulatory  variety — typhus  levissimus,  typhus  ambulans — and  does 
not  therefore  appear  in  the  anamnesis. 

The  blood-serum  of  healthy  persons  and  of  persons  suffering  from 
other  specific  infections,  undiluted  or  in  much  lower  dilution  than  is  used 
in  the  Widal  test,  sometimes  causes  loss  of  motility  and  clumping  of  the 
bacilli  in  cultures,  but  not  with  the  same  promptness  and  energy,  and  this 
property  in  non-typhoid  blood  is  lost  when  higher  dilutions,  1-50,  1-100, 
are  employed. 

In  a  limited  number  of  cases  presenting  the  clinical  picture  of  enteric 
fever  but  in  which  the  Widal  test  has  remained  negative,  a  positive  reaction 
has  been  obtained  with  cultures  of  paratyphoid  bacilli — paratyphoid. 

Caution  is  therefore  necessary,  except  in  the  prompt  and  marked 
reaction  on  the  one  hand  and  in  the  cases,  on  the  other  hand,  in  which  the 
reaction  does  not  occur  at  any  time,  in  drawing  either  positive  or  negative 
conclusions.  If,  however,  due  regard  be  paid  to  the  above  mentioned 
peculiarities  in  the  reaction,  the  Widal  test  is  of  great  value  in  diagnosis. 

The  macroscopic  method  is  not  in  general  use. 

The  Widal  test,  important  as  it  is,  cannot  be  made  available  for  the 
general  practitioner  because  of  the  difficulty  of  having  constantly  on  hand 
fresh  cultures  of  the  bacilli.  Only  in  communities  in  which  there  are 
well-eciuipped  clinical  laboratories  can  its  full  usefulness  be  realized. 

The  Ophthalmic  Reaction  in  the  Diagnosis  of  Enteric  Fever. — 
Chantemesse  (1907)  announced  a  new  characteristic  reaction  for  the 
diagnosis  of  enteric  fever.  The  test  is  performed  by  instilling  into  the 
conjunctival  sac  a  solution  prepared  from  virulent  typhoid  bacilli  by  wash- 
ing, drying  and  trituration,  precipitation  with  alcohol,  and  again  drying 
and  reducing  to  powder.  The  powder  thus  obtained  is  dissolved  in  sterile 
water  in  the  proportion  of  5V  ]\Ig.  to  a  drop,  which  is  the  quantity 
employed.  A  positive  reaction  consists  in  the  occurrence,  in  from  three  to 
eighteen  hours,  of  congestion,  lachrymation,  and  a  serofibrinous  exudate. 
The  conjunctivitis  attains  its  maximum  in  a  few  hours  and  subsides  in  the 
course  of  twenty-four  to  seventy-two  hours.  In  control  cases  the  negative 
result  is  manifest  in  absence  of  change  or  at  most  a  slight  hj^peraemia  which 
passes  off  in  the  course  of  five  or  six  hours.     This  diagnostic  test  has  the 


630  MEDICAL  DIAGNOSIS. 

advantages  of  simplicity  of  technic  as  compared  with  blood  cultures  and 
the  Widal  test,  and  being  available  at  an  earlier  period  than  the  latter. 

The  urotoxic  coefficient  in  enteric  fever  is  high  and  has  been  found 
to  be  increased  in  cases  treated  by  systematic  cold  bathing.  This  fact 
which  is  intimately  related  to  the  bacteriology  of  the  disease  is  not  used 
for  diagnostic  purposes. 

2.  The  Direct  Diagnosis. — The  presence  of  B.  typhosus  in  the  blood 
or  excretions  or  a  prompt  response  to  the  Widal  test  renders  the  diagnosis 
positive  independently  of  the  clinical  phenomena.  The  direct  diagnosis 
then  rests  upon  the  bacteriological  diagnosis.  In  the  vast  majority  of  cases 
the  diagnosis  can  be  made  with  precision  at  the  bedside — a  fortunate 
matter,  since  the  elaborate  procedures  of  the  bacteriological  laboratory 
are  not  always  available. 

The  association  of  the  four  following  symptoms  is  of  cardinal 
importance: 

(a)  The  Gradually  Ascending  Temperature. — This  phenomenon 
is  available  only  when  the  observations  have  been  begun  early  in  the 
attack — second  or  third  day.  This  happens  only  in  a  limited  number  of  the 
cases;  but  a  temperature  of  103°-104°  F.  (39.5°-40°  C.)  of  subcontinuous 
type  and  a  history  of  febrile  symptoms  of  gradually  increasing  severity 
and  several  days'  duration  are  significant.  A  curve  of  remittent  type  in 
the  third  week  and  distinct  intermissions  with  progressively  f  alHng  evening 
maxima  are  of  great  diagnostic  value  in  a  case  in  which  other  diagnostic 
criteria  have  been  uncertain.  The  duration  of  the  febrile  movement  is 
important,  but  it  is  in  the  doubtful  cases  that  we  find  a  shorter  or,  more 
commonly,  a  longer  course  than  in  those  which  are  typical. 

(b)  The  pulse-frequency,  which  is  increased,  but  not  in  proportion 
to  the  temperature.  With  evening  maxima  of  104°  F.  the  pulse-frequency 
may  not  exceed  90-110  per  minute.  This  derangement  of  ratio  is  observed 
in  very  few  of  the  acute  febrile  infections.  Yellow  fever  is  conspicuous, 
but  there  can  scarcely  be  any  question  as  to  the  discrimination  between 
that  disease  and  enteric  fever.  There  is  nothing  characteristic  in  the  pulse 
itself.  Dicrotism  occurs  under  other  conditions,  but  its  early  appearance 
is  very  suggestive. 

(c)  Enlargement  of  the  Spleen. — This  is  a  constant  phenomenon, 
but  cannot  always,  on  account  of  the  distention  of  the  bowel,  be  demon- 
strated. It  occurs  in  the  other  acute  infections.  Nevertheless  enlarge- 
ment of  the  spleen  at  the  end  of  the  first  week,  associated  with  the 
other  cardinal  symptoms,  is  of  great  diagnostic  value  in  the  direct 
diagnosis. 

(d)  The  Eruption. — The  appearance  of  the  rose  spots  at  the  close 
of  the  first  or  in  the  course  of  the  second  week  is  an  event  of  the  highest 
diagnostic  significance.  A  single  spot  is  without  great  value,  and  the 
single  spot  is  usually  a  "doubtful"  spot;  but  successive  crops  of  papulo- 
macular,  rose-pink  spots,  distributed  over  the  upper  abdominal  or  lower 

■  thoracic  regions,  disappearing  upon  pressure  or  when  the  skin  is  made 
tense,  each  spot  fading  in  the  course  of  three  or  four  days,  do  not  occur  in 
any  other  febrile  infection  and  may  be  regarded  as  rendering  a  provisional 
diagnosis  positive. 


ENTERIC  OR  TYPHOID  FEVER.  631 

Symptoms  of  minor  diagnostic  importance  are  epistaxis,  the  furred 
tongue,  red  at  the  borders  and  tip,  diarrhoea  with  thin,  ochre-colored  stools 
containing  now  and  then  one  or  two  hard  masses,  and  separating  on  stand- 
ing into  a  thin  upper  and  a  thicker  sedimentary  layer,  tympanj^,  the  ner- 
vous phenomena,  and  bronchitis.  Intestinal  hemorrhage  or  perforation 
confirms  the  diagnosis  in  a  doubtful  case.  The  tendency  to  complications 
is  characteristic  of  enteric  fever,  especially  in  the  later  course  of  the  attack. 
Furunculosis,  abscess  formation,  parotitis,  bed-sores,  septic  phenomena 
-are  of  merely  suggestive  importance.  A  subnormal  temperature  and  eager 
hunger  after  defervescence  are  of  very  common  occurrence.  The  absence 
of  leucocytosis  is  of  value,  but  it  is  precisely  in  the  doubtful  cases  that 
inflammatory  processes  or  obscure  pus  collections  impair  the  value  of  this 
method  of  diagnosis. 

Among  the  symptoms  which  militate  against  the  diagnosis  but  do 
not  negative  it  entirely  are  marked  coryza,  herpes,  initial  sweating,  early 
arthritis  and  endo-  or  pericarditis;  the  continued  absence  of  abdominal 
symptoms,  as  diarrhoea,  especially  if  resistant  to  laxatives,  a  retracted 
abdomen  and  only  slight  enlargement  of  the  spleen.  The  continuing 
absence  of  the  diazo  reaction  is  not  common  in  enteric  fever. 

3.  Differential  Diagnosis. — The  data  for  a  positive  diagnosis  of  enteric 
fever  are  rarely  present  during  the  first  week.  A  provisional  diagnosis 
only  is  possible.  This  is  especially  the  case  when  the  patient  is  seen  for 
the  first  time.  During  the  fastigium  if  the  four  cardinal  symptoms  of  sub- 
continuous  high  temperature,  slow  pulse  in  proportion  to  the  temperature, 
enlarged  spleen,  and  rash  are  present  the  nature  of  the  malady  is  beyond 
question.  But  it  often  happens  that  one  or  more,  even  all  of  these  symp- 
toms, are  wanting.  The  fever  may  be  irregular,  the  pulse  rapid,  the  enlarge- 
ment of  the  spleen  not  demonstrable,  and  eruption  absent.  In  the  later 
course  of  the  attack  septic  phenomena,  various  complications,  or  an  inter- 
current relapse  may  again  render  the  diagnosis  obscure.  It  is  instructive, 
therefore,  to  consider  under  the  above  heading  (a)  the  diseases  which  resem- 
ble enteric  fever  in  the  first  week,  (b)  those  which  resemble  it  during  the 
fastigium,  and  (c)  those  which  resemble  it  at  later  periods. 

(a)  Diseases  which  Resemble  Enteric  Fever  in  the  First  Week. 
— We  must  consider  first  the  diseases  which  sometimes  resemble  it  in  its 
normal  course — influenza,  febricula,  the  exanthemata,  febrile  enteritis 
and  gastro-enteritis,  appendicitis — and  those  which  resemble  it  in  certain 
of  its  varieties — cerebrospinal  fever,  pneumonia,  central  pneumonia,  acute 
nephritis,  and  septic  conditions. 

Influenza  can  in  some  of  the  cases  be  excluded  only  after  several  days, 
especially  when  the  attack  has  begun  with  a  gradual,  step-like  elevation 
of  temperature,  diarrhoea,  and  enlargement  of  the  spleen.  I  have  many 
times  seen  epistaxis  at  the  onset  of  an  attack  of  epidemic  influenza.  The 
initial  nervous  symptoms  are  also  much  alike.  In  favor  of  influenza 
are  a  more  abrupt  onset,  catarrhal  symptoms,  especially  coryza  and  con- 
junctivitis, the  intensity  of  the  headache  and  its  localization  in  the  orbital 
regions,  a  pulse-rate  proportionate  to  the  rise  in  temperature,  and  the 
fact  that  the  attack  runs  its  course  and  defervescence  is  complete  by 
the  end  of  a  week. 


632  MEDICAL   DIAGNOSIS. 

Febricula. — Every  practitioner  sees  cases  of  transient  fever  with 
headache,  malaise,  anorexia,  and  sometimes  barely  recognizable  enlarge- 
ment of  the  spleen.  If  the  symptoms  last  twenty-four  hours  and  disappear 
altogether,  the  attack  is  known  as  ephemeral  fever;  if  they  continue  longer, 
to  six  or  seven  days  in  the  absence  of  local  trouble,  it  is  designated  febricula. 
Many  of  the  cases  are  examples  of  the  mildest  variety  of  enteric  fever  as 
shown  by  the  Wiclal  test.  The  diazo  reaction  may  also  be  present.  In  some 
instances  rose  spots  are  seen.  If  these  tests  are  negative  the  illness  is  not  due 
to  typhoid  infection,  but  to  some  other  infectious  agent,  gastro-intestinal 
catarrh,  ptomaine  poisoning  or  overwhelming  foul  odors,  or  the  fever  is  symp- 
tomatic of  some  unrecognized  local  infection  or  inflammatory  process. 

Acute  Exanthemata. — Scarlet  fever,  measles,  and  the  variolous  diseases 
may  during  the  period  of  onset  give  rise  to  the  suspicion  that  enteric  fever 
is  developing.  The  character  of  the  temperature  range,  the  coryza  in 
measles,  the  angina  of  scarlatina,  the  intense  headache  and  backache  of 
variola,  together  with  the  initial  rashes  when  present  and  the  appearance 
of  the  definite  eruption  in  a  relatively  short  time,  settle  any  question  as 
to  the  essential  nature  of  the  infection.  A  doubt  only  can  arise  in  regard 
to  the  eruption  of  measles.  In  several  instance*  I  have  seen,  especially 
in  children,  a  typhoid  eruption  so  copious  as  to  suggest  the  exanthem  of 
measles.  In  measles  the  rash  shows  itself  upon  the  fourth  day  after  a 
slight  fall  of  temperature,  usually  first  on  the  face  and  later  over  the  trunk 
and  limbs,  presents  a  crescentic  arrangement,  and  is  preceded  by  marked 
catarrhal  symptoms. 

Febrile  Enteritis  and  Gastro-enteritis. — As  a  rule,  gastric  and  intestinal 
catarrhs  run  their  course  without  fever.  Febrile  cases  do,  however,  occur. 
It  is  to  the  infrequent  cases  of  this  kind  that  such  terms  as  gastric  fever  and 
mucous  fever  owe  their  existence.  Most  of  the  cases  so  designated  by 
practitioners  are  cases  of  enteric  fever,  and  these  terms  are,  fortunately, 
falling  into  disuse.  The  prominence  of  dyspeptic  symptoms,  colicky  pains, 
the  irregular  course  of  the  fever,  the  absence  of  disparity  between  the 
pulse-frequency  and  the  elevation  of  temperature  weigh  heavily  against 
the  diagnosis  of  enteric  fever,  and  a  negative  Widal  reaction  up  to  the  time 
of  complete  defervescence  would  be  conclusively  against  such  a  diagnosis. 

Appendicitis. — The  gastro-intestinal  symptoms  and  especially  the 
pain  and  tenderness  may  if  attended  by  a  rise  in  temperature  simulate 
enteric  fever.  I  have  known  of  several  instances  in  which  a  patient  suffering 
from  the  latter  disease  has  been  admitted  to  a  hospital  at  night  and  at  once 
operated  upon,  with  the  recognition  upon  the  following  day  of  the  true 
nature  of  the  disease.  This  mistake  ought  not  to  occur.  The  sudden  onset, 
the  localization  of  the  pain,  the  high  degree  of  circumscribed  tenderness, 
the  absence  of  fever,  or  its  irregularity  when  present,  and  the  lack  of  the 
cardinal  symptoms  upon  which  the  diagnosis  of  enteric  fever  rests  should 
put  the  practitioner  upon  his  guard.  It  is,  however,  to  be  borne  in  mind 
that  after  the  middle  of  the  second  week  of  enteric  fever  perforation  of  the 
appendix  has  been  observed. 

Right  tubo-ovarian  disease  with  fever  may  also  simulate  enteric  fever. 
The  presence  of  a  tender  mass  upon  the  right  side  with  fixation  of  the  uterus 
and  leucocytosis  are  of  positive  diagnostic  significance. 


ENTERIC  OR  TYPHOID  FEVER.  633 

Meningotyphoid  —  cerebrospinal  fever  —  takes  first  place  among  the 
diseases  which  simulate  enteric  fever  in  its  more  irregular  forms.  In  fact 
the  resemblance  between  the  cerebrospinal  form  of  enteric  fever  in  the 
first  week  and  cerebrospinal  fever  is  so  great  that  a  differential  diagnosis 
is  in  a  majority  of  the  cases  altogether  impossible.  The  onset  is  sudden 
with  intense  headache,  photophobia,  delirium,  painful  rigidity  of  the  back 
of  the  neck,  and  sometimes  vomiting.  Kernig's  sign  may  be  present. 
Examination  of  the  fluid  obtained  by  lumbar  puncture  may  show  the 
meningococcus.  The  appearance  of  rose  spots  and  abdominal  symptoms 
at  the  end  of  the  first  week  and  mitigation  of  the  nervous  symptoms  are 
characteristic  of  enteric  fever.     Herpes  is  common  in  cerebrospinal  fever. 

Pneumonia. — Pneumotyphus  must  be  very  rare.  I  have  seen  a  very 
limited  number  of  cases.  The  sudden  onset  with  chill,  high  fever,  pain  in 
the  side,  cough,  and  the  signs  of  consolidation  are  very  misleading.  The  later 
course  is  that  of  enteric  fever.  The  difficulties  are  increased  in  the  irregular 
cases  of  enteric  fever  in  aged  persons.  Such  cases  have  been  regarded  as 
pneumonia  until  at  the  autopsy  the  intestinal  lesions  of  enteric  fever  have 
been  found.  The  recognition  of  intercurrent  croupous  pneumonia  at  the 
height  of  the  disease  is  a  comparatively  easy  matter  provided  that  system- 
atic routine  examination  by  the  methods  of  physical  diagnosis  are  made. 

There  are  cases  of  central  pneumonia,  occurring  independently  of 
enteric  fever,  which  simulate  it  very  closely.  These  cases  run  their  course 
for  days  with  no  other  symptoms  than  those  of  fever  and  perhaps  a  trifling 
cough.  Pain,  rusty  sputum,  and  the  signs  of  consolidation  are  not  present. 
The  diagnosis  rests  upon  the  abrupt  onset  with  chill  and  high  temperature, 
difficulty  in  breathing,  the  early  appearance  of  herpes,  and  a  slight  degree 
of  jaundice.  Leucocytosis  is  of  diagnostic  value.  It  is  to  be  remembered 
that  this  sign  may  be  absent  in  the  gravest  cases  of  pneumonia  and  present 
in  enteric  fever  complicated  by  inflamma.tory  or  purulent  processes.  The 
absence  of  the  temperature  curve  of  enteric  fever,  of  relative  slowness  of 
the  pulse,  of  considerable  enlargement  of  the  spleen,  and  of  rose  spots  is 
important.  The  occurrence  of  rusty  sputum,  even  when  scanty,  localized 
bronchophony,  a  tympanitic  percussion  sound,  and  crepitant  rales  estab- 
lish the  diagnosis  of  a  central  pneumonia,  which  is  fully  confirmed  when 
defervescence  takes  place  by  crisis  and  free  sweating. 

Nephrotyphus. — The  cases  which  begin  with  the  clinical  phenomena 
of  an  acute  nephritis  present  great  diagnostic  difficulties  during  the  first 
week  and  the  practitioner  who  brings  to  the  study  of  his  cases  in  a  system- 
atic manner  the  ordinary  clinical  methods — early  and  thorough  examination 
of  the  urine,  for  example — may  in  this  particular  group  of  cases  encounter 
uncertainties  that  his  less  careful  brother  may  avoid.  There  are  headache, 
vertigo,  mental  dulness,  disinclination  for  effort,  loss  of  appetite,  and  fever. 
Epistaxis  occurs  in  both  conditions.  The  illness  looks  like  enteric  fever; 
the  urine  is  that  of  an  acute  inflammation  of  the  kidneys.  It  is  scanty,  high- 
colored,  of  high  specific  gravity — 1.024  to  1.030 — and  contains  much  albu- 
min, together  with  hyalogranular  and  epithelial  tube-casts,  cylindroids,  and 
red  blood-corpuscles.  Rose  spots,  splenic  tumor,  a  more  or  less  character- 
istic temperature  range,  and  the  duration  of  the  attack  render  the  diag- 
nosis clear.     The  nephritis  does  not  tend  to  become  chronic. 


634  MEDICAL  DIAGNOSIS. 

Sepsis. — I  employ  this  term  here  to  cover  the  conditions  included 
under  septicaemia,  pyaemia,  and  septicopysemia.  In  general  the  differential 
diagnosis  between  these  conditions  and  enteric  fever  is  not  attended  with 
difficulty.  Where  there  is  trauma  or  obvious  bone  disease  or  demonstrable 
suppuration  no  question  arises.  There  are,  however,  forms  of  sepsis, 
especially  those  of  cryptogenetic  origin,  having  in  common  with  enteric 
fever  high  temperature,  splenic  tumor,  and  nervous  symptoms  in  which 
the  diagnosis  is  very  uncertain.  Among  the  symptoms  which  favor  the 
diagnosis  of  sepsis  are  the  following:  irregular  fever  with  marked  remis- 
sions and  intermissions  early  in  the  illness;  chills  followed  by  profuse 
perspiration;  endocarditis  of  the  septic  or  malignant  form;  septic  arthritis 
involving  a  single  joint  or  many;  tenderness  upon  pressure  over  the  bones 
— sternum,  clavicles,  tibiae — and  retinal  hemorrhage.  The  pulse  also  is 
very  frequent  and  arrhythmic.  In  many  of  the  cases  there  are  marked 
meningeal  symptoms  and  cutaneous  lesions,  herpes,  urticaria,  erythema, 
and  petechias  are  common.  We  do  not  overlook  the  fact  that  sepsis 
frequently  occurs  in  the  course  of  enteric  fever  and  that  there  is  a  recog- 
nized form  of  typhoid  septicaemia — facts  which  are  of  importance  in  the 
diagnosis  of  individual  cases. 

(b)  Diseases  which  Resemble  Enteric  Fever  in  the  Fastigium. — 
Malaria,  typhus  and  relapsing  fevers,  internal  anthrax,  miliary  and  tuber- 
culous peritonitis,  certain  forms  of  sepsis,  and  malignant  endocarditis 
may  be  grouped  in  this  category. 

Malarial  fever  may  as  a  rule  be  readily  differentiated  from  enteric 
fever.  The  regularly  intermitting  forms  present  no  difficulties.  In  the 
estivo-autumnal  form  the  diagnosis  may  be  uncertain  for  several  days. 
The  appearance  after  a  time  of  the  parasite  in  the  blood  settles  all  doubt 
as  to  the  nature  of  the  disease.  Meanwhile  the  absence  of  chills,  the  con- 
tinued fever  with  very  moderate  remissions,  together  with  weakness,  diar- 
rhoea, and  a  palpable  spleen,  suggest  enteric  fever.  The  malarial  and  the 
typhoid  infection  may  be  present  in  the  same  patient  at  the  same  time. 
With  the  estivo-autumnal  variety  this  association  is  not  uncommon,  as  was 
shown  in  soldiers  returning  from  Cuba  and  Porto  Rico  during  the  Spanish- 
American  War.  With  the  tertian  and  quartan  parasites  the  association  is  rare 
and  these  organisms  are  very  seldom  present  in  the  blood  of  individuals 
suffering  from  enteric  fever.  A  hybrid  disease  such  as  is  indicated  by  the 
term  typhomalarial  fever — a  separate  nosological  entity — does  not  exist. 

Typhus  fever  may  be  differentiated  from  enteric  fever  by  the  erup- 
tion, which  in  the  latter  is  far  and  away  more  sparse  and  appears  several 
days  later  in  the  course  of  the  attack.  Cases  in  which  the  rash  appears 
early  and  is  so  copious  as  to  suggest  typhus  fever  do  occur,  but  they  are 
extremely  rare.  It  does  not,  save  in  the  rarest  cases  of  hemorrhagic  enteric 
fever,  become  petechial,  as  is  the  rule  in  typhus.  The  abrupt  rise  and 
critical  fall  of  temperature  in  typhus  are  very  significant,  as  is  also  the 
high  pulse-frequency.  Dicrotism  is  often  present  in  both  diseases.  The 
difference  in  the  duration  of  the  two  diseases,  typhus  lasting  usually  from 
ten  to  fourteen  days,  is  to  be  noted.  The  Widal  reaction  is  almost  invari- 
ably wholly  absent  in  typhus.  Blood  cultures  may  become  necessary  in 
a  doubtful  case. 


ENTERIC  OR  TYPHOID  FEVER.  635 

Relapsing  fever  may  be  readily  differentiated  from  enteric  fever  by 
its  abrupt  onsejb  with  chill  and  very  high  temperature,  jaundice,  pain  and 
tenderness  in  the  epigastric  zone,  critical  defervescence,  period  of  complete 
apyrexia,  and  relapse.  The  presence  of  the  spirochseta  of  Obermeier  in  the 
blood  is  absolutely  conclusive.  In  typhus  and  relapsing  fevers  the  prev- 
alence of  an  epidemic  is  to  be  taken  into  consideration  in  the  differential 
■diagnosis.  Too  great  importance  must  not,  however,  be  attached  to 
epidemic  influence.  When  an  epidemic  exists  it  does  not  necessarily  follow 
that  a  person  taken  ill  has  contracted  the  prevalent  disease. 

Internal  anthrax  presents  the  symptoms  of  a  severe  infectious  disease 
with  intestinal  symptoms.  Fever,  diarrhoea,  and  splenic  enlargement 
occur.  There  are  symptoms,  however,  which  scarcely  belong  to  enteric 
fever,  as  repeated  vomiting,  colic,  bloody  diarrhoea,  haematuria,  dyspnoea, 
cyanosis,  and  submucous  extravasations  of  blood  in  the  mouth.  An  exami- 
nation of  the  blood  reveals  the  presence  of  anthrax  bacilli.  If  B.  anthracis 
is  not  present,  inoculation  experiments  must  be  practised. 

Acute  miliary  tuberculosis  is  occasionally  mistaken  for  enteric  fever. 
This  error  in  diagnosis  arises  from  the  fact  that  the  former  disease  fre- 
quently begins  rapidly  in  persons  apparently  in  good  health,  with  fever,  en- 
largement of  the  spleen,  and  nervous  symptoms,  and  without  demonstrable 
signs  of  organic  lesions  upon  physical  examination.  The  presence  in  rare 
cases  of  a  scanty  eruption  of  rose-colored  maculopapules  not  to  be  dis- 
tinguished from  the  rash  of  enteric  fever  adds  greatly  to  the  uncertainties 
of  the  diagnosis.  Their  recurrence  in  crops  is  in  favor  of  the  latter  affection. 
The  Widal  test  should  be  tried  and,  in  the  case  of  a  negative  result,  repeated 
at  intervals  of  some  days.  In  such  cases  there  is  usually  little  sputum  and 
neither  that  which  is  expectorated  nor  the  urine  contains  tubercle  bacilli. 
Careful  examination  of  the  chest  will  often  elicit  suggestive  signs,  as  vesiculo- 
tympanitic resonance  at  an  apex  and  a  few  scattered  small  mucous  or 
coarse  crepitant  rales  of  high  pitch.  Cyanosis  and  dyspnoea  are  prominent 
symptoms.  The  pulse,  in  the  absence  of  an  associated  meningitis  in  which 
it  is  often  slow,  is  frequent,  feeble,  and  arrhythmic,  showing  in  particular 
remarkable  variations  in  frequency  in  the  course  of  brief  intervals  of  time. 
The  splenic  enlargement  is  less  marked  than  in  enteric  fever;  but  there  are 
a  few  cases  of  the  latter  disease  in  which  the  spleen  is  but  little  enlarged 
and  many  in  which  during  the  fastigium  the  enlargement  cannot  be  demon- 
strated on  account  of  the  meteorism.  The  diazo  reaction  is  sometimes 
absent  in  enteric  fever  and  often  present  in  tuberculosis.  This  last  is  there- 
fore of  secondary  importance  in  the  differential  diagnosis  between  these 
two  diseases.  A  complicating  meningitis  may  occur  in  either  affection, 
but  is  much  more  common  in  tuberculosis.  If  an  ophthalmoscopic  exami- 
nation, which  should  be  repeated  from  time  to  time,  reveals  the  presence 
of  tubercles  in  the  choroid,  the  diagnosis  is  established.  The  atypical 
course  of  the  temperature  in  tuberculosis,  especially  its  extreme  irregularity, 
the  occurrence  of  remissions,  and  its  occasional  morning  exacerbations 
and  evening  remissions — inverse  type — are  of  great  diagnostic  value. 

Tuberculous  peritonitis  may,  in  certain  of  its  forms,  present  a  mis- 
leading resemblance  to  enteric  fever.  The  attack  begins  gradually  with 
abdominal  tenderness,  meteorism,  and  diarrhoea.     There  are  moderate  fever 


636  .  MEDICAL  DIAGNOSIS. 

of  subcontinuous  or  remittent  type  and  rapid  wasting.  The  diagnostic 
criteria  are  those  already  mentioned  under  acute  miliary  tuberculosis. 
Ascites,  a  doughy  distention  of  the  abdomen,  the  presence  of  enlarged 
mesenteric  glands  or  a  sausage-shaped  omental  tumor  are  confirmatory 
data  in  tuberculous  disease. 

Sepsis  may  present  the  same  difficulties  in  diagnosis  from  enteric  fever 
in  this  period  as  in  the  first  week.  The  points  of  differentiation  are  the 
same  and  have  already  been  set  forth  in  sufficient  detail.  The  long-con-, 
tinned  symptomatic  fever  of  deep-seated  suppuration,  often  obscure,  may 
in  the  absence  of  chills  and  sweating  closely  simulate  enteric  fever.  This 
is  especially  true  of  the  deep  abscesses  which  occasionally  occur  in  visceral 
and  bone  tuberculosis. 

Malignant  endocarditis  is  not  rarely  mistaken  for  enteric  fever.  Chang- 
ing murmurs,  embolism,  and  the  presence  of  leucocytosis  are  of  great 
diagnostic  aid.  The  Widal  reaction  and  blood  cultures  when  positive  as 
regards  B.  typhosus  dispel  any  doubts  as  to  the  presence  of  enteric  fever. 

(c)  Diseases  which  Resemble  Enteric  Fever  in  its  Later  Course. 
— Septic  conditions,  various  complications,  and  intercurrent  relapse  greatly 
modify  the  period  of  decline.  In  fact  the  terminal  course  of  an  ordinarily 
well-characterized,  uncomplicated  attack  of  enteric  fever  is  often  as  typical 
as  the  onset.  The  falling  temperature  with  its  remittent  and  intermittent 
curve,  the  cleaning  tongue  and  urgent  hunger,  the  clearing  mind  and  natural 
sleep,  all  coming  on  toward  the  close  of  an  illness  of  three  or  four  weeks' 
duration,  would  almost  justify  a  diagnosis  in  the  absence  of  a  history  of 
the  previous  course  of  the  attack.  Yet  this  favorable  course  is  often  greatly 
modified  by  the  above  conditions. 

Sejjsis  of  obscure  origin  —  cryptogenetic  —  sometimes  sepsis  due  to 
obvious  causes,  as  purulent  effusion,  abscess  formation,  or  caries,  may  so 
dominate  the  clinical  picture  as  to  raise  a  doubt  in  regard  to  the  true  nature 
of  the  primary  attack.  In  default  of  a  satisfactory  anamnesis  the  methods 
of  the  laboratory,  especially  blood  cultures,  the  examination  of  the  urine 
for  B.  'typhosus,  and  the  Widal  test  are  in  many  cases  essential  to  a  positive 
diagnosis.  Comphcations,  as  pleurisy  with  effusion,  bronchopneumonia, 
pulmonary  abscess  or  gangrene,  malignant  endocarditis,  cystitis  and  pye- 
litis, and  various  nervous  diseases  may  assume  such  a  degree  of  prominence 
as  to  dwarf  the  significance  of  the  early  symptom-complex  and  raise  the 
question  as  to  whether  or  not  the  previous  symptoms  have  been  those  of 
enteric  fever  or  simply  earher  manifestations  of  the  present  disease.  Here 
also  the  results  of  laboratory  research  render  positive  assistance. 

Intercurrent  relapse  frequently  prolongs  the  attack  to  six  or  seven  weeks. 
Fresh  crops  of  rose  spots,  the  character  of  the  temperature  range,  which  may 
after  having  been  strongly  remittent  again  become  subcontinuous,  the  per- 
sistent enlargement  of  the  spleen,  and  the  other  symptoms  of  a  specific 
rather  than  a  septic  infection  afford  the  criteria  for  a  diagnosis.  If  these 
symptoms  are  ill  defined  or  there  be  secondary  infection  or  marked  and 
grave  complications,  the  diagnosis  of  intercurrent  relapse  remains  uncertain. 

Urcemia  in  its  chronic  forms  may  suggest  enteric  fever  at  the  later 
periods  of  its  course  by  a  rapid  and  feeble  pulse,  dry  and  fissured  tongue, 
stupor,  wandering  delirium,  subsultus,  and  continued  fever  of  mild  type. 


ENTERIC  OR  TYPHOID  FEVER.  637 

The  urinary  findings,  the  condition  of  the  arteries,  a  negative  Widal  reaction, 
and  the  previous  history  are  usually  sufficient  for  the  differential  diagnosis. 

4.  Diagnosis  by  Exclusion. — Enteric  fever  is  by  far  the  most  common 
of  the  febrile  infectious  diseases;  with  the  exception  of  intestinal  symptoms, 
enlargement  of  the  spleen,  trifling  bronchitis,  and  a  relatively  slow  pulse, 
there  are  no  constant  evidences  of  visceral  disease;  the  age  at  which  the 
disease  is  most  common  and  the  immunity  which  is  established  by  the 
attack  are  facts  available  in  a  doubtful  case  for  the  diagnosis  by  exclusion. 

5.  A  Provisional  Diagnosis. — There  are  cases  in  which  a  positive 
diagnosis  cannot  be  made  when  the  patient  is  seen  for  the  first  time.  Delay 
may  be  required  for  the  accumulation  of  the  necessary  data  in  the  progress 
of  the  attack  to  a  point  at  which  characteristic  symptoms  appear.  A 
provisional  diagnosis  becomes,  under  these  circumstances,  imperative. 
Pending  the  decision  a  due  regard  of  the  welfare  of  the  patient  and  the 
community  demands  the  exercise  of  all  the  measures  of  treatment  and  all 
the  precautions  against  the  spread  of  the  disease  that  we  would  employ 
if  a  positive  diagnosis  were  made. 

The  Diagnosis  of  Intestinal  Perforation. — The  direct  diagnosis 
of  this  accident  rests  upori  the  association  of  the  symptoms  to  which  it 
gives  rise.  There  are  cases,  however,  in  which  several  of  the  more 
characteristic  symptoms  are  not  present,  and  every  clinical  phenomenon 
of  intestinal  perforation  may  show  itself  in  the  course  of  enteric  fever  in 
perforative  lesions  of  other  organs,  as  the  appendix,  gall-bladder,  or  peptic 
ulcer  of  the  stomach  or  duodenum;  while  acute  abdominal  symptoms  with 
or  without  collapse,  followed  by  the  signs  of  local  or  general  peritonitis, 
may  be  the  manifestations  of  intussusception,  volvulus,  strangulation  of 
a  Meckel's  diverticulum,  softened  splenic  infarct,  hepatic  abscess  or  pseudo- 
abscess  of  the  mesenteric  glands.  Prompt  recourse  to  surgical  measures 
in  any  of  these  conditions  may  be  the  only  means  of  saving  life.  In  the 
face  of  the  urgent  symptoms  of  some  grave  intra-abdominal  accident  it 
is  better  in  selected  cases  not  to  lose  time  in  the  attempt  to  make  a  diag- 
nosis of  the  lesion  by  ordinary  measures  but  at  once  to  open  the  abdomen 
and  ascertain  the  actual  condition  and  if  possible  correct  it.  This  diag- 
nostic procedure  is  justified  by  the  fact  that  enteric  fever  patients  bear 
ansesthesia  and  operation  well. 

Prognosis.  —  The  mortality  varies  greatly  in  different  outbreaks, 
the  range  being  from  five  to  seventeen  per  cent.  It  is  slightly  higher  in 
hospital  than  in  private  practice.  After  the  first  year,  the  prognosis  is  in 
general  less  favorable  as  the  age  of  the  individual  increases.  The  mortality 
is  greater  after  puberty;  after  forty  it  rises  rapidly  and  in  aged  persons 
enteric  fever  is  a  very  fatal  disease.  In  respect  of  prognosis  the  infantile 
type — high  evening  temperatures  with  marked  morning  remissions  through- 
out— is  much  more  favorable  than  the  adult  type  of  the  disease — high  or 
moderate  evening  exacerbations  with  very  slight  morning  remissions. 
Fat  persons  do  not  bear  enteric  fever  well.  Their  powers  of  resistance  to 
infections  in  general  are  less  than  in  the  spare  and  muscular;  there  is  an 
increased  tendency  to  parenchymatous  degenerations  of  the  viscera;  the 
evidences  of  myocardial  changes  are  early  noted,  and  the  nursing  and 
treatment  are  less  satisfactory.     Those  given  to  the  abuse  of  alcohol  also 


638  MEDICAL  DIAGNOSIS. 

bear  the  disease  badly.  Women  in  general  show  a  higher  mortality  than 
men,  and  pregnant  and  lying-in  women  attacked  by  enteric  fever  are  in 
great  danger.  When  the  disease  develops  in  persons  suffering  from  chronic 
disease,  especially  affections  of  the  heart,  chronic  bronchitis,  emphysema^ 
goitre,  and  pulmonary  tuberculosis,  the  prognosis  is  less  favorable  than  in 
those  in  previous  good  health.  When  the  tuberculous  patient  survives  the 
attack,  the  lung  trouble  usually  manifests  itself  with  increased  intensity. 
There  are,  however,  exceptions  to  this  rule.  I  have  seen  several  cases  in 
which  an  apparent  arrest  took  place  after  convalescence.  An  antecedent 
chronic  nephritis  adds  to  the  gravity  of  the  case.  Diabetes  mellitus  is 
also  unfavorable.  The  temperature  is  not  usually  high  and  sugar  disappears 
from  the  urine,  but  the  resisting  powers  of  the  patient  are  much  impaired. 

The  intensity  of  the  infection  as  shown  by  high  temperature  maxima, 
the  limited  range  of  the  remissions,  prolongation  of  the  fever,  and  the 
prominence  of  nutritional  disorders  and  nervous  symptoms  is  of  prog- 
nostic importance.  The  outlook  is  relatively  much  more  favorable  in  the 
cases  in  which  the  fever  is  moderate  and  the  associated  symptoms  of  mild 
degree — typhus  levissimus — and  in  those  in  which,  while  the  fever  is  high 
and  the  morbid  phenomena  severe,  the  course  is  short — abortive  cases. 
In  general  an  abrupt  rise  of  temperature  occurs  in  the  latter  group  of  cases 
and  is  therefore  not  without  value  as  indicating  a  short  attack.  Even  in 
these  cases  a  severe  complication,  a  relapse,  or  the  gravest  accidents — 
hemorrhage,  perforation — may  occur.  These  events  are,  however,  much 
more  common  in  cases  otherwise  severe. 

The  maintenance  of  the  power  of  the  heart  as  indicated  by  the  pulse 
is  very  important  in  prognosis.  So  long  as  the  frequency  remains  low  as 
compared  with  the  fever  and  the  volume  is  fair,  the  outlook  is  relatively 
favorable;  but  an  increased  pulse-frequency,  associated  as  it  almost  invari- 
ably is  in  this  disease  with  loss  of  power,  is  of  grave  prognostic  significance. 
This  is  particularly  the  case  when  there  are  developed  at  the  same  time 
such  evidences  of  circulatory  failure  as  pulmonary  hypostasis,  faint  cyanosis, 
coolness  of  the  extremities,  pulmonary  oedema,  and  symptoms  of  collapse. 
The  prognosis  becomes  progressively  more  ominous  as  the  frequency  of 
the  pulse  increases.  In  children  and  neurotic  individuals,  especially 
women,  a  frequent  pulse  is  less  significant,  particularly  when  it  again 
becomes  slower. 

As  a  general  rule  the  gravity  of  the  case  is  proportionate  to  the  intensity 
of  the  nervous  symptoms.  Continuing  delirium,  stupor,  coma,  and  partic- 
ularly coma  vigil,  are  of  grave  import;  so  also  are  meningeal  symptoms, 
apoplectiform  seizures,  and  local  and  general  convulsions.  Less  alarming 
are  the  psychic  derangements  which  occur  toward  the  close  of  the  attack 
and  during  convalescence — postfebrile  insanit3^ 

The  prognosis  is  rendered  unfavorable  by  the  development  of  compli- 
cations and  sequels.  These  are,  as  has  been  already  stated,  more  numerous 
than  in  any  other  infectious  febrile  disease  and  not  infrequently  determine 
the  outcome  of  the  case. 

Intestinal  hemorrhage,  when  slight  and  occurring  early  in  the  attack, 
is  not  necessarily  unfavorable.  Large  bleedings  occurring  early  are  dis- 
tinctly so,  for  four  reasons:  they  indicate  grave  local  lesions  and  usually 


PARATYPHOID  FEVERS. 


639 


also  intense  infection;  they  debilitate  the  patient  and  lower  his  powers  of 
resistance;  they  are  often  repeated  after  a  longer  or  shorter  interval  and 
in  some  instances  are  followed  by  perforation,  and  finally  they  constitute 
a  distinct  contraindication  to  the  treatment  by  systematic  cold  bathing. 

Intestinal  perforation  is  almost  always  followed  by  the  fatal  issue. 
The  patient  succumbs  in  the  course  of  a  few  days  to  the  consecutive  peri- 
tonitis. In  rare  instances  a  longer  period  may  elapse  and  a  very  few  cases 
of  spontaneous  recovery  have  been  noted.  A  favorable  prognosis  cannot 
be  made  and  the  only  chance  for  the  patient  lies  in  prompt  surgical  inter- 
vention. Peritonitis  without  perforation  constitutes  a  complication  of 
most  gloomy  import.  It  is  probable  that  a  proportion  of  the  cases  described 
as  perforation  with  recovery  have  been  instances  of  this  kind. 

Finally  the  prognosis  is  much  influenced  by  the  general  management 
of  the  individual  case  and  treatment.  Skilful  nursing,  a  careful  dietary, 
the  avoidance  of  drugging,  and  systematic  cold  bathing  have  reduced  the 
death-rate  to  about  seven  and  one-half  per  cent.  The  earlier  the  treatment 
is  instituted  the  better  the  result. 


PARATYPHOID  FEVERS. 

Definition.— A  group  of  infectious  febrile  diseases,  caused  by  organ- 
isms   intermediate    between    Bacillus    typhosus    and    Bacillus    coli    and 
presenting  the  clinical  phenom- 
ena of  enteric  fever. 

Etiology. — There  are  a 
number  of  organisms  in  this 
intermediate  series,  including 
the  Bacillus  enteritidis,  and  sev- 
eral varieties  causing  diseases 
in  animals. 

Buxton  has  suggested  the 
following  classification: 

"  Paracolons. — Those  which 
do  not  cause  typhoidal  symp- 
toms in  man.  A  group  con- 
taining many  different  members 
but  culturally  alike. 

"Paratyphoids. — Those 
which  cause  typhoidal 
symptoms. 

"(A)  A  distinct  species  cul- 
turally unlike  the   paracolons. 

"  (B)  A  distinct  species 
culturally  resembling  the 
paracolons. " 

Cases  of  paratyphoid  have 
been  reported  from  all  parts  of 
the  world  in  which  systematic  laboratory  work  in  bacteriology  is  carried 
on.     It  has  occurred  in  series  of  enteric  fever  cases,  in  house  epidemics, 


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-Jefferson  Hospital. 


640 


MEDICAL  DIAGNOSIS. 


and  under  circumstances  which  render  it  probable  that  it  is  sometimes 
a  water-borne  disease. 

Symptoms. — The  features  of  the  reported  cases  are  very  variable. 

1.  Many  of  the  cases  cannot  be  distinguished  from  enteric  fever 
except  by  the  failure  of  the  blood-serum  to  agglutinate  B.  typhosus 
and  its  power  to  agglutinate  the  organisms  of  this  group.  Hemorrhage, 
crural  phlebitis,  and  relapse  occur. 

2.  Others  present  the  clinical  features  of  septic  infections  and  resemble 
the  so-called  typhoid  septicaemia  or  enteric  fever   with  intercurrent  or 

terminal  sepsis — cases  in  which 
the  diagnosis  is  reached  by  ex- 
clusion rather  than  by  the  pres- 
ence of  the  ordinary  clinical 
features  of  enteric  fever. 

3.  Finally  the  organisms 
have  been  found  in  abscesses  in 
cases  in  which  no  history  of 
enteric  fever  has  been  obtained. 
The  first  group  of  cases, 
those  which  are  clinically  indis- 
tinguishable from  enteric  fever, 
are  almost  always  mild  and 
terminate  in  recovery.  The 
anatomical  lesions  are  therefore 
as  yet  undescribed.  The  last 
group  is  without  interest  in  this 
respect.  Cases  of  the  second 
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nection with  four  fatal  cases 
collected  from  the  literature, 
one  of  which  occurred  in  my 
service  in  the  Pennsylvania 
Hospital  and  was  studied  by 
Longcope.  The  most  constant 
lesion  was  enlargement  of  the 
spleen.  The  intestinal  conditions  were  variable.  In  two  of  the  cases  the 
intestines  were  normal.  Ulcers  were  present  in  the  others,  but  they 
resembled  those  of  dysentery  rather  than  of  enteric  fever.  In  all  the  cases 
the  solitary  follicles,  the  Peyer's  patches,  and  the  mesenteric  glands  were 
unaffected.     The  other  changes  present  were  those  of  a  septicaemia. 

Diagnosis. — The  direct  diagnosis  of  paratyphoid  rests  upon  the 
failure  of  the  blood-serum  to  agglutinate  B.  typhosus  and  its  power  to 
agglutinate  B.  paratyphosus  or  B.  paracoli. 

It  is  in  the  highest  degree  probable  that  reported  cases  of  mild  enteric 
fever — typhus  levis,  typhus  levissimus^and  cases  of  the  so-called  septi- 
csemic  variety  have  been  instances  of  paratyphoid.  Whether  or  not  a 
separate  disease  should  be  recognized  merely  upon  the  agglutinating  prop- 


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Hospital, 


■  Pennsylvania 


TYPHUS  FEVER.  641 

erties  of  the  blood-serum  is  open  to  question.  The  working  hypothesis 
that  cUnical  conditions  not  to  be  differentiated  from  enteric  fever  may 
be  caused  by  a  number  of  alhed  pathogenic  organisms  is  supported  by 
the  facts  reported  by  Achard  and  Bensaude  (1896),  Widal  (1897),  Gwyn 
(1898),  and  many  observers  since. 

II.  TYPHUS  FEVER. 

Typhus  Exanthematicus;  Jail,   Camp,  or  Ship  Fever. 

Definition. — An  acute,  infectious,  epidemic  disease  characterized  by 
sudden  onset,  intense  fever,  a  peculiar  rash,  at  first  macular,  later  pete- 
chial, great  prostration,  marked  nervous  symptoms,  a  defervescence  usually 
critical,  and  an  average  duration  of  about  fourteen  days.  There  are  no 
characteristic  anatomical  lesions. 

Typhus — t6<po?  smoke — used  by  Hippocrates  to  define  a  confused 
state  of  the  mind  with  a  tendency  to  stupor,  expresses  a  prominent  con- 
dition of  the  disease.  Typhus  has  become  a  rare  disease.  Its  practical 
disappearance  dates  from  the  early  part  of  the  nineteenth  century,  when 
enteric  fever  became  more  prevalent.  Sporadic  cases  and  small  local 
epidemics  of  typhus  occasionally  occur  in  great  cities,  particularly  in 
Great  Britain  and  Ireland  and  in  Russia. 

Etiology. — Predisposing  Influences. — Typhus  is  a  disease  of  cold 
and  temperate  climates.  Its  prevalence  is  but  little  influenced  by  the 
season  of  the  year  or  by  meteorological  conditions.  Overcrowding  plays 
the  most  important  part  among  predisposing  influences  to  typhus.  Do- 
mestic and  personal  filthiness,  insuflftcient  food,  and  intemperance  are  also 
of  importance.  Typhus  is  a  disease  of  the  poor  and  under-fed  of  large 
cities.  Age  and  sex  are  without  influence.  Occupation  is  without  influence 
except  as  it  involves  actual  exposure  to  the  contagion,  as  in  the  case  of 
hospital  attendants,  physicians,  clergymen,  and  those  who  care  for  the  dead. 

The  Exciting  Cause.  —  The  infecting  agent  has  not  yet  been 
demonstrated. 

Typhus  fever  is  readily  transmissible  from  the  sick  to  the  well  by 
actual  contact,  by  means  of  the  atmosphere  to  short  distances,  and  by 
fomites.  The  infecting  principle  is  thrown  off  in  the  expired  air  of  the 
patients  and  in  the  exhalations  from  their  bodies.  It  probably  finds  access 
by  means  of  the  breath  or  by  the  saliva  which  is  swallowed. 

The  attack  confers  an  immunity  which  in  most  instances  is  permanent. 

Symptoms. — The  period  of  incubation  is  about  twelve  days.  It  may 
be  less.  Prodromes,  consisting  of  lassitude,  vertigo,  headache,  loss  of 
appetite,  and  restlessness  at  night,  occasionally  occur. 

Stage  of  Invasion. — The  onset  is  abrupt  and  marked  by  a  chill  or 
chilliness,  followed  by  fever.  In  children  the  onset  may  be  attended  by 
vomiting  or  convulsions.  The  skin  is  hot,  the  face  flushed,  the  eyes  injected, 
headache  is  constant  and  severe.  There  is  a  feeling  of  dulness  and  con- 
fusion, with  vertigo  and  tinnitus  aurium.  The  patient  complains  of  pain 
in  the  back  and  soreness  of  the  limbs  and  joints.  There  is  early  muscular 
weakness  and  an  extreme  sense  of  prostration.    There  is  confusion  of  mind 

41 


642 


MEDICAL  DIAGNOSIS. 


and  failure  of  memory.  Delirium  occurs  early;  it  may  be  mild  and  wander- 
ing or  active  and  noisy.  The  tongue  is  at  first  large,  pale,  and  coated  with 
a  thick  fur,  but  presently  becomes  brown  and  dry.  Appetite  is  lost;  there 
is  thirst;  the  secretion  of  saliva  is  diminished;  taste  is  perverted  and  a 
stale,  unpleasant  odor  loads  the  breath.  There  is  constipation  as  a  rule 
but  in  some  instances  diarrhoea.  The  pulse  is  full  but  compressible.  It 
soon  grows  feeble  and  varies  in  frequency  from  120-130.  Dicrotism  is 
uncommon.  The  temperature  rises  rapidly.  By  the  third  or  fourth  day 
it  may  reach  103°-105°  F.  (39.5°-40.5°  C),  and  continues  at  this  range 
with  moderate  morning  remissions  until  the  crisis.  Hyperpyrexia,  107°- 
109°  F.  (42°-42.7°  C),  not  infrequently  precedes  death. 

Stage  of  Eruption. — On  the  fourth  or  fifth  day,  less  often  at  the 
end  of  the  first  week,  the  eruption  appears.  It  consists  of  numerous  roseola- 
like spots  of  irregular  outline  and  from 
one  to  three  lines  across,  scattered  sin- 
gly or  arranged  in  close-set  groups  like 
the  rash  of  measles.  These  spots  are  at 
first  of  a  dirty  rose  color,  slightly  raised 
above  the  surface  of  the  surrounding 
skin,  and  disappear  upon  pressure.  In 
the  course  of  a  day  or  two  they  become 
darker  and  are  then  no  longer  elevated 
but  appear  as  faint,  dirty  brown  stains 
without  defined  margins.  A  little  later 
petechise  show  themselves  at  the  centre 
of  many  of  these  spots.  The  spots  fade 
during  the  first  half  of  the  second  week 
and  disappear  with  or  without  desqua- 
mation toward  its  close.  In  many  of 
the  cases  petechise  appear  about  the 
time  the  typical  rash  begins  to  fade. 
A  faintly  reddish,  lightly  defined  mottling  or  marbling  of  the  skin  between 
the  spots  or  groups  of  spots  also  occurs.  This  mottling  has  been  described 
from  its  appearing  to  lie  beneath  the  surface  as  the  subcuticular  eruption 
of  typhus.  The  appearance  of  the  rash  varies  greatly,  the  differences  being 
determined  by  the  general  abundance  of  the  two  eruptions,  by  the  relative 
preponderance  of  one  or  the  other,  and  by  the  extent  of  the  petechise. 
The  spots  and  mottling  together  constitute  the  "  mulberry  rash"  of  Jenner. 
The  eruption  usually  appears  first  on  the  sides  of  the  chest  or  abdomen 
and  spreads  in  a  brief  time  over  the  body  and  limbs.  It  rarely  occurs  upon 
the  neck  or  face.  It  may  first  appear  upon  the  back  of  the  hands.  The 
roseola-like  rash  may  be  absent  altogether,  the  faint  subcuticular  mottling 
alone  being  present.  The  entire  absence  of  eruption  is  very  rare.  Sudamina 
are  not  common. 

The  odor  surrounding  the  patient  has  been  regarded  as  characteristic. 

Stage   of   Nervous   Prostration.  —  During    the  second   week  the 

depression  becomes  profound.      Headache  passes  into  delirium   and  the 

impairment  of  the  mental  powers  is  extreme.     Drowsiness  and  stupor  are 

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215. — Typhus   fever — fatal   on   16th  day 
of  attack. 


TYPHUS  FEVER.  643 

may  be  low  and  wandering  or  noisy  and  boisterous.  Stupor  alternates 
with  sleeplessness.  Coma  vigil,  subsultus  tendinum,  and  picking  at  the 
bedclothes  may  occur.  The  tongue  is  dry,  fissured,  and  crusted.  Sordes 
collect  upon  the  teeth  and  lips.  The  conjunctivae  are  deeply  injected; 
the  pupils  are  contracted;  deafness  is  often  present.  The  flushing  of  the 
face  gives  place  to  a  dusky  pallor  and  emaciation  progresses.  There  is 
cough  and  rales  are  heard  in  all  parts  of  the  chest.  Hypostatic  congestion 
occurs  in  severe  cases.  The  heart's  action  is  faint  and  indistinct;  the 
pulse  small,  weak,  often  difficult  to  count — ranging  from  112-140  or  more. 
A  systolic  murmur  in  the  mitral  area  is  not  infrequent.  The  area  of  splenic 
dulness  is  increased.  The  state  of  the  bowels  varies  from  constipation  to 
irregular,  scanty  dejections  or  moderate  diarrhoea.  The  urine  is  decreased 
in  amount,  high  colored,  and  frequently  albuminous.  In  severe  cases  the 
discharges  are  passed  involuntarily  or  there  is  retention  of  urine.  Areas 
of  the  skin  subjected  to  pressure  show  a  tendency  to  slough.  The  surface 
now  becomes  cooler  and  is  often  moist. 

In  malignant  cases  death  occurs  in  the  course  of  a  few  days — typhus 
siderans;  more  commonly  between  the  tenth  and  seventeenth  days.  The 
mode  of  death  is  by  coma  or  by  asphyxia  in  consequence  of  sudden  pul- 
monary engorgement  or  by  failure  of  the  heart,  the  pulse  becoming 
imperceptible,  the  surface  cold,  livid,  and  bathed  in  sweat.  In  the  milder 
cases  and  especially  in  children  the  rash  is  slight,  petechise  are  absent,  and 
defervescence  takes  place  at  the  end  of  the  first  or  the  beginning  of  the 
second  week.  In  the  average  cases  defervescence  takes  place  about  the 
fourteenth  day  by  crisis,  the  temperature  falling  in  a  single  night  or  in 
the  course  of  twenty-four  or  forty-eight  hours  to  the  normal  or  even 
below  it.     The  convalescence  is  rapid.     Relapse  is  extremely  rare. 

Complications  and  Sequels. — Laryngitis,  bronchitis,  and  broncho- 
pneumonia are  common.  Gangrene  of  the  lung  may  occur.  Independently 
of  scurvy,  which  has  been  a  frequent  concomitant  in  typhus  epidemics, 
bleeding  from  the  nose,  gums,  bowels,  urinary  passage,  and  the  vagina  has 
been  noted,  as  well  as  the  spitting  and  vomiting  of  blood.  In  certain 
epidemics  gangrene  of  the  extremities,  the  nose,  and  the  genitalia,  and 
cancrum  oris  have  occurred.  Septic  parotitis  and  arthritis  occur  and 
extensive  subcutaneous  abscesses.      Various  palsies  are  met  with. 

Diagnosis. — The  direct  diagnosis  of  typhus  during  epidemics  is 
usually  a  simple  matter.  In  early  or  isolated  cases  the  nature  of  the  disease 
must  remain  in  doubt  until  the  appearance  of  the  eruption.  The  abrupt 
onset,  initial  chill,  and  sudden  rise  of  temperature  are  important.  The 
critical  defervescence  about  the  fourteenth  day  is  characteristic. 

Differential  Diagnosis.— Enteric  fever  (see  p.  634).  Relapsing 
FEVER  in  its  great  epidemics  has  prevailed  in  connection  with  typhus. 
The  stage  of  complete  apyrexia,  the  clear  mind,  epigastric  pain  and  tender- 
ness, absence  of  eruption,  the  low  death-rate,  and  the  spirochsetai  of  Ober- 
meier  serve  to  differentiate  this  disease  from  typhus.  Cerebrospinal 
FEVER  may  at  the  onset  resemble  typhus.  Associated  headache,  vomiting, 
and  painful  rigidity  of  the  muscles  of  the  back  of  the  neck,  Kernig's  sign, 
and  in  fatal  cases  characteristic  lesions  are  of  diagnostic  importance.  The 
presence  of  the  Diplococcus  intracellularis  meningitidis  in  the  fluid  with- 


644  MEDICAL  DIAGNOSIS. 

drawn  by  lumbar  puncture  will  determine  the  question.  Plague. — 
Nausea  and  vomiting,  pallor,  and  the  early  appearance  of  glandular  swellings 
are  characteristic.  The  duration  of  the  plague  is  much  shorter  than  that 
of  typhus  and  the  mortality  greater.  Malaria. — The  malignant  malarial 
fevers  of  tropical  and  subtropical  climates  occasionally  present  strong 
resemblances  to  typhus.  These  fevers  are,  however,  endemic,  not  conta- 
gious, unattended  by  specific  eruptions,  show  greater  enlargement  of  the 
spleen  and  in  the  blood  the  malarial  parasite.  Measles  and  typhus  in 
children  are  attended  by  a  somewhat  similar  eruption  about  the  fourth 
day  of  the  attack.  In  measles  catarrhal  phenomena  are  prominent  during 
the  stage  of  invasion;  the  eruption,  which  first  shows  itself  upon  the  face, 
is  brighter  in  its  tints  and  very  rarely  petechial.  Alcoholism. — Certain 
forms  of  alcoholism  are  attended  by  trembling  delirium  like  that  occasion- 
ally seen  in  typhus.  Shivering,  headache,  pains  in  the  limbs,  fever,  and 
eruption  are  absent. 

Prognosis  and  Mortality. — The  mortality  ranges  from  10  to  20  per 
cent.  It  is  much  influenced  by  age;  not  exceeding  4  per  cent,  under  ten 
years  and  rising  above  50  per  cent,  after  sixty.  Among  individual  peculi- 
arities unfavorably  affecting  the  prognosis  are  intemperate  habits,  disease 
of  the  kidneys,  gout,  obesity,  and  mental  depression. 

III.   RELAPSING  FEVER. 

Fehris  Recurrens;  Sjpirillum  Fever. 

Definition. — An  acute,  infectious,  epidemic  disease  caused  by  the 
spirochseta  of  Obermeier,  characterized  by  a  febrile  paroxysm  of  five  to 
seven  days  terminating  by  crisis,  an  interval  of  complete  apyrexia  of 
about  the  same  length  of  time  and  one  oi"  more  abrupt  relapses.  There 
are  no  characteristic  anatomical  lesions. 

Relapsing  fever  has  prevailed  extensively  in  Europe  and  particularly 
in  Ireland,  usually  in  association  with  typhus  fever.  It  has  occurred  in 
India  and  other  tropical  countries.  Relapsing  fever  has  never  taken 
foothold  in  America. 

Etiology. — Predisposing  Influences. — The  conditions  favoring  the 
development  of  relapsing  fever  are  those  which  predispose  to  typhus. 
Destitution,  filth,  and  overcrowding  play  the  most  important  part.  The 
Irish  writers  have  especially  insisted  upon  the  connection  between  this 
fever  and  famine.  Parry,  on  the  other  hand,  found  the  patients  in  the  out- 
break in  Philadelphia  with  a  single  exception  well  fed  and  in  a  position  to 
obtain  a  plentiful  supply  of  milk,  meat,  and  eggs,  or  other  articles  of  diet 
that  were  ordered.  Climate  has  no  direct  influence  upon  the  development 
or  propagation  of  relapsing  fever.  The  season  of  the  year  is  "without  influ- 
ence. Age,  sex,  and  occupation  are  likewise  without  influence  except  that, 
as  in  the  case  of  other  directly  contagious  diseases,  attendants  upon  the 
sick,  including  medical  men,  are  exposed  to  constant  danger  of  con- 
tracting the  disease.  In  the  great  Irish  outbreaks  a  large  proportion  of 
the  cases  admitted  to  the  hospitals  were  wandering  musicians,  pedlers, 
beggars,  and  tramps. 


RELAPSING  FEVER. 


645 


The  Exciting  Cause.  —  Obermeier  in  1873  demonstrated  in  the 
blood  an  organism  now  recognized  as  the  specific  cause  of  relapsing  fever. 
This  micro-organism  is  a  slender  spirillum  or  spirochseta  varying  in  length 
from  16  to  40  ix,  twisted  spirally  in  from  ten  to  twenty  turns.  In  fresh 
blood  it  is  very  active.  Under  a  low  power  it  shows  itself  by  the  commo- 
tion among  the  blood-corpuscles,  caused  by  its  rapid  movements.  Culture 
experiments  have  not  been  satisfactory.  Koch,  however,  observed  the 
formation  of  tangled  masses  and  an  increase  in  the  length  of  the  spirochseta 
in  blood-serum.  These  micro-organisms  are  present  in  the  blood  only 
during  the  febrile  paroxysm.  About  the  time  of  the  crisis  they  disappear 
and  are  not  found  during  the  apyi-exia.  At  this  period  minute,  highly 
refractive  bodies  are  seen  in  the  blood  which  have  been  thought  by  some 
observers  to  be  spores,  by  others  debris  of  the  organisms,  masses  of  which 
may  still  be  discovered  in  the  tissues  of  the  spleen.  Upon  the  occurrence 
of  relapse  active  spirochsetse  are  again 
found  in  the  blood.  Relapsing  fever 
may  be  produced  in  man  by  inoculation 
with  the  blood  of  a  patient,  and  several 
instances  are  recorded  where  infection 
has  followed  wounding  of  the  hands  at 
autopsies.  Koch,  VanDyke  Carter,  and 
others  have  produced  the  disease  in 
monkeys  by  inoculation.  Tictin,  in 
Odessa,  suspected  suctorial  insects  to  be 
the  medium  of  transmission  of  the  dis- 
ease and  was  able  to  produce  an  attack 
in  a  healthy  monkey  by  inoculation  of 
blood  sucked  by  a  bed-bug  from  an 
infected  monkey.  This  observation  ex- 
plains many  facts  relating  to  the  spread 
of  the  disease.  In  monkeys  killed  ten  hours  after  the  crisis  the  parasites 
are  found  in  the  phagocjrtes  in  the  spleen.  They  have  not  been  found  in 
the  secretions  or  excretions.  In  the  case  of  abortion  they  have  been 
found  in  the  blood  of  the  foetus. 

No  immunity  from  subsequent  attacks  is  experienced  by  those  who 
have  suffered  from  relapsing  fever.  Second  and  third  attacks  in  the 
same  individual  within  the  course  of  a  few  months  have  been  observed 
in  many  epidemics. 

Symptoms. — The  period  of  incid^ation  under  ordinary  circumstances 
varies  from  five  to  seven  days.  It  may  exceptionally  be  only  twenty-four 
hours,  or  twelve  or  fourteen  days. 

The  Primary  Paroxysm. — Prodromes  are  as  a  rule  absent.  The 
onset  is  marked  by  chills  or  chilliness,  rapid  rise  of  temperature,  headache, 
and  pain  in  the  back  and  limbs.  Sweating  is  common.  Appetite  is  lost 
and  nausea  and  vomiting  are  common,  sometimes  persistent.  The  tongue 
is  usually  moist,  covered  with  a  thick  white  or  yellowish-white  fur.  It  is 
apt  to  continue  in  this  condition  throughout  the  paroxysm.  In  a  small 
proportion  of  the  cases  it  becomes  dry  or  shows  a  dry  brownish  streak  in 
the  middle.    The  bowels  are  as  a  rule  constipated.    In  a  considerable  pro- 


FiG.  216. — Spirillum  of  relapsing  fever  in  blood. 


646 


MEDICAL  DIAGNOSIS. 


portion  of  the  cases  jaundice  occurs.  There  is  no  characteristic  eruption. 
Sudamina  appear  and  facial  herpes  occasionally  occurs.  As  early  as  the 
second  day  there  is  distress  in  the  epigastric  zone.  The  liver  and  spleen 
are  now  found  to  be  enlarged,  the  latter  reaching  some  distance  below  the 
ribs.  There  is  marked  tenderness  in  the  splenic  and  hepatic  areas.  General 
muscular  pain  and  soreness  constitute  prominent  symptoms  of  the  disease. 
These  pains  are  especially  severe  in  the  calves  of  the  legs.  They  are  present 
when  the  body  is  in  repose  but  are  aggravated  both  by  movement  and  pres- 
sure. The  mind  is  usually  clear;  delirium  rare.  Sleeplessness  is  a  dis- 
tressing symptom.  Epistaxis  may  occur  but  is  not  common.  The  fever  is 
intense,  104°-107°  F.  (40°-41.7°  C),  and  subcontinuous  in  type.  The  pulse 
is  frequent,  110-130.  It  is  of  moderate  fulness  and  tension,  often  quick,  and 
sometimes  dicrotic.  About  the  fifth  to  the  seventh  day,  sometimes  as  early 
as  the  third,  or  again  as  late  as  the  tenth  day,  crisis  occurs.  The  deferves- 
cence takes  place  in  the  course  of  a  few  hours  and  is  frequently  attended 

by  profuse  sweating  or  diarrhoea. 
The  temperatui'e  may  fall  several 
degrees  below  the  normal.  In  rare 
instances  the  crisis  is  attended  by 
transient  violent  delirium.  In  fee- 
ble persons  collapse  may  occur. 
The  urine  not  infrequently  contains 
albumin. 

•  The  Intermission. — The  crisis 
nearly  always  sets  in  during  the 
night.  The  patient  in  the  course 
of  a  few  hours  experiences  remark- 
able relief  and  very  often  declares 
himself  quite  well.  The  pains, 
headache,  and  gastric  symptoms 
There  is  first  a  feeling  of  weakness 
This  period  usually  lasts  about 

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promptly  disappear  with  the  fever. 

but  strength  augments  from  day  to  day. 

a  week.     In  some  instances  it   does  not  exceed   four  or  five  days. 

a  limited  number  of  cases  the  relapse  does  not  occur. 

The  Relapse. — Between  the  twelfth  and  twentieth  days  from  the 
beginning  of  the  attack,  but  in  by  far  the  greater  number  of  cases  on  or 
about  the  fourteenth  day,  the  patient,  with  the  same  suddenness  as  before, 
again  falls  ill.  The  relapse  sets  in  usually  at  night.  The  symptoms  are  a 
repetition  of  those  of  the  primary  paroxysm.  Usually  they  are  somewhat 
less  severe  and  the  relapse  is  of  shorter  duration,  being  commonly  about 
three  days,  sometimes  not  more  than  twenty-four  hours.  Occasionally  a 
second  relapse,  less  frequently  a  third,  occurs  and  in  very  rare  instances 
a  fourth  has  been  noted. 

Convalescence. — At  the  termination  of  the  disease,  especially  after 
repeated  relapses,  the  patient  is  much  prostrated,  there  is  marked  ema- 
ciation, and  the  convalescence  is  tardy,  weeks  often  elapsing  before  the 
health  is  restored. 

Complications    and    Sequels Mild    bronchitis    is    not    uncommon. 

Pneumonia  has  been  frequent  in  some  of  the  epidemics.     Chronic  valvular 


VARIOLOUS  DISEASES.  647 

disease  and  myocarditis  render  the  patient  liable  to  sudden  death  from 
syncope.  The  sudden  swelling  of  the  spleen  may  cause  rupture  of  its 
capsule.  Nephritis  is  a  rare  complication.  Hsematemesis  and  hematuria 
have  been  noted.  Parotid  bubo  has  been  a  prominent  complication  in 
some  epidemics.  Pregnant  women  almost  invariably  abort  or  miscarry 
during  the  course  of  relapsing  fever.  This  accident  exceptionally  occurs 
in  the  first  paroxysm,  commonly  in  the  second.  The  foetus  even  at  the 
approach  of  term  perishes  and  the  life  of  the  mother  is  often,  though  not 
invariably,  lost.  Forms  of  ophthalmia  have  been  common  sequels  in  some 
of  the  epidemics.     Palsies  may  occur  as  the  result  of  peripheral  neuritis. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  abrupt  onset,  high 
temperature,  enlargement  of  the  liver  and  spleen,  the  critical  defervescence 
at  the  end  of  five  to  seven  days,  and  the  occurrence  of  relapse.  The  presence 
of  spirochsetse  in  the  blood  renders  a  doubtful  diagnosis  positive.  Lowen- 
thal  used  the  serum  test  upon  active  spirilli  with  positive  results  in  30  out 
of  39  tests.  In  14  cases  he  was  able  by  this  method  to  make  a  diagnosis 
after  the  disease  was  past,  thus  determining  the  true  nature  of  a  previous 
illness  of  doubtful  character. 

Prognosis. — The  prognosis  is,  as  a  rule,  favorable.  The  mortality  in 
different  epidemics  varies  between  two  and  four  per  cent.  Death  may 
occur  from  the  intensity  of  the  fever  and  the  consequent  exhaustion, 
usually  at  the  close  of  the  relapse,  or  by  progressive  exhaustion  after 
repeated  relapses.    It  may  occur  from  collapse  at  the  time  of  crisis. 

IV.   THE   VARIOLOUS  DISEASES. 
Variola — Smallpox. 

Definition.  —  An  acute,  infectious,  endemic  and  epidemic  disease, 
highly  contagious,  characterized  by. fever  of  typical  course  and  a  general 
eruption  which  passes  through  the  progressive  stages  of  macule,  papule, 
vesicle,  pustule,  and  crust. 

Etiology. — Predisposing  Influences. — Smallpox  may  be  regarded 
as  the  prototype  of  contagious  diseases.  It  is  endemic  and  in  the  absence 
of  vaccination  occasionally  epidemic  in  every  climate  and  among  all  races. 
Outbreaks  are  more  common  in  the  great  centres  of  population,  but  when 
the  disease  is  transported  to  countries  in  which  it  has  never  or  not  recently 
prevailed,  as  in  Iceland  or  in  North  America  among  the  aborigines,  it  has 
raged  as  a  veritable  scourge.  The  negro  races  are  peculiarly  susceptible 
and  suffer  more  severely  than  whites. 

Age  confers  no  immunity.  The  foetus  in  utero  may  develop  the 
disease  if  the  pregnant  mother  has  contracted  it.  Miscarriage  as  in 
other  grave  infections  is  liable  to  occur  and  the  foetus  may  be  born  with 
the  signs  of  the  disease  or  the  child  at  term  may  develop  it  within  the 
period  of  incubation.  In  rare  instances  the  foetus  may  bear  the  scars. 
Sometimes  the  child  in  a  smallpox  hospital  is  born  without  signs  of  the 
disease,  and  may,  if  at  once  vaccinated,  escape.  Such  children  are  very 
delicate.  Welch  has  seen  a  case  at  the  age  of  eighty-three.  Sex  is  with- 
out  influence.     The   menstrual    period   and    pregnancy   are   supposed    to 


648  MEDICAL  DIAGNOSIS. 

render  individuals  especially  liable  to  contract  the  disease.  Questions 
relating  to  vaccination  and  revaccination  and  exposure  render  generali- 
zations in  regard  to  these  conditions  useless.  Previous  disease  has  no 
influence.  Neither  acute  nor  chronic  affections  confer  immunity,  save  in 
so  far  as  patients  suffering  from  acute  infections  such  as  scarlet  or  enteric 
fever,  measles,  or  influenza  are  less  exposed  to  the  contagion  in  limited 
epidemics  than  persons  going  about. 

The  Exciting  Cause. — Bodies  resembling  protozoa  in  the  lesions 
were  first  described  by  Guarniere — Cytoryctes  variolce.  Later  Councilman 
and  his  associates  demonstrated  a  protozoon  with  a  cytoplasmic  stage  and 
a  double  cycle  and  small  structureless  bodies  in  the  lower  layer  of  the 
epithelial  cells.  Various  observers  have  confirmed  these  findings.  These 
organisms  bear  a  definite  relation  to  the  lesions  and  the  hypothesis  that 
they  are  the  cause  of  the  disease  is  tenable. 

The  infecting  principle  is  thrown  off  in  the  expired  air  and  in  the 
exhalations  from  the  skin,  in  the  secretions  and  excretions,  and  in  the 
crusts  of  the  unruptured  and  ruptured  pocks  formed  during  desiccation. 
The  disease  is  transmissible  during  the  whole  course  of  the  attack  from 
the  initial  stage,  before  the  appearance  of  the  exanthem,  until  the  dried 
crusts  have  entirely  separated  and  the  person  and  clothing  of  the  patient 
have  been  disinfected.  It  may  be  communicated  by  approach,  contact, 
by  a  third  person  himself  immune,  and  by  any  articles  serving  as  fomites. 
The  dried  scales  and  pus  and  the  discharges  from  the  nose  and  mouth 
floating  in  the  air  as  dust  play  the  chief  role  in  the  dissemination  of  the 
virus,  and  it  is  by  this  means  that  transmission  through  the  atmosphere, 
in  the  absence  of  any  communication,  has  taken  place  at  distances  of  one 
hundred  metres  or  more.  It  is  inoculable  by  means  of  the  lymph  of  the 
vesicles,  pus,  crusts,  and  the  blood — the  contents  of  the  vesicles  being  most 
virulent  at  the  time  when  turbidity  appears,  the  blood  during  the  early 
stages  of  the  attack.  The  corpses  of  those  dead  of  variola  communicate 
the  disease  to  susceptible  persons  not  only  in  the  performance  of  autop- 
sies or  dissections  but  also  in  their  ordinary  disposal  for  burial.  The  danger 
is  greatest  in  the  immediate  proximity  of  cases,  but  under  certain  condi- 
tions it  extends  to  remote  distances.  In  this  connection  the  part  played 
by  flies  and  other  insects  is  not  to  be  overlooked.  The  poison  is  not 
only  virulent,  it  is  also  in  the  highest  degree  tenacious  and  persistent. 
Infected  clothing  that  has  been  packed  away  may  after  several  years  give 
rise  to  the  disease  and  thus  become  the  unsuspected  cause  of  outbreaks 
in  localities  long  free  from  the  disease.  Cases  have  been  traced  to  baled 
rags  brought  from  distant  countries  as  an  article  of  commerce.  It  clings 
to  articles  of  furniture,  carpets,  and  rooms,  and  is  liable  in  times  of  epidemics 
to  infect  cabs  and  other  public  conveyances. 

The  usual  mode  of  access  is  by  way  of  the  inspired  air.  The  suscep- 
tibility to  the  disease  is  in  the  absence  of  vaccination  almost  universal. 
Natural  immunity  has,  however,  been  observed,  and  very  rare  instances 
are  now  encountered  in  which,  vaccination  having  been  unsuccessful, 
even  when  repeated,  the  individual  has  failed  to  contract  variola  upon 
exposure.  Temporary  immunity  in  unvaccinated  persons  has  also  in 
rare  cases  been  observed.     An  acquired  immunity  results  from  the  attack. 


VARIOLOUS  DISEASES.  649 

In  most  instances  it  is  permanent.  Second  attacks  are  exceedingly  rare 
and  third  attacks  almost  unknown.  Louis  XV,  of  France,  who  had  small- 
pox at  fovu'teen,  died  of  a  second  attack  at  the  age  of  sixty-four.  The 
immunity  acquired  by  vaccination  is  of  variable  duration,  the  limit  of 
which  varies  between  five  and  ten  years. 

Variola  is  transmissible  to  monkeys  by  inoculation,  and  among  the 
domestic  animals,  the  cow  and  horse,  a  local  reaction  takes  place.  The 
variolous  disease  of  sheep  is  analogous  to  but  not  identical  with  smallpox 
in  the  human  body. 

Symptoms. — Cases  of  smallpox  present  wide  variations  in  intensity 
and  clinical  manifestations,  from  a  malady  trifling  in  itself  to  an  over- 
whelming illness  terminating  in  death  as  early  as  the  third  or  fourth  day. 
The  differences  mainly  but  not  exclusively  appear  at  the  time  of  the  erup- 
tion, the  symptoms  of  the  stage  of  invasion  being  much  more  constant. 
For  purposes  of  description  the  following  scheme  is  convenient: 

A.  Variola  vera — Smallpox. 

(a)  V.  discreta — Discrete  smallpox. 

(b)  V.  confluens — Confluent  smallpox. 

(c)  V.   hsemorrhagica — Hemorrhagic  smallpox, 

i.   Purpura  variolosa, 
ii.   V.  pustulosa  hsemorrhagica. 

B.  Variola  modificata — Modified  smallpox. 

(a)  Varioloid. 

(b)  Variola  sine  eruptione. 

The  period  of  incubation  varies  from  five  to  fifteen  days.  In  the 
majority  of  cases  it  is  twelve  or  thirteen  days.  The  incubation  is  apt  to 
be  shorter  in  the  malignant  forms  of  the  disease.  At  the  time  when  inoc- 
ulation was  practised  the  local  reaction  and  constitutional  symptoms 
frequently  appeared  toward  the  end  of  the  third  or  during  the  fourth  day. 
Prodromes  are  as  a  rule  absent. 

The  course  of  the  attack  may  be  divided  into  the  stage  of  invasion, 
the  stage  of  eruption,  and  the  stage  of  desiccation  and  decrustation. 

L  Invasion. — The  initial  symptoms  are  acute,  usually  intense,  excep- 
tionally mild.  There  is  no  constant  relation  between  the  severity  of 
this  stage  and  the  gravity  of  the  subsequent  course  of  the  attack.  The 
mildest  varioloid  may  begin  with  violent  symptoms.  On  the  other  hand, 
symptoms  of  slight  intensity  at  the  onset  are  not  often  followed  by  con- 
fluence or  grave  hemorrhagic  conditions.  The  attack  usually  begins 
with  a  chill  which  may  be  repeated  several  times  during  the  first  twenty- 
four  hours.  In  young  children  a  general  convulsion  may  take  the  place 
of  the  chill.  Severe  headache  usually  frontal,  dizziness,  pain  in  the  back, 
and  vomiting  occur.  The  temperature  rises  in  the  course  of  some  hours  to 
103°-104°  F.  (39.5°-40°  C.)  and  frequently  reaches  maxima  of  105°- 
106°  F.  (40.5°-4Ll°  C).  Its  type  during  the  stage  of  invasion,  namely, 
until  the  signs  of  eruption  begin  to  appear,  is  subcontinuous,  with  slight 
morning  remissions.  The  respiration  and  pulse  are  accelerated,  the  former 
not  infrequently  reaching  30-36  per  minute,  the  latter  120-140.  The 
pulse  may  be  full  and  bounding;    in  grave  and  malignant  cases  it  is  often 


650  MEDICAL  DIAGNOSIS. 

feeble  and  soon  becomes  irregular  and  intermittent.  The  skin  is  hot 
and  dry,  the  cheeks  reddened,  the  conjunctiva  injected.  The  tongue  is 
at  first  slightly  swollen,  indented  by  the  teeth,  and  covered  with  a  thick, 
moist,  yellowish-white  fur.  Pharyngitis  appears  early  and  there  is  pain 
upon  swallowing.  The  breath  is  foul.  Thirst,  loss  of  appetite,  and  nausea 
sometimes  leading  up  to  repeated  vomiting,  accompany  the  fever.  The 
nervous  symptoms  of  the  onset  persist  throughout  this  stage.  Headache, 
dizziness,  and  pains  in  the  back  and  limbs  become  even  more  severe. 
Insomnia  alternates  with  light  slumber  and  delirium,  sometimes  wandering, 
sometimes  furious.  The  lumbosacral  pain  is  excruciating  and  during  an 
epidemic,  when  associated  with  high  fever,  headache,  and  vomiting,  is  of 
diagnostic  importance.  In  severe  cases  occasionally  there  is  marked  pre- 
cordial oppression.  Physical  examination  of  the  heart  and  lungs  yields 
negative  results.  Exceptionally  a  few  scattered  rales  are  heard.  The 
area  of  liver  dulness  is  not  increased.  The  spleen  is  usually  palpable; 
it  may  remain  normal  in  cases  of  varioloid  and  in  hemorrhagic  cases. 
Constipation  is  the  rule.  The  urine  is  scanty  and  high  colored.  Febrile 
or  toxic  albuminuria  is  common.  Hsematuria  is  a  frequent  attendant 
condition  in  purpura  variolosa.  The  blood  shows  no  characteristic  changes. 
It  does  not  tend  to  form  rouleaux.  There  is  rapid  disintegration  of  red 
cells  ;  during  the  fever  they  are  normal  or  increased,  but  upon  the  occur- 
rence of  defervescence  the  number  of  red  cells  diminishes  suddenly. 
Regeneration  takes  place  slowly.  In  hemorrhagic  cases  the  anaemia  comes 
on  quickly  and  is  proportionate  to  the  amount  of  blood  extravasation. 
There  is  no  leucocytosis  in  the  mildest  cases  such  as  occur  in  vaccinated 
persons  nor  in  the  initial  stages  of  graver  cases.  Leucocytosis  does  not 
appear  in  the  absence  of  complications  until  suppuration  takes  place,  and 
is  due  to  infection  by  pus  organisms  and  not  to  the  poison  of  variola  itself. 
Menstruation  is  excessive  and  if  the  onset  of  smallpox  occurs  toward  its 
close  the  flow  is  increased  and  prolonged. 

During  this  stage  the  so-called  initial  or  accidental  rashes  occur.  They 
are  more  common  in  some  epidemics  than  others,  but  are  encountered 
in  from  ten  to  fifteen  per  cent,  of  all  cases.  Two  varieties  may  be  recog- 
nized which  differ  in  form,  distribution,  and  in  prognostic  importance. 
The  more  common,  roseola  variolosa,  is  macular^  suggesting  the  eruption 
of  measles,  though  it  does  not  present  the  characteristic  papules  nor  their 
grouping  in  crescents.  This  rash  usually  appears  upon  the  second  day  and 
disappears  within  twenty-four  hours,  never  persisting  after  the  appear- 
ance of  the  pocks.  It  comes  out,  as  a  rule,  first  upon  the  face,  next  upon 
the  body,  and  finally  in  abundance  upon  the  extremities.  It  is  full)* 
developed  in  the  couise  of  some  hours  and  then  fades  somewhat  more  slowly. 
It  is  more  common  in  mild  than  in  severe  cases.  The  second  form,  ery- 
thema variolosa,  is  much  less  common.  It  appears  early,  usually  upon  the 
first  da}',  and  may  in  some  cases  antedate  the  fever  and  other  constitutional 
phenomena.  It  consists  of  a  vivid  dark  crimson  efflorescence,  throughout 
which  are  scattered  numerous  purpuric  spots  of  varying  size, — hemor- 
rhagic erijthe^na.  The  distribution  of  this  rash  is  remarkable.  The  regions 
involved  constitute  the  "triangles  of  Simon,"  of  which  the  first,  the  more 
common,  has  its  base  line  across  the  abdomen,  its  lateral  boundaries  along 


VARIOLOUS  DISEASES.  651 

the  inner  portions  of  the  thighs,  and  its  apex  at  the  knees;  the  second, 
of  which  there  are  usually  two,  occupy  the  lateral  thoracic  region,  the 
axillae,  a  portion  of  the  inner  surface  of  the  arm,  and  extend  forward  upon 
the  chest.  This  rash  lasts  until  after  the  true  exanthem  appears.  It  grad- 
ually fades,  the  purpuric  spots  more  slowly  than  the  surrounding  erythema. 
Within  the  limits  of  these  triangles  the  variolous  exanthem  frequently 
comes  out  less  abundantly  than  elsewhere  upon  the  surface  of  the  body. 
Some  observers,  as  Hebra,  noted  this  form  of  the  initial  rash  more  commonly 
in  females.  It  is  of  unfavorable  prognostic  omen.  The  duration  of  the 
stage  of  invasion  is  three  days.  In  rare  cases  the  eruption  may  first  appear 
toward  the  end  of  the  second  day;  more  rarely  still,  not  until  toward  the 
close  of  the  fourth  day. 

2.  The  Stage  of  Eruption. — From  the  time  of  the  appearance  of  the 
exanthem  the  divergence  of  the  clinical  varieties  begins.  The  essential 
difference  between  variola  vera  or  true  smallpox  and  variola  modificata  or 
varioloid  consists  in  the  fact  that  in  the  former  suppuration  takes  place 
in  the  fully  developed  pocks,  with  well-marked  secondary  fever,  while  in 
the  latter  most  of  the  pocks  undergo  involution  from  the  vesicular  stage 
without  further  constitutional  disturbance. 

A.   Variola  Vera. 

(a)  The  Discrete  Form. — About  the  end  of  the  third  or  the  beginning 
of  the  fourth  day  the  eruption  appears.  It  shows  itself  first  upon  the 
face  and  scalp,  particularly  at  the  edge  of  the  hair,  and  in  some  cases  upon 
the  wrists.  It  spreads  downward  over  the  trunk  and  extremities.  By  the 
close  of  the  third  day  of  the  eruption  and  sixth  of  the  attack  it  is  fully 
developed  and  the  surface  is  more  or  less  thickly  covered  with  pocks,  which 
are  more  abundant  and  advanced  upon  the  face,  where  they  first  appeai'ed, 
than  elsewhere.  Here  and  there  are  to  be  seen  scattered  individual  pocks 
that  appear  later  than  those  which  surround  them.  The  exanthem  is 
often  conspicuously  copious  in  local  areas  which  are  submitted  to  habitual 
pressure  by  the  clothing,  as  the  collar,  corset,  or  garters,  or  recently  irri- 
tated by  some  application,  as  iodine  or  a  sinapism.  It  is  usually  less  abun- 
dant in  the  hypogastric  region  and  inner  surfaces  of  the  arms  and  thighs 
than  elsewhere  and  upon  the  lower  than  the  upper  extremities. 

As  the  eruption  comes  out  the  temperature  falls,  the  constitutional 
symptoms  subside,  and  the  patient  feels  so  much  better  that  he  regards 
himself  as  convalescent. 

The  evolution  of  the  pock  is  as  follows:  The  macule  consists  of  a 
red  spot,  disappearing  upon  pressure  and  varying  in  size  from  the  head 
,of  an  ordinary  toilet  pin  to  a  split  pea.  The  color  and  distribution  of  the 
rash  at  this  period  suggest  measles  and  the  differential  diagnosis,  especially 
in  adults,  may  be  difficult.  Within  twenty-four  hours  a  distinct  hard 
papule  appears  which  feels  like  a  shot  embedded  in  the  skin.  This  rapidly 
becomes  acuminate  and  there  develops  at  the  summit  a  minute  vesicle 
with  clear  contents,  which  gradually  extends  to  the  size  of  the  papule 
and  becomes  tense  from  the  increase  of  contained  lymph.  The  greater 
number  of  the  fully  developed  vesicles  present  a  well-marked  and  highly 


652 


MEDICAL  DIAGNOSIS. 


characteristic  central  depression — primary  umbilication.  At  the  centre  of 
this  depression  may  be  found  in  many  but  not  in  all  of  the  pocks  a  hair 
follicle  or  the  duct  of  a  sebaceous  gland.  Finally  the  clear,  opalescent 
contents  become  cloudy,  then  opaque  and  yellow,  the  vesicle  is  converted 
into  a  pustule — stage  of  7naturation — and  with  this  change  the  umbilica- 
tion disappears  and  the  fully  developed  pock  becomes  hemispherical. 
The  pustule  is  surrounded  by  a  distinct  areola  several  millimetres  in  width 
and  the  skin  is  slightly  swollen.  By  the  third  day  the  pock  has  reached 
its  full  development  and  enters  upon  the  stage  of  involution  or  desiccation. 
Resorption  of  the  contents  rapidly  takes  place,  the  roof  of  the  pustule 


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Fig.  218. — Discrete  smallpox.     Moderate  fever  of  suppuration  ;  recovery. — Royer. 

sinks  in,  —  secondary  vvibilication,  —  hard,  yellowish-brown  or  blackish 
crusts  form,  which  gradually  separate,  leaving  abruptly  defined,  shallow 
scars,  with  glistening  red  bases,  which  in  the  course  of  time  become  white 
and  finally  disappear.  If  the  cutis  has  been  implicated  permanent  scars — 
pittings — are  formed.  The  resulting  disfigurement  in  ordinary  discrete 
smallpox  is  commonly  slight. 

The  time  occupied  by  the  successive  stages  is  approximately  as  fol- 
lows: macular  one  day;  papular  one  day;  vesicular  three  days;  pustular 
three  days;  desiccation  five  to  ten  days.  Puncture  of  the  vesicles  with 
a  fine  needle  is  followed  by  the  escape  of  a  portion  only  of  its  lymph,  which 
is  enclosed  in  several  spaces  limited  by  septa.  Upon  the  palms  and  soles 
the  pocks  are  as  a  rule  scanty  and  owing  to  the  thickness  of  the  epidermis 


VARIOLOUS  DISEASES. 


653 


they  remain  for  some  time  deeply  embedded.  Early  in  the  second  week 
of  the  attack  with  the  maturation  of  the  pocks  secondary  fever  and  more 
or  less  severe  constitutional  symptoms  occur.  The  skin  is  swollen,  tense, 
and  sore,  especially  upon  the  face,  the  eyelids  are  tumid,  and  the  counte- 
nance greatly  disfigured.  There  is  marked  leucocytosis.  The  secondary 
fever  rises  rapidly  to  about  the  range  of  that  of  the  initial  stadium  and 
falls  by  lysis  which  in  many  cases  is  rapid  so  that  defervescence  is  complete 
and  the  patient  enters  upon  convalescence  in  thirty-six  or  forty-eight  hours, 
namely,  about  the  eleventh  or  twelfth  day  of  the  attack.  The  fever  may, 
however,  last  several  days.  Delirium  is  common  in  severe  cases  and  sui- 
cidal tendencies  may  show  themselves.     General  septicaemia  may  develop. 

The  mucous  membranes  exposed  to  the  air  are  involved  usually  at 
the  same  time  with  the  skin;  not  rarely  earlier.  The  nasal  chambers, 
the  buccal  and  pharyngeal  surfaces, 
the  palate,  and  the  larynx  and  tra- 
chea are  the  seat  of  a  more  or  less 
abundant  eruption.  The  tongue  is 
less  frequently  attacked,  though  now 
and  then  pocks  may  be  observed 
upon  the  border  and  its  under  sur- 
face. The  anal,  preputial,  and  vulvar 
regions  are  later  affected.  The  pocks 
upon  mucous  membranes  are  at  first 
analogous  to  those  upon  the  skin. 
Under  the  influence  of  heat  and 
moisture  in  the  vesicular  stage  their 
roofs  undergo  maceration  and  dis- 
crete superficial  ulcers  are  formed. 
The  mucous  lesions  are  associated 
with  catarrhal  processes  and  add 
greatly  to  the  sufferings  of  the  pa- 
tient.     Among    the    symptoms    to 

which  they  give  rise  are,  in  the  mouth,  pain  and  difficulty  in  swallowing, 
hoarseness  and  aphonia,  and  excessive  secretion,  and  about  the  meatus 
urinarius  in  both  sexes,  distressing  pain  in  micturition.  These  symptoms 
are  greatly  aggravated  in  the  stage  of  suppuration.  Among  persons 
not  protected  by  vaccination  the  discrete  form  has  fortunately  in  all 
times  been  the  most  common. 

(b)  The  Confluent  Form. — The  pocks  are  closely  set  and  run  together, 
especially  upon  the  face,  hands,  wrists,  and  feet.  This  grave  form  of  the 
disease  is  encountered  among  those  children  and  adults  alike  who  have 
not  been  protected  by  vaccination  and  revaccination.  It  has  not  been 
especially  common  in  particular  epidemics  nor  is  it  transmitted  from 
person  to  person.  On  the  other  hand  the  mildest  case  of  varioloid  may 
give  rise  to  an  infection  resulting  in  variola  confluens,  while  the  latter 
may  cause  in  a  partially  protected  person  variola  discreta  or  varioloid. 
Personal  predisposition  must  therefore  enter  largely  into  its  causation. 

The  invasion  symptoms  usually  are  very  severe.  The  eruption  appears 
some  twelve  or  eighteen  hours  earlier  than  is   common  in  the  discrete 


Fig.  219. — Discrete  smallpox. — Royer. 


654 


MEDICAL  DIAGNOSIS. 


form — in  some  cases  by  the  end  of  the  second  or  the  beginning  of  the 
third  day.  The  earlier  its  appearance  the  greater  the  danger  of  confluence. 
Its  efflorescence  is  rapid  so  that  by  the  end  of  the  second  day,  the  fourth 
or  fifth  of  the  attack,  it  has  invaded  the  entire  body  from  the  head  to  the 
feet.  The  remarkable  remission  of  fever  and  amelioration  of  the  general 
symptoms  seen  upon  the  appearance  of  the  eruption  in  the  discrete  form 
seldom  occur.  As  a  rule  the  improvement  in  this  respect  is  only  partial^ 
fever  persisting  throughout  the  attack  and  becoming  intense  as  suppuration 
takes  place.     The  skin  is  swollen  and  hypersemic;    the  individual  pocks 


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Fig.  220. — Confluent  smallpox.     Incomplete  defervescence  upon  appearance  of  rash;   severe  secondary 
fever;   death  on  the  16th  day. — Royer. 


in  the  papular  stage  are  small  and  crowded  upon  the  skin;  they  are  rapidly 
converted  into  vesicles,  which,  increasing  in  size,  soon  become  pustules. 
During  this  process  confluence  takes  place  and  extensive  superficial  abscesses 
are  formed.  The  face  in  severe  cases  presents  the  appearance  of  a  thick 
yellowish  mask.  Upon  the  arms  and  legs  the  pocks  are  numerous  and 
limited  patches  of  confluence  are  sometimes  seen,  especially  upon  parts 
subjected  to  pressure,  as  the  buttocks,  while  they  remain  discrete  upon 
the  trunk.  The  swelling  of  the  hands  and  feet  increases  and  these  parts 
are  the  seat  of  most  distressing  tension,  pain,  and  tenderness.  The  eruption 
is  abundant  upon  the  mucous  membranes  of  the  nose,  mouth,  pharynx, 
and  larynx.  Confluence  may  give  rise  to  extensive  superficial  ulceration. 
Deep  abscess  formation  may  occur  in  the  tonsils  or  in  the  retropharyngeal 


VARIOLOUS  DISEASES. 


655 


tissues  and  necrosis  of  the  laryngeal  cartilages  which  may  be  associated 
with  oedema  of  the  glottis.  The  cervical  lymph-glands  are  enlarged  and 
tender.  At  this  period  purulent  metastases  in  distant  organs  frequently 
develop.  Toward  the  end  of  the  first  or  at  the  beginning  of  the  second 
week  the  fever  rises  to  104°  F.  (40°  C.)  or  higher,  the  pulse  to  120.     De- 


FiG.  221. — Confluent  smallpox. — R,oyer. 

lirium,  very  often  maniacal,  sets  in;  the  patient  is  often  with  difficultv 
restrained  from  leaving  his  bed,  and  with  the  signs  of  a  profound  toxtemia, 
progressively  feebler  and  more  frequent  pulse,  subsultus,  involuntary 
discharges,  or  preagonistic  hyperpyrexia,  death  closes  the  scene.  When 
recovery  occurs,  the  cutaneous  and  constitutional  symptoms  undergo 
gradual  improvement,  and  irregular 
fever  may  even  in  the  absence  of 
complications  prolong  the  convales- 
cence into  the  fourth  week. 

3.  Stage  of  Desiccation  and 
Decrustation. — The  areola  fades  ; 
the  pustule  sinks  and  becomes  flat- 
tened; its  edge  is  sharply  defined 
against  the  surrounding  skin  and 
separation  gradually  takes  place,  the 
entire  process  occupying  in  V.  dis- 
creta  two  weeks  or  more  and  in  V. 
confluens  a  longer  time.  As  a  rule 
the  desiccation  begins  in  the  face 
and  scalp,  where  crusts  may  be  seen, 
while  upon  the  extremities  the  exanthem  is  still  in  the  pustular  stage. 
In  some  instances  the  desiccation  takes  place  on  all  parts  of  the  skin 
at  the  same  time.  Many  of  the  pustules  break  and  the  exuding  con- 
tents dry  in  the  form  of  broad  thin  crusts.  The  process  of  desiccation 
is  attended  by  intense  itching.  The  pocks  upon  the  palms  and  soles  are 
limited  in  number  and  form  hard  circumscribed  nodules  in  the  thick  epi- 


Fir..  222  —Exfoliation  of  the  palmar  epider- 
mis contamma,  embedded  pocks  occurring  in  the 
later  stage  of  severe  smallpox. — After  Welch  and 
Schamberg. 


656 


MEDICAL  DIAGNOSIS. 


dermis,  which  in  the  course  of  three  or  four  weeks  undergo  separation  and 
may  be  picked  out.  The  hair  usually  falls  out  and  in  some  cases  the  nails 
are  lost.  In  the  confluent  form  the  thick  epidermis  of  the  hands  and  feet 
is  sometimes  cast  off  entire.  The  crusts  upon  separation  sometimes  reform 
and  the  ulcerative  lesions  of  the  skin  heal  slowly  by  granulation.  Upon 
the  face  the  resulting  scars  are  much  more  disfiguring  than  the  pitting  of 
V.  discreta.  They  are  extensive,  of  irregular  outline,  and  intersected  by 
lines  and  bands  which  gradually  undergo  contraction,  causing  ectropion 
of  the  eyelids  and  lips  and  interfering  with  the  muscles  of  expression. 

The  appearance  of  the  patient  in  the  stage  of  maturation,  particu- 
larly in  V.  confluens,  is  horrible.  The  swollen  face,  thickly  covered  with 
pustules  and  blebs,  some  of  which  are  broken  and  exude  a  sticky  pus,  or 
with  a  hideous  mask  of  necrotic  skin,  the  tumid  and  closed  eyelids,  the 
distorted  nose  and  lips,  the  disfigured  ears,  the  foul  secretions,  and  the 

stench  which  surrounds  the 
wretched  being  create  an  impres- 
sion not  to  be  forgotten  and  merit 
the  popular  adjective  loathsome 
applied  to  the  disease. 

(c)  Hemorrhagic  Forms. — i. 
Purpura  Variolosa. —  This  is  the 
most  malignant  form  of  variola. 
It  is  fortunately  comparatively 
rare  and  in  some  epidemics  no 
cases  have  been  observed.  It  may 
occur  at  any  period  of  life,  is  less 
common  among  children  than 
grown  persons,  and  affects  as  a  rule 
young  and  vigorous  adults.  The 
influence  of  vaccination  and  especially  of  repeated  revaccination  is  of  the 
greatest  importance  in  preventing  this  clinical  manifestation  of  the  variolous 
infection.  The  incubation  is  short — five  to  eight  days.  Prodromes,  especially 
lumbosacral  pains,  are  not  uncommon.  The  invasion  is  attended  with  pro- 
found constitutional  disturbance.  Fever  may  be  moderate,  but  there  is  great 
prostration;  the  pulse  is  small  and  frequent,  the  respiration  accelerated,  and 
the  patient  experiences  a  feeling  of  overwhelming  illness.  Headache  and 
backache  are  severe  and  precordial  and  epigastric  distress  are  often  asso- 
ciated with  vomiting  and  purging.  The  mind  remains  clear.  Commonly 
upon  the  second  day,  sometimes  earlier,  a  diffuse,  scarlatiniform  rash  makes 
its  appearance  upon  the  lower  part  of  the  body  and  the  extremities  and 
shortly  thereafter  upon  the  face.  Purpuric  spots  of  varying  size  rapidly 
appear.  Ecchymoses  invade  and  frequently  entirely  cover  the  face.  The 
conjunctivae,  eyelids,  and  loose  tissues  adjacent  are  distended  with  a  san- 
guinolent  oedema  and  in  a  short  time  the  greater  part  of  the  surface  of  the 
body  is  involved  in  a  livid,  purplish-red  discoloration.  Mucous  hemor- 
rhages are  common,  epistaxis,  bleeding  from  the  gums,  and  haematuria  being 
the  usual  forms;  haemoptysis,  haematemesis,  and  melaena  less  frequent. 
Metrorrhagia  is  common  and  pregnant  women  abort.  In  rare  instances 
death  may  take  place  without  the  occurrence  of  free  hemorrhage.      Very 


Fig.  223. — Hemorrhagic  smallpox. — Royer. 


VARIOLOUS  DISEASES. 


657 


often  there  is  no  trace  of  the  exanthem.  If  hfe  be  prolonged  a  few  scattered 
blood-tinged  papules  may  be  discovered  upon  the  forehead  and  wrists. 
This  form  of  variola  terminates  in  death  within  a  week  and  very  often 
as  early  as  the  fourth  or  fifth  day. 

ii.  Variola  Pustulosa  Hasmorrhagica. — This  form  is  much  more  com- 
mon than  the  preceding  and  usually  occurs  in  feeble  and  cachectic  per- 
sons and  drunkards  who  are  not  protected  by  vaccination.  The  attack 
develops  as  an  ordinary  severe  case  of  variola,  which  becomes  hemorrhagic 
in  the  vesicular  or  pustular  stage.  Exceptionally  bleeding  takes  place 
into  some  of  the  pocks  while  yet  in  the  papular  stage.  The  bleeding  is 
in  many  instances  restricted 
to  the  eruption  upon  the 
lower  part  of  the  body  and 
the  lower  extremities. 
Blood  extravasation  may 
also  involve  the  skin  beyond 
the  pocks  and  free  hemor- 
rhages from  mucous  sur- 
faces may  lead  up  to  the 
fatal  issue.  The  earlier  in 
the  course  of  the  attack  the 
hemorrhages  appear  the 
graver  the  outlook.  Death 
commonly  results  at  the  end 
of  the  first  or  in  the  begin- 
ning of  the  second  week. 
Recovery  may  occur  in 
cases  in  which  hemorrhage 
into  the  pocks  does  not  take 
place  until  the  stage  of  sup- 
puration.  A  distinction 
must  be  made  between  this 
form  of  variola  and  cases  of 
V.  discreta  in  which,  owing 
to  mechanical  violence, 
pressure,  or  other  accidents, 
blood  is  extravasated  into 
a  few  vesicles  or  pustules.  To  the  latter  group  must  be  referred  cases  of 
hemorrhage  into  the  pustules  of  the  legs  in  patients  who  have  gotten 
out  of  bed  during  their  delirium.  Osier  describes  a  series  of  six  cases 
in  which  hemorrhage  into  the  vesicles  was  followed  by  "  a  rapid  abortion 
of  the  rash  and  speedy  recovery." 


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B.  Variola  Modificata. 

(a)  Varioloid. — This  term  is  applied  to  the  modified  form  of  smallpox 
which  occurs  in  persons  who  possess  a  partial  immunity  as  the  result  of 
vaccination  and  revaccination.  It  is  characterized  anatomically  by  the 
fact  that  the  typical  exanthem  causes  as  a  rule  only  superficial  lesions 

42 


658  MEDICAL  DIAGNOSIS. 

upon  the  skin  and  therefore  rarely  leaves  permanent  scars;  clinically  by 
the  absence  of  the  stage  of  suppuration  and  the  secondary  fever  and  a. 
shorter  and  more  favorable  course.  The  period  of  incubation  is  the  same. 
The  onset  is  abrupt  and  in  many  cases  the  initial  symptoms  are  severe. 
Generally  the  symptoms  of  the  stage  of  invasion  are  relatively  mild.  Head- 
ache and  backache  may,  however,  be  intense.  If  an  initial  rash  appears  it 
is  the  macular  variety — roseola  variolosa.  The  papules  appear  toward  the 
close  of  the  third  or  in  the  beginning  of  the  fourth  day,  first  upon  the  face 
and  then  elsewhere,  spreading  from  above  downward.  They  vary  in  num- 
ber from  ten  or  twelve  upon  the  face  and  hands  to  a  copious  eruption 
distributed  over  the  entire  surface.  AYithin  forty-eight  hours  their  appear- 
ance is  complete,  although  during  the  latter  part  of  this  period  a  few  fresh 
papules  may  be  recognized  here  and  there  among  those  which  first  ap- 
peared. The  fever  ends  at  once  by  crisis  and  the  general  symptoms  rapidly 
improve.  The  development  of  many  of  the  pocks  is  arrested  in  the  papular 
stage;  others  abort  early  in  the  vesicular  stage  and  in  some  few  the  con- 
tents of  the  vesicles  may  become  cloudy  and  slightly  opacpie.  Desiccation. 
sets  in  early  and  goes  on  with  rapidity.     Convalescence  is  usually  complete. 

(b)  Variola  sine  Eruptione. — During  outbreaks  of  variola  cases  are 
sometimes  observed  in  which  no  trace  of  eruption  can  be  discovered.  The 
diagnosis  rests  upon  etiological  as  well  as  upon  clinical  grounds.  A  history 
of  exposure,  sudden  onset,  fever,  intense  lumbosacral  pains,  and  critical 
defervescence  upon  the  third  day  justify  a  provisional  diagnosis  of  smallpox 
without  eruption.  The  transmission  of  the  disease  to  others  would  render 
the  diagnosis  positive.  Variola  sine  eruptione  occurs  in  young  persons 
who  have  been  well  vaccinated-and  invariably  runs  a  favorable  course. 

The  modification  of  variola  caused  by  artificial  inoculation  is  no  longer 
encountered  in  western  countries.  About  the  eighth  day  local  reaction  was 
manifest  at  the  point  of  inoculation.  Fever  and  constitutional  symptoms 
developed  and  were  followed  by  a  typical  exanthem,  not  usually  copious. 

A  rare  anomaly  in  the  pock  is  described  under  the  name  of  horn-pox 
or  wart-pox — V.  verrucosa.  The  eruption  appears  upon  the  third  or  fourth 
day  but  instead  of  developing  as  usual  the  papules  undergo  desiccation 
upon  the  fifth  or  sixth  day  and  are  converted  into  dense  warty  or  horny 
nodules.     This  change  is  more  common  upon  the  face  than  elsewhere. 

Complications  and  Sequels. — The  complications  are  not  numerous 
and  mostly  develop  during  the  stage  of  suppuration.  They  consist  mainly 
of  extensions  of  the  suppurative  inflammatory  process  in  the  skin  or  mucous 
membranes  or  of  metastatic  infections.  It  follows  that  they  are  more 
common  and  severe  in  proportion  to  the  extent  and  intensity  of  the  sup- 
puration— in  V.  confluens  than  in  V.  discreta,  and  infrequent  in  varioloid. 
Bed-sores  and  acute  gangrene  are  frequent  in  severe  cases.  Erysipelas 
is  not  uncommon.  Phlegmonous  inflammation  of  the  skin  may  occur. 
Furunculosis  and  acne  are  often  troublesome  diu-ing  convalescence.  Super- 
ficial erosions  in  the  larynx  may  in  healing  give  rise  to  adhesions  which 
result  in  permanent  hoarseness;  the  cartilages  may  be  involved  and  acute 
cedema  of  the  larynx  may  cause  sudden  death.  Lesions  of  the  larynx 
play  an  important  part  in  the  causation  of  bronchitis  and  bronchopneu- 
monia which  is  perhaps  the  most  common  of  the  complications.     Croupous 


VARIOLOUS  DISEASES. 


659 


pne\imonia  is  infrequent;  pulmonary  abscess  may  occur.  Purulent  pleurisy 
has  been  common  in  some  epidemics.  Cardiac  complications  are  infrequent. 
Myocardial  changes  are  observed.  An  apex  systoHc  murmur  may  occur. 
Pericarditis  is  rare.  Simple  endocarditis  is  not  common  in  smallpox. 
Malignant  endocarditis  has  been  in  some  instances  found  post  mortem. 
Venous  thrombosis  may  occur  during  the  later  course  of  the  attack.  In 
the  digestive  tract  parotitis  and  inflammatory  affections  of  the  other  sali- 
vary glands  occasionally  occur.  Their  frequency  varies  in  different  epidemics. 
Pseudomembranous  angina  is  common  in  severe  cases  and  especially  in  the 
hemorrhagic  forms.  The  vomiting  of  the  initial  stage  is  not  apt  to  persist. 
Diarrhoea  is  frequent,  especially  in  children.     Dysenteric  symptoms  are 


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frequently  mentioned  by  the  older  authorities  but  are  rare  at  present. 
Complications  in  the  urinary  tract  are  infrequent.  Toxic  albuminuria  is 
common;  nephritis  rare.  Hsematuria  is  usual  in  the  malignant  cases. 
Inflammation  of  the  ovaries  and  of  the  testicles — orchitis  variolosa — may 
occur.  ^  Pregnant  women  usually  abort.  Pysemic  arthritis  and  acute 
necrosis  of  bones  or  cartilages  may,  as  in  the  other  severe  acute  infections, 
develop  during  the  convalescence.     Diabetes  mellitus  is  a  rare  sequel. 

The  nervous  system  is  especially  prone  to  react  to  the  variolous  infec- 
tions. In  children  general  convulsions  are  common  at  the  outset  and  may 
be  repeated.  In  adults  and  especially  in  alcoholics  maniacal  dehrium  may 
terminate  in  coma.  Post-febrile  insanity  sometimes  occurs.  It  is  less 
common  than  after  influenza  and  enteric  fever  and  commonly  ends  in 
recovery.    Epilepsy  is  a  very  rare  sequel.    Purulent  meningitis  and  enceph- 


660  MEDICAL  DIAGNOSIS. 

alitis  are  likewise  rare  complications.  Hemiplegia  has  been  observed  in 
a  few  instances.  Transient  aphasia  has  been  noted.  Paraplegia  may 
occur  at  any  time  dm*ing  the  attack.  It  begins  abruptly;  is  usually  sub- 
acute, and  may  involve  the  sphincters.  In  some  instances  the  symptoms 
have  been  those  of  acute  ascending  paralysis  and  the  termination  rapidly 
fatal.  The  palsies  of  the  lower  extremities  and  the  monoplegias  observed 
occasionally  are  manifestations  of  an  infectious  neuritis.  Ataxic  S3/mptoms 
may  occur.  Paralysis  of  the  soft  palate  analogous  to  that  which  follows 
diphtheria  sometimes  occurs.  Paralysis  of  individual  muscles  or  muscle- 
groups,  as  the  deltoid,  and  circumscribed  areas  of  cutaneous  anaesthesia 
have  been  described. 

Otitis  media  purulenta  is  a  frequent  complication.  It  results  from  the 
extension  of  the  catarrhal  inflammation  by  Way  of  the  Eustachian  tube. 
It  usually  develops  during  the  stage  of  suppuration.  Exceptionally  puru- 
lent disease  of  the  mastoid  arises  with  necrosis  of  the  bone,  or  the  labyrinth 
may  be  involved.  Serious  affections  of  the  eye  with  resulting  blindness 
were  common  in  former  times.  They  are  relatively  infrequent  at  present 
because  of  the  greater  attention  now  given  to  the  early  ocular  lesions.  The 
conjunctivitis  incident  to  the  disease  may  become  chronic.  Diffuse  kera- 
titis may  occur  and  result  in  ulceration  and  perforation  with  destruction 
of  the  eyeball.  Iritis  and  choroiditis  are  less  common.  In  the  purpuric 
cases  retinal  hemorrhages  may  occur.  Pocks  develop  very  commonly 
upon  the  outer  surface  of  the  eyelids  and  result  in  scar  formation  with 
ectropion  and  its  attendant  evils.  Much  less  commonly  they  involve  the 
palpebral  conjunctiva  and  very  rarely  the  ocular  conjunctiva.  Synechise 
!hay  result. 

External  and  internal  nasal  deformities  sometimes  result  from  the 
ulcerative  processes  and  subsequent  scar  formation.  Necrosis  of  the  carti- 
laginous sei3tum  with  perforation,  occlusion  of  a  nasal  chamber,  partial 
adhesion  of  the  soft  palate,  and  loss  of  the  sense  of  smell  are  among  the 
sequels  of  smallpox. 

Diagnosis. — A  correct  diagnosis  where  there  is  a  question  of  variola 
is  one  of  the  most  critical  and  important  of  the  duties  of  the  physician. 
A  mistake  may  be  the  cause  of  an  extended  and  disastrous  epidemic. 

The  DIRECT  DIAGNOSIS  of  typical  variola  is  unattended  by  difficulty 
after  the  appearance  of  the  eruption.  In  the  atypical  and  modified  forms 
the  difficulties  are  frequently  insurmountable.  During  the  prevalence  of 
an  epidemic  every  case  of  sudden  illness  is  suspected.  The  sudden  occur- 
rence of  headache,  rigors,  intense  backache,  epigastric  pain,  nausea  and 
vomiting,  and  high  temperature  is  important.  The  initial  rashes  may  be 
misleading.  The  measly  rash — roseola  variolosa — bears  in  many  instances 
some  resemblance  to  measles,  for  which  the  disease  may  be  mistaken. 
More  commonly,  however,  during  an  epidemic  measles  is  mistaken  for 
variola.  The  scarlatinal  rash — erythema  variolosa. — lacks  as  a  rule  the 
vividness  of  the  eruption  of  scarlet  fever  and  differs  from  it  in  distribution, 
occupying  the  abdominocrural  or  pectoral  triangles  of  Simon.  In  fact 
the  occurrence  of  this  rash  in  connection  with  the  foregoing  symptoms 
renders  the  diagnosis  of  smallpox  almost  positive.  A  history  of  exposure 
and  the  absence  of  vaccination  scars  are  of  diagnostic  importance.     The 


VARIOLOUS  DISEASES.  661 

development  toward  the  close  of  the  third  or  at  the  beginning  of  the  fourth 
day  of  an  eruption  of  red  macules  upon  the  face,  scalp,  and  wrists,  rapidly 
becoming  papular  and  feeling  like  shot  embedded  in  the  skin,  coincidently 
with  a  marked  remission  in  the  febrile  movement,  renders  the  diagnosis 
positive.  In  any  doubtful  case,  especially  in  the  negro,  the  buccal  and 
faucial  mucous  membrane  should  be  carefully  examined. 

In  malignant  hemorrhagic  smallpox  death  may  occur  before  the  char- 
acteristic rash  develops.  If  the  patient  survive  to  the  end  of  the  third  or 
fourth  day  a  few  shrunken,  shotty  papules  may  be  felt  about  the  roots  of 
the  hair  and  upon  the  wrists. 

Differential  Diagnosis. — Smallpox  during  its  initial  stage  presents 
some  points  of  superficial  resemblance  to  the  following  diseases:  1.  Scarlet 
Fever. — There  is  erythematous  sore  throat,  more  or  less  painful.  The  rash 
is  brighter  and  more  intense  than  the  erythematous  initial  rash  of  small- 
pox, in  which  petechise  are  very  commonly  present.  It  appears  first  upon 
the  chest  and  throat  and  is  rapidly  diffused.  2.  Measles. — The  stage  of 
invasion  is  accompanied  by  marked  catarrhal  symptoms.  The  rash  appears 
about  the  fourth  day  but  is  distinctly  maculopapular,  lacking  the  shot-like 
firmness  of  the  variolous  papule  and  showing  a  crescentic  arrangement. 
There  is  no  remission  in  the  febrile  movement  upon  the  development  of 
the  rash.  3.  Typhus. — The  eruption  is  rare  upon  the  face  and  when 
present  in  this  region  is  comparatively  faint.  The  macules  are  not  hard 
or  elevated.  There  is  no  fall  of  temperature  upon  the  appearance  of  the 
eruption. 

During  the  vesicular  and  pustular  stage  smallpox  may  be  mistaken 
for:  4.  Varicella. — Errors  in  diagnosis  between  these  two  diseases 
are  very  common.  In  varicella  initial  symptoms  are  usually  absent.  The 
eruption  is  always  discrete  and  appears  in  successive  crops.  It  is  usually 
not  observed  until  it  has  reached  the  vesicular  stage.  The  vesicles  are 
irregularly  oval  or  circular,  tensely  distended  with  a  transparent  fluid. 
They  are  clear,  bright,  and  pearly.  Primary  umbilication  does  not  occur, 
but  in  rare  cases,  as  the  contents  of  the  vesicles  undergo  resorption,  the 
roof  of  the  vesicle  falls  in,  giving  rise  to  the  condition  known  as  secondary 
umbilication.  5.  Pustular  Syphilides. — Individual  pustules  occasionally 
bear  a  close  resemblance  to  the  variolous  pock.  The  polymorphous  char- 
acter of  syphilitic  eruptions,  their  symmetrical  distribution,  their  persist- 
ence, the  presence  of  mucous  patches,  the  history  of  the  case,  and  the 
nature  of  the  febrile  movement  when  present  serve  to  render  the  differ- 
ential diagnosis  a  relatively  easy  matter.  6.  Pustular  glanders  is 
attended  with  malaise,  pyrexia,  and  pain  in  the  limbs.  There  is  an  eruption 
of  indurated  red  papules  upon  the  summit  of  which  pustules  develop. 
There  is  a  fetid  nasal  discharge.  The  invasion  symptoms  and  the  course 
of  the  disease  are  totally  unlike  smallpox.  7.  Cerebrospinal  Fever. — 
The  sudden  onset,  intense  symptoms,  and  petechial  rash  may  lead  to  errors 
of  diagnosis.  Painful  rigidity  of  the  back  of  the  neck  and  spastic  con- 
traction of  the  limbs  may  be  present  in  both  these  conditions.  Papules 
should  be  carefully  sought  for  at  the  roots  of  the  hair  and  upon  the  wrists. 
Photophobia,  pupillary  inequalities,  strabismus,  and  very  irregular  fever 
suggest  meningitis  rather  than  smallpox.  Lumbar  puncture  is  important. 
8.  Drug  Exanthems. — Iodide  of  potassium,  the  bromides,  and  the  local 


662  MEDICAL  DIAGNOSIS. 

use  of  croton  oil  may  produce  rashes  suggesting  smallpox,  but  the  resem- 
blance is  extremely  superficial  and  the  true  nature  of  these  affections 
becomes  apparent  upon  examination. 

Prognosis  and  Mortality. — In  persons  not  protected  by  vaccination 
smallpox  is  a  very  fatal  disease.  In  the  older  epidemics  the  mortality 
ranged  from  40  to  60  per  cent,  and  smallpox  was  dreaded  alike  from  its 
loathsomeness,  its  high  mortality,  and  its  serious  sequels.  At  the  present 
time  the  mortality  of  smallpox  is  greatly  influenced  by: 

1.  Vaccination  and  Revaccination. — During  the  nineteenth  cen- 
tury smallpox  epidemics  diminished  in  the  most  remarkable  manner  in 
extent  and  frequency  and  showed  a  correspondingly  lowered  mortality. 
Nevertheless  among  the  unvaccinated  the  gravity  of  the  disease  and  the 
death-rate  are  practically  unchanged.  MacCombie's  statistics  show  in  3940 
unvaccinated  cases  of  all  ages  1758  deaths — 44.6  per  cent.  Among  17,756 
vaccinated  cases  1441  deaths,  a  mortality  of  8.1  per  cent.  Welch,  Municipal 
Hospital,  Philadelphia,  reported  in  2831  cases  of  variola  1534  deaths^  a 
mortality  of  54.18  per  cent.,  and  in  2169  cases  of  varioloid  28  deaths,  a 
mortality  of  1.29  per  cent.  In  Sheffield  in  the  outbreak  of  1887-8,  of  4703 
cases  474,  or  10  per  cent.,  terminated  fatally.  Of  552  patients  not  vacci- 
nated 274,  or  49.6  per  cent.,  died;  while  of  4151  vaccinated  patients  200, 
or  4.8  per  cent.,  died. 

The  character  of  the  vaccination  is  of  great  importance  as  affecting 
the  prognosis.  The  relative  value  of  multiple  or  repeated  vaccinations  is 
shown  by  McCombie's  analysis  of  11,724  cases.  This  author  regards  an 
area  of  |-  to  J  square  inch  of  well-foveated  surface  as  indicating  efficient 
vaccination.  He  found  the  mortality  among  cases  with  one  good  mark  to 
be  6.4  per  cent.;  among  those  with  one  indifferent  mark,  16.7  per  cent. 
Among  those  with  two  good  marks,  3.7  per  cent.;  among  those  with  two 
indifferent  marks,  11.2  per  cent.  Among  those  with  three  good  marks  3.7 
per  cent.;  among  those  with  three  indifferent  marks  7.4  per  cent.  With 
four  or  more  good  marks  2.7  per  cent.;  with  four  or  more  indifferent  marks 
4.8  per  cent.,  and  concludes  that  the  protection  against  a  fatal  attack  is 
three  or  four  times  greater  among  patients  with  efficient  than  those  with 
indifferently  successful  vaccination.  W.  M.  Welch  analyzed  5000  cases 
with  reference  to  the  character  of  the  cicatrices,  whether  produced  in 
primary  vaccination  or  in  revaccination,  with  the  following  result:  The 
mortality  among  persons  having  good  scars  was  8  per  cent.;  fair  scars  14 
per  cent. ;  those  with  poor  scars  27  per  cent. ;  average  mortality  in  persons 
showing  the  cicatrices  of  vaccination  16  per  cent.;  mortahty  among  un- 
vaccinated persons  58  per  cent. 

Death  from  smallpox  is  rare  in  persons  whose  primary  vaccination 
was  efficient  and  in  whom  revaccination  has  been  successful.  These  well- 
established  facts  are  of  the  greatest  practical  importance. 

2.  The  Virulence  of  the  Attack. — Smallpox  modified  by  efficient 
vaccination  and  revaccination  is  a  comparatively  trifling  disease  with  a 
death-rate  but  little  exceeding  1  per  cent,  of  all  cases.  Ordinary  discrete 
smallpox  is  a  grave  affection  with  a  greath^  increased  mortality.  Con- 
fluent smallpox  is  even  more  grave,  the  majority  of  the  cases  terminating 
in  death,   and  those  recovering  frequently  suffering  from  serious,  often 


VARIOLOUS  DISEASES.  663 

irremediable,  sequels.  Finally,  the  hemorrhagic  form — jyurpura  variolosa — 
is  invariably  fatal.  Petechial  rashes  and  hemorrhagic  phenomena  are 
especially  unfavorable.  A  rise  of  temperature  directly  after  the  appear- 
ance of  the  eruption  is  a  bad  sign.  Continuing  delirium,  persistent  high 
temperature,  and  convulsions  are  of  grave  prognostic  omen. 

3.  The  Patient's  Surroundings. — Unfavorable  hygienic  conditions, 
overcrowding,  poverty,  and  want  greatly  increase  the  mortality. 

4.  The  Occurrence  of  Complications. — The  compHcations  of  variola 
affect  the  prognosis  unfavorably.  Certain  epidemics  have  been  attended 
with  an  unusual  death-rate  in  consequence  of  the  frequent  occurrence  of 
ordinary  grave  complications.  The  laryngeal  and  pulmonary  compli- 
cations are  especially  ominous. 

5.  Age. — Among  the  conditions  unfavorably  affecting  the  death-rate  in 
individual  cases  age  is  of  great  importance.  In  young  children  the  disease 
is  peculiarly  fatal.  Unvaccinated  infants  in  the  first  year  mostly  die,  and 
the  mortality  is  high  up  to  the  tenth  year.  From  ten  to  twenty  years  of 
age  there  is  a  slight  decrease  in  the  death-rate,  which  after  the  thirtieth 
year  again  rises. 

6.  Previous  Illness. — Previous  severe  illness  and  alcoholism  render 
the  prognosis  unfavorable. 

7.  Pregnancy, — Pregnant  women  are  especially  liable  to  the  disease 
in  the  confluent  and  hemorrhagic  forms.  Abortion  usually  occurs  and  is 
apt  to  be  followed  by  septic  infection.  To  this  rule  there  are  fortunately 
occasional  exceptions.  The  foetus  may  show  a  well-developed  eruption 
and  quickly  die  or  it  may  develop  the  eruption  shortly  after  birth.  In  cases 
in  which  abortion  does  not  occur  the  child  may  undergo  the  disease  in  utero 
and  be  after  birth  immune  alike  to  vaccination  and  variola. 

Vaccinia,  Cowpox,  Kinepox. 

Definition. — An  eruptive  disease  of  the  cow,  communicable  only  by 
inoculation  and  causing,  when  transmitted  to  the  human  being,  local 
reaction  in  the  form  of  a  pock  and  constitutional  disturbances  which  are 
followed  by  a  more  or  less  lasting  immunity  against  smallpox. 

Vaccination. 

Definition. — The  artificial  inoculation  of  vaccine  virus  for  the  pur- 
pose of  producing  immunity  against  smallpox. 

Arm  to  arm  vaccination  was  formerly  very  generally  practiced  in  order 
to  perpetuate  the  lymph  and  secure  its  greatest  purity.  The  use  of  crusts 
came  into  vogue  at  a  later  period.  Bovine  vaccine  lymph  has  now  come 
into  general  use,  and  has  the  advantage  over  the  arm  to  arm  method  of 
avoiding  the  opening  of  the  vesicle  and  thus  affording  the  opportunity  for 
accidental  infection  and  of  wholly  eliminating  the  danger  of  syphilis  and 
other  mfections.  When  it  is  necessary  to  use  human  lymph  it  should  be 
taken  upon  the  eighth  day  from  a  typical  unbroken  vesicle  in  a  perfectly 
healthy  child  at  least  three  months  old.  The  vesicle  must  be  pricked  at 
several  points,  care  being  taken  not  to  draw  blood.     The  lymph  may  be 


664 


MEDICAL  DIAGNOSIS. 


in  a  preserved  dry  state  upon  sterilized  bone  points  or  slips.  When  required 
for  use  the  dry  lymph  is  moistened  by  a  few  drops  of  warm  sterilized  water. 
It  may  also  be  preserved  in  capillary  glass  tubes,  each  containing  the 
quantity  required  for  one  vaccination,  sufficiently  long  to  admit  of  sealing 
in  the  flame  of  a  spirit  lamp,  thin  enough  to  enable  them  to  be  instan- 
taneously sealed,  and  strong  enough  to  be  handled  and  transported. 

Glycerinated  Lymph. — The  thorough  incorporation  of  four  parts  of 
a  sterilized  50  per  cent,  solution  of  chemically  pure  glycerin  in  water  with 
one  part  of  lymph  or  vesicle  pulp,  and  the  storing  of  this  mixture  in  sealed 
capillary  glass  tubes,  protected  from  light  for  some  weeks,  is  followed  by 
the  destruction  not  only  of  the  ordinary  saprophytic  bacteria  found  in  the 
lymph,  but  also  of  tubercle  bacilli  and  the  streptococcus  of  erysipelas. 

Lymph  thus  treated  is  fully  as  effi- 
cient as  ordinary  lymph. 

Vaccinia  produced  by  human- 
ized lymph  has  a  somewhat  more 
rapid  evolution  than  that  caused  by 
bovine  virus  and  is  attended  with 
milder  constitutional  symptoms. 

The  Technic. — The  outer  sur- 
face of  the  arm  near  the  insertion 
of  the  deltoid  is  usually  selected. 
In  infants  the  left  arm  is  preferable. 
In  females  the  outside  of  the  leg  just 
below  the  knee  is  sometimes  chosen. 
The  surface  must  be  washed,  dried 
with  a  soft  towel,  and  the  lymph 
inserted  by  puncture,  multiple  super- 
ficial crossed  incisions,  or  after  the 
removal  of  the  epidermis  by  scrap- 
ing. The  spots  are  to  be  rendered 
moist  by  the  exuding  serum  but  care 
should  be  taken  not  to  draw  blood.  For  this  purpose  a  thoroughly  sterilized 
old-fashioned  thumb  lancet  or  an  ordinary  flat-headed  surgical  needle  should 
be  employed.  The  insertion  should  be  performed  at  two  points  about  an 
inch  apart  and  the  diameter  of  the  abraded  or  scarified  area  should  be  about 
one  centimetre.  The  clothing  should  not  be  replaced  until  the  serum  has 
thoroughly  dried.  A  thin  layer  of  sterilized  gauze  should  be  lightly  applied 
and  held  in  place  by  means  of  adhesive  plaster,  not  encircling  the  limb. 
This  should  be  occasionally  renewed.  The  pock  should  be  kept  dry  and 
clean,  and  may  be  lightly  dusted  with  starch  or  toilet  powder.  The  new- 
born should  be  vaccinated  only  during  the  prevalence  of  smallpox.  Children 
are  commonly  vaccinated  in  the  course  of  the  third  month.  In  case  of 
failure  the  operation  must  be  repeated.  Persons  exposed  to  the  contagion 
of  smallpox  should  be  immediately  revaccinated.  The  immunity  conferred 
diminishes  with  time.  Revaccination  should  be  performed  at  the  seventh 
year  of  age,  again  at  puberty,  and  from  time  to  time  as  epidemics  occur. 
Typical  Vaccination. — The  period  of  incubation  varies  from  three 
to  five  days.    At  the  end  of  this  time  local  reaction  shows  itself  in  the  form 


Fig.  226.- 


— Scars  from  an  infantile  vaccination. — 
After  Welch  and  Schamberg. 


PLATE  XII. 


^ 


3 


• 


4 


S 


I* 


Typical  Vaccination. 

1.  Papules.    2.  Vesicles  with  clear  contents.    3.  Vesicles  with  opaque  contents.    4.  Fully  developed 
pocks  with  erythematous  areola.    5.  Crusts,    i'..  Appearance  immediately  after  sejiaration  ot  crusts. 


VARIOLOUS  DISEASES. 


665 


of  one  or  more  reddish  papules  at  the  point  of  inoculation.  These  in  the 
course  of  five  days  develop  into  compound  vesicles,  the  contents  of  which 
are  at  first  clear  but  later  become  opaque.  By  the  eighth  day  the  vesicle 
is  fully  developed  and  is  round  or  oval  with  prominent  and  well-defined 
edges  and  a  depressed  or  umbilicated  centre.  About  the  tenth  day  an 
erythematous  areola  usually  appears  and  the  contents  of  the  pock  become 
purulent.  The  surrounding  skin  is  swollen,  indurated,  and  tender.  Scab- 
bing now  begins  at  the  centre  of  the  pock  and  rapidly  extends  toward  its 
borders.    The  areola  fades  about  the  end  of  the  second  week,  and  the  pock 


Fig.  227. — Two  sisters  suffering  from  .-smallpox.  The  one  on  the  right  was  successfully  vaccinated  ia 
infancy  ;  she  contracted  a  mild  varioloid  and  recovered  without  any  scarring.  The  other,  unvaccinated^ 
developed  a  severe  smallpox,  and  recovered,  though  considerably  pitted. — After  Welch  and  Schamberg. 


is  converted  into  a  thick  brownish  crust  which  gradually  becomes  dry  and 
hard  and  separates  between  the  twentieth  and  twenty-fifth  days  after  the 
vaccination,  leaving  a  scar  of  a  dusky  red  color  which  gradually  becomes 
white  and  pitted  or  foveated.  The  corresponding  superficial  lymphatic 
glands,  namely,  the  axillary  or  inguinal,  as  the  case  may  be,  during  the 
evolution  of  the  pock  become  slightly  enlarged  and  tender. 

The  constitutional  reaction  is  commonly  slight.  It  shows  itself  by 
moderate  fever,  restlessness  at  night,  loss  of  appetite,  and  irritability. 
These  phenomena  usually  appear  upon  the  third  or  fourth  day  and  con- 
tinue until  the  early  part  of  the  second  week.  Erythema,  roseola,  or  urti- 
caria may  develop  at  any  time  during  the  course  of  the  vaccine  disease. 
These  eruptions  are  usually  transient.  Leucocytosis  shows  itself  about 
the  third  day  coincidently  with  the  appearance  of  the  local  eruption,  and 


666  MEDICAL  DIAGNOSIS. 

again  about  the  time  the  pock  reaches  maturity.  The  resulting  immunity 
against  vaccinia  Hke  that  against  variola  varies  in  duration  in  different 
individuals.  In  rare  instances  it  is  permanent,  but  as  a  rule  successful 
revaccination  may  be  performed  in  the  course  of  some  years.  The  pock 
of  revaccination,  however,  lacks  in  most  instances  the  typical  develop- 
ment of  the  primary  vaccine  lesion.  The  constitutional  reaction  in 
revaccination  is  sometimes  severe.  If  no  characteristic  lesion  follows 
the  attempt  at  revaccination,  the  operation  should  be  repeated  once  or 
twice  at  short  intervals. 

Atypical  Vaccinia  in  Man. — 1.  Variations  in  the  Number  of  Pocks. 

(a)  Supernumerary  pocks  occasionally  develop  in  the  vicinity  of  the 
original  vaccine  lesion. 

(b)  Confluent  pocks  may  in  rare  instances  be  formed  by  the  coales- 
cence of  the  supernumerary  pocks  either  among  themselves  or  with  the 
original  lesions. 

(c)  Generalized  vaccinia  or  vaccinal  eruptive  fever  is  less  common.  It 
consists  of  a  vaccine  rash  developing  in  various  parts  of  the  body,  especially 
about  the  wrists  or  on  the  back.  Secondary  pocks  usually  begin  to  develop 
about  the  eighth  or  tenth  day  after  vaccination  and  are  often  more  abun- 
dant on  the  vaccinated  limb  than  elsewhere.  The  pocks  appear  in  succes- 
sive groups  so  that  they  may  be  seen  in  all  stages  of  development.  The 
disease  sometimes  lasts  several  weeks. 

(d)  Vaccinal  Eruptions  Generalized  by  Autoinoculation. — Supernumer- 
ary pocks  may  be  produced  by  scratching  with  the  nails  after  they  have 
been  in  contact  with  the  ruptured  vaccine  pock.  They  may  occur  in  any 
part  of  the  body  and  vary  from  one  or  two  to  many.  The  number  is  some- 
times very  great.  They  have  been  observed  upon  the  cheek,  lips,  tongue, 
buttocks,  breast,  and  the  genital  organs.  On  the  mucous  surface  of  the 
vulva  the  resulting  ulceration  may  give  rise  to  the  suspicion  of  venereal 
disease. 

(e)  Local  vaccinal  eruptions  may  arise  at  the  seat  of  previously  existing 
cutaneous  lesions,  as  impetigo,  eczema,  acne,  or  psoriasis. 

2.  Variations  in  the  Size  of  the  Pocks. 

(a)  Two  or  more  of  the  primary  vesicles  caused  by  vaccination  may 
coalesce  to  form  one  large  pock. 

(b)  The  size  of  the  pock  may  be  increased  by  coalescence  of  supernumer- 
ary pocks  in  the  immediate  neighborhood. 

3.  Variations  in  the  Contents  of  the  Pock. — In  cachectic  indi- 
viduals the  contents  of  the  vesicle,  instead  of  being  clear  and  limpid  at 
the  end  of  the  first  week,  may  be  watery,  hemorrhagic,  or  purulent. 

4.  Variations  in  the  Evolution  of  the  Pock. 

(a)  Acceleration. — The  pock  develops  more  rapidly  in  summer  than  in 
winter.  Its  evolution  is  apparently  hastened  by  idiosyncrasies  on  the  part 
of  individuals  and  by  the  character  of  the  lymph  employed. 

(b)  Retardation. — Cases  occur  in  revaccination  in  which  vesicles  ap- 
parently aborted  become  active  a  week  or  more  after  the  original  insertion. 

(c)  Abortion. — The  non-development  of  the  pock  is  determined  by  the 
im.munity  of  the  patient,  the  quality  of  the  lymph,  and  the  skill  of  the 
vaccinator.  In  revaccination  a  bright  red  papillary  lesion,  "  raspberry 
excrescence,"  sometimes  develops  about  a  week  after  the  insertion  of  the 


VARIOLOUS  DISEASES.  667 

lymph.  Vesicles  do  not  form  and  the  papules  remain  hard  and  dense  for 
several  weeks.  There  is  no  areola,  and  healing  ultimately  takes  place 
without  the  formation  of  a  scar. 

5.  Variations  in  the  Involution  of  the  Pock. — These  anomalies 
are  determined  by  vaccinal  injuries.  Secondary  infection  may  take  place 
at  the  time  of  the  operation  or  subsequently  if  the  pock  is  injured.  It  may 
be  due  to  the  use  of  contaminated  lymph  or  infected  instruments  or  may 
arise  at  a  later  period  from  other  causes.  Vaccination  is  not  wholly  free 
from  the  danger  of  accident.  Severe  inflammation,  suppuration,  deep- 
seated  ulceration,  or  gangrene  may  occur  in  mismanaged  cases.  Erysipelas 
is  an  occasional  complication.  Cellulitis,  abscess  formation,  and  septicaemia 
may  occur.  These  accidents  are,  however,  not  peculiar  to  vaccination.  They 
may  arise  in  any  lesion  of  the  skin  in  default  of  proper  antiseptic  measures. 

6.  Variations  in  Healing  and  the  Formation  of  Scar. — The 
lesion  of  the  skin  caused  by  vaccination  is  usually  fully  healed  by  the  end 
of  the  third  week.  It  may,  however,  remain  open  for  some  weeks.  The 
scar  sometimes  manifests  hypertrophy  or  puckering  or  runs  into  keloid. 

7.  Transmission  of  Chronic  Specific  Disease  by  Vaccination. 

A.  Vaccination  and  Syphilis. — Vaccina  syphilis. — Syphilis  has  been 
transmitted  by  vaccination,  but  the  number  of  well-authenticated  cases  is 
limited.  The  general  use  of  bovine  lymph  has  rendered  invaccinated 
syphilis  a  remote  possibility.  It  may,  however,  occur  in  consequence  of 
the  use  of  lymph  taken  from  an  individual  suffering  from  syphilis  or  from 
contamination  of  the  instrument  or  wound  or  it  may  be  due  to  infection 
from  the  vaccinator.    The  sequence  of  events  is  as  follows: 

If  the  subject  be  susceptible  to  vaccination  the  pocks  may  show  no 
departure  from  the  normal  course,  but  in  some  instances  they  abort.  If 
they  be  irritated,  the  vaccinal  sore  may  become  inflamed,  suppuration  may 
occur,  and  the  ulcers  may  scab  over  and  again  break  out.  Whether  the 
vaccination  runs  a  typical  or  an  atypical  course,  a  chancre  with  indurated 
base  eventually  forms  at  the  point  of  inoculation,  and  the  signs  of  general 
infection  at  a  later  period. 

Acland  makes  the  following  deductions  from  a  well-known  case  of 
autovaccinp,tion  with  vaccine  virus  from  a  syphilitic  child;  they  are  in 
entire  accordance  with  general  observation. 

(a)  That  vaccination  can  be  successfully  performed  with  lymph  taken 
from  a  source  tainted  with  syphilis  without  necessarily  communicating 
that  disease. 

(b)  That  if  syphilis  be  communicated  in  the  process  of  vaccination  it 
does  not  follow  that  all  the  points  of  insertion  will  become  infected. 

(c)  That  the  evolution  of  syphilis,  as  regards  the  primary  and  secondary 
stages,  is  not  necessarily  disturbed;  that  it  is  neither  accelerated  nor  re- 
tarded by  simultaneous  vaccination. 

(d)  That  no  care  in  the  selection  of  lymph  obviates  the  risk  of  vaccinat- 
ing from  an  obviously  tainted  source. 

(e)  That  when  syphilis  is  communicated  by  vaccination,  the  first  ap- 
pearance of  the  disease  is  at  the  seat  of  puncture. 

B.  Vaccination  and  Tubercle. — The  communication  of  pulmonary 
tuberculosis  as  a  result  of  vaccination  is  of  exceeding  rarity.     It  may  in 


668  MEDICAL  DIAGNOSIS. 

fact  be  doubted  whether  it  has  ever  occurred.  In  well-regulated  vaccine 
laboratories  the  animals  used  are  previously  submitted  to  the  tuberculin 
test.  It  has  been  suggested  that  they  should,  after  the  collection  of  the  vac- 
cine material,  be  slaughtered  and  submitted  to  examination  for  tuberculous 
lesions.  In  case  of  their  presence,  the  vaccine  material  must  be  rejected. 
In  some  few  instances  lupus  has  been  observed  at  the  seat  of  vaccination. 

C.  Vaccination  and  Leprosy. — The  alleged  cases  of  transmission  of 
leprosy  by  vaccination  are  open  to  serious  doubt. 

D.  Vaccination  and  Cancer.— There  are  no  authentic  cases  on  record 
in  which  cancer  has  resulted  from  vaccination  or  developed  in  the  vaccina- 
tion scar. 

E.  Vaccination  and  Tetanus. — The  vaccine  lesion,  like  other  wounds 
of  the  skin,  renders  the  patient  liable,  under  certain  circumstances  and  the 
absence  of  proper  precautions,  to  tetanus  infection.  A  limited  number  of 
instances  of  fatal  tetanus  after  vaccination  are  reported. 

•Acland  has  arranged  the  dates  at  which  various  eruptions  or  complica- 
tions may  be  looked  for  after  vaccination,  as  follows: 

1.  During  the  first  three  days:  erythema;  urticaria;  vesicular  and 
bullous  eruptions;    invaccinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity:  urticaria; 
lichen  urticatus;    erythema  multiforme;    accidental  erysipelas. 

3.  About  the  end  of  the  first  week,  and  generally  after  the  maturation 
of  the  pocks:  generalized  vaccinia — (a)  by  autoinoculation,  (b)  by  general 
infection;  impetigo;  accidental  erysipelas;  vaccinal  ulceration;  glandular 
abscess;    septic  infections;    gangrene. 

4.  After  the  involution  of  the  pocks:  invaccinated  diseases,  for 
example,  syphilis. 

V.    VARICELLA. 

Chicken-pox. 

Definition. — An  acute  infectious,  endemic  and  epidemic  disease  of 
childhood  characterized  by  mild  constitutional  symptoms  and  a  vesicular 
exanthem  which  develops  in  irregular,  successive  crops. 

Chicken-pox  was  formerly  confused  with  smallpox  and  until  recently 
there  have  been  those  who  regarded  it  as  a  greatly  modified  and  very  mild 
variety  of  smallpox.  It  is  now  generally  looked  upon  as  an  entirely  dis- 
tinct disease.  One  of  these  diseases  never  gives  rise  to  the  other;  the 
attack  of  one  does  not  confer  immunity  against  the  other,  and  it  is  no  rare 
event  for  a  person  who  has  recently  suffered  from  one  to  contract  the  other. 
Vaccination  confers  no  immunity  against  varicella,  and  children  who  have 
recently  suffered  from  varicella  react  to  vaccination  in  the  ordinary  manner. 

Etiology.  —  Predisposing  Influences.  —  Varicella  is  a  wide-spread 
disease,  endemic  and  frequently  epidemic  in  the  great  centres  of  popu- 
lation, usually  in  the  autumn  or  early  spring.  As  in  the  case  of  other 
readily  transmissible  infections,  sporadic  cases  occur  and  frequently 
become  the  centre  of  house  epidemics  or  extended  outbreaks.  The  liabil- 
ity is  general,  and  scarcely  any  individual  who  has  not  had  the  disease 
escapes  when  it  makes  its  appearance  in  a  school  or  other  public  institu- 


VARICELLA.  669 

tion.  It  is  a  disease  of  childhood,  the  majority  of  cases  occurring  before 
the  eighth  year  and  few  after  the  tenth.  It  is  comparatively  infrequent 
during  the  first  year  and,  though  rare,  occasional  cases  occur  after  puberty. 
Sex  is  wholly  without  influence  as  a  predisposing  factor. 

The  exciting  cause  is  not  known.  The  disease  is  highly  conta- 
gious and  usually  communicated  in  the  ordinary  intercourse  of  children  in 
the  family,  the  school,  or  the  playground.  Direct  contact  is  not  necessary, 
the  infection  being  communicable  at  some  little  distance  by  the  air  and  to 
greater  distances  by  persons  who  pass  from  the  sick  to  those  who  are  sus- 
ceptible, and  finally  by  means  of  fomites.  Inoculation  experiments  have 
shown  that  it  is  present  in  the  contents  of  the  vesicles.  Outbreaks  of 
varicella  are  sometimes  associated  with  measles,  whooping-cough,  scarlet 
fever,  or  variola. 

Symptoms. — The  period  of  incubation  is  usually  thirteen  or  fourteen 
days  Prodromes  as  a  rule  do  not  occur.  In  a  majority  of  the  cases  the  erup- 
tion is  the  first  sign.  It  first  appears  usually  upon  the  face  and  spreads 
into  the  hairy  scalp  and  progressively  over  the  trunk  and  extremities.  It 
sometimes  comes  out  first  upon  the  back  and  shoulders  and  very  often  at 
the  same  time  upon  the  wrists  and  forearms.  The  pocks  are  more  numerous 
upon  the  trunk  and  upon  the  upper  than  the  lower  portions.  The  rash 
consists  of  small  red,  scattered  flat  papules,  circular  or  ovoid  in  shape, 
"which  rapidly  develop  into  vesicles.  They  usually  come  out  in  irregular 
crops,  fresh  spots  continuing  to  appear  among  the  older,  so  that  by  the 
fourth  or  fifth  day  they  are  seen  in  all  stages  of  evolution  and  involution. 
Some  few  of  the  papules  do  not  develop  into  vesicles  at  all  but  undergo 
complete  resolution  in  the  course  of  several  hours.  Nearly  all  of  them 
develop  into  vesicles  which  are  fully  formed  within  twenty-four  hours. 
Not  infrequently  the  papular  stage  is  so  brief  that  the  fully  developed 
vesicle  appears  upon  skin  that  shortly  before  seemed  entirely  normal. 
The  vesicles  are  usually  at  first  hemispherical  and  appear  to  be  superficially 
situated  in  the  skin.  Their  contents  are  limpid,  so  that  they  sometimes 
present  the  appearance  of  a  drop  of  clear  or  faintly  yellowish  fluid  resting 
upon  the  surface.  In  the  course  of  a  few  hours  they  become  milky  and 
then  seropurulent  and  in  a  further  brief  period  desiccation  takes  place 
with  the  formation  of  flat,  yellowish-brown,  firmly  adherent  crusts,  which 
separate  in  about  a  week,  leaving  in  the  majority  of  instances  no  scar. 
The  vesicles  are  readily  ruptured  by  scratching  and  other  injury.  Under 
these  circumstances,  and  when  the  lesion  approaches  more  nearly  to  that 
of  variola  and  involves  the  deeper  structures  of  the  skin,  pitting  may 
result,  especially  upon  the  face.  It  is  probable  that  spontaneous  rupture 
of  the  vesicles  does  not  occur.  The  pock  in  varicella  commonly  has  little 
or  no  areola,  but  in  the  severer  cases  marked  infiltration  and  hypersemia 
of  the  surrounding  skin  may  be  observed.  The  diameter  of  the  vesicle 
varies  from  1  to  15  or  20  millimetres;  their  number  from  ten  to  hundreds. 
They  are  in  most  cases  discrete,  but  when  very  numerous  confluence  may 
often  be  discovered  upon  careful  search.  Primary  umbilication  does  not 
occur,  but  as  desiccation  takes  place  a  depression  in  the  centre  of  the  crust — 
secondary  umbilication — is  sometimes,  seen.  The  eruption  occurs  upon 
the  mucous  membrane  of    the  mouth.      It  is  rare  upon  the    conjunctivae 


670  MEDICAL  DIAGNOSIS. 

and  upon  the  labia  and  prepuce.  In  these  situations,  under  the  influence 
of  warmth  and  moisture  the  roof  of  the  vesicle  is  rapidly  destroyed  and 
the  lesion  converted  into  a  circumscribed  superficial  ulcer.  The  peripheral 
lymph-glands  are  not  infrequently  slightly  swollen  and  tender.  In  the 
lighter  forms  there  is  little  or  no  elevation  of  temperature  during  the  whole 
course  of  the  disease;  in  the  more  severe  cases  fever,  if  not  previously 
present,  develops  with  the  rash,  to  the  abundance  of  which  it  bears,  how- 
ever, no  constant  relation.  It  commonly  subsides  in  two  or  three  days 
and  very  seldom  lasts  a  week.     It  does  not  conform  to  type. 

The  duration  of  the  attack  is  variable.  Three  or  four  weeks  may 
elapse  before  the  separation  of  the  last  crusts.  Relapses  do  not  occur. 
The  immunity  acquired  is  in  most  instances  permanent.  In  rare  cases 
subsequent  attacks  have  been  observed. 

The  anomalies  of  the  disease  relate  to  the  rash.  In  rare  instances 
some  of  the  vesicles  contain  blood,  with  ecchymoses  and  bleeding  from  the 
mucous  surfaces — Varicella  hcemorrhagica;  still  more  rarely  they  develop 
into  bullae  like  those  of  pemphigus  or  ecthyma — V.  bullosa;  in  cachectic 
children  some  of  the  skin  lesions  may  become  extensively  ulcerated  or 
even  gangrenous,  and  death  occur  as  the  result  of  exhaustion — V.  gangrenosa 
vel  escharotica. 

Diagnosis.  —  Direct  Diagnosis.  —  Varicella  in  cases  seen  from  the 
beginning  is  easily  recognized.  The  mildness  of  the  initial  symptoms,  the  per- 
sistence of  fever  if  present  upon  the  appearance  of  the  eruption,  the  character 
of  the  individual  pock,  which  is  essentially  vesicular,  its  rapid  evolution, 
the  absence  of  primary  umbilication,  the  appearance  of  the  lesions  in  irregu- 
lar crops,  so  that  papules,  vesicles,  and  crusts  are  seen  at  the  same  time  in 
the  same  region,  are  of  diagnostic  importance.  Varicella  is  usually  endemic 
in  cities;   variola  occasionally  epidemic. 

Differential  Diagnosis. — This  important  matter  principally  relates 
to  the  discrimination  of  varicella  from  smallpox,  and  the  chief  points  are 
indicated  in  the  foregoing  paragraph.  In  smallpox  the  onset  is  abrupt; 
the  fever  high;  headache  and  backache  intense.  There  are  cases  in  which, 
at  the  period  of  desiccation,  the  differential  diagnosis  cannot  be  made. 

The  resemblance  of  urticaria,  pemphigus,  and  other  diseases  of  the 
skin  to  varicella  is  remote. 

Prognosis. — Varicella  is  a  benign  affection.  Convalescence  is  in  the 
majority  of  cases  uneventful  and  complete.  In  rare  instances  death  has 
resulted  from  nephritis,  sepsis,  or  laryngitis. 


VI.  SCARLET  FEVER. 

Scarlatina. 

Definition. — An  acute,  infectious  disease,  occurring  sporadically  and  in 
circumscribed  epidemics,  and  characterized  by  erythematous  angina,  a  diffuse 
uniform  exanthem  followed  by  desquamation,  and  a  tendency  to  nephritis. 

Etiology. — Predisposing  Influences. — No  region  can  claim  immu- 
nity from  scarlet  fever.  It  occurs  in  every  climate  and  attacks  all  races. 
It  may  prevail  at  any  season,  but,  owing  to  the  mode  of  life  and  the  closer 


SCARLET  FEVER.  671 

intercourse  of  school  children  in  autumn  and  winter,  epidemics  are  more 
extensive  and  severe  at  these  seasons  of  the  year.  Among  personal  condi- 
tions predisposing  to  this  disease  age  plays  an  important  part.  Children 
at  the  breast  are  rarely  attacked.  More  than  half  the  cases  occur  before 
the  fifth  year  and  90  per  cent,  before  the  tenth.  Adults  occasionally  con- 
tract the  disease.  After  puberty  the  liability  rapidly  diminishes.  Sex  is 
without  influence. 

Exciting  Cause. — The  specific  pathogenic  germ  is  not  yet  known. 
Streptococci  have  been  demonstrated  in  the  skin  and  the  blood  during 
life  and  in  the  viscera  after  death,  and  the  disease  has  been  regarded 
as  a  streptococcus  infection.  These  micro-organisms  are,  however,  present 
under  widely  different  conditions.  Mallory  found  between  the  epithelial 
cells  of  the  epidermis  a  protozoon  which  assumed  rosette  forms  like  the 
malarial  parasite.  Inoculation  experiments  upon  human  beings  have 
demonstrated  the  presence  of  the  infecting  agent  in  the  blood,  the  tears, 
the  secretions  of  the  nose,  larynx,  and  bronchi,  the  urine,  the  desquamating 
skin,  and  in  the  contents  of  miliary  vesicles.  It  is  probably  eliminated  in 
the  discharges  from  the  bowels.  The  disease  caused  by  artificial  inocula- 
tion is  usually  of  severe  form.  The  infecting  principle  is  virulent  and 
tenacious.  It  is  transmitted  directly  from  the  sick  to  the  well  and  indirectly 
by  means  of  fomites.  These  may  be  the  clothing  of  the  patient,  the  bed- 
ding and  furniture  of  his  room,  toys,  books,  letters  or  other  articles  with 
which  he  has  been  in  contact  or  which  have  been  exposed  to  an  atmosphere 
bearing  the  fine  dust  made  up  of  his  dried  secretions  or  the  particles  of  his 
desquamating  skin.  The  vessels  he  has  used  and  remnants  of  food  may 
also  convey  the  disease.  Persons,  themselves  insusceptible,  may  be  the 
carriers  of  the  contagion  to  others  at  a  distance.  Physicians  and  nurses 
are  especially  exposed  to  this  risk  and  the  experience  of  the  medical  pro- 
fession in  this  respect  is  peculiarly  sad.  The  only  way  to  escape  catas- 
trophe is  to  reahze  its  danger.  Household  pets,  as  cats,  dogs,  and  birds, 
may  under  certain  circumstances  carry  the  disease.  Several  epidemics 
have  been  traced  to  milk  supply.  It  is  probable,  as  shown  by  Dornbliith, 
that  the  milk  has  been  merely  the  means  of  conveyance.  The  cream  is 
especially  liable  to  cause  the  disease,  and  the  risk  is  avoided  by  boiling. 
The  poison  is  not  borne  to  any  great  distance  in  the  air.  Its  virulence  is 
greatly  diminished  by  oxygen,  sunlight,  and  diffusion.  On  the  other  hand, 
it  shows  under  opposite  conditions  a  vital  persistence  greater  than  that 
of  any  other  disease.  Articles  of  clothing  folded  and  packed  away  have 
given  rise  to  the  disease  after  months  and  even  after  years.  The  time  at 
which  the  patient  becomes  a  source  of  contagion  has  been  the  subject  of 
controversy.  It  is  not  only  probable  but  it  is  also  safe  to  assume  that 
transmission  may  occur  at  any  time,  from  the  beginning  of  the  attack  until 
desquamation  is  completed,  or,  in  the  case  of  a  pathological  discharge,  as  in 
otitis  media,  for  an  indefinite  period.  The  infecting  principle  gains  access  by 
way  of  the  inspired  air.  Occasionally  the  attack  of  scarlet  fever  is  compli- 
cated by  another  specific  infection,  as  erysipelas,  measles,  pertussis,  vari- 
cella, enteric  fever,  or  diphtheria.  The  Klebs-Loffler  bacillus  may,  how- 
ever, be  absent  in  throat  affections  of  the  most  severe  character,  even 
those  in  which  pseudomembrane  is  conspicuous.      It  is  now  thought  that 


672  MEDICAL  DIAGNOSIS. 

the  febrile  and  desquamative  diseases  to  which  certain  of  the  domestic  ani- 
mals, as  the  cat,  dog,  and  horse,  are  subject — forms  of  "  distemper" — are  not, 
as  was  formerly  supposed,  identical  with  scarlet  fever  in  the  human  being. 

The  individual  predisposition  to  scarlet  fever  is  much  less  general 
than  to  measles,  variola,  and  many  other  contagious  diseases.  Many  persons 
upon  exposure  escape.  Individuals  sometimes  escape  upon  close  exposure 
and  contract  the  disease  years  later.  Certain  families  show  an  immunity 
transmitted  from  generation  to  generation;  on  the  other  hand  many 
families  suffer  from  a  fatal  liability.  The  immunity  after  puberty  is  not 
w^holly  due  to  previous  attacks.  The  attack  confers  an  immunity  which 
•commonly  is  permanent.  Second  attacks  are  very  rare.  I  have  seen  three 
attacks  separated  by  intervals  of  several  years  in  the  same  person.  Certain 
individuals  who  possess  an  immunity  acquired  by  the  attack  in  early  life 
.suffer  from  slight  sore  throat  when  exposed  to  the  infection. 

The  disease  frequently  occurs  sporadically  under  circumstances  in 
which  it  is  impossible  to  trace  its  transmission.  Any  such  case  may  become 
the  focus  of  an  epidemic.  General  epidemics  are  made  up  of  series  of  local 
or  circumscribed  outbreaks.  They  last  longer  than  epidemics  of  measles, 
sometimes  several  months,  and  show  remarkable  remissions  and  exacerba- 
tions. Epidemics  of  scarlet  fever  differ  greatly  in  the  severity  of  the  primary 
disease  and  in  the  prominence  of  severe  complications. 

Symptoms. — The  period  of  incubation  varies  from  one  to  seven  days; 
in  the  majority  of  cases  the  disease  develops  on  the  third  or  fourth  day  after 
exposure.     A  short  incubation  is  commonly  followed  by  a  severe  attack. 

(a)  Stage  op  Invasion. — The  onset  is  usually  abrupt,  without  pro- 
dromes. It  very  often  comes  on  at  night.  The  intensity  of  the  initial 
symptoms  is  frequently  in  direct  relation  to  the  severity  of  the  subsequent 
course  of  the  disease.  A  chill  is  rare;  convulsions  are  common,  especially  in 
young  children.  Vomiting  may  be  the  first  symptom.  It  is  in  many  cases 
repeated.  The  temperature  rises  in  the  course  of  a  few  hours  to  104°-106°  F. 
(40°-41.1°  C),  and  the  skin  is  extremely  dry  and  hot.  In  very  mild  cases 
the  temperature  may  not  exceed  101°-102°  F.  (38.3°-38.9°  C).  Older 
children  complain  of  sore  throat  and  upon  inspection  the  mucous  membrane 
of  the  soft  palate,  tonsils,  and  pharynx  shows  a  uniform  erythematous 
blush  varying  in  intensity  according  to  the  severity  of  the  case.  The  hard 
palate  shows  a  finely  stippled  punctiform  rash.  Febrile  phenomena  are 
marked — a  furred  tongue,  red  at  the  tip  and  edges,  refusal  of  food,  thirst, 
scanty,  high-colored  urine,  restlessness,  somnolence,  and  delirium.  Cough 
and  other  symptoms  of  impHcation  of  the  respiratory  tract  are  slight  or 
altogether  absent. 

(b)  Stage  of  Eruption. — The  eruption  appears  during  the  latter 
part  of  the  first  or  in  the  course  of  the  second  day,  coming  out  first  upon 
the  neck,  chest,  especially  in  the  infra-axillary  regions,  and  spreading  over 
the  face  and  body  to  the  extremities  with  such  swiftness  that  in  the  course 
of  from  twenty-four  to  thirty-six  hours  the  entire  surface  is  covered.  It 
consists  at  first  of  minute,  close-set  red  points,  coarser  and  more  widely 
separated  upon  the  legs  than  elsewhere.  The  intervening  skin  rapidly 
becomes  reddened  and  slightly  swollen.  In  severe  cases  oedema  of  the 
hands  and  fingers  is  often  marked  and  a  Hke  condition  of  the  eyelids  occurs. 


SCARLET  FEVER. 


673 


The  fully  developed  rash  upon  the  back,  abdomen,  and  thighs  is  of  an  intense 
scarlet  or  violet-red  color,  difficult  to  describe  or  reproduce  and  quite 
unlike  that  of  any  other  eruptive  disease.  It  has  been  compared,  but  very 
inappropriately,  to  the  color  of  the  boiled  lobster.  Its  distribution  over 
the  surface  of  the  body  is,  in  the  great  majority  of  cases,  nearly  uniform, 
with  the  common  exception  of  a  ring  around  the  mouth  which,  remaining 
free,  is  in  strildng  contrast  with  the  rest  of  the  face.  Exceptionally  the 
face  and  neck  only  are  involved,  or  the  body  and  extremities,  and  in 
some  instances,  especially  in  adults,  the  rash  is  irregularly  patchy  in 
areas  varying  in  diameter  from  5  to  20  cm.,  oval  or  circular,  not  abruptly 


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Fig.  229. — Scarlet  fever. 


marginate  but  shading  off  into  the  surrounding  skin.  The  eruption  is 
largely  hypera?mic  and  the  white  streak  produced  by  drawing  the  finger 
over  the  surface  immediately  disappears. 

Sudamina  may  appear  and  in  a  group  of  cases — scarlatina  miliaria — 
the  skin  is  extensively  covered  with  minute  yellow  vesicles.  In  the  more 
intense  eruptions  punctiform  hemorrhages  may  appear  and  in  malignant 
cases  petechiae  and  extensive  subcutaneous  hemorrhagic  effusions. 

Subjectively  sensations  of  tension,  burning,  and  pricking,  together 
with  more  or  less  intense  itching,  attend  the  eruption  and  to  these  symptoms 
the  restlessness  and  jactitation  in  many  of  the  cases  are  largely  due.  Swell- 
ing of  the  peripheral  lymph-nodes,  especially  in  the  region  about  the 
angles  of  the  jaw,  is  common  and  in  some  instances  they  are  very  tender. 

43 


674  MEDICAL  DIAGNOSIS. 

The  rash  reaches  its  height  upon  the  third  or  fourth  day  and  gradually 
fades  first  where  it  first  appeared.  By  the  end  of  the  first  week  it  has  in 
most  instances  wholly  vanished. 

The  tongue  is  at  first  covered  with  a  thick  whitish  fur  through  which 
project  the  tips  of  the  swollen  red  papilla? — an  appearance  described  as 
the  strawberry  tongue.  In  the  course  of  a  few  days  the  coating  separates, 
leaving  the  whole  dorsum  of  the  tongue  red  and  rough,  the  so-called  straw- 
berry or  raspberry  tongue  of  writers.  These  terms  are  neither  exact  nor 
descriptive  and  ought  to  be  abandoned.  The  bowels  are,  as  a  rule,  consti- 
pated. Diarrhoea  may  be  an  early  symptom  and  is  sometimes  severe. 
It  may  occur  as  the  result  of  a  simple  catarrhal  enteritis  or  of  a  dysenteric 
colitis  with  tenesmus  and  bloody  stools.  In  grave  cases  meteorism  may 
be  present. 

In  a  majority  of  the  cases  there  is  simply  an  erythematous  angina 
with  slight  enlargement  of  the  tonsils  and  palatine  arches;  in  other  cases 
these  and  the  contiguous  structures  are  intensely  swollen  and  infiltrated 
and  foci  of  suppuration  may  appear;  finally,  more  or  less  extensive  pseudo- 
membrane  may  develop  with  intense  inflammation,  cervical  adenitis,  and 
inflammatory  infiltration  and  oedema  of  the  tissues  of  the  neck.  The 
ordinary  inflammation  is  due  to  the  scarlatina  poison;  the  graver  forms 
and  many  of  the  pseudomembranous  inflammations  to  secondary  infection 
by  pus-producing  micro-organisms,  while  true  diphtheria  occurs  as  a 
complication  resulting  from  infection  by  the  Klebs-Loffler  bacillus. 
Membranous  laryngitis  is  rare  in  scarlet  fever  and  still  more  rare  is  the 
development  of  a  membranous  (croupous)  exudate  in  the  bronchi. 

The  temperature  conforms  much  less  closely  to  type  than  that  of 
measles  or  variola.  It  is  much  modified  by  secondary  infections.  Its 
rise  is  abrupt,  to  104°-106°  F.  (40°-41.1°  C.) ;  it  remains  with  slight  morning 
remissions  about  this  level  until  the  eruption  is  fully  developed,  about  the 
third  day.  From  this  point  in  uncomplicated  cases  the  temperature  grad- 
ually falls  coincidently  with  the  fading  of  the  rash,  until  toward  the  end 
of  the  first  week  the  defervescence  is  complete.  In  mild  cases  the  maximum 
temperature  may  not  exceed  102°  F.  (38.9°  C),  while  in  the  gravest  cases 
hyperpyrexia  may  occur— 105.8°-109°  F.  (41°-42.8°  C).  The  tempera- 
ture finally  reaches  subnormal  ranges  and  the  morning  remissions  continue 
in  some  cases  to  be  subnormal  for  two  or  three  weeks.  It  is  important  to 
continue  thermometric  observations  for  some  time  after  the  acute  symp- 
toms have  ceased. 

The  pulse  is  rapid,  120-160;  its  tension  notably  increased.  In  uncom- 
plicated cases  the  erythrocytes  and  haemoglobin  are  but  moderately 
decreased.  Leucocytosis  is  marked  from  the  onset.  In  postscarlatinal 
nephritis  profound  anaemia  rapidly  develops.  The  area  of  splenic  dulness 
is  increased  and  the  lower  margin  of  the  organ  may  be  palpable.  The 
area  of  hver  dulness  is  not  enlarged.  The  urine  during  the  period  of  invasion 
and  in  the  early  days  of  the  eruption  may  show  a  trace  of  albumin  with  a 
few  tube-casts — toxic  or  febrile  albuminuria.  This  disappears  with  the 
defervescence.  Systematic  examination  of  the  urine  should  be  made  at 
intervals  of  two  or  three  days  until  desquamation  has  ceased  and  convales- 
cence is  fully  established. 


SCARLET  FEVER. 


675 


(c)  Stage  of  Desquamation. — Desquamation  follows  the  disappear- 
ance of  the  rash.  It  may  begin  at  once  or  not  until  after  several  days 
have  elapsed.  It  first  shows  itself,  as  a  rule,  upon  the  neck  or  chest;  some- 
times upon  the  abdomen  above  the  inguinal  folds.  It  bears  some  relation 
to  the  intensity  of  the  eruption,  being  in  mild  cases  furfuraceous,  in  grave 
cases  lamellar  or  membranous.  The  thicker  layers  of  the  skin  upon  the 
hands  and  feet  may  come  off  in  extensive  patches  and  children  sometimes 
remove  the  epidermis  of  several  fin- 
gers like  the  rag  of  a  glove.  The 
average  duration  of  the  desquama- 
tion is  about  two  weeks,  but  the  proc- 
ess is  in  many  cases  repeated  and 
may  continue  for  five  or  six  weeks. 
The  palmar  and  plantar  surfaces  are 
the  last  to  cease  shedding.  Occa- 
sionally the  hair  falls  out. 

Varieties. — The  cases  differ 
greatly  in  severity  and  duration 
and  may  be  arranged  in  the  follow- 
ing groups: 

1.  The  Ordinary  Form — Scar- 
latina Simplex. — This  variety  has 
been  outlined  in  the  foregoing  gen- 
eral description.  It  presents  varying 
grades  of  severity,  but  the  symptom- 

•  complex  is  well  defined  and  the  acute 
process  in  uncomplicated  cases  comes 
to  an  end  by  the  sixth  or  seventh  day. 

2.  Larval  or  Undeveloped 
Forms. — (a)  Scarlatina  Afebrilis. — 
The  objective  phenomena  of  illness 
are  absent  and  the  patient  does  not 
regard  himself  as  sick.  Fever  is 
absent  or  shght— 100°  F.  (37.8°  C), 
and  lasts  only  a  few  hours.  The  rash 
also  is  faint,  usually  limited  to  the 
throat  and  chest,  and  transient,  (b) 
Scarlatina  sine  Eruptione.  —  There 
may  be  sudden  fever  with  sore  throat  and  vomiting  but  the  skin  remains 
free  from  eruption.  At  most  there  is  a  transient  faint  erythematous  blush 
such  as  is  often  observed  in  acute  indifferent  febrile  attacks  in  young 
persons  of  blond  complexion,  (c)  Scarlatina  sine  Angina. — Fever  may 
be  present  and  the  eruption  may  be  more  or  less  well  defined  but  the 
appearance  of  the  throat  remains  normal  ■  throughout  the  sickness. 

These  incompletely  developed  cases  often  give  rise  to  great  difficulties 
in  diagnosis.  They  occur  with  some  frequency  in  certain  epidemics  and 
are  to  be  recognized  by  the  epidemic  tendency,  the  severe  complications 
which  frequently  develop,  the  occurrence  of  postscarlatinal  nephritis,  and 
the  fact  that  they  may  become  centres  of  infection.     The  afebrile  forms 


Fig.  230. — Desquamation  upon  face,  neck,  and  chest 
after  scarlet  fever. — After  Welch  and  Schamberg. 


676  MEDICAL  DIAGNOSIS. 

are  especially  likely  to  spread  the  disease.  It  not  infrequently  happens 
that,  in  a  family  of  children,  one  may  apparently  escape  the  attack  and 
play  about  as  usual,  until,  as  the  others  recover,  desquamation  or  sudden 
pallor,  dropsy,  and  albuminuria  make  it  evident  that  he  also  has  suffered 
the  infection  but  without  the  usual  symptoms. 

3.  Malignant  Forms — Scarlatina  Maligna. — (a)  Scarlatina  Sid- 
erans. — These  cases  occur  sporadically  and  during  severe  epidemics.  The 
child  is  overwhelmed  at  once  by  the  intensity  of  the  infection.  Blinding 
headache,  vomiting,  convulsions,  hyperpyrexia,  delirium  passing  rapidly 
into  coma  succeed  one  another  in  appalling  succession.  There  is  suppres- 
sion of  urine;  the  heart's  action  is  progressively  rapid  and  feeble  and 
dyspnoea  occurs.  Death  ensues  within  twenty-four  or  thirty-six  hours, 
(b)  Scarlatina  HcB7norrhagica. — Petechise  appear  and  develop  in  a  brief 
time  into  vibices  and  extensive  suggillations.  Epistaxis  and  haematuria 
are  common.  All  the  evidences  of  a  profound  toxaemia  occur  and  death 
takes  place  in  the  course  of  two  or  three  days.  Enfeebled  and  badly 
nourished  infants  and  especially  the  inmates  of  public  institutions  are 
particularly  liable  to  this  form  of  scarlet  fever,  but  it  occasionally  occurs 
in  well-nourished  children  living  under  favorable  circumstances. 

4.  The  Anginose  Form — Scarlatina  Anginosa. — The  throat  symp- 
toms early  dominate  the  clinical  picture.  Intense  inflammation  of  the 
tonsils  and  contiguous  structures  is  attended  with  pain,  dysphagia,  and 
mechanical  dyspnoea.  Pseudomembrane  develops  and  may  extend  over 
the  soft  palate  and  uvula  into  the  nasopharynx  and  nasal  chambers  or 
downward  to  the  larynx.  The  Eustachian  tube  is  involved  with  infection 
of  the  middle  ear.  Local  necrosis  takes  place  and  the  fetor  is  almost 
unbearable.  The  glands  of  the  neck  are  enlarged.  General  sepsis  fre- 
quently results  with  fatal  termination.  If  life  be  prolonged  the  separation 
of  the  sloughs  may  give  rise  to  fatal  hemorrhage  from  the  carotid  artery. 

5.  Protracted  Form — Scarlatina  Typhosa. — Severe  and  prolonged 
cases  with  delirium,  profound  prostration,  sustained  high  temperature, 
and  all  the  evidences  of  grave  general  infection.  Gastro-intestinal  disturb- 
ances and  marked  tympany  may  be  present.  The  fever  may  continue  for 
two  or  three  weeks  and  terminate  in  lysis.  This  form  has  been  described 
also  as  septic  or  adynamic  scarlatina. 

6.  Surgical  and  Puerperal  Scarlatina. — Some  years  ago  the 
subject  of  scarlet  fever  after  surgical  operations  and  in  the  lying-in  woman 
attracted  much  attention.  Scarlatiniform  rashes  may  occur  under  two 
conditions:  First,  the  patient  maj^,  at  the  time  of  operation  or  confinement 
or  thereafter,  contract  scarlet  fever  and  present  all  the  symptoms  of  the 
disease;  in  this  case  the  surgeon  or  accoucheur  must  question  himself  as 
to  his  part  in  conveying  the  infecting  principle;  and  second,  the  patient 
may  develop  an  erythema  as  the  result  of  sepsis  or  as  a  drug  exanthem. 
The  angina  and  peculiar  appearance  of  the  tongue  are  not  present.  The 
distribution  of  the  rash  is  irregular  and  its  course  not  that  of  the  eruption 
of  scarlet  fever.  Local  erythema  may  result  from  carbolic  acid  or  subli- 
mate solutions  of  undue  strength,  and  general  rashes  from  certain  drugs, 
as  copaiba,  oil  of  santol,  and  quinine.  Desquamation  may  occur  as  the  result 
of  intense  erythema  due  to  any  cause.  These  cases  have  become  infre- 
quent under  the  methods  of  modern  surgery. 


SCARLET  FEVER.  677 

Complications  and  Sequels. — The  complications  of  scarlet  fever  are 
numerous.  They  are  mostly  due  to  secondary  streptococcus  infection, 
the  primary  infection  rendering  the  tissues  vulnerable  and  lowering  the 
powers  of  resistance  of  the  organism.  They  are  usually  severe  and  have 
much  to  do  with  the  gravity  of  the  disease.  Some  epidemics  are  character- 
ized by  the  prominence  of  certain  complications.  Almost  any  tissue  of 
the  body  may  become  the  seat  of  inflammation  and  abscess  formation 
during  an  attack.     The  following  are  more  commonly  involved: 

(a)  Throat. — Pseudomembranous  and  necrotic  inflammation  of  the 
faucial  structures  occurs  in  the  anginose  form.  It  is  described  as  scarla- 
tinal diphtheria  and  may  develop  during  the  stage  of  invasion  or  upon  the 
appearance  of  the  exanthem.  In  grave  cases  there  is  extensive  inflammatory 
oedema  of  the  neck — "collar  of  brawn."  General  septicaemia  is  apt  to 
supervene  and  in  many  epidemics  the  throat  affection  is  the  cause  of  high 
mortality.  As  a  rule  the  throat  affection  is  due  to  streptococcus  infection; 
much  less  commonly  there  is  a  true  complicating  diphtheria. 

(b)  Kidneys. — Nephritis  constitutes  the  most  common  and  important 
complication.  Toxic  or  febrile  albuminuria  occurring  at  the  height  of  the 
fever  is  usually  transient  and  without  greater  significance  than  the  same 
condition  in  other  diseases,  as  pneumonia.  Much  more  important  is  the 
albuminuria  which  comes  on  with  the  fading  of  the  rash  or  during  the 
stage  of  desquamation.  The  anatomical  condition  in  the  quickly  fatal 
cases  is  that  of  a  glomerulonephritis  of  varying  intensity.  Clinically  the 
following  grades  may  be  recognized: 

1.  Mild  Catarrhal  Nephritis. — The  urine  remains  normal  in  amount. 
It  contains  a  moderate  amount  of  albumin  and  a  few  tube-casts.  Cylin- 
droids  are  present.  There  is  no  blood.  Qildema  is  slight  and  is  confined 
to  the  eyelids  and  the  pretibial  areas.  The  process  may  last  a  few  weeks 
and  terminate  in  complete  recovery  or  it  may  be  the  starting  point  of  a 
chronic  nephritis.  Sudden  intensification  of  the  symptoms  may  occur 
with  anuria  and  fatal  uraemia,  oedema,  or  effusion  into  the  serous  sacs  or 
the  larynx. 

2.  Graver  cases  with  increased  albumin,  casts,  and  blood.  The  urine 
is  diminished  and  there  is  slight  or  moderate  oedema  of  the  face  and  lower 
extremities.  Effusion  into  the  serous  sacs  may  occur.  The  symptoms  are" 
not  urgent,  but  anaemia  is  pronounced  and  the  nephritis  tends  to  become 
chronic.  Uraemia  may  suddenly  develop.  When  apparent  recovery  takes 
place  renal  inadequacy  is  often  established,  and  the  albuminuria  of 
adolescence  or  the  nephritis  following  an  acute  illness  or  exposure  to  cold 
years  afterwards  may  be  traced  to  this  condition.  These  are  the  cases 
that  under  well-directed  treatment  frequently  end  in  recovery. 

3.  Very  severe  cases  with  rapidly  developing  intense  anaemia,  general 
anasarca,  anuria,  or  the  passage  of  small  amounts  of  bloody  or  porter- 
colored  urine  which  coagulates  upon  the  application  of  heat  and  is  loaded 
with  blood  and  casts.  Uraemic  accidents,  vomiting,  facial  spasm,  convul- 
sions, and  coma  promptly  occur,  and  despite  treatment  a  large  proportion 
of  the  cases  die. 

In  rare  instances  cedema  may  occur  without  albuminuria.  Under 
these  circumstances  the  dropsy  may  change  its  location,  coming  and  going 


678  MEDICAL  DIAGNOSIS. 

without  apparent  cause.  It  may  be  associated  with  effusion  into  the  serous 
sacs,  especially  ascites,  oedema  of  the  glottis  or  sudden  pulmonary  oedema. 
This  form  of  oedema  may  be  the  result  of  angemia  or  cachexia. 

(c)  Joints. — Rarely  during  the  acute  attack,  more  commonly  in  the 
second  or  third  week,  there  may  develop  inflammation  of  the  joints,  syn- 
ovitis scarlatinosa,  so-called  scarlatinal  rheumatism.  The  cases  may  be 
arranged  in  two  groups:  1.  Those  in  which  a  serous  synovitis  of  more  or 
less  intense  character  is  present,  involving  most  frequently  the  small  joints 
of  the  fingers,  the  wrists  and  knees,  exceptionally  the  spinal  articulations, 
and  terminating  in  complete  resolution  in  the  course  of  a  few  days.  Several 
joints  are  usually  affected — polyarthritis — but  there  is  little  or  no  rise  of 
temperature  and  the  joint  affection  lacks  the  fugacious  character  so  marked 
in  rheumatic  fever.  This  form  has  been  regarded  as  due  to  the  scarlatinal 
poison.  2.  Suppurative  arthritis,  usually  implicating  a  single  joint  and 
appearing  as  a  local  manifestation  of  a  general  septic  process.  Streptococci 
have  been  demonstrated  in  the  intra-articular  exudate. 

(d)  Heart. — Benign  endocarditis  may  occur  alike  when  joint  compli- 
cations are  present  and  in  their  absence.  Malignant  endocarditis  is  very 
rare.  Pericarditis  is  much  less  frequent  than  endocarditis.  If  effusion 
takes  place  it  may  be  purulent  or,  in  grave  cases,  hemorrhagic.  Myocarditis 
is  not  uncommon.  Hypertrophy  and  dilatation  are  constant  accompani- 
ments of  scarlatinal  nephritis  in  children;  they  are  less  frequent  in  adults. 
It  is  of  importance  to  perform  auscultation  of  the  heart  and  lungs  ad  a  matter 
of  daily  routine  in  every  case  of  scarlet  fever.  There  is  no  reason  why 
rheumatic  fever  may  not  occur  as  a  complication  of  scarlatina  and  account 
for  the  joint  affection  and  cardiac  lesions  in  certain  cases. 

(e)  Respiratory  Organs. — Bronchitis  and  inhalation  pneumonia — 
bronchopneumonia — are  present  in  cases  attended  with  severe  lesions  of 
the  upper  air-passages.  Hypostatic  congestion  is  common  in  the  gravest 
cases.  Croupous  pneumonia  is  rare.  Pleurisy  is  relatively  common.  It 
may  be  plastic;  more  frequently  it  is  serofibrinous  or  purulent;  rarely 
hemorrhagic.    It  usually  develops  about  the  middle  of  the  second  week. 

(f)  Auditory  Apparatus. — Infection  of  the  middle  ear  by  way  of  the 
Eustachian  tube  is  very  common.  It  occurs  in  almost  every  case  of  anginose 
scarlatina  and  is  attended  by  serious  dangers,  both  near  and  remote.  In 
about  85  per  cent,  of  the  cases  both  ears  are  affected.  Suppurative  otitis 
media  results  with  perforation  of  the  tympanic  membrane.  The  inflamma- 
tion may  extend  to  the  labyrinth  or  to  the  mastoid  cells.  Extensive  necrosis 
of  parts  of  the  temporal  bone  vaay  result.  Paralysis  of  the  facial  nerve  is  a 
rare  sequel.  Meningitis,  brain  abscess,  and  sinus  thrombosis  may  occur. 
In  the  absence  of  those  accidents  spontaneous  healing  may  take  place  in 
the  course  of  a  few  weeks.  More  commonly  the  otitis  becomes  chronic 
and  in  many  cases,  despite  treatment,  gives  rise  to  permanent  impairment 
or  loss  of  hearing.  Burkhardt-Merian  found  among  4309  cases  of  acquired 
deaf-mutism  445,  or  10.3  per  cent.,  to  be  due  to  scarlet  fever. 

(g)  Lymphatic  Glands. — Imphcation  of  the  lymphatic  system  occurs 
in  all  cases.  In  mild  scarlet  fever  there  is  commonly  some  degree  of  enlarge- 
ment of  the  superficial  lymph-nodes,  especially  in  the  neck.  It  is,  however, 
slight  and  undergoes  resolution  during   convalescence.      In  more  serious 


SCARLET  FEVER.  679 

cases  the  glands  may  be  enormously  swollen  with  cellulitis  of  the  surround- 
ing tissues.  Phlegmonous  inflammation — angina  Ludovici — may  occur 
and  lead  to  extensive  necrosis  with  erosion  of  vessels  and  fatal  hemorrhage. 
Retropharyngeal  abscess  is  a  very  rare  complication.  The  enlargement 
of  the  cervical  glands  is  occasionally  persistent. 

(h)  Among  the  rarer  complications  and  sequels  are  enterocolitis, 
local  periostitis,  noma,  perforation  of  the  soft  palate,  symmetrical  gangrene, 
and  various  palsies.  Protracted  angemia  may  occur  and  the  growth  and 
development  of  the  child  may  be  greatly  retarded.  Acute  psychoses, 
mania,  or  melancholia  sometimes  develop  during  convalescence.  These 
conditions  are  commonly  of  brief  duration,  coming  to  an  end  in  the  course 
of  some  hours  or  days.  Exceptionally  they  last  several  weeks.  Hereditary 
predisposition  is  present  in  many  of  the  cases.  Boys  more  frequently 
suffer  than  girls.     The  prognosis  is  uniformly  favorable. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  sudden  onset  with 
rapid  rise  of  temperature,  vomiting,  and  nervous  disturbances,  as  convul- 
sions or  stupor,  the  erythematous  angina  often  accompanied  with  pseudo- 
membranous exudate,  the  peculiar  tongue,  the  exanthem,  the  desquamation, 
and  the  swelling  of  the  superficial  lymph-nodes.  The  prevalence  of  an 
epidemic  or  a  history  of  exposure  is  of  importance' in  doubtful  cases. 
There  are  cases  in  which  for  a  time  the  diagnosis  must  remain  uncertain. 

Differential  Diagnosis. — 1.  Measles. — Less  abrupt  onset,  catarrhal 
symptoms,  Koplik's  sign,  longer  period  of  invasion,  a  distinctly  maculo- 
papular  rash,  coarse,  measly,  and  thick-set,  with  an  irregularly  crescentic 
arrangement,  the  less  intense  sore  throat,  the  absence  of  leucocytosis,  and 
the  fine  desquamation  are  important  criteria.  The  rash  appears  upon 
the  third  or  fourth  day  or  later,  and  first  upon  the  face.  It  is  duller  in  hue 
than  that  of  scarlet  fever.  In  rare  cases  of  measles  in  which  a  uniform, 
vivid  red  rash  covers  the  face  and  body,  maculopapules  will  be  found 
about  the  wrists  or  ankles. 

2.  Rotheln. — The  eruption  may  closely  resemble  that  of  scarlet 
fever.  The  disease  is  usually  slight;  fever  and  constitutional  disturbances 
are  insignificant;  angina  is  absent  or  trifling;  the  adenitis  involves  the 
postauricular  glands  to  a  greater  extent  than  the  anterior  chains;  and 
the  prevalence  of  an  epidemic  is  of  diagnostic  importance. 

3.  Septicemia. — Not  only  so-called  surgical  and  puerperal  infection 
but  other  forms  of  septicaemia  may  present  rashes  almost  identical  with 
that  of  scarlet  fever.  Certain  of  these  cases  show  also  erythematous  sore 
throat  with  a  tongue  thickly  furred  and  red  at  the  edges  and  tip,  and  if 
death  does  not  occur  desquamation  may  take  place  precisely  as  in  scarlet 
fever.  The  diffei^ential  diagnosis  is  difficult  and  may  in  any  given  case 
be  impossible. 

4.  Diphtheria. — False  membrane  may  develop  early  and  present 
the  appearance  of  true  diphtheria.  Scarlet  fever  with  intense  pseudo- 
membranous angina,  diphtheria  with  an  erythematous  rash,  and  the  coex- 
istence of  scarlet  fever  and  diphtheria  are  to  be  considered.  The  early 
membranous  sore  throat  of  scarlet  fever  does  not  usually  show  the  presence 
of  the  Bacillus  diphtherise,  which  is,  however,  usually  present  in  the  later 
forms.    The  erythema  of  diphtheria  is  comparatively  rare  and  when  present 


680  MEDICAL  DIAGNOSIS. 

lacks  the  uniform  distribution  and  the  intense  scarlet  color  of  that  of 
scarlet  fever.  In  every  suspected  case  a  bacteriological  examination  must 
be  forthwith  made. 

5.  Other  Acute  Infections. — In  rare  instances  rashes  suggestive 
of  scarlet  fever  occur  in  influenza,  cerebrospinal  fever,  variola, — the  initial 
rashes, — varicella,  and  enteric  fever.  The  differential  diagnosis  must  rest 
upon  the  symptom-complex  in  individual  cases.  As  a  rule  little  real  diffi- 
culty arises  and  even  that  is  dispelled  in  a  brief  time. 

6.  Acute  Exfoliative  Dermatitis.  —  Sudden  onset  with  fever, 
scarlatiniform  eruption  rapidly  becoming  universal  and  fading  after  five 
or  six  days  with  membranous  desquamation  present  a  problem  in  diagnosis 
difficult  of  solution.  The  absence  of  angina  and  the  tongue  of  scarlet 
fever,  the  occurrence  of  alopecia,  the  loss  of  the  nails,  a  tendency  to  recur 
periodically,  the  occurrence  in  adults,  and  the  sporadic  character  of  this 
rare  disease  in  which  the  case  never  becomes  a  focus  of  contagion  usually 
render  the  diagnosis  a  simple  matter.  Cases  first  seen  during  the  stage 
of  erythema  sometimes  present  great  difficulties  in  diagnosis. 

7.  Erythema  Simplex. — This  dermatosis  occurring  in  young  children 
may  suggest  scarlet  fever.  The  trifling  constitutional  disturbance,  the 
transient  eruption,  the  absence  of  angina,  and  in  most  cases  absence  of 
desquamation  are  of  diagnostic  value. 

8.  Drug  Exanthems. — Local  erythematous  rashes  may  follow  the 
application  of  mustard,  solutions  of  carboHc  acid,  corrosive  sublimate,  or 
other  irritants.  Circumscribed  or  diffuse  eruptions  may  follow  the  internal 
administration  of  belladonna,  quinine,  the  iodides,  more  rarely  chloral, 
sulphonal,  antipyrin,  turpentine,  and  the  hypodermic  injection  of  tuberculin. 
These  rashes  are  not  accompanied  by  fever,  a  fact  which  may  be  rendered 
unavailable  in  diagnosis  by  the  presence  of  fever  in  the  condition  for  which 
the  drug  is  administered;  nor  by  angina,  save  in  the  cases  of  belladonna, 
in  which  dryness  and  redness  of  the  throat  are  conspicuous;  and  certain 
of  them  occasion  symptoms  which  are  distinctive — tinnitus  in  the  case  of 
quinine,  coryza  in  iodine,  and  so  forth.  The  difficulty  in  diagnosis  is 
usually  slight. 

It  may  be  said  that  the  greater  the  experience  of  the  practitioner  in 
the  acute  exanthemata,  the  greater  his  hesitancy  to  make  a  positive  diag- 
nosis in  doubtful  cases.  The  only  safe  rule  of  practice  is  to  regard  every 
uncertain  case  as  a  possible  source  of  infection  and  treat  it  accordingly 
until  the  diagnosis  becomes  clear. 

Prognosis. — The  mortality  varies  greatly  in  different  epidemics.  It 
is  modified  by  the  severity  of  the  infection  and  the  prevalence  of  grave 
comphcations  and  is  lower  in  private  practice  than  in  hospitals.  In  some 
outbreaks  the  disease  has  been  benign,  the  death-rate  not  exceeding  5  per 
cent. ;  in  others,  exceedingly  severe,  with  a  maximum  mortaUty  of  30  or 
even  of  40  per  cent.  The  prognosis  in  individual  cases  is  influenced  by  the 
following  conditions:  1.  Age.  The  danger  is  much  greater  in  infancy  and 
early  childhood  than  later.  A  large  proportion  of  the  deaths  occur  between 
the  third  and  sixth  years.  The  absolute  mortality  among  adults  is  low  but 
my  observation  leads  me  to  believe  that,  in  proportion  to  the  number  of 
cases,  scarlet  fever  after  puberty  is  very  fatal.    2.  Sex.    It  is  said  that  the 


MEASLES.  681 

mortality  is  higher  among  males  than  females.  3.  The  previous  health 
of  the  patient.  Delicate,  poorly  nourished,  and  sickly  children  bear  the 
disease  badly.  Like  the  other  acute  infections  scarlet  fever  is  severe  and 
attended  with  a  high  death-rate  in  orphan  asylums  and  similar  institutions. 

The  danger  is  great  in  proportion  to  the  intensity  of  the  primary  infec- 
tion as  shown  by  early  high  fever,  stupor,  delirium,  restlessness,  the  evi- 
dences of  general  septic  infection,  and  the  prominence  of  local  infective 
processes,  such  as  membranous  or  suppurative  angina,  cervical  cellulitis, 
laryngeal  obstruction,  bronchitis,  bronchopneumonia,  pleural  effusion, 
heart  complications,  and  nephritis.  Hemorrhagic  cases  are  usually  fatal. 
A  persistently  high  pulse-rate  is  of  itself  an  unfavorable  sign. 

The  prognosis  must  in  all  instances  be  guarded.  Apparently  benign 
cases  may  develop  the  gravest  symptoms  or  fatal  nephritis  may  occur 
during  convalescence.  No  case,  however  favorable,  can  be  regarded  as 
out  of  danger  until  at  least  four  weeks  have  elapsed  from  the  onset  of  the 
attack. 

VII.   MEASLES. 

Rubeola;    Morhilli. 

Definition. — An  acute  febrile  infection  occurring  in  epidemics,  and 
characterized  by  initial  coryza,  bronchial  catarrh,  and  a  generalized  maculo- 
papular  eruption. 

Etiology. — Predisposing  Influences. — The  susceptibility  to  measles 
appears  to  be  almost  universal.  The  disease  prevails  in  every  climate 
and  attacks  all  races.  Negroes  suffer  more  severely  than  whites  and  are 
more  liable  to  develop  grave  complications  and  sequels.  Season. — Outbreaks 
take  place  at  all  times  of  the  year  but  are  more  common  in  the  winter  and 
spring  than  in  the  warmer  seasons.  Age  plays  an  important  part.  Measles 
is  peculiarly  a  disease  of  childhood.  Adults  not  protected  by  an  attack 
in  early  life  may  contract  it  and  frequently  manifest  the  symptoms  in  an 
aggravated  form.  It  is  more  common  after  puberty  than  scarlet  fever. 
Congenital  cases  have  been  observed;  it  is  rare  during  the  first  six  months 
of  life.  The  great  majority  of  cases  occur  before  the  tenth  year.  The 
sexes  are  alike  liable. 

Exciting  Cause.  —The  specific  pathogenic  cause  has  not  been  demon- 
strated. Inoculation  experiments  upon  human  beings  have  shown  the 
presence  of  the  infecting  principle  in  the  blood,  in  the  tears,  in  the 
secretions  of  the  nasal,  pharyngeal,  and  bronchial  mucous  membrane,  and 
in  the  contents  of  vesicles  occasionally  present.  Inoculation  with  the 
epithelial  scales  thrown  off  at  the  close  of  the  disease  has  been  unsuccessful. 
Transmission  of  the  disease  under  ordinary  circumstances  takes  place  by 
the  breath  or  the  nasal  or  bronchial  secretion.  It  may  result  directly  from 
close  approach  or  contact  with  the  patient,  or  remotely  through  the  con- 
veyance of  the  poison  by  a  third  person  or  by  fomites.  Measles  is  very 
commonly  disseminated  in  school  or  upon  playgrounds  by  children  who 
appear  to  be  suffering  from  ordinary  nasal  or  bronchial  catarrh  but  who 
are  in  reality  in  the  pre-eruptive  stage.  The  infecting  principle  is  intensely 
active  but  neither  tenacious  nor  persistent  as  is  that  of  scarlet  fever.    The 


682  MEDICAL  DIAGNOSIS. 

disease  is  communicable  during  its  whole  course  from  the  earliest  appear- 
ance of  coryza.  The  individual  predisposition  to  measles  is  so  general 
that  upon  exposure  very  few  escape.  The  adult  who  suffers  has,  as  a  rule, 
not  been  exposed  to  the  infection  in  childhood  and  is  often  an  only  child 
who  has  been  educated  at  home.  A  congenital  immunity  seems  to  exist 
in  rare  instances.  In  the  majority  of  cases  an  acquired  immunity 
results  from  the  attack.  Second,  or  even  third,  attacks  may  occur  at 
intervals  of  some  years,  but  they  are  infrequent.  I  cannot  agree  with  those 
who  regard  multiple  recurrences  as  common,  since  my  experience  coincides 
with  that  of  Jiirgensen  and  Eichhorst  in  Germany,  and  Holt  in  this  country, 
who  hold  that  second  attacks  are  rare.  Measles  in  cities  is  in  a  certain 
sense  endemic.  Sporadic  cases  occur  at  intervals  and  constitute  the  starting- 
point  of  more  or  less  extensive  epidemics.  When  the  susceptible  individuals 
in  the  affected  locality  have  had  the  disease  the  epidemic  ceases.  The 
poison  is-  frequently  carried  to  neighboring  regions  by  persons  in  the  period 
of  incubation  or  in  the  pre-eruptive  stage,  who  become  centres  of  infection 
for  new  local  epidemics.  Extensive  outbreaks  occur  at  intervals  of  five 
or  six  years  and  at  long  intervals  the  disease  becomes  pandemic.  Occasion- 
ally other  epidemic  diseases  of  children,  especially  whooping-cough  and 
varicella,  precede,  accompany,  or  follow  outbreaks  of  measles.  Outbreaks 
are  common  in  time  of  war  among  the  younger  recruits  and  conscripts, 
many  of  whom  come  from  country  districts  in  which  the  disease  has  not 
prevailed  for  long  periods. 

Symptoms. — The  period  of  incubation  is  from  seven  to  fourteen 
days,  usually  about  ten.  In  artificially  inoculated  cases  it  is  commonly 
less  than  ten.  Prodromes  are  common.  They  consist  of  loss  of  appetite, 
restless  sleep,  fretfulness,  and  in  many  cases  feverishness  or  light  fever. 

(a)  Stage  op  Invasion. — The  prodromal  symptoms  are  intensified. 
There  is  chilliness  which  may  be  repeated,  sometimes  shivering,  but  con- 
vulsions and  distinct  chills  are  uncommon.  The  temperature  rises,  reaching 
102°-104°  F.  (38.9°-40°  C.)  upon  the  first  or  second  day.  It  then  falls  a 
degree  or  more  to  rise  again  upon  the  appearance  of  the  exanthem.  Nausea, 
vomiting,  and  headache  are  present.  The  tongue  is  furred.  Coincidently 
with  the  appearance  of  these  symptoms  coryza  develops  and  is  often 
intense.  The  phenomena  are  those  of  an  ordinary  severe  influenza.  Irrita- 
tion and  smarting  of  the  eyelids,  lachrymation,  photophobia,  persistent 
sneezing,  running  at  the  nose,  sore  throat,  discomfort  in  swallowing,  hoarse- 
ness, and  cough,  at  first  of  a  brassy  or  croupy  character,  develop  one  upon 
the  other  in  rapid  succession  and  varying  intensity.  These  initial  catarrhal 
symptoms  are  characteristic  and  occur  in  the  mildest  cases  in  which  chilli- 
ness, fever,  and  the  associated  signs  of  the  reaction  of  the  organism  to 
general  infection  are  not  observed.  Upon  inspection  the  vessels  of  the 
conjunctivae  are  injected,  the  eyelids  swollen,  the  nasal  mucosa  tumid  and 
reddened.  The  mucous  membrane  of  the  mouth  and  throat  is  erythema- 
tous, while  upon  the  soft  palate  and  roof  of  the  mouth,  and  particularly 
upon  the  buccal  mucous  membrane,  are  to  be  seen  pin-head  or  split-pea- 
sized,  circumscribed,  round  or  irregularly  shaped  reddish  blotches  slightly 
or  scarcely  at  all  raised  above  the  surrounding  surface,  usually  discrete, 
sometimes  confluent.    This  eruption  also  shows  itself  in  the  larynx  and  is 


MEASLES. 


683 


doubtless  the  cause  of  the  laryngobronchial  symptoms  as  it  is  of  the 
coryza.  It  has  been  called  the  enanthem  in  contradistinction  to  the  rash 
upon  the  skin,  the  exanthem.  In  a  strong  light  there  may  be  seen  upon 
some  of  the  spots  upon  the  mucosa  of  the  cheeks  and  lips  minute  bright 
whitish  or  bluish-white  flecks  described  by  Koplik.  These  flecks  appear  early 
and  soon  disappear,  and  since  they  have  not  been  observed  in  other  diseases 
are  of  value  in  the  early  diagnosis  of  measles.  The  duration  of  the  stage  of 
invasion,  or,  as  it  is  sometimes  called,  the  catarrhal  stage,  is  commonly  three 
or  four  days;   exceptionally  it  is  shorter  or  it  may  be  as  long  as  a  week. 


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•S~ 

^ 

7 

t 

9 

*>■,$ 

v% 

oP 

7-7> 

T-i.'' 

i}y 

y 

y' 

>K> 

A 

'{■h^- 

tK" 

>%<> 

>y 

Fig.  231.— Measles. 


Fig.  232. — Frank  uncomplicated  measles 
in  a  woman  aged  52. 


(b)  Stage  of  Eruption. — The  fever  rises  and  may  reach  104°- 106^  F. 
(40°-41.1°  C),  the  pulse-rate  may  be  140  or  higher.  Delirium  or  stupor 
may  be  present  in  the  severer  cases.  The  patient  complains  of  heat  and 
burning  of  the  skin,  sore  throat  and  general  discomfort,  and  is  restless 
and  wakeful.  Usually  upon  the  second  or  third  day  of  the  eruption  great 
and  rapid  amelioration  of  all  these  symptoms  occurs  and  the  fever  which 
has  remained  high  falls  by  crisis  or  by  rapid  lysis  to  normal  or  subnormal 
ranges.  The  eruption  appears  as  small  red  or  brownish-red  soft  flat  papules 
which  rapidly  increase  in  size  and  in  numbers.  When  fully  developed  the 
individual  spots  are  irregularly  circular  or  oval  and  differ  greatly  in  size, 
the  average  diameter  being  that  of  a  split  pea.  They  are  unevenly  dis- 
tributed but  close  set  and  very  often  confluent,  especially  upon  the  face, 


684  MEDICAL  DIAGNOSIS. 

buttocks,  hands  and  feet,  where  there  is  also  some  tumefaction.  They  are 
circumscribed  and  the  intervening  skin  is  normal  or  slightly  hypersemic. 
Not  infrequently  a  crescentic  arrangement  may  be  made  out  elsewhere. 
The  color  momentarily  fades  upon  pressure  or  upon  tension  of  the  skin. 
The  eruption  appears  first  upon  the  forehead,  chin,  and  cheeks;  it  invades 
the  hairy  scalp  and  spreads  rapidly  to  the  neck,  back,  hands  and  arms, 
anterior  surface  of  the  trunk  and  lower  extremities,  commonly  in  the  order 
named,  invading  the  entire  surface  in  the  course  of  twenty-four  or  thirty- 
six  hours.  By  the  end  of  the  second  or  during  the  third  day  the  eruption 
is  fully  developed.  In  severe  cases  punctiform  hemorrhages  now  appear 
in  some  of  the  papules,  especially  upon  portions  of  the  body  exposed  to 
pressure.  This  condition  is  not  significant  and  must  not  be  confounded 
with  the  true  hemorrhagic  variety  of  the  disease.  From  this  time  the 
eruption  rapidly  fades,  first  where  it  first  appeared,  namely,  upon  the  face, 
and  in  the  course  of  a  further  period  of  two  or  three  days  disappears,  leaving 
faint  yellowish  or  dirty-brown  areas  of  pigmentation  which  in  turn  gradually 
pass  away.  In  the  beginning  of  the  stage  of  eruption  and  in  many  cases 
throughout  its  course  the  skin  is  moist  and  often  bathed  in  free  perspira- 
tion. At  the  height  of  the  eruption  the  superficial  lymph-nodes  of  the 
neck  and  elsewhere  are  often  slightly  swollen  and  tender. 

(c)  Stage  of  Desquamation. — Following  the  fading  of  the  rash  des- 
quamation takes  place  in  the  form  of  fine  branny  scales,  so  fine  that  the 
condition  may  be  easily  overlooked.  This  process  begins  on  the  face  and 
involves  the  entire  surface,  occupying  about  a  week.  The  catarrhal  symp- 
toms in  uncomplicated  cases  gradually  disappear,  so  that,  by  the  end  of 
the  second  week  from  the  initial  coryza,  convalescence  is  fully  established. 
Cough  frequently  persists.  In  the  absence  of  inflammatory  complications 
leucocytosis  does  not  occur.  Epistaxis  is  common  at  the  height  of  the 
attack;  diarrhoea  is  apt  to  occur  at  some  time  during  its  course.  Relapses 
of  measles  are  extremely  rare. 

During  epidemics  atypical  cases  occur.  They  are  not  common.  Varia- 
tions in  the  rash  may  consist:  (1)  in  the  development  of  distinct  papules, 
hard  to  the  touch  but  not  extending  deeply  into  the  skin — morbilli  papulosi; 
(2)  a  vesicular  form,  m.  vesiculari;  (3)  cases  in  which  the  eruption  does 
not  appear,  although  the  general  symptoms  and  the  coryza  are  present — 
m.  sine  exanthema;  (4)  cases  in  which  the  mucous  membranes  are  not 
involved — m.  sine  enanthema.  To  these  must  be  added  variations  in  the 
constitutional  manifestations.  In  rare  cases  there  is  no  rise  of  tempera- 
ture— ni.  afebriles.  In  the  malignant  forms  the  organism  is  unable  to 
withstand  the  intensity  of  the  infection  and  death  takes  place  in  the 
course  of  two  or  three  clays  after  sustained  hyperpyrexia,  profound 
adynamia,  or  hemorrhages  into  the  skin  and  mucous  membranes.  The 
malignant  forms  are  very  rare  in  private  practice;  they  occasionally  occur 
in  asylums  and  in  the  fierce  epidemics  of  camps,  and  were  common  in  the 
first  outbreak  among  the  natives  of  the  Fiji  Islands,  where  measles  pre- 
vailed as  a  veritable  scourge.  Death  may  occur  before  the  rash  appears, 
or  a  few  papules  may  show  themselves  upon  the  forehead  and  wrists. 
Hemorrhagic  or  black  measles  —  m.  hcemorrhagica — is  characterized  by 
convulsions,  delirium  and  coma,  petechise,  bleeding  from  mucous  surfaces, 
and  profound  constitutional  depression. 


MEASLES. 


685 


Complications  and  Sequels. — Epidemics  differ  greatly  as  regards  the 
frequency  and  severity  of  complications.  In  their  absence  measles  is  a 
comparatively  benign  malady,  but  they  are  sufficiently  common  to  place  it 
among  the  more  serious  diseases  of  childhood.  Debilitated  and  badly  nour- 
ished children  living  in  unhygienic  surroundings  and  those  in  asylums  and 
institutions  are  especially  liable.  The  ordinary  complications  are  due  to  an 
extension  or  intensification  of  the  catarijial  processes  peculiar  to  the  disease. 

Otitis  media  is  not  very  uncommon.  It  may  result  in  perforation  of 
the  tympanic  membrane  and  permanent  impairment  of  hearing,  or  lead  to 
sinus  thrombosis,  meningitis,  or  abscess  of  the  brain.  Purulent  conjuncti- 
vitis may  occur  and  in  neglected  cases  infiltration  and  ulceration  of  the 
cornea.  Catarrhal  laryngitis  is  of 
frequent  occurrence;  the  pseudo- 
membranous form  is  rare  and  very 
dangerous;  oedema  of  the  glottis  is 
very  uncommon.  Diphtheria  is  much 
less  frequent  in  measles  than  in 
scarlet    fever. 

The  catarrhal  bronchitis  so 
prominent  in  the  disease  is,  in  itself, 
without  serious  significance,  and  in 
favorable  cases  terminates  in  reso- 
lution with  the  convalescence.  Its 
tendency  to  extend  to  the  finer  tubes 
and  give  rise  to  lobular  collapse  and 
bronchopneumonia  constitutes  the 
gravest  danger.  If  the  involvement 
of  the  vesicular  structure  is  limited 
there  is  increase  of  fever  with  accel- 
eration of  the  pulse,  harassing  cough, 
and  disturbance  of  respiration.  The 
sickness  is  prolonged  but  terminates 
favorably.  When  the  lesions  are 
extensive  the  symptoms  become 
urgent  and  a  large  proportion  of  the 
cases  die.  It  is  to  this  compHcation  that  the  high  death-rate  of  measles 
under  unfavorable  circumstances  is  due.  Croupous  pneumonia  is  much 
less  common.  Pleural  effusion  is  rare.  Acute  enterocolitis  is  a  frequent 
and  serious  complication  in  some  epidemics.  Toxic  albuminuria  occa- 
sionally occurs  as  in  other  febrile  infections,  and  the  diazo  reaction 
is  present.  There  is  httle  tendency  to  nephritis.  Arthritis  is  very  rare. 
In  young  and  debilitated  children  gangrenous  stomatitis  and  in  girls 
gangrene  of  the  pudenda  occur  during  convalescence  with  greater  fre- 
quency than  in  any  other  infectious  disease. 

Among  the  common  sequels  are  chronic  local  inflammations,  con- 
junctivitis, otitis,  nasal  catarrh,  laryngitis,  and  bronchitis.  The  intestinal 
catarrh  arising  as  a  complication  may  lead  to  chronic  colitis.  Tuberculo- 
sis is  a  very  common  sequel.  The  lesions  of  measles  are  such  as  to  render 
the  patient  peculiarly  hable  to  this  infection,  but  the  rapidity  with  which 


Fig.  233. — Cancrum  oris   complicating  measles.- 
After  Welch  and  Schamberg. 


686  MEDICAL  DIAGNOSIS. 

tuberculous  bronchopneumonia  and  acute  miliary  tuberculosis  develop 
in  many  instances  renders  it  probable  that  a  latent  tuberculous  process 
has  been  roused  into  activity  during  the  attack.  Pulmonary  tuberculosis 
is  a  common  remote  sequel  of  measles  in  the  adult,  and  miliary  tuberculosis 
and  tuberculous  meningitis  may  frequently  be  traced  to  measles  in  earlier 
life.  In  some  cases  enlarged  caseating  bronchial  glands  may  be  the  starting- 
point  of  the  general  infection.  Among  the  rarer  sequels  are  tuberculosis 
of  the  cervical  lymph-nodes  and  of  the  bones  and  joints.  Palsies  occur 
as  the  result  of  peripheral  neuritis  but  are  much  more  rare  than  in  diph- 
theria or  scarlet  fever. 

Diagnosis. — The  direct  diagnosis  of  well-developed  measles  after  the 
appearance  of  the  eruption  is  generally  unattended  with  difficulty. 
During  an  epidemic  coryza  persistent  sneezing  and  fever  are  suspicious. 
The  appearance  of  the  eruption  on  the  second  or  third  day  upon  the  mucous 
membrane  of  the  mouth  and  throat,  and  Koplik's  sign  are  of  positive 
diagnostic  value. 

The  DIFFERENTIAL  DIAGNOSIS  concerns:  1.  RoTHELN  (see  p.  689).  2. 
Variola  (seep.  661).  3.  Typhus  fever  (see  p.  644).  4.  Scarlet  fever 
(see  p.  679). 

5.  Syphilitic  roseola  usually  occurs  in  the  adult.  The  eruption 
if  carefully  examined  is  seen  to  be  polymorphous,  the  enlargement  of  the 
superficial  lymphatic  glands  is  greater,  and  the  signs  of  syphilis  are  to  be 
found  in  the  mouth  and  throat  and  upon  the  genitalia. 

6.  Drug  Exanthems. — Exceptionally  the  administration  of  salicy- 
lates, antipyrin,  quinine,  turpentine,  or  copaiba  is  followed  by  a  rash  sug- 
gesting rather  than  resembling  that  of  measles.  These  rashes  are  not 
accompanied  by  fever  or  throat  symptoms,  nor  have  they  the  uniform 
appearance  and  distribution  of  the  measles  exanthem  (see  p.  683). 

In  the  negro  the  difficulties  in  doubtful  cases  are  increased;  but  the 
mode  of  onset,  the  coryza  and  bronchitis,  and  the  peculiarities  of  the  rash 
upon  the  mucosa  of  the  mouth  are  of  diagnostic  importance.  The  soft  flat 
papules  may  be  distinguished  in  the  darkest  skin. 

The  diagnosis  in  certain  cases  must  for  a  time  remain  doubtful,  espe- 
cially when  the  disease  appears  sporadically  or  prevails  during  epidemics 
of  rotheln,  scarlatina,  variola,  or  typhus. 

Prognosis. — The  character  of  the  prevailing  epidemic  and  previous 
condition  of  the  individual  greatly  modify  the  prognosis.  The  death-rate 
during  the  first  six  months  of  life  is  relatively  low;  it  reaches  its  maximum 
during  the  second  year  and  rapidly  falls  after  the  fifth  year.  After  the 
twentieth  year  it  rises  again.  In  private  practice  the  mortality  is  about 
3  per  cent.,  in  some  epidemics  not  more  than  1.8  per  cent.;  in  hospital  and 
asylum  practice  and  in  camps  and  barracks  it  may  reach  30  per  cent.  The 
vital  statistics  of  measles  are  misleading,  because  the  people  regard  the 
disease  as  an  insignificant  malady  and  among  the  lower  classes  only  the 
more  serious  cases  come  under  medical  observation.  Uncomplicated 
measles  is,  in  point  of  fact,  a  benign  infection,  but  the  tendency  to  pul- 
monary complications  renders  it  one  of  the  gravest  diseases  of  childhood. 
It  is  estimated  that  about  one-third  of  the  cases  in  which  bronchopneu- 
monia develops  terminate  fatally. 


RUBELLA.  687 

VIII.    RUBELLA. 

Roiheln;    German  Measles;    Epidemic  Roseola. 

Definition.  —  An  acute  epidemic  infectious  disease  characterized 
by  a  diffuse  maculopapular  eruption  and  swelling  of  the  superficial 
lymphatic   glands. 

Rubella  has  some  points  of  resemblance  to  scarlet  fever  and  to  measles 
and  was  at  one  time  regarded  as  a  hybrid  of  the  two.  It  is  now  known  to 
be  an  independent  substantive  affection. 

Etiology.  —  The  infecting  principle  has  not  yet  been  discovered. 
The  disease  is  readily  transmissible  and  usually  prevails  in  extensive  epi- 
demics. Outbreaks  occur  in  series,  followed  by  long  intervals  during  which 
the  disease  does  not  recur.  In  the  absence  of  an  acquired  immunity  persons 
at  any  age  are  susceptible.  Rubella  does  not  protect  against  the  infection 
of  scarlet  fever  or  of  measles,  nor  do  these  diseases  protect  those  who  have 
passed  through  them  against  rubella. 

Symptoms. — The  period  of  incubation  varies  from  ten  to  twenty  days. 
Prodromes  are  usually  absent. 

Stage  of  Invasion.  —  The  symptoms  are  generally  mild.  They 
consist  of  the  ordinary  manifestations  of  the  reaction  of  the  organism  to  an 
infection  of  little  intensity,  and  the  coryza,  laryngitis,  and  pharyngitis 
which  usually  precede  the  exanthemata.  The  duration  of  this  stage  is 
not  constant,  varying  from  a  few  hours  to  two  or  three  days.  The  symp- 
toms may  be  so  slight  as  to  be  altogether  overlooked  and  the  rash  may 
then  be  the  first  indication  of  illness.  The  elevation  of  temperature  is 
trifling,  usually  about  100°  F.  (37.8°  C),  and  rarely  exceeding  102°  F. 
(38.9°  C),  and  transient.  In  asylums  and  foundling  institutions  rubella 
sometimes  prevails  as  a  serious  malady. 

Stage  of  Eruption.  —  The  rash  commonly  appears  upon  the  first 
day;  it  may  be  as  late  as  the  third.  It  shows  itself  first  upon  the  face 
and  neck,  and  spreads  in  the  course  of  twenty-four  hours  over  the  body 
and  extremities.  It  consists  of  round  or  oval  reddish  spots  about  the 
diameter  of  a  split  pea,  mostly  discrete,  sometimes  confluent,  and  surrounded 
by  areas  of  hypersemic  skin.  In  some  of  the  cases  extensive  tracts  of  the 
skin  are  intensely  hyperamic  so  that  the  rash  resembles  that  of  scarlet 
fever  rather  than  measles.  The  crescentic  arrangement  of  the  papules, 
seen  in  measles,  cannot  usually  be  made  out.  The  eruption  frequently 
fades  irregularly  in  patches  some  hours  after  it  comes  out,  so  that 
certain  areas  of  the  surface  are  covered  and  not  the  entire  body  at  the 
same  time.  In  the  course  of  two  or  three  days  the  rash  gradually  disap- 
pears with  fine  furfuraceous  desquamation,  leaving  a  faint  pigmentation 
which  persists  for  a  short  time.  Slight  itching  commonly  accompanies 
the  rash.  The  superficial  lymphatic  glands,  especially  those  of  the  neck, 
are  slightly  enlarged.  They  undergo  resolution  in  a  short  time  after 
the  fading  of  the  eruption.  The  suboccipital  and  lateral  chains  are 
commonly  involved  to  a  greater  extent  than  the  anterolateral.  The 
enlargement  of  the  lymph-nodes  in  some  instances  precedes  the  appear- 
ance of  the  eruption. 


688 


MEDICAL  DIAGNOSIS. 


Relapses  are  rare;  complications  infrequent.  Albuminuria,  bronchitis, 
coHtis,  and  pneumonia  have  been  noted.  Herpes  may  occur.  There  are 
no  special  sequels.  The  immunity  acquired  by  the  attack  is  not  always 
permanent.     Second  and  third  attacks  may  occur. 

Diagnosis. — The  early  cases  may  present  great  difficulty  in  diagnosis. 
When  an  epidemic  is  prevalent  the  recognition  of  rubella  is  easy.  The  direct 
DIAGNOSIS  rests  upon  the  trifling  nature  of  the  disease,  the  short  initial  period, 
the  character  of  the  eruption,  its  patchy  distribution,  the  early  enlargement 
of  the  glands,  and  the  absence  of  severe  throat  symptoms  and  coryza. 

DIFFERENTIAL  DIAGNOSIS  OF  SCARLET  FEVER,  MEASLES,  AND  RUBELLA. 


Scarlet  Fever. 


Contagion 

Transmissibility 


Period  of  Incubation 
Prodromes 

Koplik  Spots 

Vomiting 

Temperature 

Catarrhal  Symptoms 
Tongue  

Throat 

Lymph-nodes 

Pulse 

Urine 

Eruption 


Highly  contagious 

By  direct  contact,  ap- 
proach, and  fomites 


Average  2  to  /  days 


Highly  contagious Variable  in  epidemics. 


By  direct  contact,  fo- 
mites, and  through  the 
air 

Average  9  to  14  daj-s  .  .  .  . 


Direct  contact  and  fomites; 
not  through  the  air. 


Absent    or    very    brief —  i  Commonly  3  to  4  days, 
onset  commonly  sudden  i      Drowsiness  and  ca- 
I      tarrhal  symptoms 
! 

Not  present Present  in    about  90  per    Not  present. 

cent,  of  cases  j 

Common  at  onset Infrequent j  Rare. 


Variable;  average  1  to  3 
weeks. 

Slight  and  of  short  duration. 


High— 103°-105°F.— last-  ;  High,    lasting    about     a 
ing  about  a  week  week,  average  102°- 

I      104°  F. 


Slight  elevation,  seldom 
more  than  101°-102°  F. — 
subsides  in  1  to  3  days. 


More  or  less  intense  ery- 
thematous angina 

Glands  at  angle  of  the  jaw 
enlarged 


Desquamation  . 
Convalescence  . 


Commonly  absent Prominent  throughout ...    Slight. 

Whitish   fur,  enlarged    Tongue  coated 

papiUse  ;  later    dry  and 
red 


Slightly  coated,  not  charac- 
teristic. 


Moderate  redness  of  mu- 
cous membranes 


Punctiform  red   spots  over 
uvula,  palate,  and    phar- 


Ce  rvi  cal,  postauricular  General  enlargement,  espe- 
and  submaxillary  cially  of  postcervical 
nodes  enlarged  chains. 


High    f  requen  cv  - 
140 


•120—  !  Corresponding   to   eleva-  '  Varies  with  fever. 
I      tions  in  temperature        i 


Early  toxic  albuminuria    Albuminuria  rare 
in  severe  cases.     Later 
signs  of  nephritis 


First  appears  on  neck  and 
chest,  spreads  slowly 
over  entire  body.  Ful- 
ly developed  about  the 
fourth  day.  Small 
punctate  efflorescence 
or  diffuse  blush  disap- 
pearing on  pressure, 
lasts  about  a  week.  In- 
tense scarlet  color;  usu- 
ally absent  around 
mouth 


Coarse,  bran-like ;  la- 
mellar 

Tardy;  complications  fre- 
quent, especially  ne- 
phritis, otitis  media,  etc 


First  appears  on  face, 
spreads  gradually  over 
entire  body.  Fully  de- 
veloped by  the  second 
or  third  day.  Consists 
of  small  papules  ar- 
ranged in  crescentic 
groups;  these  are  con- 
fluent in  places;  fades 
in  4  or  5  days;  deep  red, 
dusky   or  purplish 


Albuminuria  very  rare  and 
slight. 


First  appears  on  face, 
spreading  to  neck  and 
breast,  tlien  to  arms,  legs 
and  feet.  Fades  in  parts 
first  involved  while 
spreading  to  others.  Two 
varieties  —  morbilliform, 
small,  slightly  elevated 
papules,  discrete,  some- 
times confluent;  scarlatin- 
iform.  Duration  2  to  4 
days  or  less.  Color  rose 
red  but  variable. 


Branny 


Slow;  tendency  to  com- 
plications as  broncho- 
pneumonia and  other 
infectious  diseases,  es- 
pecially tuberculosis 


Fine,  branny. 


Rapid 
tions. 


without     complica- 


WHOOPING-COUGH.  689 

Differential  Diagnosis. — Rubella  is  most  frequently  mistaken  for 
mild  measles  or  scarlatina.  From  measles  it  is  distinguished  by  the  want  of 
prominence  of  catarrhal  phenomena,  the  slighter  fever,  the  brighter  hue 
of  the  eruption,  the  absence  of  the  crescentic  grouping  of  the  papules,  the 
fact  that  the  adenitis  involves  to  a  greater  degree  the  suboccipital  and 
postauricular  glands,  and  the  absence  of  Koplik's  sign;  from  scarlatina  by 
its  gradual  onset,  benign  character,  the  absence  of  severe  throat  symptoms, 
the  peculiarities  of  the  rash,  the  character  of  the  desquamation,  the  tongue, 
and  the  fact  that  there  is  no  special  tendency  to  nephritis. 

Prognosis. — Rubella  is  a  benign  disease  almost  invariably  terminating 
in  recovery.  In  foundling  hospitals  and  asylums  it  has  sometimes  assumed 
unusual  severity,  and  fatal  cases  have  occurred  commonly  as  the  result  of 
an  intercurrent  pneumonia,  colitis,  or  nephritis,  rather  than  of  the  primary 
disease  (see  table  on  opposite  page). 

THE    FOURTH    DISEASE. 

In  1900  Dukes  described  an  infectious  disease  which  he  called  ''the 
fourth  disease."  This  communication  attracted  considerable  attention 
and  the  subject  has  been  discussed  by  a  number  of  clinicians.  The  incuba- 
tion period  is  stated  to  be  about  the  same  as  that  of  German  measles,  ten 
to  twenty-one  days.  Prodromes  were  absent  in  most  of  the  cases  but 
malaise  and  a  mild  erythematous  angina  were  occasionally  observed  at  the 
time  of  the  appearance  of  the  rash.  The  evolution  of  the  exanthem  was 
rapid,  the  entire  body  being  covered  in  the  course  of  a  few  hours.  Whether 
or  not  it  was  present  upon  the  face  is  not  stated.  Its  color  was  like  that 
of  scarlet  fever  but  brighter.  The  superficial  lymph-nodes  were  enlarged. 
The  temperature  was  subfebrile,  not  often  exceeding  101°  F.  (38.5°  C). 
Upon  the  subsidence  of  the  eruption  there  was  desquamation.  Sequels 
were  not  observed  and  the  attack  did  not  confer  immunity  against  scarlet 
fever  or  rubella.  This  affection  has  not  been  generally  recognized  as  a 
clinical  entity. 

IX.    WHOOPING-COUGH. 

Pertussis;    Tussis  Convulsiva. 

Definition. — An  infectious  endemic  and  epidemic  disease  character- 
ized by  hypersesthesia  and  catarrh  of  the  respiratory  tract  and  a  peculiar, 
spasmodic  cough  occurring  in  paroxysms  which  terminate  in  a  prolonged 
inspiration  attended  by  a  shrill  crowing  sound  or  whoop. 

Etiology.^PREDisposiNG  Influences. — Whooping-cough  is  a  widely 
prevalent  disease.  The  individual  susceptibility,  like  that  to  measles,  is 
almost  universal.  Very  few  persons  unless  rendered  immune  by  a  previous 
attack  escape  upon  exposure.  Nearly  twice  as  many  cases  occur  during 
the  winter  and  spring  as  during  the  summer  and  autumn.  It  is  peculiarly 
a  disease  of  infancy  and  early  childhood.  More  than  one-half  the  cases 
occur  during  the  first  two  years  of  Hfe;  very  few  cases  after  the  second 
dentition.  That  the  immunity  after  the  seventh  year  is  acquired  rather 
than  congenital  is  shown  by  the  fact  that  in  individuals  not  protected  by  a 
previous  attack  the  disease  may  be  contracted  upon  exposure  at  any  period 

44 


690  MEDICAL  DIAGNOSIS. 

of  life.  Sucklings  are  not  exempt.  Sex  is  without  influence  in  early  life, 
but  among  adults  women  are  more  liable  than  men,  a  fact  to  be  explained 
in  part  by-  increased  exposure,  in  part  by  the  more  common  neurotic  con- 
stitution in  women.  Pregnancy  appears  to  be  attended  with  an  especial 
liability.  The  previous  condition  of  health  is  of  great  importance.  Delicate 
children  and  those  suffering  from  nasal  or  bronchial  catarrh  are  especially 
liable  to  contract  the  disease  upon  slight  exposure. 

Exciting  Cause. — The  specific  infecting  agent  has  not  yet  been  dem- 
onstrated. Afanassiew,  1887,  discovered  in  the  secretions  a  short  bacillus, 
cultures  of  which  injected  into  the  respiratory  passages  in  animals  produce 
catarrhal  inflammation.  Koplik  has  more  recently  found  a  bacillus  resem- 
bling that  of  influenza  but  larger,  which  he  regards  as  the  cause  of  the 
disease.  Spengler  and  others  have  described  an  organism  to  which  the 
name  Bacillus  pertussis  has  been  given. 

Clinical  experience  makes  it  clear  that  the  infective  material  is  elim- 
inated by  way  of  the  mucous  discharges  and  perhaps  by  the  expired  air. 
It  reaches  the  organism  with  the  inspired  air.  Actual  contact,  close  ap- 
proach, or  fomites,  especially  such  articles  as  the  handkerchief  or  towel, 
constitute  the  usual  means  of  transmission  from  the  sick  to  the  well.  Under 
certain  circumstances  a  third  person  may  readily  transmit  the  infective 
material.  The  dried  sputum  circulating  as  dust  in  the  atmosphere  is  prob- 
ably also  a  source  of  infection.  The  disease  is  transmissible  from  the 
earliest  appearance  of  the  catarrhal  symptoms,  and  since  it  cannot  be 
recognized  until  the  spasmodic  stage,  and  since  in  suitable  weather  the 
patients  are  kept  as  much  as  possible  in  the  open  air,  the  patient  alike 
in  the  nursery  and  school  and  out  of  doors  is  in  constant  danger  of  dis- 
seminating it.  The  attack  confers  an  immunity  which  in  most  cases  is  life- 
long. The  occasional  occurrence  of  cases  in  elderly  persons,  who  have 
passed  through  an  attack  in  childhood,  living  in  the  house  with  children 
suffering  from  the  disease,  shows,  however,  that  the  protection  is  not  always 
permanent. 

Whooping-cough  is  endemic  in  large  cities  when  it  takes  the  form  of 
extended  epidemics  at  irregular  intervals  of  from  two  to  four  years.  Its 
prevalence  is  sometimes  so  wide-spread  as  to  merit  the  descriptive  term 
pandemic.  Outbreaks  are  not  infrequently  associated  with  epidemics  of 
measles,  scarlet  fever,  or  varicella,  and  these  diseases  occasionally  run  their 
course  coincidently  with  whooping-cough  in  the  same  individual. 

Symptoms. — The  period  of  incubation  varies  from  seven  to  ten  days. 
If,  after  exposure,  two  full  weeks  elapse  without  the  development  of  catar- 
rhal symptoms,  the  probability  becomes  very  strong  that  infection  has  not 
taken  place. 

The  Course  of  the  Attack. — (a)  The  catarrhal  stage  begins  with  the 
symptoms  of  an  ordinary  subacute  bronchitis,  which  gradually  increase  in 
intensity.  In  the  course  of  some  days  the  cough  tends  to  become  par- 
oxysmal, the  spells  being  more  frequent  and  severe  during  the  night  and 
after  meals.  Running  at  the  nose,  hoarseness,  and  a  croupy  ringing  cough, 
the  indications  of  a  nasal  and  laryngeal  catarrh  of  moderate  severity,  are 
associated  symptoms.  There  is  very  often  fever  of  moderate  grade.  The 
duration  of  this  stage  is  about  a  week  or  ten  days.    Cases  vary  greatly  in 


WHOOPING-COUGH.  691 

this  respect,  however,  some  children  developing  the  whoop  in  the  course 
of  a  day  or  two  from  the  beginning  of  the  catarrhal  symptoms,  others  not 
until  three  or  four  weeks  have  elapsed. 

(b)  Spasmodic  or  Paroxysmal  Stage. — The  fever  subsides.  The  catar- 
rhal symptoms  continue  and  may  be  intensified.  The  cough  becomes  dis- 
tinctly paroxysmal  and  characteristic,  the  attacks  ending  in  a  long-drawn 
"whoop"  from  which  the  disease  receives  its  name.  The  true  nature  of 
the  disease  is  now  first  apparent.  The  patient  experiences  a  sensation  of 
tickling  in  the  larynx  or  under  the  sternum.  Little  children  run  terrified 
to  the  nurse  or  mother  and  cling  to  her;  older  persons  grasp  some  object, 
as  the  arms  of  a  cuair,  for  support.  The  fully  developed  paroxysm  usually 
begins  with  a  long-drawn  inspiration  which  is  immediately  followed  by  a 
series  of  ten  or  fifteen  short  explosive  coughs  of  increasing  intensity  and 
repeated  so  rapidly  that  breathing  is  ineffectual  until  at  length  a  prolonged 
deep  inspiration  occurs,  during  which  the  whoop  is  produced.  One  or  more 
new  series  of  coughs  terminating  in  the  whoop  may  forthwith  follow  and 
the  paroxysms  may  not  come  to  an  end  until  a  mass  of  tough  stringy  mucus 
is  raised.  This  is  usually  small  but  in  little  children  it  is  often  very  abund- 
ant and  must  be  removed  from  the  mouth  by  the  finger.  It  may  be  ex- 
pelled in  the  act  of  vomiting.  An  abundance  of  thick  mucus  is  at  the  same 
time  discharged  from  the  nose.  The  signs  of  mechanical  disturbance  of 
the  venous  circulation  are  conspicuous.  The  face  and  neck  become  con- 
gested and  cyanotic,  the  veins  of  the  face  and  the  jugulars  stand  out  prom- 
inently, there  is  protrusion  of  the  eyeballs,  sometimes  marked  injection 
of  the  conjunctivae,  and  the  lips  are  swollen  and  blue.  As  the  attack  comes 
to  an  end  the  face  or  the  whole  body  may  break  out  into  a  more  or  less 
profuse  sweat.  In  severe  paroxysms  the  sphincters  may  be  relaxed.  Head- 
ache and  vertigo  are  common,  and  at  the  close  of  a  severe  attack  the  child 
sinks  exhausted  upon  the  mother's  lap.  The  condition  is  most  distressing, 
but  in  a  little  while  the  child  usually  recovers  himself  and  goes  about 
his  play  until  another  spell  occurs.  The  single  paroxysm  lasts  from 
fifteen  to  forty-five  seconds,  rarely  longer;  when  two  or  more  immediately 
succeed  each  other,  the  whole  attack  may  be  prolonged  to  two  or  three 
minutes.  They  are  fortunately  not  all  of  the  same  intensity,  frequent 
milder  attacks  occurring  between  those  which  are  more  severe.  They  may 
be  brought  on  by  taking  food  or  drink,  especially  anything  cold,  by  laughter 
or  vexation,  and  in  some  cases  by  traction  of  or  pressure  upon  the  tongue. 
They  are  more  frequent  in  a  close  room  than  in  the  open  air  and  by  night 
than  during  the  day.  The  number  of  paroxysms  varies  from  three  or  four 
to  sixty  to  one  hundred  during  twenty-foiu-  hours.  Severe  paroxysms 
after  the  taking  of  food  almost  always  cause  vomiting  and  the  patients 
very  often  become  much  emaciated  and  reduced  in  strength.  In  many 
cases,  however,  as  soon  as  the  distressing  symptoms  are  over  the  child 
will  eat  another  meal,  which  should  always,  under  these  circumstances,  be 
offered  to  it.  The  violence  of  the  cough  forces  the  tongue  against  the 
lower  incisor  teeth  and  very  often  causes  laceration  of  the  mucous  mem- 
brane of  the  frsenum,  which  is  followed  by  superficial  ulceration.  A  marked 
leucocytosis  occurs.  In  very  mild  cases  the  paroxysms  are  not  only  less 
frequent  but  they  are  also  less  violent,  and  occasional  cases  occur  in  which 


692  MEDICAL  DIAGNOSIS. 

the  whoop  is  absent  throughout  the  attack,  the  nature  of  which  is  apparent 
from  the  presence  of  other  cases  in  the  house,  the  spasmodic  spells  of  cough- 
ing attended  with  vomiting  and  terminating  with  the  expulsion  of  a  mass 
of  tenacious  mucus,  and  the  protracted  course  of  the  illness. 

The  cough  is  the  result  of  an  extended  irritation  involving  the  upper 
air-passages.  It  is  probable  that  the  gradual  accumulation  of  mucus  in  the 
region  of  the  bifurcation  of  the  trachea  plays  an  important  role  in  its  pro- 
duction. The  mechanism  of  the  whoop  consists  in  the  forcible  indrawing 
of  air  through  the  spasmodically  narrowed  glottis.  The  disease  has  the 
characteristics  of  a  neurosis  affecting  the  respiratory  tract. 

Laryngoscopic  examination  frequently  shows  the  mucous  membrane 
of  the  larynx  to  be  congested  and  swollen,  especially  in  the  interarytenoid 
space,  and  sometimes  the  seat  of  hemorrhagic  patches  or  superficial  ero- 
sions. Irritation  of  the  mucous  membrane  between  the  arytenoids  or  of 
the  posterior  surface  of  the  epiglottis  with  a  sound,  always  causes  the 
paroxysm.  A  similar  condition  of  congestion  and  swelling  has  been  ob- 
served in  the  trachea,  in  which  a  plug  of  mucus  has  been  seen  just  before 
the  paroxysm — Roosbach.    The  difficulty  of  such  examinations  is  obvious. 

Physical  examination  yields  unimportant  signs.  The  resonance  is 
impaired  during  the  paroxysm  and  increased  at  its  close.  Auscultation 
yields  commonly  an  enfeebled  vesicular  murmur  and  a  few  bronchial  rales, 
usually  dry — sonorous  or  sibilant. 

The  average  duration  of  the  spasmodic  stage  is  about  one  month. 
The  symptoms  progressively  increase  in  intensity  for  a  fortnight  or  longer, 
remain  stationary  for  a  time,  and  gradually  subside.  In  mild  cases  this  stage 
may  not  exceed  a  week  or  ten  days,  or  the  whoop  may  be  wholly  absent;  in 
severe  cases  it  may  be  prolonged,  especially  if  the  patient  must  be  housed, 
as  in  the  winter,  for  three  or  four  months,  with  remissions  and  exacerbations. 

(c)  Stage  of  Decline. — The  paroxysms  diminish  in  severity  and  fre- 
quency; the  expectoration  becomes  more  abundant  and  less  tenacious; 
and  finally,  as  at  the  beginning,  the  symptoms  are  those  of  an  ordinary 
catarrhal  bronchitis,  which  varies  in  intensity  and  continues  two  or  three 
weeks  in  favorable  and  much  longer  in  unfavorable  cases,  especially  dur- 
ing the  winter  months  when  convalescents  must  be  kept  housed. 

The  duration  of  the  attack  varies  between  two  and  four  months. 
A  majority  of  the  cases  in  older  children  can  scarcely  be  regarded  as  ill. 
They  are  out  of  bed  and  eat  well,  and  in  proper  weather  can  pass  some 
hours  in  the  open  air.     They,  however,  lose  flesh  and  become  pale. 

A  cough  habit  is  often  developed  during  the  attack,  and  for  several 
months  after  full  convalescence  has  been  established,  with  every  cold 
or  nasobronchial  catarrh,  however  trifling,  a  paroxysmal  cough  with 
whooping  returns,  and  this  is  particularly  the  case  with  the  children  of 
neurotic  parents.  Under  these  circumstances  the  disease  is  not  commu- 
nicated. Relapses  practically  do  not  occur.  Second  attacks  are  by  no 
means  uncommon,  but  as  has  already  been  mentioned  they  usually  occur 
after  the  lapse  of  years,  and  children  and  their  parents  or  grandparents 
often  suffer  at  the  same  time. 

Complications  and  sequels  are  numerous  and  may  be  arranged  in 
two  categories,  the  mechanical  and  the  infectious. 


WHOOPING-COUGH.  693 

(a)  The  mechanical  complications  and  sequels  are  caused  by  increased 
respiratory  pressure  during  the  paroxysm,  or  circuhitory  disturbances. 
Acute  emphysema  is  common.  It  is  as  a  rule  transient.  If  it  persists 
pseudohypertrophic  emphysema  results.  Rupture  of  the  tissue  of  the 
lung  may  give  rise  to  interstitial  emphysema,  or  the  air  may  find  its  way 
along  the  peribronchial  connective  tissue  to  the  anterior  mediastinum  or 
upwards  and  give  rise  to  subcutaneous  emphysema  of  the  neck.  Pneu- 
mothorax is  less  common.  Dilatation  of  the  right  heart  may  occur  in 
consequence  of  the  interference  with  the  pulmonary  circulation  during 
the  paroxysms.  It  is  possible  that  valvular  disease  may,  in  some  instances, 
be  due  to  the  heart  strain  of  severe  whooping-cough.  The  pulse  after  the 
paroxysm  is  often  feeble  and  irregular,  and  progressively  so  as  the  attack 
goes  on.  The  vomiting  is  largely  due  to  mechanical  disturbance  caused 
by  cough.  Sometimes  the  jDatient  vomits  freely  during  several  paroxysms 
daily  for  j^eriods  of  weeks,  and  as  a  result  is  greatly  reduced  in  flesh  and 
strength.  Partly  as  the  result  of  the  violent  succussion  and  partly  from 
exhaustion,  involuntary  discharges  of  gas  or  fecal  matter  are  of  common 
occurrence  in  severe  paroxysms.  Prolapse  of  the  bowel  and  hernia  are 
common  and  must  be  ascribed  to  the  same  causes.  Involuntary  discharge 
of  urine  likewise  occurs.  Pregnant  women  frequently  abort.  Very  common 
are  lesions  of  the  blood-vessels  during  the  paroxysms,  resulting  in  hemor- 
rhages into  the  skin,  particularly  about  the  forehead  and  eyes,  and  into  the 
mucous  membranes,  especially  subconjunctival  ecchymoses.  Much  less 
common  are  slight  hemorrhages — not  more  than  a  few  drops — from  the  ear 
in  consequence  of  superficial  lacerations  of  the  tympanitic  membrane. 
Epistaxis  is  very  frequent,  haemoptysis  rare.  Hemorrhage  from  the  bowel 
is  very  unusual,  and  when  it  occurs  is  due  to  the  mechanical  derangements 
which  cause  prolapse.  Convulsions  are  not  uncommon,  especially  in  very 
young  children,  and  have  been  ascribed  to  the  engorgement  of  the  cerebral 
vessels.  Meningeal  and  cerebral  hemorrhages  occur,  but  these  accidents 
are  extremely  infrequent.  Hemiplegia  and  aphasia  may  result.  Sudden 
death  has  occurred. 

(b)  The  infectious  complications  include  inflammatory  enlargement 
of  the  bronchial  glands,  sufficient  in  some  instances  to  give  rise  to  dulness 
over  the  manubrium;  bronchopneumonia,  which  is  very  common  and 
the  cause  of  death  in  the  majority  of  the  fatal  cases;  tuberculosis,  which 
may  take  the  form  of  a  tuberculous  bronchopneumonia,  miliary  tuber- 
culosis, or  an  acute  caseous  consumption;  croupous  pneumonia,  which  is 
infrequent;  pleurisy,  still  more  rare;  and  nephritis,  likewise  very  uncom- 
mon. Other  inflammatory  complications  are  seldom  encountered.  Tran- 
sient albuminuria  is  not  infrequent  and  glycosuria  is  occasionally  observed. 
Many  of  the  complications  are  essentially  chronic  and  persist  as  sequels. 
The  patients  not  infrequently  show  an  especial  predisposition  to  recur- 
rences of  bronchial  catarrh.    Emphysema  and  asthma  are  common  sequels. 

Diagnosis. — The  direct  diagnosis  of  whooping-cough  during  the  early 
part  of  the  catarrhal  stage  is  impracticable.  In  the  course  of  a  week  the 
increasing  severity  of  the  symptoms  and  the  tendency  of  the  cough  to 
become  paroxysmal  and  worse  at  night,  to  cause  vomiting,  suffusion  of 
the  eyes,  and  flushing  of  the  face,  render  the  diagnosis  during  an  epidemic, 


694  MEDICAL  DIAGNOSIS. 

or  with  a  history  of  exposure,  a  probable  one.  A  like  uncertainty  arises 
in  regard  to  very  mild  cases.  A  child  may  cough  for  several  weeks  without 
having  a  well-developed  paroxysm.  '  If  there  be  no  fever,  only  a  few  rales 
now  and  then  upon  auscultation,  and  ordinary  treatment  be  without 
effect,  the  diagnosis  by  exclusion  may  be  made.  The  occurrence  of  the 
whoop  renders  the  diagnosis  easy  and  certain.  It  is  to  be  remembered 
that  pressure  upon  or  traction  of  the  tongue,  the  act  of  swallowing,  and 
emotional  disturbances  may  cause  a  paroxysm — facts  which  the  physician 
may  use  for  diagnostic  purposes.  The  diagnosis  may  also  be  difficult  in 
early  infancy,  when  the  cough  attending  ordinary  bronchitis  sometimes 
assumes  a  paroxysmal  character  and  is  attended  with  a  croupy  or  crowing 
sound  that  is  suggestive  of  the  whoop.  The  ulcer  upon  the  frsenum  and 
subconjunctival  or  other  hemorrhages  are  not  apt  to  occur  in  mild  cases 
and  these  only  present  diagnostic  uncertainties. 

Prognosis. — Uncomplicated  whooping-cough  tends  to  run  a  favor- 
able course.  The  great  tendency  to  compHcations  places  it,  however, 
among  the  most  serious  of  the  diseases  of  childhood.  It  has  been  estimated 
that  fully  two-thirds  of  the  deaths  from  this  disease  occur  within  the  first 
year.  After  the  fourth  year  the  danger  rapidly  diminishes.  Broncho- 
pneumonia and  enterocolitis  are  the  most  common  causes  of  death.  Con- 
vulsions very  often  occur  in  fatal  cases  in  early  infancy.  Dehcate  and 
badly  nourished  children,  those  Hving  under  improper  hygienic  conditions, 
those  who  have  rickets  or  who  have  been  debilitated  by  a  recent  attack  of 
measles,  influenza,  or  other  serious  infection  are  apt  to  suffer  severely. 
The  aged  bear  whooping-cough  badly.  It  is  peculiarly  fatal  among  negroes. 
The  danger  of  early  or  remote  tuberculosis  lends  especial  importance  to 
this  disease.  Death  may  occur  during  a  paroxysm  from  intracranial 
hemorrhage  or  asphyxia,  but  such  accidents  are  exceedingly  uncommon. 
The  prognosis  is  to  some  extent  modified  by  the  frequency  as  well  as  by 
the  severity  of  the  paroxysms.  Cases  run  a  more  favorable  course  in  sum- 
mer than  in  winter.  Reliable  general  statistical  facts  relating  to  the  mor- 
tafity  are  not  available.  Many  of  the  milder  cases  never  come  under  medical 
observation.  In  foundling  asylums  and  children's  hospitals  the  death- 
rate  may  exceed  twenty-five  per  cent. 

X.    MUMPS. 

Epidemic   Parotitis. 

Definition. — An  acute  infectious  disease,  prevailing  in  limited  epi- 
demics, and  characterized  by  inflammation  and  enlargement  of  the  sahvary 
glands,  especially  the  parotid. 

Etiology.  —  Predisposing  Influences.  —  Mumps  is  a  wide-spread 
disease  and  is  usually  endemic  in  large  cities.  Sporadic  cases  occur  and 
become  foci  of  circumscribed  outbreaks  which  run  a  fingering  course  of 
months  or,  in  some  instances,  of  a  year  or  more.  The  infecting  principle 
is  much  less  readily  transmitted  than  that  of  many  of  the  contagious  dis- 
eases and  the  congenital  immunity  much  more  common.  In  general 
practice  extensive  epidemics  are  infrequent,  but  when  the  disease  appears 


MUMPS. 


695 


in  reformatory  institutions  and  schools  a  large  proportion  of  the  inmates 
usually  contract  it.  The  cases  are  more  numerous  in  the  spring  and  autumn 
than  at  other  seasons.  Mumps  is  peculiarly  a  disease  of  childhood  and 
adolescence.  It  is  not  common  in  early  infancy  nor  after  the  twentieth 
year.     More  boys  than  girls  suffer  in  a  ratio  estimated  as  high  as  two  to  one. 

Exciting  Cause. — The  specific  cause  has  not  been  demonstrated. 
The  disease  is  directly  transmitted  by  personal  contact.  Rare  instances 
have  been  observed  in  which  the  contagion  has  been  indirectly  transmitted 
by  a  third  person  or  by  fomites,  especially  clothing.  Two  views  may  be 
entertained  as  to  the  mode  of  infection.  The  first  is  the  one  generally 
accepted,  namely,  that  the  pathogenic  principle  finds  its  way  from  the 
mouth  to  the  glands  along  the  course  of  the  salivary  ducts  and,  as  the 
parotid  is  usually  involved,  through  the  duct  of  Stenson;  second,  that  the 
infection  is  a  general  one,  to  which 
certain  anatomical  structures,  as  the 
salivary  glands  and,  in  particular,  the 
parotid  gland,  especially  react.  The 
occasional  occurrence  of  inflammation 
of  the  testes,  and  of  the  ovaries  and 
mammae  in  the  female,  and  the  defi- 
nite incubation  and  typical  course  of 
the  disease  lend  support  to  this  view. 

Symptoms. — The  period  of  incu- 
bation varies  from  fourteen  to  twenty- 
one  days.  In  rare  instances  it  has 
appeared  to  be  shorter.  Prodromes 
are  commonly  absent.  In  mild  cases 
the  swelling  and  associated  local 
symptoms  constitute  the  earliest 
manifestations.  In  severer  cases 
more  or  less  pronounced  constitu- 
tional disturbance,  with  shivering,  vomiting,  and  moderate  fever,  100°- 
101°  F.  (37.8°-38.3°  C),  characterize  the  invasion,  which  is  abrupt  and 
precedes  the  local  inflammation  by  about  twenty-four  hours.  In  severe 
cases  the  temperature  may  reach  103°-104°  F.  (39.5°-40°  C).  A  feehng 
of  tension  with  soreness  is  felt  just  below  one  ear,  more  commonly 
the  left.  Upon  examination  slight  swelling  may  be  observed,  which 
increases  until,  in  the  course  of  forty-eight  hours,  it  reaches  its  maxi- 
mum. The  parotid  is  now  greatly  enlarged  and  the  adjacent  tissues 
of  the  neck  and  often  of  the  side  of  the  face  tensely  osdematous.  The 
skin  is  glossy,  hard  to  the  touch,  its  folds  are  obliterated,  and,  commonly, 
by  reason  of  interference  with  the  circulation  by  pressure,  white  in  color. 
It  pits  only  slightly  upon  pressure.  The  swelling  occupies  the  lateral 
region  of  the  neck  between  the  jaw  and  the  mastoid  process,  extending 
upward  to  the  zygoma  and  downward  and  forward  toward  the  clavicle 
and  the  median  line.  Its  extent  varies  with  the  intensity  of  the  attack. 
The  ear  is  pushed  upward,  and  its  lobule,  which  occupies  the  centre 
of  the  swelling,  is  sharply  pushed  outward.  In  almost  all  instances  the 
other  side  is  affected  in  a  day  or  two,    sometimes  not  for  several  days  or 


Fig.  234. — Mumps. — Cotton. 


696  MEDICAL  DIAGNOSIS. 

until  the  inflammation  upon  the  side  first  affected  has  subsided.  Very 
often  the  swelling  of  the  second  gland  is  so  sHght  that  it  can  only  be  de- 
tected upon  close  scrutiny.  The  disfigurement  is  marked  and  when  both 
sides  are  affected  the  patient  may  be  scarcely  recognizable.  In  some 
instances  the  other  salivary  glands  are  involved,  and  several  cases  have 
come  under  my  observation  in  house  epidemics  in  which  the  submaxillary 
glands  have  been  inflamed  while  the  parotids  have  remained  unaffected. 
The  sublingual  glands  and  the  lachrymal  glands  may  also  be  involved. 
Movements  of  the  jaw,  the  act  of  deglutition  and,  in  severe  cases,  even 
phonation  are  attended  with  difficulty  and  pain.  There  is  trouble  in  tak- 
ing any  form  of  nourishment,  even  liquids.  The  fetor  is  often  extreme. 
Movements  of  the  head  are  restricted  and  in  order  to  relieve  tension  there 
is  flexion  of  the  neck  toward  the  affected  side.  The  salivary  secretion  is 
usually  diminished,  exceptionally  increased.  Its  reaction  may  be  acid. 
Slight  deafness  and  earache  often  occur,  and  in  rare  instances  otitis  media. 
Permanent  deafness,  usually  one-sided  and  complete,  without  otitis  media, 
has  been  observed.  This  condition  develops  suddenly  during  the  course 
of  the  disease  or  in  convalescence,  with  nausea  and  vomiting,  vertigo  and 
a  staggering  gait.  It  is  probably  due  to  a  lesion  of  the  labyrinth.  After 
from  five  to  ten  days  the  swelling  gradually  subsides,  the  stiffness  and 
impairment  of  movement  disappear,  and  normal  conditions  are  restored. 
Local  desquamation  may  occur.  The  glandular  inflammation  undergoes 
resolution  without  abscess  formation.  If  suppuration  occurs  it  is  due  to 
a  mixed  infection  and  must  be  regarded  as  a  complication.  The  pus  may 
be  evacuated  externally  or  may  burrow  in  the  tissues  of  the  neck.  Secondary 
pyothorax  or  pyopericardium  may  follow  with  or  without  general  sepsis. 

Orchitis  occurs  in  about  one-third  of  the  cases  after  puberty.  In 
infancy  and  childhood  it  is  exceedingly  rare.  It  usually  affects  one  testicle 
onl}^,  occasionally  both.  Weight,  swelling,  and  pain  are  the  symptoms. 
The  testicle  may  be  enormously  enlarged.  Epididymitis  is  not  common. 
There  may  be  effusion  into  the  tunica  vaginalis,  scrotal  oedema,  and  a  mild 
mucopurulent  urethral  discharge.  Atrophy  may  result  and,  when  both 
testicles  are  involved,  loss  of  the  procreative  function.  Even  with  some 
atrophy  of  both  testicles  functional  power  may  be  retained.  In  adoles- 
cents and  young  adults  great  anxiety  upon  this  question  arises  during  the 
attack.  Mastitis  may  occur  in  boys.  In  females  also,  usually  after  the  age 
of  puberty,  enlargement  and  tenderness  of  the  breasts,  pain  and  tender- 
ness in  the  ovaries,  hsematoma  of  the  labia,  or  a  vulvovaginal  discharge 
may  occur.  These  phenomena  are  very  uncommon.  Thyroid  enlarge- 
ment is  extremely  rare. 

Exceptionally  the  symptoms  are  very  severe.  High  fever  may  be 
accompanied  by  vomiting,  delirium,  and  sleeplessness.  Great  exhaustion  may 
result.  As  a  rule  the  patient  is  not  seriously  ill.  The  constitutional  dis- 
turbance comes  to  an  end  within  a  week;   the  local  symptoms  more  slowly. 

Relapse  is  extremely  rare.  The  attack  confers  an  immunity  which 
is  practically  permanent. 

Complications  and  Sequels. — The  frequent  involvement  of  the  gen- 
erative organs  and  the  fact  that  it  sometimes  precedes  the  parotitis  or 
occurs  without  it  compel  the  recognition  of  these  local  inflammations  as 


INFLUENZA.  697 

incidental  manifestations  of  the  disease  rather  than  comphcations.  The 
frequency  of  actual  complications  varies  in  different  epidemics.  The 
fatal  cases  are  frequently  associated  with  meningeal  symptoms.  Hemi- 
plegia, coma,  and  acute  mania  may  occur.  Among  the  rare  complications 
are  albuminuria,  nephritis  with  ursemic  accidents,  polyarthritis,  endo- 
carditis, facial  palsy  from  pressure,  peripheral  neuritis,  and  hemiplegia. 
The  common  sequels  have  been  already  indicated.  The  inflamed  glands 
may  not  undergo  resolution  but  remain  enlarged  and  hard.  Ptyalism  or 
xerostomia  may  persist  for  some  time.  Parotid  bubo  is  very  rare  in  idio- 
pathic mumps.  Local  gangrene  may  occur.  Deafness  may  be  permanent. 
Optic  atrophy  is  among  the  rarest  of  sequels. 

Diagnosis. — The  direct  diagnosis  of  mumps  is  under  ordinary  circum- 
stances easy.  The  location  of  the  swelling  in  front  of  the  ear  and  below  it, 
and  the  abrupt  displacement  of  the  lobule  outwards,  together  with  the 
circumscribed  outline  at  first  corresponding  to  that  of  the  parotid,  are  im- 
portant anatomical  considerations.  Mumps  is  a  primary  affection  and 
very  rarely  goes  on  to  suppuration.  The  relative  rapidity  with  which  the 
swelling  develops  and  subsides  is  characteristic  of  mumps. 

Differential  Diagnosis. — L  Parotid  bubo.  The  glandular  inflam- 
mation is  secondary  to  some  acute  infection  or  sepsis  and  commonly  pro- 
ceeds to  multiple  or  general  abscess  formation.  This  condition  is  very 
rare  in  childhood.  2.  Acute  cervical  adenitis.  The  swelling  is  below  the 
angle  of  the  jaw.  It  does  not  at  any  time  correspond  to  the  outline  of  the 
parotid;  nor  has  it  the  location  of  the  submaxillary  glands.  It  may  be 
tuberculous  or  secondary  to  tonsillar  or  peritonsillar  infection.  Irregular 
contour,  redness,  the  absence  of  involvement  of  the  generative  glands  in 
all  cases,  and  the  absence  of  a  definite,  self-limited  course  are  to  be  con- 
sidered. 3.  Hodgkin's  disease  is  a  chronic  affection  of  the  lymphatic 
glands.  The  salivary  glands  are  not-  involved.  4.  Abscess  from  disease 
of  the  jaw  in  dental  caries  gives  rise  to  swelling  localized  in  wholly  different 
positions  from  that  of  the  parotid  and  is  not  characterized  by  definite 
constitutional  phenomena  or  transmissibility.  5.  Gonorrhoeal  orchitis 
has  a  definite  history  and  upon  examination  of  the  discharge  the  gon- 
ococcus  is  found.  Doubts  can  only  arise  when  the  inflammation  of  the 
testes  precedes  or  occurs  coincidently  with  the  parotitis. 

Prognosis. — Mumps,  in  the  vast  majority  of  cases,  is  a  mild  disease 
and  terminates  in  complete  recovery  in  a  short  time. 

XI.    INFLUENZA. 

Epidemic  Catarrhal  Fever;    La  Grippe. 

Definition. — An  acute,  infectious,  pandemic  disease,  caused  by  the 
bacillus  of  Pfeiffer.  It  is  characterized  by  catarrh  of  the  mucous  mem- 
brane of  the  respiratory  tract,  less  frequently  of  the  digestive  tract,  by 
quickly  on-coming  debility  and  nervous  symptoms.  There  is  a  tendency 
to  complications,  especially  pneumonia.  The  general  outbreaks  are 
followed  for  some  years  by  the  local  epidemic  or  endemic  occurrence 
of  the  disease. 


698 


MEDICAL  DIAGNOSIS. 


Etiology. — Predisposixg  Influexces. — When  the  disease  invades 
a  community,  a  large  proportion  of  the  population  is  attacked  without  dis- 
tinction. Previous  illness  affords  no  protection.  Aged  and  infirm  persons 
and  those  of  nervous  temperament  are  pecuHarly  liable  to  suffer,  but  the 
robust  possess  no  immunity.  All  races  and  dwellers  in  every  clime  are 
hable  to  the  disease.  Adults  are  attacked  earher  than  chilclren  and  in 
some  epidemics  the  latter  have  manifested  a  sHght  relative  immunity. 
A  limited  number  of  persons  appear  to  be  immune  and  there  are  those 
who,  ha^dng  passed  through  a  series  of  outbreaks  in  safety,  finally  acquire 
the  disease.  An  attack  of  influenza  confers  no  exemption  from  the  disease 
in  subsequent  outbreaks,  and,  independently  of  relapses,  which  are  fre- 
quent, individuals  have  been  known  to  experience  a  second  attack  during 
the  prevalence  of  the  same  epidemic.     The  disease  bears  no  relation  to 

known  atmospheric  conditions.  It  may 
prevail  at  any  season  of  the  year. 
It  follows  lines  of  travel  and  advances 
at  about  the  ordinary  rate  of  com- 
mercial intercourse.  The  duration  of 
the  outbreak  in  a  community  is  from 
four  to  eight  weeks,  exceptionally  a 
longer  time.  The  epidemic  of  1831  was 
continuously  prevalent  in  Paris  for 
nearly  a  year.  The  epidemics  rapidly 
reach  their  height  and  usually  subside 
almost  as  suddenly  as  they  begin.  In 
large  cities  influenza  makes  its  appear- 
ance at  the  same  time  in  several  differ- 
ent localities  and  spreads  from  these 
as  foci  of  infection  throughout  the 
community.  In  the  great  pandemics  of  influenza  the  other  acute 
infectious  diseases  are  less  common  than  usual. 

Exciting  Cause. — Pfeiffer — 1892 — isolated  from  the  nasal  and  bron- 
chial secretions  of  patients  suffering  from  influenza  a  bacillus  now  recognized 
as  the  cause  of  the  disease.  It  occurs  in  great  numbers  in  the  nasal  secre- 
tions and  is  frequently  seen  in  the  sputum  in  almost  pure  culture.  It 
persists  in  the  secretions  for  some  time  after  the  symptoms  have  subsided. 
The  disease  is  readily  transmissible  by  direct  contact  and  fomites; 
also  to  short  distances  by  the  atmosphere.  Influenza  bacilli  are  destroj^ed 
by  drying,  and  rapidly  perish  in  water.  They  probably  enter  the  body  by 
means  of  the  inspired  air.  Pfeiffer,  from  a  study  of  the  biological  char- 
acters of  the  influenza  bacillus,  concludes  that  its  development  outside 
the  human  body — that  is  to  say,  in  the  ground  or  in  water — is  impossible; 
that  its  dissemination  when  dry  can  take  place  only  to  a  limited  extent, 
and  that  the  contagium  is,  as  a  rule,  transferred  b}^  the  recent  moist  secre- 
tion from  the  nasal  and  bronchial  mucous  surfaces  of  influenza  patients. 
Symptoms. — Influenza  presents  the  greatest  variations  as  regards 
intensity,  from  a  trifling  indisposition  to  an  illness  of  the  gravest  kind. 
In  every  epidemic  the  majority  of  the  sufferers  manifest  the  disease  in  a 
mild  form,   very  many  in  a  rudimentary  form.     The  symptom-complex 


Fig.  235. — Bacillus  influenzae  in  sputum. 


INFLUENZA. 


699 


is  extremely  variable  and  greatly  modified  by  complications  and  sequels. 
The  period  of  incubation  varies  from  a  few  hours  to  three  days.  Prodromal 
symptoms  are  rare.  The  onset  is  abrupt,  marked  by  chilliness  or  a  chill 
which  may  be  repeated.  There  is  fever,  headache  (usually  intense),  with 
pain  back  of  the  eyeballs,  severe  pain  in  the  back,  limbs,  and  joints,  and 
a  general  feeling  of  muscular  soreness  with  tenderness  upon  pressure. 
These  symptoms  are  accompanied  by  mental  and  physical  depression, 
with  malaise  and  restlessness.  The  circulation  is  depressed,  the  spleen 
slightly  enlarged.  In  a  considerable  proportion  of  the  cases  catarrhal 
phenomena  do  not  occur  and  the  attack  consists  of  a  fever-storm  with  its 
associated  phenomena,  together  with  rapidly  developing  asthenia,  more 
or  less  profound.  The  cases  may  in  general  be  grouped  as  mild  and  severe. 
In  mild  cases  the  chill  may  be  slight  or  absent  altogether.  Headache 
and  muscle  pains  are  moderate.    There  is  a  sense  of  weariness  upon  effort, 


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236. — Influenza — remit- 
tent type. 


Fig.    237. — Influenza  —  inter- 
rupted   crisis. 


Fig.    238. — Influenza  —  inter- 
mittent type. 


■disinclination  for  affairs,  some  difhculty  in  fixing  the  attention.  Coryza, 
erythematous  angina,  and  a  tickling  cough  occur.  The  fever  is  usually 
slight,  the  temperature  not  rising  above  102°  F.  (39°  C).  Many  of  the 
patients  suffering  from  influenza  in  this  form  are  able  to  continue  their 
ordinary  avocations.  No  great  intensification  of  the  symptoms  is  neces- 
sary, however,  to  compel  them  to  betake  themselves  to  bed. 

In  the  severer  cases  the  chill  is  more  marked  or  the  shivering  more 
prolonged.  Fever  is  rapidly  established,  the  acme  being  reached  within 
twenty-four  or  thirty-six  hours.  The  temperature  may  rise  to  104°  or 
105°  F.  (40°-40.5°  C).  Sensations  of  heat  alternate  with  chilliness.  There 
is  pain  in  the  orbits  and  at  the  root  of  the  nose.  Coiyza  is  severe.  Epi- 
.staxis  is  occasionally  observed.  The  throat  is  sore ;  there  are  tickling  sen- 
sations in  the  upper  air-passages,  hoarseness,  and  sometimes  dyspnoea. 
The  cough  is  paroxysmal,  distressing,  and  at  first  unproductive.  Chest 
pains  and  stitches  in  the  side  also  occur.  The  pulse  may  be  full  and  com- 
pressible; more  commonly  it  is  feeble,  small,  and  irregular.  It  is  as  a  rule 
only  moderately  increased   in  frequency.     In  some  cases  there  is  slight 


700  MEDICAL  DIAGNOSIS. 

blueness  of  the  lips  and  finger-tips.  The  patient  is  distressed  by  want  of 
sleep.  At  the  end  of  four  or  five  days  the  febrile  symptoms  decline  rapidly, 
less  commonly  gradually.  The  defervescence  is  often  accompanied  by 
copious  sweat,  spontaneous  diarrhoea,  increased  flow  of  sedimentary  urine, 
and  considerable  amelioration  of  the  subjective  symptoms.  The  catarrhal 
symptoms  outlast  the  fever  two  or  three  days,  but  cough  and  expectora- 
tion may  persist  for  some  time.  Cutaneous  hyperesthesia  is  often  present 
and  areas  of  burning  pain  in  the  skin  occur.  Neuralgias  may  develop 
during  the  attack  and  persist  for  a  long  time. 

Symptoms  referable  to  the  nervous  system  may  dominate  the  clin- 
ical picture.  In  other  cases  gastro-intestinal  symptoms  are  conspicuous. 
The  attack  may  develop  abruptly  with  symptoms  like  those  of  cholera 
morbus.  Finally,  cases  occur  in  which  there  is  no  marked  localization  of 
the  infectious  process.  The  patient  suffers  from  fever  and  great  depres- 
sion and  simultaneous  implication  of  the  respiratory,  circulatory,  nervous, 
and  gastro-intestinal  systems. 

Herpes  is  common.  Urticaria  and  purpura  have  been  observed.  The 
sense  of  smell  is  often  lost  and  that  of  taste  impaired  or  perverted.  The 
hearing  is  blunted.  Febrile  albuminuria  is  not  uncommon  in  the  severe 
cases.  A  mild  anaemia  develops  in  grippe.  Leucocytosis  does  not  occur 
in  uncomplicated  cases. 

Attempts  have  been  made  to  arrange  the  cases  of  influenza  in  different 
groups,  and  in  theory  a  thoracic,  cardiac,  gastro-intestinal,  and  nervous 
variety  may  be  recognized.  In  practice,  however,  various  described  types 
merge  into  each  other,  and  are  so  modified  by  individual  peculiarities  of  the 
patient  and  by  complications  which  arise  in  the  course  of  the  attack  that 
there  is  but  little  advantage  in  referring  particular  cases  to  theoretical 
categories. 

The  duration  of  the  milder  forms  of  influenza  is  from  one  to  three  or 
four  days.  In  well-developed  cases  without  complications  convalescence 
sets  in  between  the  fourth  and  seventh  days.  Severe  cases  with  compli- 
cations may  be  protracted  for  several  weeks.  Relapses  occur  in  about 
10  per  cent,  of  the  cases.  If  the  fever  continues  beyond  the  seventh  or 
eighth  day  it  will  usually  be  found  upon  careful  examination  to  be  due  to 
some  complication.  The  temperature  curve  of  influenza  not  infrequently 
merges  into  that  of  a  complicating  bronchitis,  bronchopneumonia,  or 
croupous  pneumonia. 

Complications  and  Sequels. — Among  the  complications,  intense  bron- 
chitis, implicating  the  large  and  small  tubes  and  giving  rise  to  a  prolonged 
symptomatic  fever,  may  occur.  This  bronchitis  has  no  special  peculiar- 
ities. The  sputum  may  be  abundant  and  thin,  or  may  be  of  a  greenish- 
yellow  color  and  nummular.  It  is  sometimes  bloody.  Bronchopneumonia 
is  not  uncommon,  especially  in  children  and  aged  persons.  It  may  be  due 
to  the  influenza  bacillus  or  to  mixed  infection.  It  constitutes  a  serious 
complication  and  is  a  frequent  cause  of  death.  Influenza  pneumonia  may 
occur  at  any  time  during  the  course  of  the  attack.  Its  symptoms  are  fre- 
quently obscure  and  its  course  irregular.  Extensive  involvement  of  the 
lung  may  take  place  Avithout  great  rise  of  temperature.  Croupous  pneu- 
monia is  less  common.  Abscess  or  gangrene  of  the  lung  may  follow  the 
pneumonia  of  grippe.     Pleural  effusion  is  not  an  uncommon  complication 


INFLUENZA.  701 

and  empyema  may  occur.  Pulmonary  tuberculosis  may  develop  after 
an  attack  of  influenza,  or,  if  already  present,  it  is  usually  aggravated.  En- 
docarditis and  plastic  or  purulent  pericarditis  may  occur  in  connection 
with  pneumonia  or  independently  of  that  complication. 

Among  complications  relating  to  the  nervous  system  meningitis, 
encephalitis,  and  brain  abscess  are  to  be  mentioned.  Peripheral  neuritis 
not  uncommonly  develops  during  the  course  of  the  attack.  Headache, 
insomnia,  and  neuralgia  are  common  sequels.  Forms  of  neurasthenia 
occur.  Hysteria  and  chorea  have  been  noted,  and  psychic  disorders,  as 
melancholia  and  the  insanities  of  malnutrition. 

Otitis  media  constitutes  one  of  the  more  distressing  complications  and 
sequels  of  influenza.  Rapid  disorganization  of  the  structures  of  the  mid- 
dle ear  may  give  rise  to  permanent  deafness.  Persistent  vertigo  may  follow 
influenza.  Conjunctivitis  is  frequent  and  may  be  severe.  Iritis  and  optic 
neuritis  are  rare  sequels.  I  have  seen  severe  and  protracted  xerostomia 
develop  after  defervescence.  Cardiac  symptoms  are  common  and  dis- 
tressing. They  consist  of  heart  consciousness,  precordial  pain,  breath- 
lessness  and  faintness  upon  effort,  and  unsatisfactory  sleep.  The  physical 
signs  are  those  of  an  enfeebled  and  irregular  heart.  Arrhythmia,  tachy- 
cardia, and  bradycardia  are  common.  These  symptoms  are  to  be  ascribed 
in  part  to  the  disturbed  nutrition  of  the  heart  muscle  and  in  part  to  the 
derangements  of  the  cardiac  innervation.  An  attack  of  influenza  has 
appeared  in  some  instances  to  be  the  starting-point  of  pernicious  anaemia. 
Less  common  complications  and  sequels  are  parotitis,  nephritis,  phlebitis, 
venous  and  arterial  thrombosis. 

Diagnosis. — Direct  Diagnosis. — During  a  pandemic  it  is  unattended 
with  difficulty.  The  progress  of  the  outbreak,  the  number  of  individuals 
attacked  nearly  at  the  same  time  or  in  quick  succession,  the  profound 
asthenia,  and  the  prominence  of  the  nervous  symptoms  serve  to  distinguish 
it  from  other  epidemic  diseases.  Bacteriological  diagnosis  can  be  made 
by  an  examination  of  the  bronchial  sputum. 

Differential  Diagnosis. — Non-specific  Influenza. — The  differential 
diagnosis  between  influenza  and  non-specific  catarrhal  affections  rests  upon 
the  pandemic  or  epidemic  prevalence  of  the  former,  great  prostration,  and 
prominence  of  the  nervous  symptoms.  The  relation  of  these  two  diseases 
is  analogous  to  that  between  cholera  Asiatica  and  nostras.  The  diseases 
designated  by  the  term  influenza  may  be  divided  into :  (1)  pandemic  influ- 
enza vera,  caused  by  the  bacillus  of  Pfeiffer;  (2)  endemic-epidemic  influenza 
vera,  recurring  from  time  to  time  locally  after  the  pandemics,  caused  by 
the  same  infecting  agent;  (3)  endemic  influejiza  nostras — pseudo-influenza, 
catarrhal  fever — sometimes  miscalled  grippe — a  disease  sui  generis.  The 
infecting  micro-organism  is  not  known.  Enteric  Fever.— In  the  gastro- 
intestinal form  the  malaise,  headache,  dulness  of  hearing,  mental  depres- 
sion, fever,  epistaxis,  a  coated  tongue,  tender  belly,  and  diarrhoea  may 
suggest  enteric  fever.  An  attack  of  influenza  in  uncomplicated  cases  runs 
its  course  before  the  time  at  which  splenic  tumor  and  rose  spots  establish 
the  diagnosis  of  enteric  fever.  The  occurrence  of  influenza  during  the 
period  of  incubation  of  enteric  fever  ma}'  add  to  the  difficulties  of  diagno- 
sis.    Bacteriological  methods  and  especially  the  Widal  test  are  necessary 


702  MEDICAL  DIAGNOSIS. 

in  doubtful  cases.  Cerebrospinal  fever  has  prevailed  during  some,  epidemics 
of  influenza.  The  occasional  occurrence  of  cases  of  influenza  marked  by 
painful  retraction  of  the  muscles  of  the  back  of  the  neck  and  vomiting 
renders  the  differential  diagnosis  between  these  two  affections  difficult. 
Nor  is  the  fact  to  be  overlooked  that  meningitis  occurs  as  a  complication 
of  influenza.  Dengue  closely  resembles  influenza.  Each  of  these  diseases 
occurs  in  abruptly  developing  pandemics  affecting  almost  all  the  inhabi- 
tants of  the  regions  invaded.  They  resemble  each  other  in  the  frequency 
of  relapse,  liability  to  repeated  attacks  during  the  same  outbreak,  the  fact 
that  they  are  not  self-protective,  in  the  want  of  accord  between  the  grav- 
ity of  the  symptoms  and  the  low  death-rate  of  uncomplicated  cases,  the 
suddenness  of  the  attack,  intensity  of  the  pains,  and  the  high  degree  of 
mental  and  physical  depression.  Influenza  lacks,  however,  the  cutaneous 
manifestations,  the  remission  in  the  course  of  the  fever,  and  the  tendency 
to  arthritis  seen  in  dengue.  It  differs  also  in  the  liability  to  serious  com- 
plications and  in  prevailing  in  all  climates. 

Prognosis. — Death  is  rare  in  uncomplicated  cases  except  at  the  ex- 
tremes of  life.  The  very  young  bear  influenza  badly,  the  aged  bear  it 
worse.  Previous  disease  is  unfavorable.  Individuals  suffering  from  chronic 
bronchitis,  emphysema,  myocarditis,  and  nephritis  offer  diminished  resist- 
ance. Exhausting  diseases  increase  the  danger  of  the  attack.  Cases  at- 
tended by  very  severe  symptoms  usually  recover  unless  the  patient  be  very 
young  or  very  old  or  the  subject  of  some  complicating  malady.  The  prog- 
nosis in  individual  cases  is  greatly  modified  by  the  character  of  the  pre- 
vailing epidemic.  In  some  epidemics  the  death-rate  has  been  low  and  the 
mortality  from  other  diseases  only  slightly  increased.  More  commonly 
the  death-rate  of  endemic  affections  is  much  increased,  and  in  some  of  the 
early  epidemics  influenza  appears  to  have  been  attended  by  a  high  direct 
death-rate. 

XII.   DENGUE. 

Definition. — A  pandemic  infectious  disease  of  tropical  and  subtrop- 
ical climates,  characterized  by  a  febrile  paroxysm  with  recurrence,  intense 
pains  in  the  joints  and  muscles,  and  an  early  erythematous  and  a  late  poly- 
morphous eruption. 

The  popular  term  break-bone  fever  denotes  the  atrocious  character 
of  the  pain. 

Etiology. — Predisposing  Influences. — Dengue  first  excited  general 
attention  by  its  epidemic  prevalence  in  the  West  India  Islands  in  1827. 
Benjamin  Rush  observed  an  outbreak  in  Philadelphia  in  1780.  Dengue 
is,  in  the  strictest  sense,  a  pandemic  disease.  No  other  disease,  with  the 
exception  of  influenza,  prevails  so  widely  and  attacks  so  large  a  proportion 
of  the  population.  Equally  remarkable  is  its  rapidity  of  diffusion.  In  Gal- 
veston in  the  epidemic  of  1897,  20,000  persons  were  attacked  in  the  course 
of  two  months.  Dengue  is  a  disease  of  warm  climates  and  of  warm  seasons. 
When  it  has  occurred  in  the  summer  in  temperate  climates  it  has  dis- 
appeared upon  the  appearance  of  frost.  The  recent  experimental  inves- 
tigations of  Ashburn  and  Craig  led  them  to  believe  that  dengue  is  not  a 
contagious  disease,  but  that  it  is  infectious  in  the  same  manner  as  yellow 


DENGUE. 


703 


fever  and  malaria  and  that  the  mosquito  at  fault  is  probably  Culex  fatigans 
(Wied).  The  liability  is  universal.  Neither  age,  sex,  nor  occupation  confers 
immunity.  The  outbreaks  chiefly  affect  cities,  less  generally  the  open 
country.     To  this  statement,  however,  there  have  been  many  exceptions. 

Exciting  Cause. — No  organism,  either  bacterium  or  protozoon, 
can  be  demonstrated  in  either  fresh  or  stained  specimens  of  dengue  blood 
with  the  microscope  (Ashburn  and  Craig).  The  pathogenic  organism  is 
probably  ultramicrosco]3ic. 

Symptoms. — The  period  of  incubation  varies  from  three  to  five  days. 
At  the  beginning  and  at  the  height  of  epidemics  it  has  not,  in  some  cases, 


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exceeded  a  few  hours.  The  invasion  is  abrupt.  Prodromes  are  unusual; 
when  present  they  consist  of  lassitude,  headache,  a  furred  tongue,  loss  of 
appetite,  muscular  soreness,  and  chilliness.  The  attack  sets  in  with  intense 
headache,  backache,  and  severe  pains  in  the  joints  and  muscles.  The  af- 
fected joints  are  swollen,  and  the  face  and  neck  flushed  and  turgid.  Move- 
ments are  executed  with  pain  and  difficulty.  Conjunctivitis,  swelling  of 
the  eyelids,  intolerance  of  light,  and  stiffness  of  the  muscles  of  the  eyeballs 
are  common.  The  tongue  is  heavily  coated,  and  there  is  epigastric  distress 
which  is  followed  by  nausea  and  vomiting.  Appetite  is  lost  and  the  bowels 
are  constipated.  Thirst  is  not  a  prominent  symptom.  The  temperature 
rises  rapidly,  often  reaching  bv  the  end  of  the  first  twenty-four  hours 
106.7°  to  107.6°  F.  (41.5°  to  42°  C.).  The  pulse  is  tense  and  frequent,  120  to 


704  MEDICAL  DIAGNOSIS. 

140.  The  breathing  is  rapid,  the  skin  hot  and  dry.  Confusion  of  thought 
and  dehrium  occur,  and  in  children  the  attack  may  begin  with  convul- 
sions.    An  erythematous  rash  appears  in  many  of  the  cases. 

The  duration  of  the  first  febrile  paroxysm  is  variable,  lasting  from  a 
few  hours  to  several  days,  the  average  being  about  three  days.  Defer- 
vescence is  commonly  sudden  and  is  often  attended  with  critical  discharges, 
such  as  profuse  sweating,  epistaxis,  or  diarrhoea.  The  eruption  now  dis- 
appears, the  skin  becomes  moist,  and  there  is  an  amelioration  of  the  pains 
in  the  muscles  and  joints. 

The  afebrile  period  lasts  two  or  three  days.  In  some  cases  it  does  not 
occur,  or  is  so  brief  as  to  be  overlooked.  There  are  cases  in  which  the  tem- 
perature falls  but  does  not  quite  reach  the  normal.  Notwithstanding  the 
great  relief  which  the  patient  experiences,  there  remain  some  headache  and 
stiffness  of  the  muscles  and  joints.  At  the  expiration  of  several  hours, 
more  commonly  of  two  or  three  days,  a  second  febrile  paroxysm  sets  in. 
The  symptoms  are  much  the  same  as  those  of  the  initial  paroxysm  but 
less  intense.  An  eruption  of  variable  character  develops  at  this  stage  of 
the  disease.  It  is  sometimes  macular  like  the  rash  of  measles,  or  diffuse 
and  erythematous  like  that  of  scarlet  fever,  or  papular.  Sometimes  it 
resembles  an  urticaria,  and  there  are  cases  in  which  vesicles  occur.  Ap- 
pearing in  many  instances  first  upon  the  hands  and  feet,  this  eruption 
generally  invades  the  greater  part  of  the  surface  of  the  body.  In  other 
cases  it  is  limited  to  certain  areas.  It  is  attended  by  distressing  itching, 
and  gradually  fades  after  two  or  three  days,  being  followed  by  a  branny 
desquamation.  The  duration  of  the  second  paroxysm  is  from  two  to  three 
days.  Defervescence  is  gradual;  the  acute  symptoms  disappear  and  the 
patient  enters  upon  convalescence  much  enfeebled,  the  muscular  pains 
and  stiffness  of  the  joints  often  lasting  for  a  considerable  time.  The  small 
and  large  joints  are  alike  involved,  many  being  affected  at  the  same  time 
or  in  rapid  succession.  The  muscles  are  also  stiff  and  sore,  and  this,  with 
the  swollen  condition  of  the  integuments,  greatly  increases  the  difficulty  and 
awkwardness  of  movement,  especially  in  the  fingers  and  hands.  In  severe 
cases  the  mucous  membrane  of  the  mouth,  throat,  and  nose  is  inflamed. 
The  secretion  of  saliva  is  sometimes  increased  and  the  salivary  glands,  in 
particular  the  parotid,  are  swollen  and  tender.  The  superficial  lymphatics 
about  the  angle  of  the  jaw  and  in  the  groin  are  in  some  cases  enlarged. 

The  Blood. — The  white  corpuscles  are  diminished  in  number  and 
there  is  a  relative  increase  in  the  small  mononuclear  variety.  The  char- 
acteristic blood  findings  are:  (1)  the  absence  of  a  demonstrable  protozoon; 
(2)  leucopenia;  (3)  diminution  of  polymorphonuclears,  and  (4)  a  striking 
variation  in  the  percentage  of  other  leucocytes  at  different  periods  of  the 
attack  (Stitt). 

The  urine  during  the  access  of  fever  is  scanty  and  of  high  color.  With 
the  crisis  the  quantity  is  increased.     Albuminuria  is  not  usually  present. 

Diagnosis. — The  direct  diagnosis  is  not  difficult.  No  other  disease 
spreads  with  such  rapidity  through  a  community  and  attacks  so  large  a 
proportion  of  the  inhabitants. 

Differential  Diagnosis. — Influenza,  see  p.  702.  From  acute 
articular  rheumatism  dengue  differs  in  its  course  and  duration  as  well  as 


DIPHTHERIA.  705 

in  the  eruptions  which  attend  it;  from  scarlet  fever  and  measles,  in  every- 
thing except  the  occurrence  of  the  rashes,  which  resemble  the  exanthems 
of  these  diseases  only  in  the  most  superficial  way;  from  relapsing  fever 
in  all  things  except  its  course,  and  from  yellow  fever  in  many  important 
particulars,  among  which  its  extremely  low  death-rate,  the  absence  of 
jaundice  and  black  vomit,  the  infrequency  of  hemorrhage  and  albumi- 
nuria, and  the  correlation  between  the  pulse-rate  and  the  temperature  are 
of  diagnostic  importance.  Yet  upon  these  very  points  experts  have  failed 
to  agree  in  the  differential  diagnosis,  as  in  the  State  of  Texas  during  the 
epidemic  of  1897-  The  difficulty  is  increased  by  the  fact  that  yellow  fever 
and  dengue  have  the  same  habitat  and  very  often  prevail  side  by  side. 

Prognosis. — Dengue  is  seldom  fatal.  A  few  fatal  cases  have  been 
noted  in  extensive  outbreaks;  but  in  many  epidemics  in  large  cities  not 
a  single  death  has  occurred. 

XIII.   DIPHTHERIA. 

Definition. — A  specific  mfectious  disease,  caused  by  the  Klebs-Loffler 
bacillus  and  characterized  by  a  fibrinous  exudate,  usually  situated  upon 
and  in  the  mucous  membrane  of  the  upper  respiratory  passages,  and  by 
serious  constitutional  symptoms  due  to  toxins  formed  in  the  local  lesions. 

Clinically  the  term  diphtheria  is  applied  to  cases  of  pseudomembra- 
nous inflammation  in  which  the  presence  of  the  Klebs-Loffler  bacillus 
can  be  demonstrated.  Cases  of  pseudomembranous  inflammation,  which 
present  similar  local  and  constitutional  features,  but  in  which  Klebs- 
Loffler  bacilli  are  not  present,  are  designated  pseudodiphtheria  or  diph- 
theroid  angina. 

Etiology. — Predisposing  Influences. — Diphtheria  is  widely  distrib- 
uted but  is  especially  a  disease  of  temperate  climates.  The  general  prev- 
alence is  more  extensive  in  winter  and  it  is  probable  that  the  frequent 
occurrence  of  catarrhal  inflammation  of  the  pharyngeal  mucous  membrane 
constitutes  a  definite  predisposing  factor.  Severe  epidemics  are  occa- 
sionally encountered  in  summer.  Neither  altitude  nor  the  constitution,  of 
the  soil  exerts  a  special  influence.  Diphtheria  is  endemic  in  cities  and  towns, 
where  it  frequently  becomes  epidemic,  but  this  is  also  the  case  in  rural 
districts,  where  the  population  is  scattered,  and  among  hamlets  and  farms 
it  often  rages  with  extreme  virulence.  The  affection  spares  no  class  in  a 
community.  Rich  and  poor  alike  contract  it.  Crowding,  uncleanliness. 
and  neglect  of  sanitary  laws  favor  the  spread  of  the  disease  among  the 
poor;  therefore  epidemics  are  much  more  common  among  the  poor  than 
among  well-to-do  and  well-advised  persons.  These  elements  of  predis- 
position are  fully  explained  by  the  fact  that  diphtheria  is  a  readily  trans- 
missible disease.  Infants  in  the  first  year  of  life  are  rarely  affected.  The 
period  of  greatest  liability  lies  between  the  second  and  the  fifteenth  years. 
The  mortality  is  especially  great  between  the  second  and  the  fifth  years. 
The  disease  may  occur  at  any  age  and  it  not  infrequently  happens  that  the 
nurse  or  a  parent  contracts  the  disease  from  a  child,  and  many  physicians 
have  lost  their  lives  from  diphtheria  contracted  in  the  discharge  of  duty. 
In  later  childhood   and   adolescence  girls   are   attacked   more  fi'equently 

45 


706 


MEDICAL  DIAGNOSIS. 


than  boys.  The  diminished  resistance  to  pathogenic  influences  on  the 
part  of  the  local  mucous  membrane  which  accompanies  chronic  naso- 
pharyngeal catarrh,  adenoid  vegetations,  hypertrophied  tonsils,  and  laryn- 
gitis constitute  an  especial  predisposition  to  the  disease.  Certain  acute 
febrile  infections,  such  as  measles  and  scarlet  fever,  act  in  the  same  way. 
It  is  important,  however,  to  bear  in  mind  the  fact  that  the  pseudomem- 
branous inflammation  common  as  a  complication  of  the  acute  diseases 
is  more  frequently  diphtheroid  and  due  to  streptococcus  infection. 

The  attack  does  not  confer  immunity;  on  the  contrary,  certain  per- 
sons manifest  a  peculiar  susceptibility.  There  are  on  the  other  hand  per- 
sons who  appear  to  be  possessed  of  a  natural  immunity  and  do  not  contract 
the  disease  upon  exposure  nor,  in  some  instances,  even  when  the  bacilli 
are  present  in  their  throats. 

Exciting  Cause. — The  Klebs-Loffler  bacilli  are  non-motile;  they 
vary  in  length  from  2.5  to  3 /jl  and  from  0.5  to  0.8 /j.  in  breadth,  and  present 
different  forms,  some  of  which  are  pointed,  others  blunt  and  rounded  at 
the  ends,  and  less  frequently  forms  that  are  irregular  and  branching.  They 
are  very  tenacious  of  life  and  have  been  grown  in  culture  after  a  non- 
parasitic existence  under  varying  conditions  for  periods  measured  by  weeks 
and  months.  Attached  to  clothing,  bedding,  articles  of  furniture,  even 
the  walls  and  floor  of  the  room  occupied  by  the  patient,  they  maintain 
their  pathogenic  power.  Milk  serves  as  a  culture  media  in  which  they 
grow  rapidly  without  altering  its  appearance.  The  bacilli  are  found  in 
large  numbers  in  the  false  membrane  of  cases  of  true  diphtheria.  In  this 
situation  they  grow  and  multiply,  being  rarely  found  in  the  blood  during 
life.  In  the  lesions  of  the  bronchopneumonia  of  laryngeal  diphtheria  they 
may  be  the  predominant  organism.  After  death  they  are  occasionally 
present  in  the  blood  and  viscera.  They  vary  greatly  in  virulence.  Guinea- 
pigs,  the  most  susceptible  of  laboratory  animals  to  the  poison,  are  used 

for  determining  the  intensity  of  cultures. 
Non- virulent  bacilli  are  sometimes- 
spoken  of  as  the  pseudobacillus  of  diph- 
theria— a  misnomer.  The  pseudodiph- 
theria  bacillus  or  Bacillus  xerosis 
resembles  the  Klebs-Loffler  bacillus 
morphologically,  but  differs  from  it  in 
certain  cultural  peculiarities  and  being 
non-pathogenic.  The  biological  rela- 
tionship of  this  organism  to  the  Klebs- 
Loffler  bacillus  has  not  been  determined. 
The  Klebs-Loffler  bacilli  may  be 
present  upon  the  mucous  membrane  of 
cases  which  show  no  membranous  exu- 
date and  present  the  clinical  picture 
of  a  lacunar  tonsillitis  or  a  simple 
erythematous  angina.  They  are  very 
often  found  in  the  throat  and  nose  of  individuals  who  have  passed 
through  an  attack  of  diphtheria  and  are  fully  convalescent.  Under  these 
circumstances  they  may  persist  for  weeks  or  months,  during  which  time 


Fig.  240. — Bacillus  diphtherise  from   culture 
on  Loffler's  blood-serura. 


DIPHTHERIA.  707 

the  patient  may  communicate  the  disease  to  others  or  pass  through  one 
or  more  fresh  attacks  himself.  They  are  frequently  isolated  from  the 
throats  of  healthy  persons,  both  the  nurses  and  attendants  upon  the  sick 
and  others  living  in  the  same  house  with  the  patient  or  convalescent. 
The  organisms  have  been  found  in  the  hair  and  clothing  of  nurses  and  in 
the  dust  of  diphtheria  wards.  The  disease  may  be  communicated  by  means 
of  infected  milk. 

The  foregoing  facts  shed  considerable  light  upon  the  endemic  and 
epidemic  prevalence  of  the  disease,  as  well  as  the  occurrence  of  sporadic 
cases.  They  enable  us  to  understand  the  persistence  of  diphtheria  in 
localities,  the  occurrence  of  house  and  neighborhood  epidemics,  the 
simultaneous  occurrence  of  scattered  cases  in  a  school  district,  and  the 
development  of  cases  in  patients  long  confined  in  hospital  wards,  after 
visiting  days. 

The  Toxin. — The  general  symptoms  are  caused  not  by  the  bacilli  but 
by  toxins  formed  by  them.  Susceptible  animals  may  be  rendered  immune 
by  the  injection  of  progressively  stronger  doses  of  attenuated  cultures  of 
the  bacilli  or  increasing  quantities  of  the  toxin.  By  suitable  treatment 
in  this  manner  large  animals,  as  the  horse,  may  be  rendered  to  a  high 
degree  immune. 

Symptoms. — The  period  of  incubation  varies  from  two  or  three  to 
seven  days.  The  onset  is  marked  by  slight  chilliness  and  sometimes  in 
young  children  by  convulsions.  The  signs  of  a  febrile  infection,  elevation 
of  temperature,— 102°-103°  F.  (38.9°-39.5°  C.),— malaise,  backache,  and 
muscle  pains  follow.  These  symptoms  vary  greatly  in  intensity.  Older 
children  and  adults  complain  of  sore  throat.  An  examination  of  the  fauces 
must  be  made  as  a  matter  of  routine  in  infants  who  are  taken  acutely  ill. 
The  pseudomembranous  exudate  rapidly  forms  upon  the  mucous  surfaces 
of  the  tonsils  and  adjacent  parts  and  shows  a  marked  tendency  to  spread 
upwards  to  the  nasopharynx,  the  nasal  chambers  and  accessory  sinuses, 
the  tear  duct  and  the  Eustachian  tube,  or  downwards  to  the  epiglottis, 
larynx,  trachea,  bronchi.  Much  less  frequently  the  oesophagus,  stomach, 
and  duodenum  are  invaded.  Accidental  infection  of  the  vulva  and  vagina, 
the  ear,  conjunctivae,  and  wounds  occurs.  The  larynx  is  primarily  involved 
in  a  large  proportion  of  the  cases. 

According  to  the  local  lesions  the  following  groups  of  cases  are  to  be 
considered : 

1.  Faucial  Diphtheria. — The  mucosa  is  at  first  reddened  and  there 
is  difficulty  in  swallowing.  The  membrane  usually  first  appears  upon  one 
tonsil  and,  in  the  course  of  a  few  hours,  without  bridging  across,  upon  the 
other.  After  some  hours,  or  it  may  be  a  day  or  two,  it  has  in  neglected  cases 
covered  the  tonsils  and  spread  to  the  half-arches,  the  soft  palate  and  uvula, 
and  to  the  pharynx — pharyngeal  diphtheria.  Meanwhile,  the  tonsils  are 
enlarged  and  the  soft  palate  and  uvula  are  swollen,  reddened,  and  oedema- 
tous.  The  membrane,  at  first  whitish,  soon  assumes  a  gray  or  dirty 
yellowish-white  color.  As  a  rule  the  patch  or  patches  are  distinctly  mar- 
ginate  and  surrounded  by  a  border  of  red  deeper  than  that  of  the  general 
mucosa.  The  membrane,  when  forcibly  detached,  leaves  an  eroded  surface 
with  punctate  bleeding,  upon  which  a  fresh  pellicle  soon  appears.     The 


708  MEDICAL  DIAGNOSIS. 

lymph-nodes  about  the  angle  of  the  jaw  are  swollen  and  tender.  Vari- 
ations in  the  character  of  the  exudate  occur.  It  may  be  throughout  punc- 
tiform  and  restricted  to  the  tonsils,  or  punctiform  at  the  outset  but  rapidly 
becomes  membraniform,  and  extends.  Again  the  exudate  may  be  pul- 
taceous  rather  than  pseudomembranous.  Finally,  there  are  cases  with 
acute  erythematous  angina  and  constitutional  symptoms  in  which  no 
membrane  is  present  but  virulent  Klebs-Loffler  bacilli  are  found  in 
the  secretions.  The  breath  of  the  patient  has  a  fetid,  sickening  odor, 
which  surrounds  his  person  and  permeates  the  atmosphere  of  the  room. 

2.  Nasal  Diphtheeia.  —  The  Klebs-Loffler  bacilli  are  frequently 
found  in  the  nasal  secretions  when  the  exudate  has  invaded  the  pharynx, 
although  no  membrane  is  present  in  the  nasal  chambers.  When  membra- 
nous exudate  is  present  two  conditions  occur.  In  the  first  the  nares  are 
occupied  by  a  thick,  tough  membrane,  which  rarely  extends  to  the  adjacent 
parts  and  in  which  Klebs-Loffler  bacilli  are  present,  but  the  constitutional 
symptoms  are  very  slight  or  altogether  absent.  The  disease  shows  very 
little  tendency  to  affect  other  children  in  the  family. 

The  second  and  far  more  common  form  of  nasal  diphtheria  may  be 
primary,  but  usually  arises  in  the  course  of  the  attack  by  extension  from 
the  pharynx  or  autoinoculation  by  way  of  the  nostrils.  Exceptionally 
the  symptoms  are  mild,  but  in  the  majority  of  cases  both  the  local  and 
constitutional  symptoms  are  most  intense — a  fact  attributed  to  the  abun- 
dant supply  of  lymph-vessels  to  the  mucous  membrane  of  the  nose  and 
consequent  free  absorption  of  diphtheria'  toxin. 

3.  Laryngeal  Diphtheria. — The  term  membranous  croup  was  at 
one  time  used  without  distinction  to  designate  all  forms  of  membranous 
laryngitis.  This  misleading  and  dangerous  custom  is  fortunately  passing 
away.  More  than  four-fifths  of  such  cases  in  large  series  of  statistics  have 
shown  the  presence  of  Klebs-Loffler  bacilli.  In  a  considerable  proportion 
of  the  rest  the  result,  for  various  reasons,  has  been  doubtful,  while 
in  the  small  remainder  other  organisms,  chiefly  streptococci,  have  been 
found.  While  the  clinical  symptoms  are  practically  the  same,  the  differ- 
ential diagnosis  can  readily  be  made  bj^  laboratory  methods,  and  the  mem- 
l)ranous  laryngitis  associated  with  the  Klebs-Loffler  bacillus  is  called 
laryngeal  diphtheria,  while  that  in  which  other  organisms  are  exclusively 
present  is  known  as  diphtheroid  laryngitis  or  pseudodiphtheritic  laryn- 
gitis. The  latter  affection  is  rarel}'-  a  primary  disease,  but  usually  arises 
as  a  complication  in  the  course  of  some  acute  disease — scarlet  fever,  variola. 

The  local  symptoms  of  laryngeal  diphtheria  are  at  first  those  of  an 
acute  laryngitis,  with  hoarseness  and  a  rough,  so-called  "croupy"  or  laryn- 
geal cough.  In  the  course  of  twenty-four  or  thirty-six  hours  the  patient — 
usually  a  child — suddenly  becomes  worse,  with  symptoms  of  laryngeal 
stenosis — dyspnoea,  slight  cyanosis,  rapid  pulse,  aphonia,  brassy  cough, 
and  restlessness.  These  symptoms,  which  commonly  develop  at  night, 
are  at  first  paroxysmal,  with  intervals  of  quiet  breathing  and  sleep.  In 
favorable  cases,  after  two  or  three  paroxysms  without  marked  dyspncea 
or  cyanosis,  the  child  falls  asleep  and  awakes  in  the  morning  greatly 
improved.  Not  rarely  the  attack  recurs  upon  the  succeeding  night  with 
more  intensity. 


DIPHTHERIA.  709 

The  respiratory  obstruction,  which  is  at  first  due  in  part  to  laryngeal 
spasm,  with  the  increasing  exudate  soon  ceases  to  be  paroxysmal  and  be- 
comes continuous  with  exacerbations  and  remissions.  Inspiration  and  to 
a  greater  extent  expiration  are  increasingly  difficult.  The  auxiliary  re- 
spiratory muscles  are  brought  into  play,  the  lower  intercostal  spaces  and 
epigastrium  show  inspiratory  retraction.  The  voice  is  reduced  to  a  husky 
whisper.  The  cyanosis  of  the  lips  and  finger-tips  becomes  more  intense. 
There  is  urgent  air  hunger  and  after  a  period  of  extreme  restlessness  the 
patient  sinks  into  a  semiconscious  listlessness,  with  general  relaxation  and 
a  freely  perspiring  skin,  only  to  start  up  again  in  the  course  of  a  few  minutes, 
tossing  about  and  struggling  for  air.  Occasionally  in  a  severe  paroxysm 
of  cough  shreds  of  membrane  are  coughed  up  with  great  temporary  or  even 
permanent  relief.  In  other  cases,  a  fold  of  detached  membrane  becomes 
lodged  in  the  glottis  and  is  followed  by  fatal  asphyxia.  The  fatal  issue  is, 
as  a  rule,  preceded  by  increasing  dyspnoea  and  cyanosis,  a  period  of  distress- 
ing jactitation,  coma,  and  slight,  shuddering  convulsions.  Pharyngeal 
exudate  may  be  present,  the  membrane  invading  the  larynx  from  above — 
descending  croup;  the  invasion  being  from  the  larynx  upward — ascending 
croup.  In  many  of  the  cases  the  membraniform  exudate  is  situated  wholly 
within  the  larynx,  where  it  may  be  seen  upon  laryngoscopic  examination — 
a  procedure  usually  attended,  however,  with  great  practical  difficulties. 
If  the  duration  of  the  attack  be  prolonged,  bronchopneumonia  occurs. 
This  complication  may  be  due  to  an  extension  of  the  bronchitis,  caused 
by  i-etained  secretions,  to  the  finer  bronchial  tubes — secondary  infection — 
or  to  an  infralaryngeal  extension  of  the  exudate  along  the  trachea  and  into 
the  bronchial  tubes — a  true  diphtheritic  tracheobronchitis.  Thus  arises 
respiratory  obstruction  at  two  anatomical  levels,  namely,  at  the  larynx 
and  in  the  smaller  bronchial  tubes,  a  condition  often  difficult  of  recognition 
because  of  the  diminution  of  tidal  air  and  consequent  fainter  vesicular 
sounds  and  small  mucous  rales  on  the  one  hand,  and  the  loud  laryngeal 
stridor  and  coarse  tracheal  rales*  on  the  other;  a  fact  of  great  practical 
importance  because  a  successful  intubation  or  tracheotomy,  which  wholly 
relieves  the  obstruction  at  the  upper  level,  can  have  no  effect  whatever 
upon  that  at  the  lower  level. 

4.  Other  Sites  of  the  Diphtheritic  Exudate. — The  conjunctiva 
may  be  the  seat  of  a  primary  or  secondary  diphtheria.  In  the  latter  case 
the  extension  is  by  way  of  the  tear  duct  or  by  autoinfection.  The  symp- 
toms may  be  those  of  a  catarrhal  conjunctivitis,  the  bacilli  being  present 
in  the  secretions,  or  they  may  be  very  serious.  The  invasion  of  the  middle 
ear  by  way  of  the  Eustachian  tube  may  be  the  occasion  of  an  otitis  causing 
destruction  of  the  tympanic  membrane  and  erosions  of  the  external  meatus 
covered  with  a  characteristic  membrane.  Vulvar  and  vaginal  diphtheria 
is  occasionally  encountered.  Diphtheria  of  the  skin  occurs  in  the  ordinary 
forms  of  faucial  and  nasal  diphtheria  when,  as  is  not  rarely  the  case,  fis- 
sures and  abrasions  form  about  the  nostrils  and  corners  of  the  mouth  and 
become  infected.  The  membrane  in  diphtheria  of  the  anus  or  genitalia  may 
likewise  invade  the  adjacent  cutaneous  surfaces.  Wounds  and  ulcerated 
surfaces  in  persons  suffering  with  diphtheria  are  liable  to  be  the  seat  of  an 
adherent   pseudomembrane   associated   with    the    Klebs-Loffier    bacillus. 


710  MEDICAL  DIAGNOSIS. 

The  organism  may  be  present  in  inflamed  or  necrotic  lesions  with  mem- 
brane and,  in  rare  instances,  wound  infection  may  occur  in  the  absence  of 
throat  affection  or  traceable  exposure  to  diphtheria  cases  or  fomites.  A 
large  proportion  of  the  cases  of  pseudomembranous  inflammation  of  wounds 
are  due  to  streptococcus  infection  or  to  mixed  infection.  Local  diphtheritic 
lesions,  when  severe,  are  frequently  associated  with  more  or  less  necrosis 
and  gangrene. 

In  favorable  cases  the  process  of  separation  of  the  membrane  and 
healing  may  be  observed  in  faucial  diphtheria.  After  some  days  the  ex- 
tension of  the  process  is  arrested  and  in  the  slighter  cases  the  membrane 
becomes  thinner,  less  distinct  at  the  margins,  and  gradually  disappears. 
In  the  more  severe  forms  it  appears  thicker  at  the  margins,  which  curl 
outward  from  the  underlying  surface,  and  separates  en  bloc  or  by  a  gradual 
disintegration.  In  either  case  the  outlying  mucous  membrane  loses  its 
redness  and  oedema  and  shows  rapid  and  marked  improvement.  Local 
ulcerations  often  persist,  which,  in  healing,  may  give  rise  to  adhesions  of  the 
uvula  to  a  tonsil  or  of  the  soft  palate  in  part  to  the  wall  of  the  pharynx, 
and  the  like. 

Infragiottic  membranes  separate  from  the  underlying  surface  in  more 
or  less  extensive  membraniform  shreds.  Pathologically  the  conditions 
differ  in  the  mucous  membranes  above  the  glottis,  which  are  provided  with 
a  squamous  epithelium,  and  in  those  below  it  which  have  a  columnar  and 
ciliated  epithelium.  In  the  former  the  membrane  is  found  not  only  upon, 
but  also  in,  the  substance  of  the  mucosa,  while  in  the  latter  it  is  super- 
ficial, involving  largely  the  epithelial  surfaces  and  not  causing  necrosis 
of  the  underlying  tissues. 

Diphtheritic  Toxcemia;  the  Systemic  Infectio?i. — There  is,  in  the  major- 
ity of  cases,  a  general  correspondence  between  the  intensity  of  the  local 
lesions  and  the  severity  of  the  constitutional  symptoms.  To  this  rule, 
however,  there  are  important  exceptions.  There  may  be  extensive  and 
intense  faucial  or  nasal  membranous  inflammation  with  relatively  mild 
general  symptoms,  or  profound  toxeemia  with  limited  and  apparently  su- 
perficial local  lesions.  It  has  been  assumed  in  explanation  of  this  discrep- 
ancy that  certain  individuals  may  be  more  susceptible  to  the  diphtheria 
bacillus  and  others  more  susceptible  to  its  toxins.  It  is  more  in  accord- 
ance with  the  known  facts  to  explain  these  differences  by  assuming  that 
in  some  instances  the  bacilli  form  a  larger  amount  of  more  virulent  toxin 
than  in  others  and  that  severe  local  lesions  are  in  part  due  to  the  action 
of  associated  organisms — mixed  local  infections.  This  explanation  finds 
support  in  the  fact  that  the  graver  symptoms  are,  as  a  rule,  not  at  first 
present  but  arise  later  when  the  local  disease  is  at  its  height.  The  sever- 
est form  is  septic  diphtheria,  the  outcome  of  the  simultaneous  action  of 
the  diphtheria  bacilli,  streptococci,  and  saprophytic  bacteria  which  are 
present  in  the  necrotic  lesions. 

The  general  symptoms  of  the  attack  of  diphtheria  are  those  of  a  mild 
or  intensely  severe  general  infection.  The  onset  is  marked  by  chilliness, 
a  chill,  followed  by  vomiting,  fever  of  atypical  course,  headache,  and  anor- 
exia. The  temperature  varies  not  only  in  different  cases  but  also  in  the 
course  of  the  attack  in  the  same  case.     Often  but  slightly  above  normal, 


DIPHTHERIA.  711 

it  sometimes  reaches  104°  F.  (40°  C).  In  the  severest  cases  the  tempera- 
ture is  sometimes  subnormal.  The  pulse  in  severe  cases  is  small,  weak, 
and  irregular,  and  in  some  of  the  gravest  cases  there  is  bradycardia.  In 
the  septic  cases  with  gangrenous  lesions  the  constitutional  depression  may 
be  extreme,  with  frequent  thready  pulse,  high  fever,  and  nervous  symp- 
toms, or  there  may  be  ashen  pallor,  great  enlargement  of  the  superficial 
lymph-glands,  and  a  subnormal  temperature.  A  leucocytosis  is  present 
alike  in  the  mild  and  moderately  severe  cases. 

The  following  visceral  changes  occur:  The  toxin  of  diphtheria  acts 
especially  upon  the  heart  muscle  and  the  nervous  system.  The  myo- 
cardium shows  fatty  degeneration.  Endocarditis  is  rare  and  the  bacilli 
have  been  found  in  the  lesions.  Pericarditis  is  extremely  rare.  Pulmo- 
nary complications  are  very  common  and  are  often  the  cause  of  death, 
especially  in  laryngeal  diphtheria.  The  most  common  condition  is  bron- 
chopneumonia. Klebs-Loffler  bacilli  and  streptococci  are  often  present, 
but  the  organism  in  the  greater  number  of  cases  is  the  pneumococcus. 
The  liver,  spleen,  and  kidneys  show  the  parenchymatous  changes  present 
in  the  severe  infections. 

Complications  and  Sequels.— T'/ie  Heart. — Irregular  action  is  common. 
A  faint,  blowing,  systolic  murmur  is  heard  in  a  majority  of  the  cases. 
Rapid  action,  associated  with  gallop  rhythm  and  epigastric  pain,  and  brady- 
cardia are  grave  symptoms.  Acute  dilatation  due  to  granular  and  fatty 
degeneration  may  be  the  cause  of  sudden  death  in  the  course  of  an  other- 
wise favorable  convalescence.  Paralysis  occurs  in  from  15  to  20  per  cent, 
of  the  cases.  It  is  usually  incomplete.  In  rare  cases  it  comes  on  as  early 
as  the  seventh  day,  but  commonly  not  until  the  second  or  third  week  and 
sometimes  later.  It  is  more  frequent  in  adults  than  in  children.  Diph- 
theritic palsy  may  follow  cases  in  which  the  local  and  constitutional  symp- 
toms are  mild.  The  palate  is  most  frequently  involved,  the  symptoms 
being  speech  having  the  nasal  quality  and  the  regurgitation  of  fluids 
through  the  nose  in  swallowing.  Upon  inspection  the  soft  palate  is  seen 
to  be  relaxed  and  immobile  upon  phonation.  Sensation  is  likewise  greatly 
diminished.  The  constrictors  of  the  pharynx  may  be  affected.  The  in- 
trinsic and  extrinsic  muscles  of  the  eye  are  also  frequently  involved. 
Strabismus,  ptosis,  and  loss  of  accommodation  result.  The  loss  of  power 
may  affect  a  single  limb  or  the  arms  "or  legs  together.  As  a  rule  it  is  the 
result  of  peripheral  neuritis,  and  the  limbs  are  flaccid,  with  impairment  or 
abolition  of  the  tendon  reflexes.  Multiple  neuritis  is  common.  The  paralysis 
may  affect  the  extensors  of  the  feet  or  there  may  be  complete  paraplegia. 
"When  the  arms  are  involved  the  patient  is  often  unable  to  help  himself. 
In  other  cases  an  acute  ataxia,  resembling  tabes  but  without  the  lightning- 
pains  and  pupillary  phenomena,  has  been  observed.  This  condition  may 
be  attributed  to  the  action  of  the  toxin  upon  the  posterior  columns  and 
posteiior  nerve-roots  and  is  analogous  to  the  derangements  of  coordination 
experimentally  produced  in  animals  by  the  injection  of  Klebs-Loffler 
bacilli  or  the  diphtheria  toxin. 

The  occurrence  of  albuminuria  is  common  and  may  be  noted  as  early 
as  the  first  day  of  the  attack.  This  early  change  in  the  urine  must  be 
regarded  as  a  "  toxic  "  albuminuria.     The  albumin  in  favorable  cases  dis- 


712  MEDICAL  DIAGNOSIS. 

appears  in  the  course  of  some  days.  In  cases  of  greater  severity  it  persists 
and  red  blood-corpuscles  and  epithelial  and  hyaline  casts  appear.  The 
condition  is  that  of  an  acute  nephritis.  Anasarca,  contrary  to  the  course 
of  the  renal  affection  in  scarlet  fever,  is  very  rarely  encountered  and  the 
acute  nephritis  shows  very  little  tendency  to  become  chronic. 

Hemorrhage  from  the  local  lesions  occasionally  occurs  in  the  severer 
cases  of  faucial  and  nasal  diphtheria.    Epistaxis  may  be  the  first  symptom. 

A  diffuse  erythematous  rash  occasionally  develops  early  in  the  course 
of  the  disease.  Urticaria  is  by  no  means  infrequent,  and  petechise  and 
purpuric  hemorrhages  appear  in  the  later  stages  of  the  grave  cases.  Jaun- 
dice, as  in  other  septic  conditions,  is  often  present  in  the  worst  cases. 

Psendodiphtheria. — The  diphtheroid  affection  is  rarely  transmitted 
to  other  patients  or  the  attendants.  As  a  rule  the  local  process  is  of  mod- 
erate intensity  and  the  constitutional  symptoms,  if  present  at  all,  are  mild. 
There  are,  however,  cases  in  which  the  most  intense  streptococcus  infec- 
tion is  associated  with  non-diphtheritic  membranous  inflammation  of  the 
throat  or  nose. 

Diagnosis. — Direct  Diagnosis. — This  rests  upon  the  presence  of 
a  false  membrane  having  the  characters  above  described;  bacteriologi- 
cally,  upon  the  presence  of  the  Klebs-Loffler  bacillus.  There  are,  however, 
cases  of  membranous  inflammation  in  which  the  Klebs-Loffler  bacillus 
is  not  present — diphtheroid  angina — and  the  bacillus  may  be  frequently 
demonstrated  in  cases  presenting  the  clinical  phenomena  of  an  ordinary 
lamnar  tonsillitis  or  simple  tonsillar  or  pharyngeal  catarrh,  or  in  the  throats 
of  persons  in  health.  This  want  of  accord  between  the  clinical  and  bac- 
teriological diagnosis  is  apparent  rather  than  real.  The  same  thing  is  seen 
in  other  affections,  as,  for  example,  tuberculosis.  It  is  a  question  of  the 
seed  and  the  soil.  The  bacillus  varies  in  virulence  and  the  individual  in 
power  of  resistance.  The  Klebs-Loffler  bacillus  is  the  criterion.  Mem- 
branous inflammations  associated  with  it  constitute  diphtheria;  non-mem- 
branous inflammations  in  which  it  is  present  are  diphtheritic,  as  tonsillitis, 
pharyngitis,  rhinitis,  and  the  like.  The  recognition  of  the  diphtheritic  char- 
acter of  many  of  these  milder  throat  affections  marks  an  important  recent 
advance  in  practical  medicine. 

Bacteriological  Diagnosis. — For  the  positive  determination  of 
the  true  character  of  an  acute  throat  affection  a  bacteriological  examina- 
tion is  often  necessary.  The  material  should  be  taken  from  the  throat 
as  early  as  possible  in  the  course  of  the  attack  and  at  a  time  when  no  anti- 
septic, and  in  particular  no  mercurial  preparation,  has  recently  been  applied. 
An  immediate  diagnosis  may  sometimes  be  reached  by  making  a  smear 
preparation.  Cultures  require  about  fourteen  hours  at  the  body  tempera- 
ture. If  the  result  is  negative  the  examination  must  be  repeated.  When 
the  result  is  positive  the  examination  should  be  repeated  at  intervals  of 
ten  days  or  two  weeks  until  the  bacilli  are  no  longer  found.  Pending  the 
result  of  the  examination  every  acute  sore  throat  in  a  child  must  be  re- 
garded as  suspicious,  and  measures  of  isolation  and  disinfection  instituted 
without  delay. 

Therapeutic  Test, — Antitoxin  Treatment. — In  every  suspicious 
case  the  physician  should  at  once  administer  diphtheria  antitoxin  serum 


VINCENT'S  ANGINA.  713 

in  doses  corresponding  to  the  age  of  the  patient  and  the  intensity  of  the 
process.  As  the  action  of  this  remedy  is  specific  and  without  influence 
upon  forms  of  throat  affection  due  to  causes  other  than  the  Klebs-Loffier 
bacillus,  its  proper  administration  has  an  incidental  diagnostic  value  of  great 
importance.  The  dose  for  a  child  varies  from  1000  to  3000  units,  repeated 
if  necessary  at  intervals  of  eight  hours;  for  an  adult  from  4000  to  6000 
units.  In  very  grave  cases  a  total  dosage  of  50,000  or  70,000  may  be  re- 
quired. When  administered  early  the  serum  is  followed  in  the  course  of 
a  few  hours  by  local  and  general  improvement.  The  swelling  of  the  faucial 
mucous  membrane  subsides,  the  membrane  shrivels  and  gradually  dis- 
appears, the  sickening  odor  becomes  less  intense,  the  temperature  falls 
to  normal,  and  the  pulse  loses  in  frequency  and  gains  in  force.  Even  in 
apparently  hopeless  cases  improvement  and  eventual  recovery  frequentl}' 
occur.  Most  remarkable  results  are  seen  in  laryngeal  diphtheria,  so  that 
intubation  and  tracheotomy  have  become  far  less  common  than  formerl}'. 
The  diphtheria  antitoxin  serum  is  wholly  without  effect  in  pseudodiph- 
theritic  membranous  angina. 

Differential  Diagnosis. — Pseudodiphtheritic  Angina. — The  majority 
of  the  cases  of  diphtheroid  throat  inflammation  are  caused  by  the  Strepto- 
coccus pyogenes.  They  are  almost  always  secondary  to  other  infections, 
as  scarlet  fever,  variola,  measles,  or  pertussis.  The  local  process  is  usuall}^ 
less  extensive  and  the  general  symptoms  less  severe.  Exceptionally  the 
local  and  constitutional  infections  are  intense;  palsy  has  been  noted  and 
a  fatal  result  may  occur.     The  bacteriological  findings  are  diagnostic. 

Prognosis. — The  mortality  in  former  years  ranged  between  30  and 
50  per  cent.  In  local  epidemics  in  rural  districts  it  was  even  higher.  Since 
the  introduction  of  the  antitoxin  treatment  it  has  progressively  fallen  and 
is  now  about  10  per  cent.  Of  unfavorable  omen  in  individual  cases  are 
extensive  or  gangrenous  exudate,  sanious  discharge  from  the  nostrils,  an 
intense  penetrating  sickening  stench,  a  feeble,  thready  pulse,  cold,  clammy 
hands  and  feet,  and  petechise.  The  c  mmon  causes  of  death  are  laryngeal 
obstruction,  bronchopneumonia,  sepsis,  sudden  asystolism,  paralysis,  and 
uraemia. 

XIV.    VINCENT'S  ANGINA. 

Definition.  —  An  acute  febrile,  pseudomembranous  inflammation  of 
the  tonsils,  associated  with  Bacillus  fusiformis  and  the  spirochseta  of 
Vincent,  and  characterized  by  a  tendency  to  destructive  ulceration  of  the 
tissues  involved,  enlargement  of  the  lymphatic  glands  at  the  angle  of  the 
jaw,  and  an  irregular,  slow  course. 

This  affection  is  comparatively  rare  and  chief!}'  affects  children  and 
young   adults. 

Symptoms. — The  onset  may  be  acute  or  subacute,  with  the  symptoms 
of  an  ordinary  angina  or  simple  membranous  sore  throat.  The  constitu- 
tional symptoms  are  often  severe.  The  tonsils  are  usually  at  first  affected 
and,  in  some  cases,  the  local  manifestations  of  the  disease  are  confined  to 
those  organs.  More  commonly  the  uvula  and  half-arches  are  also  involved 
and  the  ulceration  may  extend  to  the  pharynx  and  even  to  the  gums.  The 
exudate  is  of  soft  consistency,  usually  of  a  greenish  or  grayish-yellow  color, 


714  MEDICAL  DIAGNOSIS. 

and  readily  detached,  leaving  a  slightly  depressed  bleeding  ulcer  with 
irregular  ragged  borders.  The  process  is  slowly  progressive,  not  readily 
yielding   to   trratment,   and    may   result   in   extensive   destruction  of  the 

parts    involved,    especially    the    uvula 
and  soft  palate. 

Diagnosis. — This  form  of  mem- 
branous angina  may  be  recognized  by 
its  tardy  progress,  the  destructive  ten- 
dency of  the  ulcerative  process,  and 
the  presence  of  Bacillus  fusiformis  and 
the  spirochseta  of  Vincent.  The  dif- 
ferential diagnosis  from  diphtheria  rests 
upon  the  above  anatomical  and  clinical 
characters  and  the  absence  of  the  Bacil- 
lus diphtherise  from  the  exudate.  In  fact 
diphtheria  can  usually  be  excluded  when 
the  associated  fusiform  organisms  and 
spirochsetse  are  present.  As  a  rule,  the 
Fig.  241.— Fusiform  bacilli  and  spirilla  in  vin-      direct  dlaguosis  depends  upon  the  labo- 

cent  s  angina. — Rosenberger.  f  f  r' 

ratory  findings.  Mucous  patches  may 
resemble  this  form  of  angina  or  it  may  develop  upon  syphilitic  lesions. 
Prognosis. — Recovery  occurs  as  a  rule  after  a  duration  varying 
from  four  or  five  days  to  several  weeks.  In  a  recent  case  in  the  Penn- 
sylvania Hospital,  Vincent's  angina  was  the  terminal  event  in  aplastic 
anaemia  in  a  young  adult  male. 

XV.    CROUPOUS    PNEUMONIA. 

Fibrinous  Pneumonia;   Lung  Fever;   Lobar  Pneumonia;   Pleuropneumonia. 

Definition.— An  acute  infectious  disease  due  to  the  Diplococcus  pneu- 
monise  of  Fraenkel  and  Weichselbaum  and  characterized  by  pulmonary 
inflammation  and  fever,  usually  of  abrupt  onset,  high  range,  and  critical 
termination. 

Etiology. — Predisposing  Influences. — Pneumonia  prevails  alike  in 
hot  and  cold  countries.  It  is  said  to  be  more  prevalent  in  the  temperate 
climates. 

Season  plays  an  important  part  as  a  predisposing  factor.  The  inci- 
dence of  the  disease  is  uniformly  greater  in  winter  and  the  early  spring. 
March  is  the  month  of  greatest  liability.  This  is  in  accordance  with  the 
fact  that  exposure  to  cold  and  especially  unusual  exposure  to  cold  and  wet 
are  very  often  soon  followed  by  the  initial  chill.  Steady,  low  temperatures 
are  less  dangerous.  Personal  Factors. — Croupous  pneumonia  may  occur 
in  the  new-born  and  in  early  infancy.  It  is  common  till  the  sixth  year. 
The  liability  then  diminishes  until  the  fifteenth  year.  From  fifteen  to  forty- 
five  is  a  period  of  special  liability.  After  sixty  the  disease  is  very  common 
and  often  constitutes  the  terminal  event  in  the  aged,  both  in  chronic  dis- 
ease and  when  the  previous  health  has  been  well  preserved.  In  infancy 
and  old  age  the  incidence  for  the  sexes  is  about  equal;  in  the  middle  period 


CROUPOUS  PNEUMONIA.  715 

of  life,  when  the  mode  of  living  is  different,  males  are  more  frequently 
affected  than  females.  There  is  no  special  racial  predisposition.  The 
negro  bears  the  disease  badly.  Ptich  and  poor  are  alike  liable.  No  occupa- 
tion is  conspicuous  as  a  predisposing  factor.  Overwork  and  sudden  expo- 
sure constitute  especial  risks.  Lumbermen  and  miners  frequentl}'  suffer. 
The  disease  is  very  common  in  cities.  Pneumonia  attacks  the  robust  and 
hearty  and  the  debilitated  and  previously  ill  with  impartial  energy.  The  alco- 
holic is  especialh'  liable.  The  last  illness  of  the  chronic  invalid  is  very  often 
pneumonia.  Pneumonia  sometimes  follows  injuries,  especially  contusions 
of  the  chest.  This  may  occur  in  the  absence  of  the  signs  of  injury  to  the 
lung.     The  term  "contusion  pneumonia"  is  used  to  describe  this  variet}'. 

Iminunity . — There  is  apparently  no  natural  immunity,  certainly  no 
permanent  acquired  immunity.  On  the  contrary,  croupous  pneumonia  is 
conspicuous  among  the  infections  for  its  liability  to  recur.  Subsequent 
attacks  have  been  noted  in  from  15  to  50  per  cent,  of  the  cases.  I  have 
seen  a  woman  who  stated  that  the  attack  was  the  twelfth,  and  several 
persons  in  whom  a  number  of  annual  attacks  occurred. 

A  powerful  protective  serum  has  been  obtained  by  the  repeated  inocu- 
lation of  various  animals,  as  the  horse,  ass,  and  coav,  with  dead  and  living 
cultures  of  the  pneumococcus.  The  specific  protective  substances — 
opsonins — are  formed  in  the  bone-marrow  and,  circulating  in  the  blood, 
enter  into  chemical  combination  with  the  iDneumococci  which  are  thus 
rendered  an  easier  prey  to  the  phagocytes.  The  formation  and  gi^adual 
accumulation  of  similar  substances  in  the  human  body  dtu-ing  the 
attack  serve  to  explain  the  crisis.  The  organisms  are  rapidly  destroyed 
within  the  exudate  in  the  lungs  and  in  the  circulating  blood.  The  dura- 
tion   of    the    local    and    general    immunit}'    which    follows    is    uncertain. 

Exciting  Cause. — Diplo coccus 
pneumoniEe  of  Fraenkel  and  Weich- 
selbaum,  ^Micrococcus  lanceolatus,  or 
pneumococcus.  This  organism  is  the 
sole  cause  of  true  acute  croupous  pneu- 
monia. It  is  present  in  the  expectoration 
and  pulmonary  exudate  in  enormous 
numbers.  Upon  examination  of  the 
lungs,  when  death  has  occurred  in  the 
stage  of  resolution,  it  is  found  only  in 
small  numbers  or  may  be  wholly'  absent 
— phagocytosis.  It  may  be  obtained 
in  blood  cultures  during  the  attack  by 
the  more  recent  methods  in  more  than 
75  per  cent,  of  the  cases.     The  pneu-     Fig.  242.— Spread  of  -sputum  showing  pneumo- 

•  i_^  f  cocci  in  pairs  and  in  chains. 

mococcus    occurs  m   man}^  other   dis-  ^ 

eases,  especially  bronchopneumonia,  pleurisy,  endocarditis  and  pericarditis, 
meningitis,  peritonitis,  in  forms  of  arthritis,  and  in  middle-ear  disease. 
Pneumococcus  Septicceynia. — An  acute  general  infection  without  locali- 
zation in  the  lungs  or  serous  membranes  is  occasionally  encountered.  This 
variety  of  pneumonia  is  analogous  to  the  primary  septicaemia  due  to 
general  infection  by  Eberth's  bacillus — typhoid  septicaemia. 


716  MEDICAL  DIAGNOSIS. 

In  its  attenuated  forms  the  pneumocoecus  is  present  in  the  secretions 
of  the  mouth  "and  bronchi  in  a  large  proportion  of  healthy  individuals. 
Its  presence  has  been  demonstrated  in  the  dust  of  rooms.  Various  other 
organisms  are  associated  with  the  pneumocoecus  in  croupous  pneumonia, 
as  secondary  or  mixed  infections.  The  most  frequently  encountered  is 
the  Streptococcus  pyogenes.  Less  common  are  staphylococci,  the  bacillus 
of  Friedlander,  B.  typhosus,  B.  diphtherise,  and  B.  influenzae.  These  bac- 
teria are  often  the  cause  of  bronchopneumonia,  which  in  some  instances 
closely  resembles  croupous  pneumonia.  The  latter  is  a  distinct,  specific  dis- 
ease uniformh'  caused  by  the  pneumocoecus,  and  the  recognition  of  its  etio- 
logical and  clinical  independence  is  a  matter  of  great  practical  importance. 

Pathological  Anatomy. — The  lesions  in  the  inflamed  lung  undergo 
progressive  changes,  which,  since  the  time  of  Laennec,  have  been  described 
as  the  stage  of  engorgement,  the  stage  of  reel  hepatization,  and  the  stage 
of  gray  hepatization.  Engorgement. — The  vesicular  tissue  is  deep  red, 
firmer  than  normal  to  the  touch,  and  on  section  shows  abundant  blood  and 
serum.  It  crepitates  upon  pressure,  and  excised  pieces  float  upon  water. 
The  capillaries  are  distended  and  the  air-vesicles  contain  blood-corpuscles 
and  swollen  detached  alveolar  cells.  Red  Hepatization. — The  air-cells 
and  terminal  bronchi  are  occupied  by  the  coagulated  exudate,  entangled 
in  which  are  pneumococci,  red  blood-corpuscles,  leucocytes,  and  alveolar  epi- 
thelium. The  affected  portion  of  lung  is  soUd  and  airless.  It  is  enlarged  and 
shows  the  oblique,  parallel  markings  of  the  ribs.  On  section  the  surface  is  of 
a  reddish-brown  color  and  granular,  an  appearance  produced  by  the  pro- 
trusion of  the  fibrinous  moulds  in  the  vesicles.  The  terminal  bronchi  also 
contain  branching  fibrinous  casts.  The  surface  yields  upon  scraping  a 
reddish,  viscid  serum.  The  hepatized  lung  is  extremely  friable.  Gray 
Hepatization. — The  lung  tissue  is  now  of  a  dirty  gray  color  and  more  friable. 
The  cut  surface  is  more  moist,  has  lost  its  granular  appearance,  and  yields 
upon  scraping  a  milky  turbid  fluid.  The  air  again  reaches  the  alveoli,  from 
which  the  fibrin  and  red  blood-cells  have  in  great  part  disappeared,  but  in 
which  are  great  numbers  of  leucocytes.  The  foregoing  stages  gradually 
merge  into  each  other  and  the  process  is  not  equally  advanced  in  all  parts 
of  the  lesion.  The  liquefaction  of  the  exudate  and  resolution  are  the 
result  of  the  action  of  proteolytic  enzymes.  The  part  of  the  lung  occupied 
by  the  exudate  varies  from  a  small  patch  to  the  entire  lung.  Commonly 
a  single  lobe  is  involved.  The  uninvolved  portions  are  usually  congested 
and  oedematous.  The  pleural  surface  opposite  the  exudate  is  always 
inflamed  when  the  latter  extends  to  the  periphery  of  the  lung.  The  bron- 
chial glands  are  enlarged  and  sometimes  softened. 

The  right  heart  is  dilated.  Pericarditis  is  not  rare,  especialh"  in  left- 
sided  and  double  pneumonias.  Endocarditis  is  common  both  in  the  simple 
and  in  the  malignant  form.  Myocardial  changes  occur.  The  spleen  shows 
moderate  enlargement  and,  in  the  kidneys,  parenchymatous  swelling  and 
the  lesions  of  interstitial  nephritis  are  frequently  present.  Meningitis  is 
by  no  means  rare  and  is  often  associated  with  malignant  endocarditis. 
Diphtheroid  colitis  is  rare.  The  liver  is  slightly  enlarged  and  deeply 
congested.  The  distribution  of  the  lesion  is  as  follows:  The  right  lung 
alone  is  involved  in  about  50  per  cent,  of  the  cases;   the  left  alone  in  about 


CROUPOUS  PNEUMONIA. 


717 


c. 

-42* 


33  per  cent. ;  both  in  less  than  20  per  cent.  In  double  pneumonia  the 
lower  lobes  are  usually  affected,  or  an  entire  lung  with  the  lower  lobe 
of  the  other.  Much  less  frequently  the  lower  lobe  of  one  lung  and  the 
upper  lobe  of  the  other  are  involved — crossed  pnetnnoriia.  Very  rarely 
both  upper  lobes  suffer. 

Croupous  pneumonia  in  the  majority  of  the  cases  occurs  as  a  sporadic 
disease.  At  the  seasons  of  greatest  prevalence  it  is  the  type  of  an  endemic 
disease.  House  epidemics  are  by  no  means  rare.  In  a  family  of  five  I 
have  seen  the  mother  and  two  children  attacked  in  rapid  succession,  two 
of  the  cases  proving  fatal.  More 
extensive  local  epidemics  occasionally 
occur  in  schools,  prisons,  and  other 
institutions. 

Symptoms. — In  the  well-devel- 
oped cases  of  croupous  pneumonia 
the  attack  runs  a  typical  course  and 
is  self-limited.  The  period  of  incuba- 
tion is  of  unknown  duration.  It  is 
probably  brief.  Prodromes  are  unus- 
ual. When  present  they  consist  of 
slight  catarrhal  symptoms.  The 
onset  is  abrupt,  with  a  chill  which  is 
commonly  severe  and  prolonged. 
The  temperature  rises  rapidly  to  the 
fastigium  — 104°-105°  F.  (40°-40.6° 
C).  Headache,  general  pains,  and 
the  sensation  of  being  very  ill  are  fol- 
lowed in  the  course  of  a  few  hours  by 
a  severe  stitch-like  pain  in  the  side. 
increased  on  full  breathing,  a  short 
dry  cough,  hurried  respiration,  and  a 
full  bounding  pulse.  Very  significant 
is  a  short,  expiratory  grunt.  The 
pain  is  often  characteristic.  The  face 
is  slightly  cyanotic,  with  dusky,  cir- 
cumscribed flushing  of  one  or  both 
cheeks;     the    eyes    are    bright;    the 

expression  anxious;  the  nostrils  dilate,  and  later  patches  of  herpes,  usually 
made  up  of  many  small  vesicles,  some  of  which  contain  blood,  appear  upon 
the  lips  and  nose.  The  patient  lies  upon  the  affected  side  or  flat  upon  his 
back.  By  the  close  of  the  second  day  there  is  scanty,  viscid,  blood-stained 
expectoration — rusty  sputum.  The  physical  signs  of  consolidation  of  the 
affected  lung  tissue  are  present — small  mucous  and  crepitant  rales  followed 
by  dulness  and  bronchial  breathing.  At  the  end  of  several  days  deferves- 
cence by  crisis  occurs  with  a  remarkable  amelioration  of  all  the  symptoms. 

The  following  symptoms  require  special  consideration:  Fever. — 
The  temperature  rises  rapidly,  sometimes  reaching  the  fastigium  within 
twelve  hours,  usually  within  twenty-four  hours.  In  childhood  and  old 
age  the  rise  is  more  gradual,  especially  if  there  is  no  chill.     Its  course  is 


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-Pneumonia  ;  acute  nephritis.     Convul 
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718 


MEDICAL  DIAGi^OSIS. 


subcontinuous  and  remarkably  constant,  the  morning  remissions  and 
evening  exacerbations  in  many  cases  not  greatly  exceeding  the  diurnal 
oscillations  in  health.  Pseudocrises  are  not  infrequent.  They  may  occur 
at  any  period  but  are  more  common  about  the  fifth  or  sixth  day.  They 
are  usually  single,  but  two  or  more  sometimes  occur.  In  the  latter  case  the 
temperature  range  suggests  an  irregular  intermittent.  The  defervescence 
in  so-called  classical  cases  is  by  crisis,  which  occurs  between  the  third  and 
twelfth  da^^s,  very  often  upon  an  uneven  day,  and  commonly  upon  the  fifth 
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Fig.  244. — Croupous  pneumonia.     Recovery. 

The  time  occupied  by  the  crisis  varies  from  two  to  several  hours.  It  is 
accompanied  by  an  abundant  sweat  and  usually  occurs  during  a  deep  and 
prolonged  sleep,  from  which  the  patient  awakes  weak  but  refreshed  and 
comfortable.  The  fall  almost  always  reaches  subnormal  ranges — 96°-97° 
F.  (35.o°-36°  C),  and  may  be  followed  by  a  postcritical  rise  and  sub- 
normal oscillations  for  a  few  days.  In  some  instances  the  crisis  is  inter- 
rupted by  a  rebound — interrupted  crisis — or  it  may  extend  over  twenty-four 
hours — protracted  crisis.  In  delayed  cases  and  in  children  the  deferves- 
cence is  often  by  lysis.  In  fatal  cases  of  the  so-called  sthenic  type  there 
may  be  a  preagonistic  rise  of  temperature  and  in  the  asthenic  cases  an 
abrupt  antemortem  fall  of  several  degrees.  The  crisis  is  sometimes  at- 
tended by  collapse  symptoms.  In  the  aged  and  in  drunkards  the  tempera- 
ture is  much  lower.     Afebrile  cases  are  encountered.     Pain. — The  pain 


CROUPOUS  PNEUMONIA. 


719 


has  all  the  characters  of  pleurisy.  It  is  stitch-like  and  lancinating,  usually 
severe,  aggravated  by  deep  breathing  and  cough,  and  referred  to  the  region 
of  the  nipple  or  the  infra-axillary  region  on  the  affected  side.  Occasion- 
ally it  is  referred  to  the  epigastrium  or  the  region  of  the  appendix:  an 
important  point  for  the  diagnostician.  In  these  cases  there  is  a  diaphrag- 
matic pleurisy.  In  apex  pneumonia  pain  is  less  constant  and  less  severe 
and  in  central  lesions  it  is  absent.  Dyspnea. — The  respiration  rate  is 
increased  in  almost  all  cases,  the  masked  pneumonias  of  drunkards  and 
the  aged  and  the  terminal  pneumonias  of  chronic  diseases  constituting 


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Fig.  245. — Croupous  pneumonia. 
Prolonged  febrile  movement,  termi- 
nating by  lysis  on  21st  day  of  attack. 


Fig.    246. — Pneumonia  ;    pseudocrisis, 
5tii  day  ;   crisis  8th  day. 


the  exceptions.  The  pulse-respiration  ratio  may  be  2:1  or  even  1.5:1. 
The  respiration-frequency  ranges  from  30  to  50,  and  in  children  as  high  as 
80  per  minute  in  cases  that  recover;  in  fatal  cases  it  is  even  more  rapid. 
The  breathing  is  shallow;  the  ancillary  muscles  are  brought  into  play; 
there  is,  in  man}''  cases,  respiratory  distress  associated  with  air  hunger  and 
a  characteristic  expiratory  grunt  or  snort.  Cough. — The  early  cough  is 
due  to  pleural  irritation  and  is  short,  hard,  and  dry.  Later  it  becomes 
frequent,  somewhat  paroxysmal,  and  productive.  It  is  attended  with 
pain,  often  severe  throughout  the  attack.  About  the  time  of  the  crisis,  it 
becomes  easier  and  is  attended  with  free  expectoration.  Terminal  pneu- 
monias and  those  of  the  aged  and  drunkards  are  often  without  cough. 


720  MEDICAL  DIAGNOSIS. 

Absence  of  cough  is  also  occasionally  observed  in  the  pneumonia  of  infancy. 
Slight  cough  after  the  crisis  is  often  ^vithout  significance;  but  severe 
paroxysmal  cough  may  be  a  sign  of  pleural  effusion.  Sputum  (see 
Part  III,  page  456).  Pulse. — At  the  onset  the  pulse  is  small,  but  it  soon 
becomes  strong  and  full.  It  is  seldom  dicrotic.  Later  it  becomes  feeble 
and  small.  The  f requeue}^  varies  in  favorable  cases  from  80  to  110.  A 
very  frequent  pulse — 130-140 — is  of  unfavorable  prognostic  import,  but 
less  so  in  children  than  in  adults.  In  feeble  and  aged  persons  the  pulse 
is  small  and  frequent  from  the  onset.  After  the  crisis  the  pulse  remains 
frequent  for  a  time  but  gradually  returns  to  normal.  The  peripheral  blood- 
pressure  during  the  earl}'  days  of  the  attack  shows  httle  or  no  change. 
Later  there  is  often  a  progressive  fall.  A  sudden  drop  may  be  the  pre- 
cursor of  death.  In  the  septic  cases  there  is  an  early  fall.  Heart  Sounds. — 
They  are  usually  distinct  and  well-defined.  The  second  pulmonary  sound 
is  accentuated.  With  engorgement  of  the  right  heart  and  incomplete 
systole  of  the  right  ventricle,  the  pulmonarj'  second  sound  becomes  pro- 
gressively fainter.  Great  impairment  of  heart  power  shows  itself  in  heart 
sounds  of  the  fetal  type.  Sudden  collapse  may  occur  early  in  the  disease, 
at  the  crisis,  or  during  convalescence,  and  terminate  in  death.  This  may 
happen  without  warning  in  previous^  healthy  persons  with  good  hearts. 
Blood. — A  decrease  of  the  red  corpuscles  occurs  at  the  time  of  the  crisis 
but  marked  anaemia  is  not  common.  A  leucocytosis  varying  from  10,000 
to  50,000  per  c.  mm.  is  present  in  most  cases  throughout  the  attack.  It 
disappears  after  the  crisis.  Its  persistence  may  be  the  sign  of  a  complica- 
tion. It  bears  some  ratio  to  the  extent  of  the  pulmonar}^  exudate.  In 
the  toxic  cases  leucocj^tosis  may  be  absent,  and  its  absence  in  any  case  is 
an  unfavorable  sign.  The  blood-plaques  and  fibrin  elements  are  increased. 
The  eosinophile  cells  are  decreased.  Pneumococci  can  be  isolated  in 
some  cases.  Digestive  System. — There  is  complete  anorexia.  The 
tongue,  at  first  covered  with  a  thick  white  fur,  becomes  red  and  glazed 
and  in  the  severer  cases  dry  and  brown.  Vomiting  is  frequent  in  children. 
Constipation  is  the  rule.  Meteorism  is  a  troublesome  condition  in  the 
graver  cases.  Fibrinous  exudates  have  been  observed  in  the  mouth  and 
nose  and  other  mucous  surfaces.  Skix. — Herpes  is  very  common — 20-60 
per  cent,  of  the  cases.  It  appears  usually  upon  the  lips  at  the  border  of 
the  mucosa;  less  frequently  upon  the  alse  nasi,  infrequently  upon  the 
genitalia  or  anus,  rarely  upon  the  buttocks.  Slight  cyanosis  may  occur. 
Redness  of  the  cheeks,  and  especially  of  the  cheek  upon  the  affected  side, 
is  very  common.  A  general  erythema  is  encountered  in  rare  cases.  As 
in  all  grave  infections  petechise  may  occur.  Sweating  is  not  common  dur- 
ing the  course  of  the  attack,  but  is  profuse  at  the  crisis.  Nervous  Sys- 
tem.— The  symptoms  referable  to  the  nervous  system  are  not  peculiar  to 
pneumonia  but  are,  in  certain  cases,  of  great  assistance  in  the  diagnosis. 
In  infants  and  young  children  convulsions  may  take  the  place  of  the  initial 
chill.  Headache  is  frequent  and  often  severe.  Insomnia  is  a  troublesome 
symptom,  often  followed  by  delirium.  The  latter  may  be  mild  and  wander- 
ing, becoming  progressively  more  severe,  even  increasing  after  the  crisis. 
In  the  intervals  there  is  marked  mental  confusion.  In  a  group  of  cases  in 
children  the  symptoms  suggest  meningitis,  and  the  actual  condition  is  very 


CROUPOUS  PNEUMONIA.  721 

often  overlooked.  There  are  cases  in  which  the  onset  is  marked  by  furi- 
bund  mania.  In  alcohoHc  cases  the  nervous  phenomena  closely  simulate 
delirium  tremens.  Finally  there  are  cases  characterized  from  the  onset 
by  dulness  and  stupor,  with  no  chill  and  but  little  fever,  in  which  pulmo- 
nary symptoms  are  nearly  or  quite  absent,  but  grave  depression  and  wan- 
dering delirium  constitute  the  only  manifestations  of  profound  toxaemia. 
The  true  character  of  such  cases  can  only  be  determined  by  a  systematic 
routine  examination  of  the  chest.  Apex  pneumonia  is  more  frequently 
attended  by  severe  nervous  symptoms.  The  attack  may  be  followed  by 
postfebrile  delusional  insanity,  which  as  a  rule  terminates  in  recovery. 
Urine. — The  secretion  has  the  usual  characters  of  fever-urine.  Toxic 
albuminuria  is  common.  Later  the  signs  of  an  acute  nephritis  may  be 
present.  Urea  and  uric  acid,  diminished  during  the  attack,  are  greatly 
increased  upon  the  occurrence  of  crisis.  The  chlorides  are  diminished 
or  absent. 

Physical  Examination. — Inspection. — The  attitude  is  variable.  In 
lung  lesions  of  moderate  extent  the  patient  lies  upon  hi?  back  or  upon  the 
affected  side;  in  pneumonia  of  an  entire  lung,  or  double  pneumonia,  he 
usually  prefers  to  be  supported  by  pillows.  The  respiratory  movement 
of  the  affected  side  is  diminished.  In  basal  pneumonia  there  may  be 
increased  movement  over  the  upper  lobe.  The  increased  compensatory 
excursus  on  the  sound  side  is  often  very  conspicuous.  The  frequent  breath- 
ing, the  action  of  the  auxiliary  muscles  of  respiration,  and  the  sudden  mus- 
cular relaxation  in  expiration  are  to  be  noted.  Orthopnoea  may  be  present 
in  severe  cases.  The  affected  side  may  look  larger,  but  the  increase  upon 
actual  measurement  is  trifling. 

The  difference  in  the  expansion  of  the  two  sides  is  very  evident  upon 
palpation.  The  vocal  fremitus  is  greatly  increased  over  the  lesion.  It 
may  be  diminished  or  absent  if  the  exudate  extends  into  the  middle-sized 
bronchi  or  a  plug  of  tenacious  mucus  occludes  a  tube  of  some  size. 

Percussion. — During  the  stage  of  engorgement  the  resonance  is  of 
higher  pitch  and  vesiculotympanitic — Skodaic  resonance.  After  hepati- 
zation has  occurred  percussion  yields  dulness,  which  varies  from  partial 
impairment  of  resonance  with  the  tj^mpanitic  quality,  to  almost  complete 
loss  of  resonance.  Flatness  is  only  present  in  massive  pneumonia  when 
the  fibrinous  exudate  extends  some  distance  into  the  larger  bronchi.  Be- 
yond the  borders  of  the  lesion  percussion  often  yields  Skodaic  resonance. 
As  resolution  takes  place  the  dulness  becomes  less  marked;  the  qualit}' 
becomes  vesiculotympanitic  and  by  degrees  the  normal  pulmonary  reso- 
nance is  restored.  A  certain  elevation  of  pitch  and  faint  tympanitic  quality 
may  persist  for  several  weeks.  Wintrich's  phenomenon  is  sometimes 
present  in  apex  pneumonia.  In  rare  cases  the  percussion  sound  has  an 
amphoric  quality  and  suggests  a  cavity.  In  central  pneumonia  the  symp- 
toms may  be  well  marked  but  percussion  may  fail  to  indicate  the  site  of 
the  exudate  until  it  reaches  the  periphery  of  the  lung,  sometimes  a  period 
of  several  days. 

Auscultation.  —  In  the  stage  of  engorgement  faint  respiratory 
sounds.  The  tidal  air  is  not  only  decreased  in  volume,  it  also  ebbs  and 
flows  with  diminished  force.     Then  follow  crepitant  rales,  heard  only  at 

46 


722  MEDICAL  DIAGNOSIS. 

the  end  of  inspiration — crepitus  indux.  In  the  stage  of  red  hepatization, 
when  dulness  appears,  the  respiration  becomes  bronchial,  at  first  soft 
and  low-pitched,  and  more  distinct  upon  expiration.  Fully  developed  it 
is  high-pitched,  heard  alike  upon  inspiration  and  expiration,  with  an 
interval  of  silence  between  the  inspiratory  and  the  expiratory  sound  and 
often,  especially  in  the  young,  having  a  loud,  snoring  quality.  In  massive 
pneumonias  in  wdiich  the  exudate  fills  the  bronchi  bronchial  breathing 
is  absent.  Upon  resolution  small  mucous  and  crepitant  rales  are  again 
heard — crepitus  redux — and  are  sometimes  foUowed  by  larger  bronchial 
rales  which  disappear  as  convalescence  advances;  more  frequently  by 
nearly  or  quite  normal  vesicular  breathing.  In  central  pneumonias  the 
auscultatory  like  the  percussion  signs  may  be  absent  for  a  time.  The 
variety  of  bronchophony  known  as  aegophony  is  sometimes  present,  but  it 
is  a  sign  of  trifling  importance. 

After  the  diagnosis  is  fully  established  it  is  not  desirable  to  make 
frequent  examinations  of  the  chest.  They  are  exhausting  to  the  patient, 
especially  as  the  crisis  draws  near,  and  in  the  absence  of  some  special 
indication  in  the  symptoms  or  general  condition  should  not  be  repeated 
oftener  than  once  in  three  or  four  days.  In  the  necessary  movements  the 
patient  must  be  carefully  assisted  and  make  as  little  effort  on  his  own 
part  as  possible. 

Complications  and  Sequels. — These  are  not  many.  Pleurisy. — In- 
flammation of  the  pleura  corresponding  to  the  exudate  is  always  present 
when  the  latter  extends  to  the  periphery  of  the  lung.  It  is  usually  fibri- 
nous and  cannot  then  be  regarded  as  a  complication.  When  serofibrinous, 
the  effusion  usually  contains  coarse  fibrin  flakes  and  there  is  much  soft 
fibrinous  deposit.  It  is  often  abundant.  Even  a  moderate  effusion  coming 
on  during  the  stage  of  hepatization  may  cause  urgent  pressure  symptoms. 
A  rare  complication  is  pleural  effusion  upon  the  opposite  side. 

Metapneumonic  Empyema. — This  complication  is  not  altogether 
infrequent.  Cases  are  sometimes  regarded  as  instances  of  delayed  resolu- 
tion. The  pneumococcus  is  usually  present  early;  the  streptococcus  after- 
wards. The  signs  of  pleural  effusion  may  appear  during  the  attack  or  after 
the  crisis.  In  the  former  case  there  may  be  pressure  symptoms,  as 
dyspnoea,  cardiac  embarrassment,  and  sensations  of  tightness,  together  with 
persistence  of  the  fever.  In  the  latter,  the  temperature  rises  and  becomes 
remittent  or  intermittent  and  there  are  irregular  profuse  sweats,  marked 
anaemia,  leucocytosis,  and  not  rarely  paroxysmal  cough.  The  diagnosis  of 
small  encapsulated  and  interlobar  empyemata  may  often  be  made  with 
confidence  in  cases  in  which  their  precise  location  remains  obscure. 

Pericarditis. — This  complication  is  comparatively  infrequent  —  5 
per  cent.  It  occurs  chiefly  in  left-sided  or  double  pneumonias.  The  exu- 
date is  usually  fibrinous.  Precordial  pain  may  be  overlooked  in  connection 
with  the  pleurisy.  A  friction  sound  may  be  obscured  by  bronchial  rales. 
The  effusion  may  be  serofibrinous  or  purulent. 

Endocarditis. — Primar}^  endocarditis  may  occur,  or  a  fresh  attack 
supervene  in  chronic  valvular  disease.  The  malignant  form  is  occasion- 
ally associated  with  meningitis.  The  signs  are  not  constant.  Of  diagnostic 
importance  are  murmurs  which  change  their  quality  or  point  of  maximum 


CROUPOUS  PNEUMONIA. 


723 


intensity,  irregular  fever  with  chills  and  sweating,  and  signs  of  embolism. 
There  are  cases  discovered  post  mortem  in  which  no  murmur  has  been 
recognized  during  life. 

Thrombosis. — This  condition  may  occur  during  convalescence.  The 
femoral  vein  is  commonly  affected.  EmboUsm  of  the  larger  arteries  is 
very  rare.    Aphasia  is  also  rare.    It  may  occur  with  or  without  hemiplegia. 

Meningitis  is  a  rare  complication  occurring  during  the  course  of  the 
attack  or  after  the  crisis.  It  has  been  observed  more  frequently  during 
epidemics  of  cerebrospinal  fever.  It  constitutes  a  most  serious  compli- 
cation.    The  pneumococcus  has  been  found  in  the  exudate.     Very  rare 


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indeed  are  multiple  neuritis,  myelitis,  and  an  ascending  paralysis  presenting 
the  characters  of  Landry's  paralysis.  Postinfective  insanity  is  rare.  In 
individuals  predisposed  to  neurasthenia  an  attack  of  pneumonia  may 
precipitate  the  outbreak. 

Gastro-intestinal  and  Other  Abdominal  Complications. — Crou- 
pous gastritis  and  colitis  have  been  described.  Appendicitis  may  occur  as 
an  intercurrent  affection.  Epigastric  pain,  which  is  especially  common 
in  children,  is  usually  due  to  diaphragmatic  pleurisy.  It  may  simulate 
peritonitis— a  fact  of  importance  in  diagnosis,  since  in  rare  instances  in- 
flammation of  the  upper  peritoneum  by  extension  from  the  pleurae  has 
been  observed.  The  abdominal  pain,  if  localized  and  attended  with  shock, 
may  suggest  acute  hemorrhagic  pancreatitis. 


724  MEDICAL  DIAGNOSIS. 

Jaundice. — Mild  jaundice  is  not  uncommon.  It  develops  early  and  has 
no  bearing  upon  the  prognosis.     A  deep  obstructive  jaundice  may  occur. 

Meteorism. — Abdominal  distention  is  a  common  and  troublesome  symp- 
tom in  the  graver  cases.  It  is  the  manifestation  of  the  action  of  toxins  upon 
the  nerve  supply  of  the  walls  of  the  gut.  By  mechanically  interfering  with 
the  action  of  the  diaphragm  it  adds  to  the  embarrassment  of  the  respiration. 

Other  Complications. — Parotid  bubo  occasionally  occurs,  especially 
in  connection  with  endocarditis  of  malignant  type.  Middle-ear  disease  is 
common  in  children,  and  polyarthritis  resembling  that  of  rheumatic  fever, 
sometimes  clearly  septic  in  character,  may  occur  during  the  course  of  the 
attack  or  during  the  convalescence. 

Relapse  is  a  rare  event.  It  is  important  not  to  mistake  the  fever  of 
delayed  resolution  or  of  empyema  for  relapse.  An  initial  chill,  high  fever, 
cough,  rusty  sputum,  and  critical  defervescence  would  justify  the  diagnosis 
of  relapse. 

Convalescence  is  commonly  rapid.  Resolution  does  not  immediately 
occur.  Impaired  resonance  with  the  vesiculotympanitic  quaUty  and 
feeble  vesiculobronchial  respiration  may  persist  for  a  fortnight  or  longer. 
Fever  and  a  leucocytosis  after  the  crisis  suggest  delayed  resolution  or 
empyema.  A  systematic  physical  examination  and  the  use  of  the  aspirator 
needle  may  become  necessary.  Persistent  dulness  is  often  due  to  a  greatly 
thickened  pleura. 

Anatomically  the  terminations  of  croupous  pneumonia  are: 

1.  Resolution.  — The  exudate  undergoes  liquefaction  and  resorp- 
tion. Only  in  small  part  is  it  expectorated.  Complete  restoration  of  the 
lung  gradually  occurs — restitutio  ad  integrum. 

2.  Delayed  Resolution.  —  Resolution  is  more  commonly  delayed 
in  pneumonias  of  the  aged  and  in  debilitated  subjects;  it  may  be  delayed 
also  in  basal  lesions  and  in  previously  robust  persons.  The  crisis  is  followed 
by  an  apparent  convalescence,  but  the  signs  of  local  consolidation  con- 
tinue. From  three  to  five  or  six  weeks  elapse  before  dulness  and  bronchial 
breathing  wholly  disappear.  Complete  recovery  ultimately  follows.  In 
a  second  group  of  cases  the  defervescence  is  by  lysis,  with  irregular,  recur- 
rent fever,  sweating,  rapid  pulse,  slight  cough,  usually  little  or  no  expec- 
toration, and  impaired  nutrition.  The  condition  simulates  pulmonary 
tuberculosis.  In  the  course  of  four  or  five  weeks,  sometimes  not  until 
two  months  or  more  have  elapsed,  complete  resolution  takes  place  and 
the  patient  regains  his  health. 

3.  Abscess. — Local  infection  with  pyogenic  organisms.  The  abscess 
cavities  are  multiple  and  small  or  they  may  coalesce  and  form  an  extensive 
depot.  Cough  is  paroxysmal  and  accompanied  by  an  abundant  purulent 
expectoration  containing  elastic  fibres,  sometimes  cholesterin  crystals 
and  hsematoidin  crystals.  The  onset  of  the  condition  is  commonly  attended 
with  increased  fever  of  hectic  type  and  other  signs  of  sepsis.  The  differ- 
ential diagnosis  between  a  circumscribed  empyema  with  bronchopulmonary 
fistula  and  pulmonarj^  abscess  rests  largely  upon  the  character  of  the  sputum. 

4.  Gangrene. — Infection  with  saprophitic  bacteria.  The  condition 
may  occur  independently  of  or  in  connection  with  abscess.  The  con- 
dition occurs  mostly  in  persons  debilitated  by  previous  bad  health.     It 


CROUPOUS  PNEUMONIA.  725 

manifests  itself  clinically  by  septic  phenomena  and  extreme  prostration 
and  by  a  disgusting,  penetrating  fetor  of  the  sputum  and  breath. 

5.  Fibroid  Induration. — Defervescence  either  by  crisis  or  lysis 
may  occur,  but  the  signs  of  consolidation — dulness,  increased  vocal  frem- 
itus, bronchial  respiration — continue  unchanged.  Occasional  rales  are 
heard.  Cough  ma^^  be  troublesome,  but  expectoration  is  scanty.  Reso- 
lution does  not  take  place  gradually  as  is  usual,  but  the  signs  become  more 
•marked  with  contraction  of  the  opposite  side  and  the  gradual  development 
of  chronic  interstitial  pneumonia — fibroid  phthisis.  In  other  cases  the 
fever  returns,  the  expectoration  increases,  and  the  course  of  the  case  is 
that  of  a  rapid  pulmonary  consumption — phthisis  florida. 

Clinical  Varieties. — The  clinical  picture  of  croupous  pneumonia  is 
made  up  of  two  essentially  different  groups  of  symptoms,  namely,  those 
due  to  the  local  pulmonary  lesion  and  those  clue  to  the  toxsemia.  As  these 
vary  greatly,  it  is  evident  that  the  individual  cases,  while  conforming  to  a 
type,  will  present  differences  which  are  determined  among  other  factors 
by  the  relative  preponderance  of  one  or  the  other  of  these  two  symptom- 
groups.  Complete  consolidation  of  a  lung  may,  on  the  one  hand,  be  ac- 
companied by  but  trifling  evidences  of  general  infection,  while,  on  the  other 
hand,  severe,  even  fatal,  toxsemia  occasionally  occurs  in  cases  in  which  the 
pulmonary  lesion  is  limited  in  extent.  The  other  factors  are:  1.  Local 
Variations. — (a)  Apex  pneumonia  is  more  common  in  children.  It  is 
frequently  associated  with  marked  cerebral  Symptoms  and  may  simulate 
meningitis.  In  the  absence  of  cough  and  sputum  the  pulmonary  lesion 
is  often  overlooked.  Pneumonia  of  the  apex  in  adults  may  be  accompanied 
by  grave  constitutional  symptoms,  (b)  Double  pneumonia  is  attended 
with  the  additional  dangers  incident  to  progressive  diminution  of  the 
respiratory  surface.  The  second  lung  is  usually  involved  a  day  or  two 
after  the  first  and  to  a  less  extent.  The  extension  of  the  process  is 
not  attended  by  a  chill,  (c)  Central  Pneumonia. — The  exudate  may  re- 
main circumscribed  about  the  root  of  the  lung  or  in  the  substance  of  a 
lobe  and  not  reach  the  periphery  for  three  or  four  days,  when  the  physical 
signs  may  be  for  the  first  time  detected.  Meanwhile  characteristic  symp- 
toms— chill,  fever,  cough,  and  rusty  sputum — are  present,  but  pain  does 
not  occur  until  the  inflammation  reaches  the  pleura,  (d)  Pneumonia  in 
Emphysematous  Persons. — The  symptoms  are  distinctive,  but,  owing  to 
the  diminished  vascular  supply  and  the  dilatation  of  the  vesicles,  there  is 
not  a  sufficient  c^uantity  of  fibrinous  exudate  to  give  rise  to  the  signs  of 
consolidation.  Several  days  may  elapse  before  the  site  of  the  lesion  can  be 
detected,  (e)  Masnve  Pneumonia. — A  rare  form  in  which  the  fibrinous 
exudate  fills  the  bronchi.  A  lobe  or  the  entire  lung  may  be  involved. 
The  affected  portion  is  converted  into  a  completel}^  airless  mass.  The 
percussion  sound  is  not  dull  but  flat.  Upon  auscultation  neither  rales  nor 
bronchial  respiration  are  heard,  and  vocal  fremitus  is  absent.  The  signs 
closely  simulate  pleural  effusion,  but  adjacent  organs  are  not  displaced, 
(f)  Migratory  Pneumonia. — The  inflammation  creeps  about,  involving  in 
succession  one  lobe  after  another,  resolution,  not  always  complete,  taking 
place  in  turn  as  new  areas  are  afi"ccted.  The  migrations  are  not  attended 
by  chills;  fever  continues  and  the  course  of  the  disease  is  much  protracted. 


726  MEDICAL  DIAGNOSIS. 

2.  The  Intensity  of  the  Process. — (a)  Larval  or  Rudimentary 
Pneumonia. — Mild  cases  occasionally  occur.  The  symptoms  consist  of 
slight  chill,  moderate  rise  of  temperature,  and  cough.  The  pulmonary 
signs  are  obscure.  The  expectoration  is  slight  in  amount  and  not  usually 
rusty.  Herpes  is  common.  The  attack  comes  to  an  end  in  the  course  of 
two  or  three  daj^s.  Its  true  nature  is  often  overlooked,  (b)  Abortive 
Pneumonia. — The  attack  begins  with  a  severe  chill.  The  fever  is  high. 
Pleural  pains,  cough,  rusty  sputum,  herpes,  and  characteristic  physical 
signs  enter  into  a  symptom-complex  which  is  complete.  In  the  course  of 
the  second  or  upon  the  third  day  the  temperature  falls  by  crisis  and  the 
patient  enters  upon  convalescence,  (c)  Intense  Pneumonia:  Sthenic  Pneu- 
mo7iia. — The  adjectives  sthenic  and  asthenic  have  to  a  great  extent  passed 
out  of  use,  but  almost  every  day  one  sees  in  a  large  hospital  service  cases 
of  pneumonia  of  great  severity  but  in  strong  contrast  as  regards  the  char- 
acter of  the  symptoms.  Those  terms  serve  a  useful  purpose  in  this 
connection.  Intense  pneumonia  occurs  in  middle  life,  in  individuals 
previously  in  good  health,  usually  males,  large,  deep-chested,  hard  workers 
in  the  open  air.  The  initial  chill  is  severe  and  prolonged,  the  temperature 
high,  the  pulse  bounding,  the  face  flushed,  chest  pain  very  intense,  the 
breathing  hurried,  cough  frequent,  sputum  hemorrhagic,  the  delirium 
active,  even  maniacal,  and  the  signs  indicative  of  an  extensive  pulmonary 
inflammation.  These  cases  are  attended  with  especial  danger  to  life, 
(d)  Toxic,  Asthenic  or  So-called  Typhoid  Pneumonia. — ^This  variety,  equally 
severe  and  even  more  dangerous,  is  in  the  strongest  contrast  to  the  variety 
just  described.  The  ordinary  symptoms  of  pneumonia  may  be  absent  and 
the  pulmonary  lesions  limited.  The  symptoms  are  those  of  profound 
toxffimia.  Early  prostration,  delirium,  jaundice,  meteorism,  and  diarrhoea 
are  present.  The  hands  and  lips  tremble  and  stupor  alternates  with 
wandering  delirium.  The  condition  is  one  of  pneumococcus  septicaemia 
or  mixed  pneumococcus  and  streptococcus  infection. 

3.  Individual  Tendencies. — (a)  Age. — In  the  new-born  croupous 
pneumonia  is  extremely  rare.  It  is  common  in  infants  and  young  children. 
Convulsions  replace  the  initial  chill.  The  apex  is  not  rarely  involved. 
Cough  is  slight  and  suppressed  or  absent  altogether.  There  is  no  expec- 
toration. Excitement,  jactitation,  boring  of  the  head  into  the  pillows, 
and  high  fever  followed  by  stupor  and  convulsions  suggest  meningitis. 
The  apex  pneumonia  is  often  wholly  overlooked.  Pneumonia  in  the  aged 
usually  develops  insidiously  without  a  distinct  chill.  There  is  little  cough 
and  expectoration.  Fever  is  moderate  and  irregular  and  the  physical  signs 
not  well  defined.  Great  depression,  inability  to  take  nourishment,  mild 
delirium,  and  a  tendency  to  stupor  are  present,  (b)  Sex. — In  women  at 
the  middle  period  of  life  pneumonia  tends  to  assume  the  toxic  form,  in 
men  the  sthenic  form;  in  infancy  and  old  age  the  course  of  the  disease  is 
the  same  in  males  and  females,  (c)  Pneumonia  in  Alcoholic  Subjects. — Two 
forms  are  to  be  considered — pneumonia  in  steady  drinkers  and  pneumonia 
during  debauch.  In  the  first  the  early  symptoms  do  not  differ  from  those 
of  ordinary  pneumonia.  Delirium  with  tremor  soon  develops,  vomiting 
is  troublesome,  the  circulation  fails,  sleeplessness  is  uncontrollable,  and 
the  signs  of  nephritis  with  ursemic  phenomena  are  common.    In  the  second 


CROUPOUS  PNEUMONIA.  727 

the  onset  is  insidious,  the  temperature  but  sHghtly  raised,  cough,  expec- 
toration, and  sputum  trifling  or  wholly  absent,  and  the  clinical  picture  that 
of  delirium  tremens.  Only  by  a  systematic  physical  examination  can  the 
condition  be  recognized,  (d)  Pneumo7iia  in  Chronic  Diseases;  Terminal 
Pneumonia. — The  terminal  event  in  many  chronic  diseases,  especially 
pulmonary  tuberculosis,  valvular  and  myocardial  disease  of  the  heart, 
arteriosclerosis,  nephritis,  diabetes,  cancer,  and  diseases  of  the  spinal  cord, 
is  croupous  pneumonia.  The  development  of  this  intercurrent  disease  is 
very  frequently  overlooked,  partly  because  it  is  very  insidious  and  presents 
none  of  its  ordinary  symptoms,  and  partly  because  the  patient  has  reached 
a  point  in  the  progress  of  the  primary  affection  in  which  a  proper  physical 
examination  can  no  longer  be  made.  The  diagnosis  is  frequently  made  in 
the  post-mortem  room.  The  intercurrent  pneumonias  of  the  acute  infec- 
tions, as  enteric  fever,  diphtheria,  and  influenza,  are  not  as  a  rule  due  to 
the  pneumococcus,  but  to  the  specific  organism  of  the  primary  disease 
in  association  with  secondary  invading  bacteria — Streptococcus  pyogenes, 
staphylococcus,  or  the  colon  bacillus. 

4.  Varieties  due  to  Differences  in  the  Determining  Causes. — 
(a)  Contusion  Pneumonia. — Contusion  of  the  chest,  or  violent  bodily 
shock  without  direct  injury  to  the  lung,  may  be  followed  in  the  course  of  a 
day  or  two  by  the  onset  of  a  well-characterized  croupous  pneumonia,  (b) 
Postoperative  Pneumonia. — The  cases  probably  do  not  all  belong  to  the 
same  group.  True  croupous  pneumonia  is  much  less  common  than  broncho- 
pneumonia, which  may  be  diffuse  or  pseuclolobar.  Croupous  pneumonia 
may  occur  after  operations  of  various  kinds,  irrespective  of  the  anaesthetic 
employed.  Bronchopneumonia  is  common  after  operations  upon  the  mouth 
and  throat,  (c)  Ancesthesia  Pneumonia. — This  variety  is  almost  always 
bronchopneumonia.  In  many  instances  the  lesions  are  so  massed  as  to 
constitute  a  pseudolobar  pneumonia.  The  symptoms  develop  in  the 
course  of  the  first  or  second  day  after  the  operation,  much  more  commonly 
when  ether  has  been  administered  and  the  mouth,  throat,  or  abdomen  has 
been  operated  upon.     It  is  probably  an  aspiration  pneumonia. 

Diagnosis. — Direct. — In  well-developed  cases  of  primary  croupous 
pneumonia  the  diagnosis  is  an  easy  matter  and  errors  are  not  often  made. 
The  mistakes  in  diagnosis  occur  mostly  in  the  aberrant  and  intercurrent 
forms  in  which  the  disease  is  latent  and  the  symptoms  masked,  and  are  the 
result  of  neglect  to  carefully  and  systematically  examine  every  patient, 
and  especially  chronic  cases,  upon  the  appearance  of  fresh  local  or  con- 
stitutional symptoms,  however  trifling  they  may  appear.  In  certain 
cases  the  general  symptoms  are  indeterminate  but  the  local  phenomena 
decisive,  in  others  the  physical  signs  are  obscure,  but  chill,  fever,  cough, 
and  sputum  are  characteristic.  In  either  of  these  conditions  the  diagnosis 
is  clear;  still  more  clear  is  it  when  both  symptoms  and  signs  are  present 
and  well  defined. 

Differential  Diagnosis. — 1.  Acute  Pneumonic  Phthisis  (see  p.  803). 
2.  Hemorrhagic  Infarct. — There  are  circumscribed  dulness  and  bloody 
sputum.  The  chill  of  pneumonia  does  not  occur;  there  may  be  complete 
absence  of  fever;  the  blood  is  less  thoroughly  admixed  with  the  sputum, 
and  finally  a  condition  capable  of  giving  rise  to  embolism  may  be  dis- 


728  MEDICAL  DIAGNOSIS. 

covered.  3.  Pulmonary  (Edema. — The  sputum  is  bloody,  but  it  is  also 
thin  and  frothy,  a  condition  only  exceptional  in  pneumonia.  Dulness  is 
not  common  and  when  present  involves  both  bases  posteriorly  and  is  far 
less  strictly  dehmited  than  in  pneumonia.  Both  conditions  may  be  pres- 
ent. Collateral  oedema — fluxion  oedema — is  common  in  pneumonia  and 
an  inflammatory  oedema  may  develop  at  the  borders  of  the  lesion.  4. 
Bronchopneumonia. — Massed  lesions  of  considerable  extent  or  involving  a 
lobe — pseudolobar  pneumonias  —  are  misleading.  Croupous  pneumonia 
generally  occurs  as  an  acute  process,  attacking  persons  in  previous  good 
health,  or  as  an  intercurrent  specific  disease  in  various  chronic  affections, 
whereas  bronchopneumonia  is  mostly  an  affection  secondary  to  some  acute 
specific  fever,  as  measles  or  other  condition  in  which  the  aspiration  of 
infectious  matter  from  the  mouth  or  throat  takes  place.  Croupous  pneu- 
monia is  furthermore  an  acute,  short,  well-characterized  disease,  beginning 
abruptly  with  a  chill  and  terminating  by  crisis,  while  bronchopneumonia 
comes  on  gradually  or  abruptly  with  temperature  rise  but  without  chill, 
continues  indefinitely,  and  terminates  in  favorable  cases  by  lysis.  In  the 
cases  in  which  the  diagnosis  is  uncertain,  sputum  is  often  absent,  but,  as 
a  rule,  to  which,  however,  there  are  exceptions,  when  present  it  is  rusty 
and  viscid  in  croupous  pneumonia  and  mucopurulent  in  bronchopneumonia. 
5.  Pleural  Effusion. — This  question  of  diagnosis  is  of  daily  occurrence  at 
the  bedside  and  demands  special  consideration  (see  p.  1099).  6.  Menin- 
gitis.— Doubts  arise  in  some  cases  of  apex  pneumonia,  especially  in  chil- 
dren. A  knowledge  that  the  pulmonary  lesions  are  often  masked  will 
remind  the  practitioner  that  in  every  case  in  which  meningeal  symptoms 
are  present  the  lungs  and  heart  are  to  be  particularly  examined.  7.  Enteric 
Fever. — There  are  two  principal  sources  of  error.  Patients  suffering  with 
toxic  pneumonia  or  the  asthenic  form  of  the  disease  present  septic  symp- 
toms identical  with  those  of  enteric  fever  with  mixed  infection.  Clinically, 
in  the  absence  of  a  satisfactory  anamnesis  the  diagnosis  is  often  obscure. 
A  positive  agglutination  with  the  Widal  test  is  mostly  conclusive.  Excep- 
tionally the  patient  may  have  passed  through  enteric  fever  some. weeks  or 
months  before.  To  this  condition  the  term  typhoid  pneumonia  is  frequently 
applied.  This  unfortunate  term  is  also  used  to  designate  cases  of  enteric 
fever  in  which  bronchopneumonia — inhalation  pneumonia — has  arisen  as  an 
intercurrent  condition.  Much  less  common  are  cases  of  enteric  fever  which 
begin  with  the  symptoms  and  soon  develop  the  signs  of  pneumonia — pneu- 
motyphus.  The  diagnosis  cannot  be  made  with  precision  until  the  eruption 
and  splenic  tumor  appear  or  a  positive  result  follows  the  agglutination  test. 
Prognosis. — Croupous  pneumonia,  taking  all  cases  together,  is  an 
extremely  fatal  disease.  The  statistics  are  unreliable.  When  the  facts 
in  the  natural  history  of  this  disease  are  considered  it  appears  probable 
that  the  mortality,  according  to  hospital  statistics,  is  too  high;  according 
to  the  impressions  of  physicians  in  private  practice,  too  low.  Especially 
misleading  are  the  figures  collected  to  support  the  efficacy  of  certain  methods 
of  treatment.  It  is  necessary  to  be  explicit.  The  clinical  varieties  are  to 
be  considered.  Apex  pneumonia  is  more  liable  to  be  associated  with  ner- 
vous symptoms  and  grave  toxgemia.  Double  pneumonia  is  attended  with 
increasing  circumscription  of  the  respiratory  surface  and  stress  upon  the 


CROUPOUS  PNEUMONIA.  729 

right  heart,  as  well  as  by  a  more  intense  toxemia.  In  the  migratory  form 
there  is  increased  clanger  from  the  prolongation  of  the  active  disease.  As 
regards  the  intensity  of  the  process,  the  powers  of  resistance  of  the  indi- 
vidual play  an  important  part.  On  the  one  hand  robust  and  previously 
healthy  persons,  free  from  alcoholism,  perish  in  a  few  days,  while  individuals 
of  feeble  constitution  recover  from  an  apparently  hopeless  attack.  The 
toxic  cases  are  mostly  fatal.  Nevertheless  the  better  the  previous  health, 
the  more  favorable  the  outlook.  That  wholly  unknown  influence  called 
by  the  older  writers  the  epidemic  constitution  is  far  from  being  unim- 
portant. The  mortality  varies  in  different  years  in  the  same  locality 
between  5  and  30  per  cent.,  and  without  discoverable  cause  there  are  alter- 
nating series  of  favorable  and  unfavorable  cases.  The  mortality  in  house 
epidemics  and  institutions  is  high.  Negroes  in  the  United  States  show 
an  increased  mortality.  The  death-rate  is  distinctly  higher  in  the  southern 
than  in  the  northern  states  of  our  country.  In  high  altitudes  the  prognosis 
is  extremely  unfavorable.  The  question  of  diagnosis  has  a  distinct  bearing 
upon  the  statistics.  The  pneumonias  of  infancy  and  old  age,  secondary 
pneumonias,  and  terminal  pneumonias  are  very  often  not  recognized.  In 
infants  bronchopneumonia  is  frequently  mistaken  for  croupous  pneumonia 
or  the  latter  for  meningitis.  In  the  aged,  pneumonia  frequently  causes 
death  without  characteristic  or  even  suggestive  symptoms.  Insidiously 
developing  intercurrent  pneumonias  may  be  wholly  overlooked  and  the 
fatal  issue  ascribed  to  the  primary  disease.  Certainly  this  is  true  of 
terminal  pneumonias — a  fact  which  accounts  for  the  discrepancy  in  the 
death-rate  from  pneumonia  as  reported  from  the  wards  and  upon  the 
protocols  of  the  post-mortem  room.  It  is  easy  to  overlook  pneumonia 
in  a  patient  dying  in  the  ward  of  a  chronic  disease:  impossible  to  do  so 
upon  the  autopsy  table. 

Statistics,  to  be  of  value,  especially  to  be  of  value  in  determining  the 
relative  efficacy  of  different  plans  of  treatment,  must  be  based  upon  large 
numbers  of  cases  analyzed  with  reference  to  all  the  factors  which  influence 
the  result  of  the  attack  in  individual  instances.  In  hospitals  the  mortality 
ranges  from  20  to  40  per  cent.  In  the  Pennsylvania  Hospital,  of  943  cases 
entered  as  pneumonia  in  seven  years,  19S  or  21  per  cent.  died.  In  the 
German  Hospital,  of  407  cases  treated  during  ten  years  108  died,  a  mor- 
tality of  26.5  per  cent.  The  mortality  in  private  practice  varies  according 
to  different  observers  from  3  or  4  to  20  per  cent.  The  series  of  cases  in 
private  practice  are  usually  too  small  to  be  of  statistical  value. 

Among  the  circumstances  which  bear  upon  the  prognosis  in  indi- 
vidual cases  are  the  following:  Under  one  year  the  death-rate  is  much 
higher  than  between  two  and  twelve.  Adolescents  and  healthy  young 
adults  bear  pneumonia  well.  The  death-rate  is  very  low  among  recruits 
and  young  soldiers,  picked  men  living  a  regular  life  in  well-constructed 
barracks.  After  sixty,  75  per  cent,  die;  yet  remarkable  recoveries  occur. 
I  have  now  under  observation  a  lady  aged  99  who  has  twice  had  well-char- 
acterized croupous  pneumonia  since  her  eightieth  year.  Women  bear 
pneumonia  comparatively  badly.  When  it  occurs  during  pregnancy  there 
is  danger  of  abortion  or  premature  labor,  but  the  danger  is  not  so  great 
as  it  was  at  one  time  thought  to  be.    In  those  previously  ill  with  chronic 


730 


MEDICAL  DIAGNOSIS. 


disease,  the  obese,  and  especially  in  those  habitually  given  to  drink,  pneu- 
monia is  especially  dangerous.  In  such  cases  also  astonishing  recoveries 
occasionally  take  place.  The  outlook  is  also  grave  in  gouty  persons  and 
those  suffering  from  emphysema.  Complications  add  greatly  to  the  grav- 
ity of  the  cases.  Pneumococcus  meningitis  may  be  regarded  as  a  fatal 
disease;  endocarditis  is  usually  of  the  malignant  type;  septic  phenomena, 
whether  due  to  the  toxaemia  of  the  primary  infection  or  to  secondary 
infection,  are   ominous.     A   low   leucocyte    count   is   unfavorable. 

Death  is  commonly  caused  by  the  action  of  the  toxins  upon  the  vas- 
omotor centres  with  progressive  lowering  of  the  blood-pressure.  In  many 
cases  over-distention  of  the  right  heart  is  at  fault.  Sudden  cedema  of  the 
lungs  frequently  precedes  the  fatal  event. 

XVI.   CEREBROSPINAL  FEVER. 


Ejpidemic  Cerebrospinal  Meningitis. 

Definition. — An  acute,  infectious,  epidemic  disease  caused  by  the 
Diplococcus  intracellularis  meningitidis,  characterized  clinically  by  sudden 
onset,  with  headache,  vomiting,  and  painful  contraction  of  the  muscles 
of  the  back  of  the  neck,  irregular  fever,  profound  nervous  symptoms, 
rapid  course,  and  high  death-rate;  anatomically,  by  inflammation  of  the 
meninges  of  the  brain  and  cord. 

Etiology. — Predisposing  Influences. — Climate  appears  to  have 
little  influence  as  a  predisposing  factor.  Outbreaks  are  more  common  and 
extensive  in  the  winter  and  spring  than  in  the  warm  seasons  of  the  j^ear. 
Densely  populated  cities  and  sparsely  settled  agricultural  regions  are  alike 
subject  to  its  prevalence.  Damp,  overcrowded,  and  unclean  habitations 
favor  its  spread,  and  persons  li^dng  on  the  ground  floor  are  especially  apt 

to  suffer.  Individuals  of  all  occupa- 
tions and  professions  are  liable  to  this 
disease.  Military  life  involves  a  spe- 
cial liability.  Among  adults  the  pro- 
portion of  males  attacked  is  greater 
than  that  of  females.  Among  chil- 
dren the  number  of  males  and  females 
is  about  equal. 

Cerebrospinal  fever  is  especially  a 
disease  of  children  and  young  adults. 
After  40  it  is  uncommon,  though  the 
diagnosis  has  been  verified  post  mortem 
in  individuals  over  70. 

Exciting  Cause. — Diplococcus 
intracellularis    meningitidis ;     meningo- 
coccus.    This  organism  is  found  in  the 
fluid  obtained  b}'  lumbar  puncture  and 
in   the   meningeal   exudate.     The    cerebrospinal   fluid   is  usually  more  or 
less  turbid,  sometimes  very  turbid,  especially  early  in  the  course  of  the 
attack.     While  turbidity  of  the  spinal  fluid  is  of  diagnostic  importance, 


1% 


'm?^- 


n^'r 


Fig.  248.— Spread  of  meningococcal  exudate 
sho'N^'ing  intracellular  meningococci. 


CEREBROSPINAL  FEVER.  731 

its  limpidity  does  not  constitute  a  negative  sign,  and  in  either  case 
cultures  are  necessary  to  the  diagnosis.  In  the  tissues  the  diplococcus  is 
almost  constantly  confined  to  the  interior  of  the  polynuclear  leucocytes. 
The  diplococci  are  found  only  in  connection  with  the  lesions  of  the  disease. 
Mixed  infections  are  not  uncommon. 

Cerebrospinal  fever  does  not  appear  to  be  contagious  in  the  sense  in 
which  we  use  the  term  in  speaking  of  smallpox,  scarlet  fever,  and  typhus. 
The  definite  micro-organism  which  causes  it  is,  in  the  majority  of  instances, 
confined  to  the  meninges  of  the  brain  and  cord,  with  little  or  no  opportu- 
nity of  transmission  to  other  individuals.  In  cases  in  which  there  are  lesions 
in  the  lungs,  ears,  and  nose,  however,  infection  of  neighboring  objects  or 
persons  may  readil}''  take  place.  Councilman  has  recently  made  the  fol- 
lowing statement:  ''The  presence  of  sporadic  cases  is  of  importance  in 
the  occurrence  of  epidemics.  The  Diplococcus  intracellularis  is  an  organ- 
ism of  feeble  vitality:  it  dies  out  easily  on  exposure  to  drying  and  light 
and  is  incapable  of  a  saprophytic  existence.  In  the  absence  of  intervening 
infections,  it  would  be  impossible  for  the  period  of  epidemics  to  be  bridged 
over.  Not  only  this,  but  there  is  evidence  that  this  organism  can  produce 
other  infections  and  may  even  live  as  an  inhabitant  on  the  normal  mucous 
membrane. " 

Second  attacks  are  exceedingly  rare.  In  most  cases  lasting  immunity 
is  established. 

Symptoms  of  the  Ordinary  Forms. — Cerebrospinal  fever  presents  a 
great  diversity  of  symptoms  in  different  cases.  No  other  acute  disease 
appears  in  such  various  guises.  Stille  has  well  called  it  a  "chameleon-like 
disorder. "  The  period  of  incubation  is  unknown.  Prodromes  are  rare. 
When  present  they  consist  of  headache,  dragging  muscular  pains,  vertigo, 
and  a  sense  of  fatigue.  The  onset  of  the  attack  is  usually  abrupt.  It  is 
marked  by  a  chill,  agonizing  headache,  nausea,  and  vomiting.  In  some 
cases  headache  is  not  a  conspicuous  symptom.  The  attack  begins  with 
vertigo  and  the  patient  acts  like  a  drunken  man.  Dragging  pains  in  the 
neck  spread  along  the  spine  and  into  the  extremities  and  are  followed  b}" 
motor  symptoms  which  progressively  develop.  These  consist  of  tetanoid 
stiffness  of  the  spinal  muscles,  great  pain  on  attempting  to  bend  the  head 
forward  or  to  turn  it  from  side  to  side,  and  awkwardness  and  difficulty 
in  movements  of  the  extremities.  Strabismus,  inequality  of  the  pupils, 
and  palsies  of  the  facial  muscles  are  common.  In  the  course  of  a  little 
time  opisthotonos  develops,  the  head  is  drawn  back,  the  spine  curved,  the 
forearms  flexed  on  the  arms  and  the  legs  on  the  thighs.  Muscular  cramps 
and  spasmodic  twitchings  occur  and  in  young  children  general  convul- 
sions. Hemiplegia  has  been  frequently  observed.  Paraplegia  may  also 
occur.  Paralysis  may  develop  during  the  course  of  the  attack  and  dis- 
appear shortly  or  persist  for  some  time.  The  sensory  symptoms  consist 
of  headache,  which  may  be  sharp,  lancinating  or  boring,  and  is  commonly 
referred  to  the  back  of  the  head;  sometimes  it  is  felt  as  a  constricting 
band ;  pain  in  the  back  of  the  neck  and  in  the  lumbar  and  epigastric  regions 
and  general  hyperesthesia,  most  marked  in  the  face  and  neck.  Various 
disturbances  of  the  special  senses,  as  photophobia,  intolerance  of  sounds, 
ringing  in  the  ears,  and  vertigo,  occur.     The  psychical  disturbances  are 


732 


MEDICAL  DIAGNOSIS. 


striking.  The  patient  is  restless  and  distressed.  His  face  is  seldom  flushed, 
usually  pale,  and  slightly  cyanotic.  In  children  there  is  great  irritability. 
Delirium  occurs  early  and  may  be  active,  even  maniacal,  or  of  a  busy 
wandering  type.  After  a  time  it  passes  into  somnolence  or  stupor,  which 
may  be  still  attended  by  more  or  less  restlessness  and  continual  movement 
on  the  bed.  In  the  worst  cases  stupor  deepens  to  coma.  The  tongue  is 
at  first  slightly  covered  with  a  whitish  fur.  In  conditions  of  great  depres- 
sion it  becomes  dry  and  brown  and  sordes  collect.  Taste  is  lost  and  the 
patient  refuses  food;  nevertheless  the  vomiting  persists.  Constipation  is 
commonly  present  throughout  the  sickness.  Toward  the  end  of  the  attack, 
however,  diarrhoea  and  involuntary  discharges  may  take  place.  Slight, 
exceptionally  marked,  enlargement  of  the  spleen  may  be  made  out.  The 
fever  is  generally  moderate,  very  irregular,  and  does  not  observe  a  typical 
course.  There  are  frequent  remissions.  In  some  instances  fever  is  slight 
or  absent  altogether.  On  the  other  hand,  the  temperature  may  reach 
105°  or  106°  F.  (40.5°-41.1°  C).  It  may  abruptly  rise  before  death.  The 
fever,  even  when  intense,  may  be  of  short  duration.  There  is  no  constant 
relation  between  the  intensity  of  the  febrile  movement  and  the  severity 
of  the  other  symptoms.  Defervescence  may  take  place  without  improve- 
ment in  other  respects,  so  that  there  are  cases  in  which  severe  nervous 
symptoms  persist  for  weeks  after  the  temperature  has  fallen  to  normal  or 
subnormal  ranges.  Many  of  the  cases  show  a  temperature  range  of  irreg- 
ularly remittent  type.  In  the  milder  cases  the  temperature  is  sometimes 
distinctly  intermittent.  The  subfebrile  temperatures  are  sometimes  broken 
by  rapid  and  transient  elevations.  The  pulse  is  also  irregular.  There  is 
no  constant  correspondence  between  the  pulse  and  temperature.  It  may 
be  soft  and  w^eak,  even  slower  than  in  health,  and  is  often  intermittent  and 

arrhythmic.    Abrupt  changes  in  the 
'  '      force  and  frequency  of  the  pulse  are 

common.  Change  in  the  frequency 
from  80  to  100  has  been  observed  in 
the  course  of  a  minute.  The  rhythm 
of  the  respiration  may  be  disturbed 
and  Cheyne-Stokes  breathing  may 
occur  in  the  graver  cases. 

Leucocytosis  is  present  through- 
out the  disease,  diminishing  toward 
the  end  of  the  attack  in  cases 
which    recover. 

Lesions  of  the  skin  are  com- 
mon. To  their  prominence  is  due 
the  old  name  of  spotted  fever.  They 
vary  greatly  in  different  epidemics. 
In  many  cases  they  are  absent  alto- 
gether. They  are  often  polymor- 
phous. Herpes  is  far  more  common 
than  any  other  eruption.  It  usually  appears  on  the  lips  and  nose, 
but  may  involve  other  parts  of  the  face  or  body  and  may  vary  from 
a  crop  of  a  few  fine  vesicles  to  an  abundant  eruption  of  large  vesicles. 


Fig.  249. — Petechial   eiuption  ;    epidemic   cerebro- 
spinal meningitis. — Royer. 


CEREBROSPINAL  FEVER.  733 

A  petechial  rash  is  frequently  observed,  and  in  some  instances  extensive 
hemorrhagic  areas  develop  in  the  skin.  The  petechise  often  resemble 
flea-bites.  They  are  distributed  in  varying  numbers  over  the  whole 
surface,  but  particularly  about  the  knees  and  elbows.  In  some  cases 
the  rash  is  abundant  and  develops  with  great  rapidity.  Patches  of 
erythema,  dusky  mottlings,  and  rose  spots  disappearing  on  pressure,  like 
the  rash  of  enteric  fever,  have  been  observed.  Among  the  rarer  cutaneous 
manifestations  are  urticaria,  erythema  nodosum,  pemphigus,  and  gangrene. 
The  urine  is,  as  a  rule,  increased.  It  may  be  much  increased  even  with 
high  temperature.  The  reaction  is  usually  acid.  A  moderate  amount  of 
albumin  is  frequently  present.  There  is  a  special  form  of  cerebrospinal 
fever  characterized  by  symptoms  of  an  acute  nephritis  and  corresponding 
to  the  renal  form  of  enteric  fever.  Glycosuria  occasionally  occurs,  and  in 
malignant  cases  hsematuria  has  been  observed.  Retention  of  urine  is 
common  in  the  graver  cases.  Polyuria  is  frequent  in  children,  and  in  some 
cases  has  persisted  for  years  after  convalescence. 

The  eye  lesions  are  referable  to  three  causes:  First,  neuritis,  due  to 
the  involvement  of  the  nerve  in  the  exudate  at  the  base  without  extension 
of  the  inflammatory  process  to  either  the  orbit  or  the  eye.  This  condition 
may  affect  the  oculomotor  and  the  optic  nerve.  Second,  inflammation 
from  the  meninges  may  extend  directly  into  the  eye  along  the  pia-arach- 
noid  of  the  optic  nerve,  causing  purulent  choroido-iritis  and  in  very  rare 
instances  suppuration  in  the  orbit.  Keratitis  may  arise  in  consequence  of 
an  extension  of  the  inflammation  from  the  iris  and  ciliary  region.  The 
third  cause  is  neuritis  of  the  fifth  nerve,  with  loss  of  sensation  and  keratitis 
and  purulent  conjunctivitis. 

Symptoms  relating  to  the  auditory  apparatus  are  very  common.  The 
auditory  nerve  is  generally  swollen  and  surrounded  by  the  exudate.  Ex- 
tensive degeneration  of  the  nerve-fibres  is  frequently  found,  being  most 
marked  in  the  chronic  cases.  The  abortive  form  of  epidemic  cerebrospinal 
meningitis  is  the  cause  of  many  cases  of  early  acquired  deafness.  Deafness 
is  frequently  due  to  disease  of  the  labyrinth.  Otitis  media  and  mastoid 
disease  occur.    The  diplococci  are  found  in  the  pus-cells. 

Coryza  has  been  frequently  observed  in  the  course  of  the  attack. 
Weigert  first  advanced  the  opinion  that  in  meningitis  the  nose  forms  the 
portal  of  entry  for  the  infectious  organisms.  It  may  be,  however,  that 
their  presence  is  due  to  an  extension  from  the  brain  and  not  to  primary 
invasion.     Epistaxis  also  occurs. 

The  wasting  in  severe  cases  is  rapid  and  extreme.  An  early,  sudden,  and 
great  loss  of  strength  is  a  frequent  and  prominent  condition  in  this  disease. 

The  symptoms  may  be  divided  into  those  due  to  the  inflammatory 
lesions  of  the  cerebrospinal  organs  and  those  due  to  a  general  infection. 
In  the  malignant  cases  both  these  groups  of  symptoms  are  of  overwhelm- 
ing severity.  In  the  mild  cases  the  nervous  symptoms  are  predominant. 
The  foregoing  symptoms  indicate  the  nature  and  severity  of  the  disease 
in  its  ordinary  form. 

Anomalous  Forms. — 1.  Malignant  (Meningitis  Cerebrospinalis  Epi- 
demica  Siderans). — The  patient  is  struck  clown  without  warning  and  speed- 
ily falls  into  a  state  of  collapse.     A  violent  chill  is  followed  by  cyanosis, 


734  MEDICAL  DIAGNOSIS. 

coldness  of  the  surface,  profuse  perspiration,  intense  headache  which  alter- 
nates with  drowsiness,  and  brief  delirium  followed  by  unconsciousness. 
There  may  be  contraction  of  the  neck.  Respiration  is  slow  and  labored; 
the  pulse  rapid  and  feeble;  the  urine  scanty  and  loaded  with  albumin. 
Purpuric  blotches  appear  on  the  surface.  Cases  of  this  kind  have  occurred 
in  many  epidemics  and  with  greatest  frequency  at  the  beginning  of  the 
outbreak.  They  may  occur  sporadically..  Death  may  ensue  in  the  course 
of  a  few  hours. 

2.  Abortive  {Meningitis  Cerebrospinalis  Epidemica  Abortiva). — The 
onset  of  the  attack  is  severe.  In  the  course  of  a  few  days  the  symptoms 
subside  and  convalescence  is  rapid. 

3.  Mild  (Meningitis  Cerebrospinalis  Epidemica  Ambulans). — Patients 
complain  of  headache,  stiffness  in  the  neck  and  spine,  and  malaise.  Vom- 
iting occurs.  Fever  is,  as  a  rule,  absent.  Cases  of  this  kind  can  only  be 
recognized  in  the  light  of  a  prevailing  epidemic. 

4.  Intermittent  {Meningitis  Cerebrospinalis  Epidemica  Intermittens). 
— This  form  is  common.     Not  only  the  fever,  but  other  symptoms  of  the 


Fig.  250. — Cerebrospinal  fever  ;  53d  day  of  the  attack. — Pennsylvania  Hospital. 

disease  show  extraordinary  exacerbations  and  remissions,  which  may  be 
repeated  at  intervals  of  twenty-four  or  forty-eight  hours.  These  cases 
may  be  due  to  successive  involvement  of  areas  of  the  meninges  or  to 
fresh  growths  of  the  organisms.  They  rarely  present  the  well-marked 
periodicity  of  the  malarious  diseases. 

5.  Chronic  {Meningitis  Cerebrospinalis  Epidemica  Chronica). — Cases 
of  this  form  occur  in  all  epidemics.  The  disease  lasts,  with  numerous  com- 
plications, remissions,  and  exacerbations,  for  several  weeks  or  in  some 
instances  for  five  or  six  months.  Emaciation  is  extreme.  The  symptoms 
may  be  due  to  the  persistence  of  conditions  left  by  the  acute  attack,  such 
as  chronic  hydrocephalus  or  abscess  of  the  brain,  or  general  neuritis. 

Complications  and  Sequels. — Among  the  complications  and  sequels 
are  pleurisy,  endocarditis,  and  pericarditis.  Bronchial  catarrh  and  deglu- 
tition pneumonia  are  very  common.  Croupous  pneumonia  has  been  com- 
mon in  some  of  the  epidemics.  This  complication  occurs  more  frequently 
at  the  close  than  at  the  beginning  of  an  epidemic.  It  is  uncertain  whether 
in  some  instances  the  cases  of  pneumonia  reported  in  connection  with  epi- 
demic meningitis  have  been  cases  of  true  croupous  pneumonia  or  cases  of 
meningococcus  pneumonia. 


CEREBROSPINAL  FEVER.  735 

Arthritis,  commonly  slight,  but  in  rare  instances  suppurative,  has 
been  noted.  The  wrist-joints  are  most  commonty  involved.  Swelling  of 
the  parotid  glands  is  an  occasional  accident  of  the  disease.  It  may  be 
slight  or  may  run  on  to  suppuration — parotid  bubo. 

Intestinal  catarrh  may  occur  as  a  complication.  Malarial  and  enteric 
fever,  and  measles,  scarlet  fever,  and  cholera  have  been  encountered  as 
intercurrent  affections. 

The  convalescence  is  irregular  and  uncertain.  After  severe  cases  it  is 
apt  to  be  tardy.     Relapses  are  not  uncommon  and  are  often  fatal. 

Among  the  more  important  sequels  are  prolonged  debility  and  ema- 
ciation, palsies  and  various  forms  of  paralysis,  impairment  of  intelligence 
in  consequence  of  chronic  meningitis  and  chronic  hydrocephalus,  espe- 
cially in  children,  and  more  or  less  complete  deafness  and  loss  of  vision. 
General  motor  weakness  and  paralysis  of  individual  cranial  nerves  or  of 
the  lower  extremities  may  persist  for  a  long  time.  They  depend  on  lesions 
of  the  brain  or  spinal  cord,  or  pressure  exerted  by  extensive  organized 
inflammatory  exudate,  or  on  peripheral  neuritis. 

Diagnosis. — Direct  Diagnosis. — The  recognition  of  cerebrospinal 
fever  by  ordinary  clinical  methods  is  a  matter  of  difficulty  in  sporadic 
cases  and  at  the  beginning  of  outbreaks.  The  diagnosis  of  any  form  of 
meningitis  is  occasionally  obscure.  Sudden  onset,  chill,  fever,  vomiting, 
delirium,  tremor,  and  painful  rigidity  of  the  back  of  the  neck  may  occur 
in  pneumonia,  the  malignant  form  of  variola,  typhus,  and  especially  in  the 
cerebrospinal  form  of  enteric  fever.  Kernig's  sign  is  found  to  be  present 
in  80  to  90  per  cent,  of  the  cases  of  meningitis  and  only  exceptionally  pres- 
ent in  other  diseases.  This  test  is  often  attended  by  evident  pain  on  the 
part  of  the  patient. 

If  meningitis  be  present  there  is  usually  no  great  difficulty  in  recogniz- 
ing cerebrospinal  fever  during  an  epidemic.  The  ordinary  and  anomalous 
forms  alike  show  a  symptom-complex  that  in  the  course  of  a  little  time  is 
distinctive.  In  all  cases  when  practicable  lumbar  puncture  should  be 
performed.  If  carried  out  early  in 
the  attack,  at  the  time  when  the 
diagnosis  is  often  as  important 
as  it  is  difficult,  the  result  is  com- 
monly conclusive. 

Lumbar  Puncture  (Quincke). 
— The  operation  is  devoid  of  danger 
and  can  be  performed  without  gen- 
eral ansesthesia.  Freezing  of  the 
skin  may  be  dispensed  with,  as  it 
is  as  painful  as  the  puncture  and 
causes  unnecessary  delay.  In  chil- 
dren excitement  may  be  avoided 
by  a  few  whiffs  of  chloroform.  ^'''-  -'''•" ^'^''™;ieni3tis*^?oyer"'''  ^'"''^'''■°"p'"^' 
Surgical  antisepsis  is  to  be  strictly 

observed.  Suitable  pointed  cannulas  are  sold  in  the  shops.  A  small 
aspirator  needle  may  be  used.  The  instrument  is  introduced  into  the 
subarachnoid  space  between  the  fourth  and  fifth  lumbar  vertebra?.      The 


736  MEDICAL  DIAGNOSIS. 

point  of  entrance  may  be  determined  by  drawing  a  line  connecting  the 
highest  points  of  the  crest  of  the  ilium  posteriorly.  This  line  passes  over 
the  spine  of  the  fourth  lumbar  vertebra.  The  point  of  entrance  is  about 
one  centimetre  below  and  one  centimetre  to  the  right  of  the  intersection 
of  the  transverse  line  and  the  median  line.  Some  prefer  the  third  lumbar 
interspace.  The  patient  should  lie  upon  the  right  side,  the  spine  being 
strongly  bowed,  the  thighs  and  knees  flexed,  and  the  left  shoulder  drawn 
forward.  The  thumb  of  the  left  hand  being  used  as  a  guide,  the  needle  is 
thrust  with  a  rotary  movement  in  an  upward  and  inward  direction  to  a 
depth  varying,  according  to  the  age  of  the  patient  and  the  thickness  of  the 
tissues,  from  about  two  and  a  half  centimetres  in  infants  to  between  four 
and  six  centimetres  in  adults.  The  fluid  runs  drop  by  drop  or  in  a  stream, 
the  normal  pressure  being  about  120  mm.  of  mercury.  In  meningitis  the 
pressure  may  reach  250-300  mm.  Normal  fluid  is  clear  and  limpid,  but 
no  conclusions  can  be  reached  without  careful  laboratory  investigation, 
including,  in  doubtful  cases,  the  inoculation  of  a  guinea-pig. 

If  the  patient  has  meningitis  the  fluid  withdrawn  is,  as  a  rule,  but 
not  invariably,  more  or  less  cloudy;  if  cerebrospinal  fever,  the  Diplococcus 
intracellularis  meningitidis — meningococcus — will  be  found  on  direct  mi- 
croscopic examination  or  in  cultures.  Positive  conclusions  can  only  be 
drawn  from  positive  results.  When  the  result  is  negative  the  operation 
must  be  repeated. 

Differential  Diagnosis. — 1.  Pneumococcus  Meningitis. — This  may 
occur  alone  or  in  connection  with  croupous  pneumonia.  The  pulmonary 
lesion  may  be  latent.  Symptoms  indicating  extensive  infection  of  the 
meninges,  of  the  cord  and  spinal  roots,  and  extension  of  the  infective  proc- 
ess along  the  cranial  nerves  are  less  marked  or  absent  altogether.  Con- 
traction of  the  muscles  of  the  neck  may  be  absent,  delirium  and  coma  are 
present  and  occur  early,  and  this  form  of  meningitis  is  fatal,  while  cases 
of  the  epidemic  form  may  recover. 

2.  Streptococcus  Meningitis.  —  This  form  is  secondary  to  infection 
elsewhere.  Fracture  of  the  skull,  especially  fracture  of  the  base,  local 
abscess  formation,  acute  endocarditis,  erysipelas  of  the  face  and  scalp, 
otitis  media  with  extension  to  the  mastoid  or  the  meninges  are  forms  of 
primary  infection.  Opisthotonos  is  neither  common  nor  well  developed. 
The  symptoms  develop  slowly  and  are  often  for  a  time  obscure.  The 
association  of  painful  rigidity,  intense  headache,  and  vomiting  is  not  con- 
spicuous.    Eye  symptoms  are  common. 

3.  Tuberculous  Meningitis. — This,  perhaps  the  most  familiar  form  of 
meningitis,  is  to  be  distinguished  from  cerebrospinal  fever  by  a  protracted 
period  of  prodromes,  more  gradual  onset,  slower  course,  slow  and  irregular 
pulse,  great  irregularity  of  the  respiration,  and  the  absence  of  eruption. 
Antecedent  tuberculous  disease,  failure  of  health  following  measles  or 
influenza,  tuberculous  glands,  or  a  hereditary  predisposition  to  tuberculous 
infection  are  found  in  the  history  of  the  patient.  In  children  or  during 
the  prevalence  of  an  epidemic  of  cerebrospinal  fever  and  in  cases  in  which 
the  tuberculous  process  involves  the  spinal  meninges  (Hirsch),  the  diag- 
nosis  is   far  from   easy.      The   result   of  spinal    puncture   is   conclusive. 

4.  The  Cerebrospinal  Form  of  Enteric  Fever  (see  p.  633). 


ERYSIPELAS.  737 

5.  Scarlet  Fever. — In  some  instances  the  sudden  onset,  high  febrile 
movement,  vomiting,  convulsions,  and  stupor  suggest  cerebrospinal  fever 
as  it  occurs  in  children.  The  presence  of  the  peculiar  redness  of  the  pala- 
tine half-arches,  rapidly  followed  by  general  erythematous  angina,  are  im- 
portant. In  the  course  of  twenty-four  or  thirty-six  hours  the  efflorescence 
will  clear  up  any  uncertainty. 

6.  Typhus  Fever. — At  one  time  cerebrospinal  fever  was  confounded 
"with  typhus  or  regarded  as  a  variety  of  that  disease.  To  Stille  is  due  the 
credit  of  having  finally  settled  every  question  of  doubt  concerning  the 
identity  of  these  two  diseases  in  this  country.  They  are  in  strong  con- 
trast in  respect  of  their  causes,  symptoms,  course,  lesions,  and  sequels. 

7.  Hysteria. — Cases  of  cerebrospinal  fever,  occurring  in  nervous  fe- 
males at  the  close  of  epidemics  or  sporadically,  have  presented  a  deUrium 
so  peculiar  and  an  array  of  symptoms  so  little  characteristic  that  they 
have  been  looked  upon  as  manifestations  of  hysteria.  This  error  in  diag- 
nosis is  no  longer  possible. 

Prognosis. — In  individual  cases  the  prognosis  can  never  be  made 
with  certainty.  The  abortive  and  fulminant  cases  run  the  most  rapid 
course.  Hirsch  has  emphasized  the  fact  that  certain  cases,  which  at  the 
onset  present  the  symptoms  of  cerebrospinal  fever,  recover  after  an  illness 
of  a  few  hours  which  terminates  in  free  sweating.  The  malignant  cases, 
on  the  other  hand,  prove  fatal  in  a  few  hours  or  two  or  three  days.  Mod- 
erately severe  cases  may  last  one  or  two  weeks  or  several  months.  The 
first  week  is  the  time  of  greatest  danger.  Symptoms  rendering  the  prog- 
nosis unfavorable  are  intense  excitement,  early  depression,  persistent 
vomiting,  irregular  respiration,  and  convulsions  alternating  with  coma. 
The  average  mortality  is  about  40  per  cent.  It  varies  in  different  epidemics 
from  20  to  75  per  cent. 

Relapses  are  not  infrequent  and  are  often  fatal. 

XVII.   ERYSIPELAS. 

Definition. — An  acute,  infectious,  endemic  affection  caused  by  the 
Streptococcus  erysipelatis  and  characterized  by  fever,  a  peculiar  circum- 
scribed inflammation  of  the  skin,  and  ready  transmissibility. 

Etiology. — Predisposing  Influences. — Erysipelas  is  a  widely  prev- 
alent disease  which  occurs  in  every  climate  and  to  which  all  races  are 
liable.  It  is  endemic  at  all  seasons  of  the  year  and  may  prevail  in  local 
epidemics  at  any  time  if  the  conditions  are  favorable  to  its  spread.  Such 
epidemics  are  more  common  and  extensive  in  the  spring.  Erysipelas  be- 
longs to  the  group  of  wound  infections  and  spreads  chiefly  by  accidental 
inoculation.  Neither  age  nor  sex  therefore  essentially  predisposes  to  the 
disease.  Incidentally  certain  conditions  of  the  individual  and  his  sur- 
roundings render  him  especially  liable.  The  integuments  afford  less  com- 
plete protection  against  infection  at  the  extremes  of  life  than  at  other 
periods.  During  the  first  two  weeks,  the  infant  is  very  liable  to  erysip- 
elas, which  most  commonly  starts  from  the  umbilicus,  though  it  may  appear 
at  any  wound  or  abrasion.  Aged  persons  frequently  suffer  from  chronic 
5  diseases  of  the  skin,  such  as  eczema,  acne,  furunculosis,  prurigo,  varicose 

47 


738  MEDICAL  DIAGNOSIS. 

ulcers  and  fissures  where  the  skin  and  mucous  membranes  merge,  and  are 
hence  especially  liable  to  accidental  inoculation.  But  these  lesions  may 
occur  at  any  period  of  life.  Wounds  and  injuries  are  more  common  in 
males  than  in  females  and  for  this  reason  the  former  suffer  from  erysipelas 
more  frequently  than  the  latter.  Those  who  have  recently  undergone 
surgical  operations  and  lying-in  women  are  peculiarly  liable  to  infection. 
Exhausting  diseases,  conditions  of  cachexia,  chronic  nephritis,  and  alco- 
holism are  important  predisposing  factors.  Among  local  conditions  filth, 
overcrowding,  defective  ventilation,  and  deficient  sunlight  are  most  im- 
portant. Unsanitary  apartments  and  buildings  frequently  become  the 
abiding  place  of  the  poison.  The  appearance  of  a  single  case  of  erysipelas 
in  a  surgical  ward  or  lying-in  hospital  is  an  imperative  reason,  not  only 
for  immediate  disinfection,  but  also  for  abandoning  its  use  for  a  period. 
Notwithstanding  these  precautions  the  disease  occasionally  continues  to 
recur  in  modern  institutions  of  approved  construction.  The  greatly  di- 
minished death-rate  after  surgical  operations  and  among  puerperal  women 
at  the  present  time  is  largely  due  to  the  infrequency  of  erysipelas,  and  this 
to  the  scientific  cleanliness  of  a  modern  technic.  A  family  or  hereditary 
predisposition  is  sometimes  observed.  An  apparent  personal  predisposi- 
tion is  not  uncommon.  Certain  individuals  contract  the  disease  several 
times,  at  intervals  varying  from  some  months  to  a  year  or  more. 

Exciting  Cause. — The  specific  cause  of  the  disease  is  the  Strepto- 
coccus erysipelatis,  or  S.  pathogenes  longus.  This  organism  belongs 
to  the  group  S.  pyogenes.  The  Streptococcus  erysipelatis  is  thrown  off 
from  the  inflamed  surface  throughout  the  whole  course  of  the  disease  and 
during  the  desquamation.  It  is  capable  of  an  indefinitely  prolonged  ex- 
istence. Under  ordinary  circumstances  it  is  not  intensely  virulent,  but 
when  a  number  of  susceptible  persons  are  crowded  together  under  bad 
hygienic  conditions  the  results  are  disastrous.  It  is  extremely  tenacious, 
adhering  to  the  clothing  and  bedding  of  the  patient  and  the  furniture  and 
walls  and  floor  of  the  room,  occupied  during  his  illness.  It  clings  also  to 
the  clothing  of  individuals  who  come  into  contact  with  the  patient,  to  the 
hands  of  operators  and  attendants,  and  to  surgical  instruments.  By  these 
means  it  may  be  and  frequently  is,  in  the  absence  of  proper  precautions, 
communicated  to  persons  at  a  distance,  who  in  their  turn  become  centres 
of  infection.  It  gains  access  to  the  organism  in  the  vast  majority  of  cases 
by  demonstrable  wounds  or  abrasions  of  the  skin,  or,  less  commonly,  of 
the  mucous  membranes.  The  most  minute  lesion  of  the  integument, 
readily  overlooked  or  already  healed  when  the  erysipelatous  flush  first 
appears,  or,  if  not  healed,  concealed  by  the  blush  itself,  may  serve  as  the 
point  of  entrance.  Fissures  at  the  angle  of  the  mouth,  nose,  or  eye,  a  lesion 
of  the  lachrymal  duct,  a  crack  in  the  fold  behind  the  ear,  a  fissured  nipple, 
an  abrasion  about  the  genitalia  or  at  the  anus,  the  prick  of  a  needle,  the 
piercing  of  the  lobule  for  ear-rings,  a  scratch,  in  fact  any  solution  of  the 
continuity  of  the  integument  whatever,  may  be  the  starting  point  of  the 
disease.  In  like  manner  any  lesion  of  the  mucous  membrane  of  the  upper 
respiratory  tract  or  of  the  oropharynx  may  become  the  seat  of  primary 
infection.  The  condition  of  the  mucous  membrane  of  the  genital  tract 
in  the  puerperal  woman  especially  invites  infection,  which  is  invariably 


ERYSIPELAS. 


739 


followed  under  these  circumstances  by  serious  results.  The  relationship 
of  certain  forms  of  puerperal  infection  and  erysipelas  is  obvious.  Chronic 
affections  of  the  nasal  or  laryngeal  mucous  membrane,  varicose  ulcers 
and  diseases  of  the  skin  render  those  suffering  from  them  hable  to  repeated 
attacks  of  erysipelas.  Abrasion  of  the  skin  for  vaccination,  or  the  use  of 
the  hypodermic  syringe  without  proper  precautions  as  to  disinfection 
and  cleanliness,  may  open  the  way  for  the  erysipelatous  infection. 

Symptoms. — The  incubation  varies  from  a  few  hours  to  several  days. 
Its  extreme  Hmit  is  not  more  than  a  week.  The  local  and  constitutional 
symptoms  of  erysipelas  of  the  face  and  head  and  of  other  parts  of  the  body 
are  identical.  When  the 
face  and  head  are  involved 
it  not  infrequently  happens 
that  the  local  injury  to  the 
skin  by  which  the  infection 
has  taken  place  cannot  be 
discovered.  Such  cases  are 
sometimes  spoken  of  as 
idiopathic — E.  verum,  E. 
cryptogeneticum.  When  the 
cutaneous  inflammation 
affects  other  parts  of  the 
body,  a  lesion  of  the  skin 
or  mucous  membrane  can 
almost  always  be  found. 
In  general  terms  the  sever- 
ity of  the  constitutional 
symptoms  is  in  proportion 
to  the  extent  and  intensity 
of  the  local  inflammation. 

Prodromes  are  as  a 
rule  absent.  The  onset  is 
commonly  marked  by  a 
rigor  or  shivering,  followed 
by  a  rapid  rise  of  temper- 
ature to  103°-105°  F.  (39.5° 
-40.5°  C).  Headache, 
pains  in  the  back  and 
occur.      In   the    course   of 


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hmbs,  nausea  and  vomiting  also  frequently 
some  hours  the  signs  of  local  inflammation 
appear.  In  many  of  the  milder  cases  the  constitutional  symptoms  are 
at  first  slight  and  the  patient  becomes  aware  of  the  trouble  by 
burning  and  pricking  sensations  in  the  affected  skin.  The  skin  is  red- 
dened, tense,  and  glossy.  It  is  swollen  and  oedematous  and  the  borders 
of  the  affected  area  are  abruptly  marginate.  It  is  hot  and  firm  to  the  touch 
and  the  patient  complains  of  subjective  sensations  of  burning,  tension, 
and  stiffness.  It  is  a  peculiarity  of  the  erysipelatous  inflammation  that, 
involving  a  limited  area  at  first,  it  tends  to  spread  broadly  in  various  direc- 
tions, advancing  by  a  well-defined  border  slightly  raised  above  the  level 
of  the  surrounding  skin.     This  advance  is  usually  from  an  ear  across  the 


740  MEDICAL  DIAGNOSIS. 

face  to  the  other  ear,  or  from  any  point,  as  the  corner  of  the  nose  or  mouth, 
or  the  canthus  of  an  eye,  rapidly  over  the  entire  face,  into  the  hairy  scalp, 
and  downwards  to  the  neck.  The  general  swelling  in  severe  cases  is  marked 
and  the  loose  skin  of  the  eyelids  and  adjacent  parts  becomes  enormously 
cedematous.  The  eyelids  cannot  be  opened,  the  nose  is  swollen  to  an 
extraordinary  bulk,  the  lips  hugely  distended,  the  ears  cushiony  and 
deformed  and  the  whole  countenance  strangely  disfigured  and  unrecogniz- 
able. As  the  inflammation  advances  cord-like  thickenings  of  the  lymphatic 
vessels  may  often  be  felt  upon  palpation  beyond  its  border  in  the  area  of 
skin  which  as  yet  presents  no  discoloration  or  oedema.  In  some  instances 
the  involved  lymphatic  vessels  appear  as  reddened  strands  or  'spots,  ad- 
vanced areas  of  infection  which  are  speedily  overtaken  by  the  progressing 
inflammation.  The  neighboring  superficial  lymphatic  glands  are  very 
often  enlarged  and  tender.  In  severe  cases  vesicles  form  upon  the  surface 
of  the  inflamed  skin,  especially  upon  the  eyelids,  ears,  and  forehead.  In 
the  course  of  three  or  four  days  the  inflammation  reaches  its  height  and 
begins  to  undergo  resolution  at  the  point  first  involved.  Here  the  color 
becomes  paler,  the  swelling  diminishes,  and  desquamation  takes  place; 
meanwhile  the  peripheral  inflammation  may  for  a  day  or  two  continue 
to  advance.  Careful  inspection  from  day  to  day  reveals  the  fact  that  at 
any  given  point  the  inflammation  reaches  its  maximum  in  the  course  of 
three  or  four  days  and  then  rapidly  subsides,  a  matter  of  importance  in 
estimating  the  worth  of  local  therapeutical  applications.  The  mucous 
membrane  of  the  mouth  and  nose  is  frequently  involved  by  extension.  The 
mouth  and  gums  are  reddened,  the  pharynx  is  congested,  the  tongue 
swollen,  dry,  and  cracked.  The  pulse  is  rapid.  The  mind  is  commonly 
clear.  In  the  course  of  six  or  seven  days  the  rash  in  favorable  cases  ceases 
to  spread,  the  redness  and  swelling  subside,  the  temperature  falls  by 
crisis,  and  the  patient  enters  upon  convalescence.  There  is  marked  leuco- 
cytosis.  The  urine  is  scanty  and  high  colored.  Febrile  albuminuria  is 
commonly  present.  Recrudescences  of  fever  frequently  occur.  Relapses 
are  not  common. 

Anomalies  in  the  clinical  course  relate  to  the  rash  and  to  the  con- 
stitutional disturbances.  That  form  in  which  vesiculation  is  abundant 
is  known  as  E.  vesiculosum;  that  in  which  bullae  form  as  E.  bullosum.  The 
contents  of  the  vesicles  and  blebs  is  usually  a  slightly  turbid  serum.  Pus 
may  be  present — E.  pustulosum.  These  lesions  may  be  ruptured  by  acci- 
dental violence  or  the  contents  may  undergo  gradual  resorption.  Thin, 
yellowish-brown  crusts  result,  which  after  a  little  time  separate  without 
scar  formation.  Deeper  abscess  formation  in  the  connective  tissue  is  not 
uncommon — E.  phlegmonosum.  A  very  grave  form  is  that  in  which,  in 
consequence  of  enfeebled  powers  of  resistance,  the  swelling  and  tension  result 
in  necrosis  and  gangrene  of  the  skin — E.  gangrcenosum.  The  inflammation 
in  rare  cases  shows  a  remarkable  tendency  to  spread — E.  migrans.  The 
inflammation  may  advance  from  the  face  over  the  neck  and  chest,  sub- 
siding in  one  area  as  it  extends  to  another,  until  it  has  traversed  the  greater 
part  of  the  body.  The  duration  of  the  disease  may  extend  over  many 
weeks,  and  death  may  occur  from  exhaustion  or  from  a  complicating  pneu- 
monia.    Anomalies  in  the  constitutional  symptoms  consist  in  the  absence 


ERYSIPELAS. 


741 


of  fever — E.  afebrile;  in  hyperpyrexia  which  is  apt  to  terminate  fatally  with 
progressive  cardiac  weakness  and  coma;  or  in  great  constitutional  depress 
sion  from  the  outset,  a  condition  to  which  cachectic  and  aged  persons  and 
those  given  to  excesses  in  alcohol  are  especially  liable.  Erysipelas  of  the  new- 
born, starting  at  the  navel,  shows  an  abruptly  marginate  area  of  redness 
and  induration,  which  may  be  superficial  but  commonly  involves  the  deeper 
tissues.  It  extends  rapidly  and  may  invade  the  greater  part  of  the  trunk. 
Suppuration  and  gangrene  sometimes  occur.  The  prognosis  is  ominous. 
Complications  and  Sequels. — The  visceral  complications  are  due  to 
general  septic  infection.     Purulent  meningitis  may  occur  in  erysipelas  of 


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Fig   ^53. — Erysipelas  ambulans.    Woman  aged  50.     Recovery. 


the  face  and  head.  When  the  inflammation  involves  the  mucous  membrane 
of  the  throat  or  invades  the  neck,  acute  oedematous  laryngitis  may  occur 
and  prove  rapidly  fatal.  Croupous  pneumonia  is  sometimes  encountered. 
Bronchopneumonia  is  a  common  late  complication  in  fatal  cases.  Otitis 
media  and  acute  nephritis  are  occasional  complications.  Septic  inflamma- 
tion of  one  or  more  joints  may  occur.  Malignant  endocarditis,  pericarditis, 
and  pleurisy  are  important  complications.  Among  the  sequels  are  areas 
of  cutaneous  hyperesthesia  or  anassthesia  and  persistent  neuralgias. 
Repeated  attacks  of  erysipelas  have  in  rare  instances  been  followed  by 
thickening  and  induration  of  the  skin.  The  hair  falls  out  after  erysipelas 
of  the  scalp,  sometimes  after  severe  attacks  involving  distant  parts  of  the 
body,  as  in  the  other  acute  infections. 


742  MEDICAL  DIAGNOSIS. 

Diagnosis. — The  direct  diagnosis  of  erysipelas  rarely  presents  diflB- 
culty.  It  rests  upon  the  sudden  onset,  the  chill  or  shivering,  fever,  and 
other  constitutional  symptoms,  and  the  peculiar  character  of  the  inflamma- 
tion of  the  skin,  in  which  rapid  advance  from  an  infected  centre,  elevation 
above  the  level  of  the  surrounding  skin,  distinct  margination,  and  the 
tendency  to  resolution  in  the  region  first  involved  while  evolution  is  tak- 
ing place  at  the  border,  are  characteristic. 

The  DIFFERENTIAL  DIAGNOSIS  between  erysipelas  and  other  forms  of 
dermatitis  can  be  easily  made.  The  main  fact  is  that  erysipelas  is  an  acute 
infectious  process  attended  with  fever  which  begins  abruptly  and  ends 
by  crisis. 

Prognosis. — Previously  sound  individuals  except  at  the  extremes 
of  life  usually  recover.  In  the  new-born  erysipelas  is  commonly  fatal,  in 
the  aged  very  often  so.  In  broken  down  and  cachectic  persons  and  drunk- 
ards the  prognosis  is  unfavorable.  Death  is  usually  the  result  of  intense 
general  infection  or  grave  complications.  Er\^sipelas  is  not  only  less  fre- 
quent, but  it  is  also  much  less  fatal  than  formerly.  The  mortality  is  about 
five  per  cent.     It  is  higher  in  hospitals  than  in  private  practice. 

XVIII.   SEPSIS. 

SepHcoemia;  Pycemia;  Septicopycemia. 

Definition. — A  disease  produced  by  the  general  invasion  and  growth 
in  the  body  of  pyogenic  micro-organisms. 

Pycemia  is  the  term  used  to  designate  the  condition  in  which  pus  col- 
lections occur  in  various  parts  of  the  body  in  consequence  of  the  lodgement 
of  infected  emboli;  sepiiccemia  —  hactercemia  —  that  condition  in  which 
purulent  collections  are  absent,  but  with  or  in  the  absence  of  a  local  infec- 
tion there  is  invasion  of  the  blood  and  tissues  by  bacteria  together  with 
the  signs  of  profound  disorder  of  the  entire  organism,  and  septicopycemia, 
the  condition  in  which  bactersemia  and  pyaemia  are  present  at  the  same 
time.  Saprcemia  is  the  condition  caused  by  the  absorption  into  the  blood 
of  septic  or  putrid  products.  The  general  term  septic  infection  or  sepsis  is 
more  convenient  and  more  in  accordance  with  the  facts.  Some  other 
definitions  are  necessary.  Infection  is  the  term  used  to  designate  the 
pathological  processes  caused  by  the  implantation  and  growth  of 
pathogenic  micro-organisms,  most  of  which  are  specific.  Toxcemia  is 
used  to  denote,  (a)  the  presence  of  soluble  toxic  substances  or  toxins  in 
the  blood,  mostly  elaborated  by  pathogenic  micro-organisms  in  their 
growth  and  multiphcation,  and  (b)  the  morbid  processes  which  those 
poisons  produce. 

Septicaemia  and  toxaemia  are  sometimes  associated,  as  in  enteric 
fever,  in  which  the  pathogenic  organism — Bacillus  typhosus — may  be 
grown  in  cultures  from  the  blood,  while  the  symptoms  of  the  disease  are 
those  of  a  continuous  intoxication;  sometimes  separate,  as  in  tetanus  and 
diphtheria,  in  which  the  infection  is  local  and  the  pathogenic  organisms 
develop  in  circumscribed  areas,  while  their  poisonous  products  produce 
characteristic  constitutional  effects. 


SEPSIS. 


743 


Etiology. — Predisposing  Influences. — The  predisposition  to  sep- 
tic infection  is  general.  It  occurs  everywhere,  at  all  periods  of  life,  and 
under  the  most  varying  circumstances.  Pathogenic  Agents. — The  pyo- 
genic cocci — streptococci  and  staphylococci — are  the  most  common.  Other 
organisms  capable  of  causing  sepsis  are  Micrococcus  lanceolatus  (pneu- 
mococcus),  gonococcus,  Bacillus  coli,  Bacillus  typhosus,  Bacillus  proteus. 
Bacillus  pyocyaneus,  and  Bacillus  influenzae. 

Symptomatology. — The  symptom-complex  is  that  of  a  severe  consti- 
tutional disease.  In  many  of  the  cases  the  general  symptoms  are  simply 
those  of  any  intense  infective  process,  without,  however,  definite  signs  of 
visceral  or  other  localization.  In  another  large  group  of  cases  to  the  fore- 
going symptoms  are  added  those  of  an  inflammatory  implication  of  the  en- 
docardium or  pericardium  with  which  the  evidences  of  myocardial  changes 
are  shortly  associated.  Again,  the  evidences  of  inflammation  of  the  bones 
and  joints  dominate  the  situation.     In  a  very  extensive  group  of  cases 


Fic.  254. — Streptococcus  pyogenes. 


Fig.  255. — Staphylococcus  pyogenes  aureus. 


the  tegumentary  structures  are  especially  involved  in  septic  inflammatory 
processes,  such  as  forms  of  eiythema,  scarlatiniform  eruptions,  malignant 
erysipelas,  and  acute  septic  phlegmon.  Subcutaneous  hemorrhages  are  com- 
mon. Finally,  we  recognize  a  great  group  of  cases  in  which  inflammatory 
and  suppurative  disease  of  the  various  viscera,  as  for  example,  the  lungs, 
kidney,  liver,  stomach,  and  intestines  or  spleen,  give  rise  to  the  chief 
manifestations  of  the  septic  process. 

The  onset  may  be  gradual,  with  chilliness  or  chills,  general  malaise, 
dragging  pains  in  the  limbs,  and  irregular  fever.  More  commonly  a  decided 
rigor  initiates  an  active  febrile  movement.  Pallor,  faint  cyanosis,  rapid 
and  feeble  pulse,  anorexia,  constipation  alternating  with  diarrhoea,  a  ten- 
dency to  profuse  sweating,  and  a  mind  strikingly  clear  and  alert  are 
symptoms  encountered  in  well-developed  sepsis.  Soreness  of  the  bones 
and  muscles,  tender  joints,  great  irregularity  of  temperature,  with  wide 
oscillations  and  a  profound  feeling  of  lassitude  are  also  common.  A  leuco- 
cytosis  of  varying  degree,  sometimes  high,  occurs  in  the  majority  of  cases. 
In  the  graver  cases  even  with  abscess  formation  at  various  points,  an 
increase  of  leucocytes  may  be  absent. 


744  MEDICAL  DIAGNOSIS. 

Toxaemia ^LocAL  Infection  with  the  Absorption  of  Toxins. — 
Familiar  examples  of  mild  and  transient  forms  are  the  chilliness  and  fever 
which  attend  an  attack  of  angina  tonsillaris  or  a  local  phlegmonous  inflam- 
mation. Most  important  are  erysipelas,  pneumonia,  diphtheria,  and  tet- 
anus,, diseases  in  which  the  pathogenic  organisms  develop  locally,  while 
the  constitutional  symptoms  are  caused  by  the  absorption  of  the  poisonous 
products  of  their  growth. 

Septicemia;  Bacteremia — Local  Infection  with  the  Invasion 
OF  Micro-organisms. — Streptococcus  and  staphylococcus  infection  is  com- 
monly at  first  local,  the  toxins  undergoing  absorption  and  causing  symp- 
toms— toxasmia.  The  process  may  be  arrested  at  this  point;  if  not,  the 
cocci  enter  the  blood  stream  and  are  carried  to  all  points  of  the  body  with- 
out causing  foci  of  suppuration.  The  cause  of  the  infection  may  frequently 
be  traced,  as  in  puerperal  sepsis  or  injuries  of  the  extremities,  along  the 
lymphatic  vessels. 

The  case  now  becomes  more  severe;  the  symptoms  more  urgent. 
Specific  infections  in  which  a  primary  local  infection  may  become  gener- 
alized are  gonorrhoea,  pneumonia,  and  puerperal  fever.  To  a  slight  extent 
the  micro-organisms  of  diphtheria  may  also  enter  the  blood  stream.  In 
the  severer  forms  of  the  specific  infectious  diseases,  as  scarlet  fever,  diph- 
theria, enteric  fever,  and  tuberculosis,  secondary  or  mixed  infections  fre- 
quently take  place,  greatly  adding  to  the  gravity  of  the  case  and  often 
obscuring  the  features  of  the  primary  disease.  The  most  active  agent  is  the 
streptococcus. 

Cryptogenetic  Septicemia — General  Septicemia  in  the  Ab- 
sence OF  Local  Infection. — Cryptogenetic  septicaemia  may  develop 
in  the  subjects  of  acute  or  chronic  disease  or  even  in  persons  in  apparently 
good  health.  This  condition  explains  a  considerable  number  of  obscure 
febrile  cases.  Many  of  the  cases  are  terminal  infections.  No  focus  of 
infection  is  apparent  during  life  or  demonstrable  after  death.  The  strep- 
tococcus is  the  common  infecting  organism,  but  the  staphylococcus,  pneu- 
mococcus,  B.  proteus  and  B.  pyocyaneus  may  be  found. 

Septicopyemia;  Pyemia — General  Infection  with  Suppura- 
tive Foci. — The  organisms  may  colonize  in  various  parts  of  the  body 
and  give  rise  to  abscess  formation.  These  suppurative  processes  are  due 
to  the  lodgement  of  infected  emboli.  The  lesions  are  known  as  embolic  or 
metastatic  abscesses.  In  infected  wounds,  septic  phlegmon,  and  osteo- 
myelitis they  are  frequently  encountered  in  the  lungs;  in  suppurative 
lesions  in  the  intestines,  or  elsewhere  in  the  parts  tributary  to  the  portal 
system,  metastatic  abscesses  occur  in  the  liver  and  may  be  accompanied 
with  suppurative  pylephlebitis.  Endocarditis  is  of  common  occurrence 
in  septicaemia.  The  most  common  organisms  in  septicopysemia  are  strep- 
tococci and  staphylococci. 

Terminal  Infections. — Secondary  or  terminal  infection  is  the  cause 
of  death  in  many  acute  and  chronic  diseases.  The  infection  may  be  local 
and  take  the  form  of  visceral  disease.  The  serous  membranes  are  espe- 
cially liable  to  these  terminal  inflammations,  and  acute  pleurisy,  pericarditis, 
peritonitis,  endocarditis,  or  meningitis  are  final  events  in  many  cases  of 
nephritis,  arteriosclerosis,  cirrhosis  of  the  liver,  and  cerebral  and  spinal 


SEPSIS.  745 

disease.  Not  rarely  the  terminal  process  is  an  acute  miliary  tuberculosis. 
The  enterocolitis  so  common  toward  the  end  of  chronic  diseases  may  be 
classed  with  the  terminal  infections.  Less  frequently  the  terminal  infection 
is  general.  This  especially  occurs  in  chronic  renal  and  cardiac  disease, 
tuberculosis,  leukaemia,  and  Hodgkin's  disease. 

Diagnosis. — Direct  Diagnosis. — It  cannot  be  made  in  the  beginning 
of  the  milder  cases.  When  the  symptoms  are  severe  or  the  illness  has  lasted 
for  some  time,  the  history  of  an  abortion  or  confinement,  an  infected 
wound  involving  the  skin  or  mucous  membrane,  an  attack  of  tonsillitis 
and  especially  middle-ear  disease,  and  the  occurrence  of  chills,  irregular 
fever,  copious  sweating,  progressive  pallor,  and  asthenia  render  the  diag- 
nosis probable.  Gonorrhoeal  infection,  the  reinfection  of  old  scars,  and  the 
previous  occurrence  of  disease  of  the  bones,  periosteum,  or  joints  are  also 
of  diagnostic  significance.  The  signs  of  an  endocarditis  are  important, 
especially  if  the  murmurs  undergo  changes  in  the  course  of  a  short  time 
or  are  associated  with  embolic  abscesses.  Blood  cultures  may  not  show 
the  presence  of  pathogenic  micro-organisms. 

Cryptogenetic  sepsis  is  more  difficult  of  diagnosis-.  The  symptom- 
complex  is  not  characteristic.  Chills  and  irregular  fever  of  wide  range, 
with  irregular,  even  prolonged  intermissions,  copious  sweating,  profound 
asthenia,  pallor,  emaciation,  followed  after  intervals  by  visceral  inflamma- 
tions, especially  affecting  the  heart,  rapid  respiration,  circumscribed  patches 
of  pulmonary  consolidation,  pleural  effusions,  enlargement  of  the  liver, 
localized  bone  disease  or  arthritis,  and  polymorphous  cutaneous  lesions, 
especially  erythema  and  hemorrhage,  are  suggestive.  The  diagnosis  must 
in  many  instances  be  made  by  exclusion. 

Differential  Diagnosis. — Acute  Miliary  Tuberculosis. — The  gen- 
eral bronchopneumonia  affecting  the  whole  of  one  or  both  lungs  which 
is  characteristic  of  this  disease  is  not  seen  in  sepsis.  If  circumscribed 
tuberculous  foci  are  present,  the  diagnosis  of  miliary  tuberculosis  is  prob- 
able. Implication  of  the  serous  membranes,  the  pleurae,  pericardium, 
meninges,  or  peritoneum  increases  the  resemblance  to  sepsis  and  renders 
the  diagnosis  more  difficult.  Chronic  Ulcerative  Phthisis. — In  the  gravest 
cases  and  particularly  in  the  stadium  ultimum,  symptoms  occur  which  are 
not  caused  by  the  Bacillus  tuberculosis.  These  secondary  infections  are 
due  to  streptococci  and  are  mostly  terminal.  Other  organisms  are  present 
in  the  sputum.  Influenza. — Severe  cases  of  influenza  may  give  rise  to 
difficulties  in  diagnosis,  especially  in  those  cases  in  which  pneumonia, 
bronchopneumonia,  pleurisy,  and  local  pus  formation  occur.  The  epi- 
demic prevalence  of  influenza,  the  sudden  onset  with  characteristic  symp- 
toms, the  prominence  of  catarrhal  symptoms  in  the  majority  of  instances, 
and  the  severe  neuralgias  early  in  the  attack  are  of  diagnostic  value. 
Enteric  Fever  (see  p.  634).  Malaria. — Perhaps  no  more  common  error  in 
diagnosis  occurs.  In  phthisis,  in  internal  abscess,  in  suppurative  disease 
of  the  liver  or  hepatic  fever  from  impacted  calculus,  in  malignant  endo- 
carditis, the  recurrent  chills,  irregular  high  temperature,  and  profuse  sweat- 
ing too  often  betraj^  the  incautious  practitioner  into  a  false  diagnosis  of 
malaria.  The  presence  of  the  malarial  parasite  in  the  blood  and  the  thera- 
peutic test,  or  either  of  them,  are  conclusive. 


746  MEDICAL  DIAGNOSIS. 

Prognosis. — The  prognosis  is  ominous.  Very  mild  cases  recover. 
Many  cases  make  an  apparent  recovery,  only  to  recur.  The  fulminant 
cases  are  fatal  in  a  short  time.  Of  visceral  localizations,  septic  endo- 
carditis is  the  most  grave.  In  the  absence  of  local  abscess  formation 
recovery  may,  in  rare  instances,  take  place  after  very  grave  constitu- 
tional symptoms  have  lasted  a  long  time.  Brilliant  results  sometimes 
follow  the  early  evacuation  of  pus  and  effectual  drainage. 

XIX.   RHEUMATIC   FEVER. 

Acute  Rheumatism;    Acute  Polyarthritis. 

Definition. — An  acute  febrile  disease  of  undetermined  causation, 
characterized  by  polyarthritis  of  fugacious  character  and  a  tendency  to 
inflammation  of  the  endocardium  and  pericardium. 

Etiology. — Predisposing  Influences. — Rheumatic  fever  is  a  disease 
of  northern  and  temperate  climates.  The  effect  of  season  is  modified 
by  local  conditions.  Cold  and  dampness,  and  especially  a  combination 
of  these  two  seasonal  conditions,  constitute  predisposing  factors  of  great 
importance.  Rheumatic  fever  is  rare  in  the  first  years  of  life  and  after 
the  age  of  fifty.  Adolescents  and  young  adults  are  especially  liable. 
The  two  hemidecades  of  greatest  liability  are  those  from  15  to  20  and  from 
20  to  25.  First  attacks  are  ver}^  rare  after  the  fortieth  year.  The  liability 
of  the  sexes  is  much  modified  by  age  and  occupation.  If  these  factors 
are  disregarded  males  appear  to  be  more  liable  than  females  in  about  the 
proportion  of  2.5  to  1.0.  Under  twenty  the  disease  is  more  common  in 
females.  The  predisposition  appears  to  be  hereditary,  usually  from  the 
maternal  side.  Those  avocations  which  involve  exposure  to  cold  and 
damp  and  sudden  violent  changes  of  temperature  constitute  a  predispos- 
ing influence  of  great  importance.  We  find  a  great  majority  of  the  cases 
among  coachmen,  cooks,  bakers,  housemaids,  sailors,  gardeners  and  out- 
door laborers.  It  is  sometimes  possible  to  trace  the  attack  to  sudden  or 
prolonged  exposure  to  cold  and  damp. 

Exciting  Cause. — The  specific  pathogenic  agent  has  not  yet  been 
conclusively  demonstrated.  The  hypothesis  that  the  infection  is  septic 
rather  than  specific  is  thought  to  find  support  in  the  character  of  the  fever, 
the  joint  affection,  the  tendency  to  implication  of  serous  membranes,  the 
sweating,  anaemia,  leucocytosis,  and  the  tendency  to  relapse.  On  the  other 
hand,  pysemic  joints  undergo  suppuration  and  pursue  a  wholly  different 
course,  and  the  pains  of  sepsis  are  not  influenced  by  the  salicylates.  The 
causal  relation  of  the  diplococci  of  Poynton  and  Paine,  of  Wasserman,  and 
of  Walker  to  the  disease  has  not  yet  been  established.  The  results  of 
streptococcus  infection  ma}'  have  no  actual  relation  with,  but  merely  a 
superficial  resemblance  to,  rheumatic  fever.  The  chemical,  metabolic,  and 
nervous  hypotheses  have  merely  a  historical  interest. 

Symptoms. — Prodromes  are  not  common.  When  present  they  con- 
sist of  sore  throat,  slight  pains  in  the  joints,  and  malaise.  Not  rarely  a  well- 
marked  attack  of  angina  tonsillaris  precedes  the  joint  affection. 


RHEUMATIC  FEVER.  747 

The  onset  is  usually  abrupt.  There  is  very  often  the  chilliness  which 
attends  the  development  of  a  mild  infective  process.  Fever  of  moderate 
intensity— 101°-103°  F.  (3S°-39.5°  C.)— and  irregular  type  follows  and  in 
the  course  of  twenty-four  or  thirty-six  hours  the  nature  of  the  attack  is 
established.  One  or  more,  usually  several,  joints  are  now  swollen,  red- 
dened, and  painful.  The  pulse  is  frequent,  full,  and  soft.  The  tongue  is 
covered  with  a  soft,  thick,  white  coating;  appetite  is  lost;  there  are  thirst, 
constipation,  and  scanty,  high-colored,  and  very  acid  urine.  There  is  fre- 
quently abundant,  highly  acid,  and  ill-smelling  perspiration.  The  joints 
are  involved  successively  but  without  regular  order.  The  large  joints, 
as  the  knee,  ankle,  shoulder,  are  most  frequently  affected;  the  smaller 
joints  of  the  hands  and  feet  somewhat  less  so.  The  wrists  and  ankles  are 
often  enlarged  and  exquisitely  tender  and  painful  from  the  simultaneous 
implication  of  many  joints  and  the  sheaths  of  the  tendons.  The  arthritis 
is  curiously  fugacious.  As  one  joint  is  attacked  the  inflammation  subsides 
in  another  previously  involved.  This  constitutes  a  characteristic  clinical 
feature  of  the  disease.  The  inflammatory  exudate  is  endo-  and  peri-articular. 
Suppuration  does  not  occur  and  ankylosis  is  very  rare,  being  not  a  phe- 
nomenon of  rheumatic  fever  but  a  secondary  process  from  want  of  use  and 
fixation  and  encountered  chiefly  in  the  knee,  elbow,  or  wrist  in  hysterical 
girls.  Symmetrical  bilateral  arthropathy  is  often  seen.  In  severe  and 
protracted  cases  numbers  of  joints  are  implicated  and  the  vertebral  artic- 
ulations do  not  always  escape. 

Pain  is  a  constant  and  conspicuous  symptom.  It  is  spontaneous  and 
usually  agonizing  upon  movement  and  pressure.  Frequently  the  weight 
of  the  sheet  cannot  be  borne.  Prostration,  inability  to  sleep,  and  abject 
helplessness  add  to  the  sufferings  of  the  patient.  The  temperature  range 
does  not  often  exceed  103°  F.  (39.5°  C.)  and  rarely,  except  in  hyper- 
pyrexia, surpasses  104°  F.  (40°  C).  It  does  not  conform  to  type  and  is 
extremely  irregular,  with  marked  remissions  and  exacerbations,  which  corre- 
spond more  closely  to  the  presence  or  absence  of  the  abundant  sweats  than 
to  the  intensity  of  the  arthritis.  The  defervescence  is  by  gradual  lysis. 
Recrudescences  are  common  and  relapse  frequently  occurs.  Anaemia  of 
high  grade  develops  with  great  rapidity.  A  leucocytosis  of  moderate 
degree  is  present.  Febrile  albuminuria  is  common.  The  saliva  is  some- 
times acid  or  neutral  in  reaction.  There  are  subacute  forms  with  less  in- 
tense symptoms  which  sometimes  tend  to  become  chronic.  In  children 
rheumatic  fever  may  be  attended  with  very  slight  or  obscure  joint  affec- 
tion but  with  marked  and  disabling  heart  lesions.  The  attack  does  not 
confer  immunity  against  subsequent  attacks;  on  the  contrary,  like  crou- 
pous pneumonia,  diphtheria,  and  erysipelas,  rheumatic  fever  tends  to  recur 
and  many  persons  in  the  course  of  time  experience  several  attacks. 

Rheumatic  Hyperpyrexia;  Cerebral  Rheumatism. — In  rare  cases 
a  day  or  so  after  the  onset,  but  usually  during  the  course  of  the  second 
week,  a  rapid  rise  of  temperature  to  108°-110°  F.  (42.5°-43.5°  C.)  occurs. 
Delirium,  stupor,  a  feeble,  frequent,  and  flickering  pulse,  and  extreme  pros- 
tration accompany  the  hyperpyrexia.  In  the  course  of  a  few  hours  the 
patient  usually  falls  into  a  comatose  state.  This  form  of  rheumatic  fever 
is  almost  always  fatal.     If  the  temperature  is  reduced  by  cold  baths  or 


748  MEDICAL  DIAGNOSIS. 

external  cold  it  rises  again.     In  some  instances  convulsions  precede  the 
coma.     Rheumatic  hyperpyrexia  is  extremely  rare  in  this  country. 

Heart. — Endocarditis,  pericarditis,  and  associated  myocardial  changes 
are  so  frequent  that  they  must  be  regarded  as  pathological  processes  in- 
cident to  the  disease  rather  than  accidental  complications.  The  incidence 
is  variously  estimated  at  33  to  50  per  cent.  It  is  probably  higher  than  these 
figures  indicate.  Endocarditis. — This  is  by  far  the  most  common  of  the 
heart  affections  and  rheumatic  fever  is  by  far  the  most  common  cause 
of  chronic  valvular  disease.  The  habihty  is  greatest  in  the  rheumatic 
fever  of  childhood  and  decreases  with  age.  On  the  other  hand  it  increases 
with  the  number  of  attacks.  The  mitral  valve  system  is  most  frequently 
involved,  the  aortic  next,  and  both  next,  the  ratio  being  about  90-25- 
20.  Ulcerative  endocarditis  is  of  infrequent  occurrence  in  rheumatic 
fever.  Pericarditis. — Pericardial  inflammation  may  be  associated  with 
endocarditis,  as  is  commonly  the  case,  or  occur  independently.  Well- 
marked  pericardial  signs  may  mask  an  indistinct  endocardial  murmur, 
which  very  often  becomes  plainly  audible  as  the  friction  sounds  subside. 
The  exudate  may  be  fibrinous,  serofibrinous,  or  purulent.  The  last  occurs 
more  frequentlj^  in  childhood.  Myocarditis. — Changes  in  the  heart  muscles — 
granular  and  fatty  degeneration — are  associated  in  varying  degree  with 
the  endocarditis  and  pericarditis,  and  manifest  themselves  clinically  by 
enfeebled  action  and  the  signs  of  dilatation. 

Lungs  and  Pleura. — Pleurisy  may  occur  and  the  exudate  is  often 
serofibrinous,  the  effusion  not,  however,  commonly  attaining  a  great  volume. 
Pneumonia  is  an  occasional  complication.  Acute  pulmonary  congestion  is 
a  grave  accident.  These  conditions  are  more  liable  to  develop  in  the 
cases  in  which  heart  lesions  are  present. 

Nervous  System. — Grave  nervous  symptoms,  delirium,  stupor,  con- 
vulsions, and  coma  arise  in  the  cases  of  hyperpyrexia  and  are  sometimes 
manifestations  of  uraemia.  Delirium  may  be  due  to  the  salicylates  or  other 
drugs  and  in  cases  of  idiosyncrasy  may  result  from  ordinary  therapeutic 
doses.  The  mental  condition  in  rheumatic  fever  is  as  a  rule,  even  in  severe 
cases,  remarkably  clear.  Chorea,  while  it  does  not  often  appear  during  the 
attack  of  rheumatic  fever,  follows  it  in  about  15  per  cent,  of  the  cases. 

Cutaneous  Affections. — These  occasionallj^  appear,  as  in  the  other 
acute  febrile  infections.  They  are  not  important  and  comprise  sudamina, 
miliaria,  urticaria,  forms  of  erythema  and  petechise.  Subcutaneous  nodules 
occasionally  develop  upon  the  tendons  and  fasciae,  about  the  wrists  and 
hands,  and  elsewhere.  They  vary  in  size  up  to  that  of  a  pea.  They  grow 
rapidty  and  slowly  disappear.  They  are  not  usually  tender  to  the  touchy 
nor  painful.  These  subcutaneous  fibrous  nodules  are  encountered  in 
greater  frequency  in  children  than  in  adults. 

Diagnosis. — Direct. — The  direct  diagnosis  of  rheumatic  fever  is  not 
usually  attended  with  difficulty.  It  rests  upon  the  association  of  the  fore- 
going symptoms,  especially  the  rapid  onset,  the  fugacious  polyarthritis, 
irregular  fever,  abundant  acid  sweats,  rapidly  developing  anaemia,  and 
tendency  to  cardiac  complications. 

Differential. — 1.  Sepsis;  Septicopyoemia. — Arthritis,  irregular  fever, 
and  endocarditis  are  common  to  both  diseases.     But  in  septic  conditions 


RHEUMATIC  FEVER.  749 

the  arthritis  is  fixed,  not  fugacious,  affects  a  few  joints,  not  many,  and 
tends  to  suppuration  and  disorganization  instead  of  restitutio  ad  integrum 
as  in  rheumatic  fever.  The  fever  in  sepsis  is  as  a  rule  more  distinctly  inter- 
mittent, with  higher  maxima,  and  is  interrupted  by  periodical  chills  some- 
times of  ague-like  regularity.  The  endocarditis  of  sepsis  is  severe,  often 
malignant,  with  embolic  phenomena  and  retinal  hemorrhages.  Cases 
occur  in  which  for  a  time  the  differential  diagnosis  between  relatively 
mild  septicopyemia  and  severe  rheumatic  fever  cannot  be  positively  made. 
2.  Acute  Osteomyelitis. — When  the  lower  end  of  the  femur  or  the  tibia  is 
afTected  the  differential  diagnosis  may  be  at  first  obscure.  In  the  rare 
cases  in  which  several  bones  are  involved  the  resemblance  to  rheumatism 
is  increased.  The  epiphysis  is  the  seat  of  the  disease  rather  than  the  joint, 
and  the  local  and  constitutional  symptoms  are  more  severe.  3.  Acute 
Arthritis  of  Early  Infancy. — The  knee  or  the  hip  is  usually  affected.  The 
affection  is  mostly  monarticular  and  goes  on  to  early  suppuration.  It 
is  commonly  pysemic;  sometimes  gonorrhoeal.  4.  Gonorrhoeal  Arthritis 
(see  p.  833).  5.  Gout. — Many  cases  of  podagra  are  falsely  diagnosticated 
as  rheumatism.  An  arthritis  confined  to  one  or  two  joints,  especially  the 
metatarsophalangeal  joint  of  the  great  toe,  the  knee,  or  the  ankle,  of  ex- 
tremely acute  onset  and  great  intensity,  with  cyanotic  redness  of  the  skin 
which  is  tense  and  glossy,  exquisitely  painful  both  at  rest  and  on  move- 
ment, and  so  tender  that  the  weight  of  the  bedclothes  can  scarcely  be 
borne,  speaks  for  gout,  especially  if  tophaceous  masses  are  present  in  the 
helix  of  the  ear  or  around  the  small  joints  and  the  patient  has  reached 
middle  age.  6.  Arthritis  Deformans. — The  acute  outbreaks  of  joint  inflam- 
mation by  which  certain  forms  of  this  disease  advance  cannot  be  differen- 
tiated from  rheumatic  fever  in  the  early  course.  There  is  fever,  together 
with  redness,  swelling,  tenderness  and  pain,  mostly  affecting  the  small 
joints.  When  these  symptoms  pass,  however,  there  remains  the  evidence 
of  changes  in  the  joints  and  periarticular  thickening.  Fresh  attacks 
of  more  or  less  intense  arthritis  occur  and  after  each  one  the  signs 
of  damage  to  the  joints  are  more  pronounced.  7.  Meningitis. — When  in 
rheumatic  fever  the  vertebral  articulations  are  involved,  there  may  be 
severe  pain  upon  movement  of  the  neck,  together  with  painful  rigidity  of 
the  muscles.  As  fever  is  present,  the  condition,  especially  in  the  absence 
of  joint  affection  of  the  extremities,  may  closely  simulate  meningitis.  The 
absence  of  severe  headache,  pupillary  derangements,  hypersesthesia, 
Kernig's  sign,  and  negative  results  upon  examination  of  the  fluid  obtained 
by  spinal  puncture  are  of  diagnostic  importance.  8.  Peliosis  Rheumatica. 
— The  multiple  arthritis  and  fever  of  Schonlein's  disease  may  suggest  rheu- 
matic fever.  The  simultaneous  appearance  of  purpura,  purpura  urticans, 
and  erythema  exudativum,  especially  when  associated  with  hemorrhage 
from  mucous  surfaces  or  the  evidence  of  internal  bleeding,  is  decisive. 
9.  Hysteria. — A  hysterical  arthritic  neurosis,  usually  involving  the  knee, 
elbow,  or  wrist,  does  not  often  closely  simulate  rheumatic  fever. 

Prognosis. — The  course  of  rheumatism  varies  from  two  or  three  to 
six  weeks  or  longer  and  is  marked  by  many  remissions  and  exacerbations, 
both  of  the  fever  and  other  constitutional  symptoms  and  the  arthropathy. 
Rheumatic  fever  tends  to  recovery.    The  mortality  does  not  exceed  2  or  3 


750  MEDICAL  DIAGNOSIS. 

per  cent,  and  death  is  the  result  not  of  the  disease  in  its  ordinary  mani- 
festations but  of  the  heart  affection  or  hyperpyrexia.  It  acquires,  however, 
a  sinister  importance  on  account  of  the  frequency  of  the  implication  of 
the  heart,  as  the  result  of  which  arise  initial  lesions  of  the  valves  and  myo- 
cardium, especially  progressive,  constituting  the  conditions  of  deformity 
and  impaired  function  known  as  chronic  valvular  disease,  irreparably 
damaging  to  function  and  ultimately  the  cause  of  death. 

XX.    YELLOW   FEVER. 

Definition. — A  febrile  disease  of  tropical  and  subtropical  countries 
due  to  an  unknown  infectious  principle  transmitted  by  the  bite  of  a  variety 
of  mosquito — Stegomyia  fasciata — and  characterized  by  jaundice,  albu- 
minuria, slow  pulse,  and  black  vomit. 

Etiology. — Predisposing  Influences. — Yellow  fever  has  frequently 
been  transported  to  the  seaboard  cities  of  the  United  States  and  toward 
the  end  of  the  eighteenth  century  prevailed  in  frightfully  disastrous  epi- 
demics in  Philadelphia  and  other  northern  cities.  It  is  a  disease  of  the 
seaboard  and  low  levels.  It  rarely  shows  itself  above  an  altitude  of  1000 
feet.  It  occurs  chiefly  in  cities  and,  during  outbreaks,  is  most  prevalent 
in  the  low,  badly  drained,  and  overcrowded  districts  occupied  by  the  poor, 
and  in  the  hot  season.  The  epidemics  in  the  United  States  have  always 
appeared  during  the  summer  and  autumn  and  come  to  an  end  upon  the 
occurrence  of  frost. 

The  Actual  Cause. — The  specific  germ  of  yellow  fever  has  not  yet 
been  demonstrated.  The  following  are  the  conclusions  of  the  Yellow 
Fever  Commission  of  the  United  States  Army: 

1.  The  mosquito — Stegomyia  fasciata — serves  as  the  intermediate 
host  for  the  parasite  of  yellow  fever.  2.  Yellow  fever  is  transmitted  to 
the  non-immune  individual  by  means  of  the  bite  of  the  mosquito  that  has 
previously  fed  on  the  blood  of  those  sick  with  this  disease.  3.  An  interval 
of  about  twelve  days  or  more  after  contamination  appears  to  be  necessary 
before  the  mosquito  is  capable  of  conveying  the  infection.  4.  The  bite 
of  the  mosquito  at  an  earlier  period  after  contamination  does  not  appear 
to  confer  any  immunity  against  a  subsequent  attack.  5.  Yellow  fever  can 
also  be  experimentally  produced  by  the  subcutaneous  injection  of  blood 
taken  from  the  general  circulation  during  the  first  and  second  days  of 
this  disease.  6.  An  attack  of  yellow  fever,  produced  by  the  bite  of  the 
mosquito,  confers  immunity  against  a  subsequent  attack  of  the  non-ex- 
perimental form  of  this  disease.  7.  The  period  of  incubation  in  thirteen 
cases  of  experimental  yellow  fever  has  varied  from  forty-one  hours  to  five 
days  and  seventeen  hours.  8.  Yellow  fever  is  not  conveyed  by  fomites, 
and  hence  disinfection  of  clothing,  bedding,  or  merchandise,  supposedly 
contaminated  by  contact  with  those  sick  with  this  disease,  is  unnecessary. 
9.  A  house  may  be  said  to  be  infected  with  yellow  fever  only  when  there 
are  present  within  its  walls  contaminated  mosquitoes  capable  of  convey- 
ing the  parasite  of  this  disease.  10.  The  spread  of  yellow  fever  can  be  most 
effectually  controlled  by  measures  directed  to  the  destruction  of  mosquitoes 
and  the  protection  of  the  sick  against  the  bites  of  these  insects.     11.  While 


YELLOW  FEVER.  751 

the  mode  of  propagation  of  yellow  fever  has  now  been  definitely  deter- 
mined, the  specific  cause  of  this  disease  remains  to  be  discovered. 

Symptoms. — The  period  of  incubation  is  three  or  four  days.  In  13 
experimental  cases  it  varied  from  41  hours  to  5  days  and  17  hours.  The 
course  of  the  attack  may  be  divided  into  a  stage  of  invasion  and  a  stage  of 
collapse.  These  periods  are,  however,  not  always  well  characterized.  1. 
Invasion. — The  onset  is  sudden,  without  prodromes,  and  commonly  in 
the  early  morning.  It  is  marked  by  chilliness,  headache,  severe  pains  in  the 
back  and  limbs,  a  rapid  rise  of  temperature  to  102°-105°  F.,  and  pungent 
heat  and  dryness  of  the  surface.  The  tongue  is  moist  and  covered  vrith  a 
thick  white  fur.  There  is  usually  some  soreness  of  the  throat,  together  with 
nausea  and  vomiting,  which  become  more  severe  upon  the  second  and  third 
day,  and  constipation.  The  facies  even  upon  the  first  day  is  suggestive, 
even  characteristic.  It  is  flushed  and  there  is  slight  tumefaction  of  the 
eyelids  and  lips.  The  conjunctivae  are  injected  and  icteroid.  Later  the 
intense  jaundice  from  which  the  disease  takes  its  name  rapidly  invades 
the  entire  surface.  The  fever  having  attained  its  fastigium  during  the  first 
day  maintains  its  elevation  for  two  or  three  days  and  subsides  in  favorable 
cases  by  lysis.  In  abortive  cases  the  temperature  may  fall  to  normal  in 
twenty-four  or  thirty-six  hours.  2.  The  Remission  or  Stage  of  Calm. — 
This  period  lasts  two  or  three  days.  The  symptoms  ameliorate  and  the 
condition  of  the  patient  is  in  every  way  more  satisfactoiy.  Convales- 
cence may  now  set  in  with  rapid  improvement,  or  there  may  be  febrile 
reaction  lasting  from  one  to  three  days  and  terminating  in  rapid  lysis,  or 
the  patient  may  pass  into:  3.  The  Stage  of  Collapse. — This  period  is 
attended  with  characteristic  ''black  vomit"  and  other  hemorrhages.  The 
vomiting,  in  the  grave  cases,  is  uncontrollable  and  copious,  being  attended 
with  great  abdominal  pain  and  exhaustion.  The  oozing  of  blood  from  the 
mucous  surfaces  and  the  occurrence  of  petechise  usually  precede  death. 

The  pulse  upon  the  first  day  does  not  usually  exceed  110  per  minute 
and,  notwithstanding  the  persistence  of  a  relatively  high  temperature, 
becomes  during  the  second  or  third  day  progressively  slower  until  it  may 
reach,  with  a  temperature  of  102°-103°  F.,  a  rate  as  low  as  50,  40,  or  even 
30  per  minute.  This  low  pulse-rate,  with  a  persistent  or  even  rising  febrile 
movement,  is  a  characteristic  and  striking  feature  of  the  disease.  Albu- 
minuria occurs  about  the  third  day  of  the  attack.  In  the  mild  cases  it  is 
transient,  but  in  the  severe  cases  it  is  continuous,  abundant,  and  accom- 
panied by  the  ordinary  signs  of  acute  nephritis.  Suppression  may  occur 
and  the  manifestations  of  uraemia,  convulsions  and  coma,  or  these  in  alter- 
nation, lead  to  a  rapidly  fatal  issue.  Delirium  may  be  present  early  in  the 
course  of  severe  cases.  The  mental  condition  is  usually,  however,  one  of 
remarkable  clearness  and  alertness. 

Varieties. — 1.  Mild  cases — "walking  yellow  fever" — present  sim- 
ply a  transient  fever  and  slight  jaundice  and  would  not  be  recognized 
except  in  the  light  of  the  prevalent  epidemic.  These  cases  are  especially 
dangerous,  since  they  may  be  the  source  of  contamination  of  mosquitoes 
and  the  subsequent  infection  of  non-immune  persons  with  the  fever  in  its 
severer  forms.  2.  Average  cases  vnth  high  fever  and  the  characteristic 
features  of  the  infection — jaundice,  vomiting,  fever,  slow  pulse,  albuminuria. 


752  MEDICAL  DIAGNOSIS. 

black  vomit  and  other  hemorrhages,  and  prostration.  3.  Malignant. — 
The  patient  is  overwhelmed  by  the  infection  and  death  occurs  in  the  course 
of  the  second  or  third  day. 

Convalescence  in  favorable  cases  is  rapid  and  complete,  the  albumi- 
nuria usually  passing  away  in  the  course  of  a  little  time.  In  severe  cases 
terminating  in  recovery,  the  convalescence  may  be  protracted  by  parotid 
bubo,  suppurative  processes  elsewhere,  or  persistent  diarrhcea.  Second 
attacks  are  exceedingly  rare. 

Diagnosis. — Direct  Diagnosis. — The  symptom-complex  in  weU- 
developed  cases  is  so  characteristic  that  a  positive  diagnosis  would  appear 
to  be  a  simple  matter,  especially  when  a  number  of  causes  have  occurred 
in  a  circumscribed  region.  Commercial  interests  and  considerations  of  local 
policy,  have,  however,  in  many  instances,  interposed  insuperable  difficulties 
to  the  recognition  of  the  early  cases — difficulties  that  have  frequently  led 
to  wide-spread  and  disastrous  epidemics.  In  some  such  instances  the 
disease  has  been  reported  as  dengue,  in  others  as  malarial  fever. 

Differential  Diagnosis. — Dengue. — The  facies,  jaundice,  albumi- 
nuria, slow  pulse,  great  severity,  and  high  mortality  clearly  differentiate 
yellow  fever  from  dengue.  The  difficulties  relate  to  the  initial  cases,  which 
may  be  mild,  and  the  fact  that  the  two  diseases  may  coexist  in  the  same 
locality.  Everj^  suspect  should  be  at  once  isolated  in  a  screened  hospital. 
Malaria. — The  differential  diagnosis  concerns  the  estivo-autumnal  variety 
which  especially  prevails  in  the  regions  and  at  the  season  of  the  year  in 
which  outbreaks  of  yellow  fever  are  liable  to  occur.  The  facies,  early  jaun- 
dice, early  albuminuria,  slight  enlargement  of  the  spleen,  hemorrhages, 
especially  black  vomit,  and  the  absence  of  the  blood  parasite  justify  the 
diagnosis  of  yellow  fever.  In  estivo-autumnal  fever  the  facies  is  not  char- 
acteristic, jaundice  and  albuminuria  are  later,  the  splenic  tumor  is  more 
marked,  black  vomit  and  bleeding  gums  are  wholly  exceptional.  In  hem- 
orrhagic malarial  fever,  hsematuria,  a  rare  symptom  in  yellow  fever,  is 
most  conspicuous. 

Prognosis. — The  mortality  ranges  from  10  to  80  per  cent.  It  varies 
greatly  in  different  epidemics.  Among  the  working  classes  and  hard 
drinkers  it  is  especially  high.  Of  favorable  prognostic  significance  are 
mild  fever,  slight  jaundice,  a  free  secretion  of  urine,  and  the  absence  of 
black  vomit.  High  fever  at  the  onset  is  ominous.  Black  vomit,  though 
serious,  is  not  invariably  followed  by  death.  Suppression  of  urine  and 
uraemic  symptoms  are  rarely  followed  by  recovery. 

XXI.    CHOLERA. 

Cholera  Asiatica;    Cholera  Infectiosa. 

Definition. — An  infectious  disease,  endemic  and  epidemic  in  certain 
districts  of  India,  and  occasionally  epidemic  in  Europe  and  America, 
caused  by  the  comma  bacillus  of  Koch  and  characterized  by  violent 
purging,  rice-water  discharges,  and  early  collapse. 

Etiology. — Predisposing  Influences. — Of  great  importance  is  expo- 
sure in  an  infected  district,  but  the  chief  danger  lies  in  the  drinking  of 


CHOLERA.  753 

water  contaminated  with  the  fecal  discharges  of  cholera  patients.  Cholera 
is  endemic  upon  the  delta  of  the  Ganges.  Thence  it  is  from  time  to  time 
transported  along  the  lines  of  commerce  to  various  parts  of  the  world. 
Cases  on  ship-board  have  reached  the  New  York  Quarantine  Station  on 
several  occasions  in  the  last  three  decades,  but  the  disease  has  not  gained 
foothold  upon  our  shores  since  1873.  It  has  prevailed  extensively  in  the 
East  in  recent  years  and  is  still  to  some  extent  epidemic  in  the  Philippines. 
Outbreaks  are  more  common  in  warm  climates — India,  Egypt,  the  Islands 
of  the  Malay  Archipelago — but  the  disease  has  prevailed  fiercely  in  Siberia 
and  Northern  Russia  and  to  some  extent  in  Canada.  Warm  weather 
favors  the  spread  of  cholera,  but  cold  does  not  arrest  it.  It  is  especially 
a  disease  of  seaport  cities  and  commercial  centres,  being  transported  by 
persons  and  effects.  It  journeys  in  the  East  with  caravans  and  pilgrims. 
It  is  not  conveyed  by  the  atmosphere  and  does  not  advance  at  a  faster 
rate  than  that  of  ordinary  commercial  intercourse.  In  epidemics  those 
who  handle  the  soiled  linen  of  the  sick  or  remove  the  discharges  are  espe- 
cially liable  to  contract  the  disease.  Physicians  and  nurses  on  the  contrary 
are  seldom  attacked.  Students  in  the  study  of  the  germs  have  contracted 
"laboratory  cholera.'"'  The  drinking  of  contaminated  water  or  milk, 
articles  of  uncooked  food  as  salads  and  the  like  washed  with  such  water, 
other  articles  of  food  accidentally  contaminated,  are  common  causes  of 
the  disease.  The  part  played  by  the  house-fly  in  mechanically  transporting 
the  pathogenic  organism  from  the  stools  to  articles  of  food  is  most  impor- 
tant.    Every  period  of  life  is  liable. 

Exciting  Cause. — The  "comma  bacillus,"  discovered  by  Koch  in 
1884,  is  the  cause  of  the  disease.  This  organism  is  present  in  all  cases  of 
Asiatic  cholera  and  does  not  occur  in  other  diseases.  It  is  a  spirochseta, 
morphologically  appearing  as  a  slightly  curved  rod,  about  half  the  length 
of  the  tubercle  bacillus  but  much  thicker  than  that  organism,  sometimes 
presenting  an  S-shaped  appearance,  and  occasionally  assuming  spiral 
curves.  As  other  organisms  present 
similar  forms,  the  characteristic  growth 
in  cultures  becomes  important.  Comma 
bacilli  are  found  in  the  stools  from  the 
onset  of  symptoms  and  in  the  rice- 
water  discharges  and  contents  of  the 
intestine  after  death  in  almost  pure 
culture.  They  are  rarely  present  in  the 
vomited  material  and  then  only  after 
violent  or  protracted  retching.  They 
are  not  present  in  the  circulating  blood 
or  in  the  viscera,  but  are  sometimes 
found  in  the  intestinal  glands  and  sub- 
mucosa.  They  have  been  demonstrated 
in  water  tanks  and  in  other  drinking  ^     ok«    a  -n       f  a  •  *•    i,  i 

o  Fig.  256. — Spirillum  of  Asiatic  cholera. 

water  supplies  during  epidemics.    The 

symptoms  are  due  to  a  virulent  toxin,  caused  by  the  bacilli,  which  acts 
chiefly  upon  the  vasomotor  system.  The  immunity  of  certain  persons 
during  epidemics,  and  the  fact  that   virulent   cholera  bacilli  have  been 

48 


754  MEDICAL  DIAGNOSIS. 

isolated  from  the  stools  of  healthy  individuals  raises  the  question  as  to 
natural  immunity.  Artificial  immunity  can  be  established  in  the  cases 
of  laboratory  animals  and  human  immunity  by  the  methods  of  Haffkin. 
General  epidemics  in  a  community  are  caused  by  contamination  of 
the  water  supply  and  usually  arise  with  great  rapidity.  Circumscribed 
outbreaks  develop  more  slowly  and  the  source  of  the  infection  cannot 
always  be  traced. 

Symptoms. — The  period  of  incubation  varies  from  two  to  five  days. 
The  course  of  the  attack  may  be  divided  into  four  stages.  Any  one  of 
these  stages  may  be  absent. 

1.  Premonitory  Diarrhcea. — Looseness  of  the  bowels  may  begin 
abruptly  or  be  preceded  by  colicky  pains  and  vomiting  with  or  without 
fever.  At  the  time  of  an  epidemic  every  case  of  diarrhoea  must  be  re- 
garded as  a  "  suspect, "  until  the  true  nature  of  the  symptoms  is  settled 
by  bacteriological  examination  of  the  discharges.  The  stools  and  any 
linen  that  is  soiled  must  be  efficiently  disinfected.  2.  Serous  Diarrhcea. — 
Diarrhoea  becomes  more  urgent,  with  frequent  large  liquid  stools,  which 
presently  assume  the  rice-water  appearance.  Or  the  attack  may  begin 
in  this  way  without  premonitory  symptoms.  There  are  griping  pains  in 
the  abdomen  and  much  bearing  down,  with  great  prostration.  The  tongue 
is  covered  with  a  thick,  whitish  fur  and  there  is  extreme  thirst.  In  the 
course  of  a  few  hours  vomiting  occurs.  Severe  muscular  cramps,  espe- 
cially in  the  legs  and  feet,  add  to  the  sufferings  of  the  patient.  Notwith- 
standing the  severity  of  the  symptoms  recovery  may,  in  favorable  cases, 
set  in  at  this  period.  The  pains  and  tenesmus  may  cease,  the  rice-water 
character  of  the  discharges  give  place  to  stools  that  are  fecal  and  bile- 
stained,  the  gastric  irritability  subside,  and  little  by  little  the  ability 
to  retain  water  and  nourishment  return.  3.  Stage  of  Collapse. — In 
other  cases  collapse  symptoms  rapidly  develop.  The  appearance  of  the 
patient  is  due  to  the  rapid  withdrawal  of  fluid  from  the  tissues.  The  skin 
is  ashy  gray,  shrivelled,  wrinkled  and  inelastic,  and  covered  with  a  clammy 
perspiration;  the  features  are  shrunken,  the  eyeballs  sunk  in  the  sockets, 
the  nose  pinched,  the  cheeks  hollow,  and  the  surface  cyanotic  and  mottled. 
The  external  temperature  is  subnormal  but  the  internal  registers  103°- 
104°  F.  (39.5°-40°  C.)  or  higher.  The  pulse  is  feeble,  thready,  and  un- 
countable. Diarrhoea  frequently  ceases  and  there  is  merely  a  continuous 
oozing  of  rice-water  material  from  the  anus.  The  voice  is  husky  and  whis- 
pering. The  mental  condition  often  remains  singularly  clear  and  alert. 
At  the  last,  coma  supervenes.  This  is  the  fatal  stage  of  cholera.  It  lasts 
from  a  few  hours  to  a  day  or  two.  The  thin  liquid  stools  are  of  a  grayish- 
white  color,  resembling  turbid  whey  or  rice-water.  They  contain  much 
granular  matter  and  small  whitish  flakes  of  mucus.  In  other  cases  they 
are  tinged  with  blood  and  have  the  appearance  and  odor  of  the  washings 
of  meat.  They  are  alkaline  in  reaction,  highly  albuminous,  and  contain 
sodium  chloride  in  large  proportion.  Under  the  microscope  epithelial 
cells  and  bacteria,  often  comma  bacilli  in  nearly  pure  culture,  are  seen. 
The  urine  is  greatly  diminished  or  anuria  may  be  present.  That  which 
is  voided  is  intensely  albuminous.  Microscopically  it  presents  the  char- 
acters of  an  acute  parenchymatous  nephritis.     Saliva  is  scanty  but  the 


CHOLERA.  755 

function  of  the  sweat-glands  is  maintained.  Cholera  Sicca. — In  rare  in- 
stances the  contents  of  the  bowel  are  retained  and  collapse  terminates 
in  death  without  diarrhoea.  4.  Reaction. — In  the  cases  which  survive 
the  stage  of  collapse  the  symptoms  characteristic  of  that  condition  grad- 
ually subside.  The  action  of  the  heart  grows  stronger,  warmth  ai^d  color 
return  to  the  skin,  which  regains  its  natural  turgor,  cyanosis  disappears 
and  is  often  replaced  by  a  reddish  mottling  or  erythematous  blush,  the 
stomach  becomes  retentive  of  water  and  bland  fluids,  the  colicky  pains 
and  violent  muscular  cramps  cease,  the  stools  are  much  less  frequent,  and 
the  secretion  of  urine  is  re-established.  With  these  signs  of  improvement 
the  disparity  between  the  external  and  internal  temperatures  passes  away. 
The  patient  now  enters  upon  convalescence  which  is  often  protracted,  but 
frequently  interrupted  by  a  relapse,  which  usually  proves  fatal. 

Cholera-typhoid. — The  stage  of  reaction  may  pass  into  a  septic  con- 
dition characterized  by  so-called  typhoid  symptoms,  due  to  secondary 
infection.  In  some  instances  the  predominant  features  are  those  of  gen- 
eral sepsis,  in  others  pulmonary,  and  frequently  they  are  ursemic.  Feeble, 
rapid  pulse,  dry  tongue,  muttering  delirium,  and  stupor  are  followed  by 
coma,  which  terminates  in  death.  As  in  other  epidemic  diseases  cases  of 
every  degree  of  severity  occur. 

Complications  and  Sequels. — The  attack  in  the  graver  cases  is  so 
severe  and  rapid  in  its  course  that  complications  as  such  are  not  common. 
Important  sequels  are  inflammation  of  the  mucous  membranes,  as  diph- 
theroid colitis,  pleurisy,  and  pneumonia,  and  abscess  formation,  especially 
parotid  bubo.  Muscle  cramps  may  persist  and  subacute  gastro-intestinal 
symptoms  are  often  present  for  a  long  time. 

Diagnosis. — Direct. — During  an  epidemic  no  doubt  arises  in  well- 
developed  cases.  The  clinical  picture  is  unmistakable.  The  uncertainty 
in  regard  to  first  cases  and  suspects  is  usually  quickly  dispelled  by  the 
course  of  the  attack.     Bacteriological  examinations  are  necessary. 

Differential. — Cholera  Nostras:  Cholera  Morbus. — The  symptoms 
and  course  of  severe  cases  do  not  differ  from  those  of  Asiatic  cholera.  The 
cases  are  sporadic  and  occur  in  hot  weather  in  temperate  climates.  There 
is  often  a  history  of  improper  food,  chilling,  or  exposure.  Vomiting,  diar- 
rhoea with  rice-water  stools,  colic,  muscular  cramps,  suppression  of  urine, 
cyanosis,  and  collapse  may  terminate  fatally  in  the  course  of  ten  or  twelve 
hours.  The  differential  diagnosis  can  only  be  made  by  laboratory  methods. 
Arsenical  and  Other  Poisoning. — Vomiting,  diarrhcsa,  and  collapse  are 
constant  symptoms  in  acute  poisoning  by  the  preparations  of  arsenic, 
mercury,  and  the  poisonous  fungi.  The  absence  of  cholera,  the  sporadic 
occurrence  of  poison  cases,  the  anamnesis,  the  evidences  of  the  poi- 
sonous substance,  or  the  vial  or  box  in  which  it  was  contained,  are 
important. 

Prognosis. — The  mildest  cases  recover;  the  severe  cases  almost  in- 
variably die.  The  mortality  ranges  in  different  epidemics  between  30  and 
80  per  cent.  In  any  given  case  alcoholism,  old  age,  or  diminished  powers 
of  resistance  from  other  causes,  marked  cyanosis,  a  temperature  much 
below  normal,  and  early  collapse  are  of  ominous  prognostic  import. 


756 


MEDICAL  DIAGNOSIS. 


XXII.   BACILLARY  DYSENTERY. 

Definition. — An  intestinal  disease,  usually  acute  but  sometimes  be- 
coming chronic,  occurring  sporadically  and  in  local  epidemics,  due  to  a 
specific  bacillus  and  characterized  by  tormina,  tenesmus,  and  frequent 
discharges  of  mucus  and  blood. 

Etiology. — Predisposing  Influences. — Dysentery  is  a  widely  spread 
disease.  It  occurs  in  all  parts  of  the  world  but  is  especially  common  in 
tropical  and  subtropical  countries.  While  bacillary  dysentery  is  much 
more  prevalent  and  disastrous  in  hot  climates,  it  is  also  common  in  tem- 
perate climates  both  as  a  sporadic  and  an  epidemic  affection.  Overcrowd- 
ing and  neglect  of  sanitary  requirements  both  in  military  and  civil  life 
are  predisposing  influences  of  great  importance.  It  follows  that  dysentery 
constitutes  one  of  the  most  serious  difficulties  in  warfare,  especially  in 

tropical  campaigns,  and  that  its  epi- 
demic outbreak  in  overcrowded  insti- 
tutions not  infrequently  occurs. 

Exciting  Cause. — Bacillus  Dysen- 
terice. — Shiga,  in  1898,  discovered  in  the 
stools  of  these  cases  a  bacillus,  having 
specific  characters,  which  he  regarded 
as  the  cause  of  the  disease,  and  to 
which  he  gave  this  name.  This  organ- 
ism has  been  found  in  the  dysentery 
of  the  Philippines,  Porto  .Rico,  in  that 
occurring  in  various  points  in  the 
United  States  and  Europe.  It  has 
been  demonstrated  in  the  summer  diar- 
rhoeas of  infancy. 

There  are  several  strains,  as  deter- 
mined by  the  relative  agglutinating 
power  of  the  immune  serum  upon  the  bacilli  in  pure  culture  and  the  action 
of  the  bacilli  upon  various  sugars,  but  the  lesions  produced  are  the  same. 
Flexner's  types  are,  (1)  the  Shiga,  (2)  the  Flexner-H arris — the  strain  prev- 
alent in  the  United  States,  and  (3)  Bacillus  Y.  The  Bacillus  dysenterise 
has  never  been  isolated  except  from  the  stools  or  lesions  in  human  beings. 
The  mode  of  infection  has  not  been  demonstrated.  The  lesions  comprise 
intense  hyperemia  of  the  mucosa  of  the  large  intestine,  with  scattered 
points  of  hemorrhage,  superficial  necrosis  over  limited  or  extended  surfaces, 
and  enlargement  of  the  solitary  follicles.  Deep  ulceration  is  not  present 
in  the  cases  that  are  early  fatal.  In  the  most  intense  cases  great  thickening 
of  the  mucosa  and  other  coats  of  the  colon  occurs,  together  with  extensive 
necrosis  and  gangrene.    The  ileum  may  be  involved. 

Symptoms. — The  period  of  incubation  does  not  exceed  forty-eight 
hours.  The  onset  is  sudden,  with  abdominal  pain  and  frequent  discharges 
consisting  at  first  of  fgeces,  followed  by  mucus  which  soon  becomes  bloody. 
There  is  urgent  inclination  to  go  to  stool,  with  twisting  abdominal  pain 
and  violent  rectal  tenesmus.  The  pyrexia,  moderate  at  first,  soon  rises 
to  103°-104°  F.   (39.5°-40°  C).     Thirst  is  intense  and  there  is  complete 


Fig.  257. — Bacillus  dysenterise  (Shiga). 


PLAGUE.  757 

loss  of  appetite.  The  pulse  is  rapid,  small,  and  feeble.  In  the  very  severe 
cases  the  patient  becomes  delirious  and  death  occurs  in  the  course  of  the 
third  or  fourth  day.  In  favorable  cases  the  urgency  of  the  intestinal 
symptoms  gradually  declines,  the  temperature  falls,  and  convalescence  may 
be  fully  established  in  three  or  four  weeks.  There  are  other  cases  in  which, 
with  subacute  symptoms,  the  cases  run  a  protracted  course.  Many  of  our 
soldiers  return  from  the  island  possessions  with  chronic  dysentery. 

Among  the  important  complications  and  sequels  are  malarial  infec- 
tion, subacute  septic  arthritis,  pleurisy,  pericarditis,  endocarditis,  and 
sepsis.  Albuminuria,  anaemia,  oedema  of  the  legs  and  feet,  and  various 
palsies  due  to  neuritis  occur  in  the  protracted  cases.  In  contrast  to  amcebic 
dysentery,  abscess  of  the  liver  is  extremely  rare. 

Diagnosis. — Direct. — Laboratory  methods  are  necessary.  In  non- 
amoebic  dysentery  the  B.  dysenterise  must  be  sought  in  the  stools.  It  is 
isolated  most  conveniently  from  the  shreds  of  mucus.  In  the  acute  cases 
the  blood-serum  agglutinates  the  bacillus  in  the  Flexner-Harris  strain  in 
dilutions  of  1-1000  up  to  1-1500;  the  Shiga  strain  agglutinates  less  readily. 

Differential.  —  Bacillary  dysentery  is  to  be  distinguished  from 
amoebic  dysentery  only  by  the  methods  of  the  laboratory. 

Prognosis. — The  outlook  in  the  sporadic  cases  in  temperate  climates 
is  favorable;  in  local  epidemics  less  so,  especially  with  bad  sanitary  ar- 
rangements. In  active  campaigns  and  tropical  dysentery  the  death-rate 
is  high.  The  dysentery  of  Japan  has  a  mortality  of  about  25  per  cent. 
After  recovery  there  is  very  frequently  prolonged  ill  health  with  gastro- 
intestinal symptoms  and  diarrhoea. 

XXIII.   THE   PLAGUE. 

Bubonic  Plague. 

Definition. — An  infectious  febrile  disease  of  the  Orient,  caused  by 
Bacillus  pestis,  and  characterized  by  glandular  swellings  or  buboes,  car- 
buncles, pneumonia,  and,  in  many  cases,  hemorrhages  beneath  the  skin 
and  from  the  mucous  surfaces. 

Etiology. — Predisposing  Influences. — This  disease,  the  great  pesti- 
lence of  Europe  and  Great  Britain  for  eleven  hundred  years,  practically 
disappeared  towards  the  close  of  the  seventeenth  century.  It  has  not 
appeared  as  an  epidemic  in  England  since  the  Great  Fire  in  London  in 
1666,  the  year  following  the  Great  Plague.  Its  cessation  is  due  to  modern 
methods  of  living.  It  has  been  said  of  Europe  that  when  the  shirt  came 
in  the  plague  went  out.  Always  smouldering  and  frequently  flaring  up 
in  the  East,  the  plague  occasionally  slipped  over  into  Lower  Italy,  Egypt, 
and  other  countries  bordering  on  the  Mediterranean,  but  not  until  the  out- 
break at  Hong  Kong  in  1894  did  it  again  threaten  to  become  a  world  pest. 
Since  that  date  it  has  continued  its  ravages,  especially  in  India,  where 
during  the  first  six  months  of  1905  nearly  900,000  persons  died  of  it,  the 
highest  mortality  for  a  half  year  made  in  the  epidemic  of  eleven  years' 
duration.  During  the  past  decade  the  plague  has  appeared  in  Egypt  and 
other  parts  on  the  Mediterranean,  South  Africa,  Oporto,   Glasgow,  New 


758 


MEDICAL  DIAGNOSIS. 


York,  Mexican  and  South  American  ports,  Australia  and  New  South  Wales. 
Occupation,  age,  and  sex  are  without  influence  as  predisposing  factors.  The 
disease  spreads  chiefly  among  the  poorer  classes.  The  prevalence  is  greatest 
in  the  hot  season,  but  outbreaks  sometimes  occur  during  the  coldest  weather. 
Personal  and  household  cleanliness  are  important.  In  Bombay  few  attend- 
ants upon  the  sick  were  attacked,  and  not  a  case  occurred  among  the 
British  soldiers  engaged  in  police  duty  and  disinfection.  Only  an  occasional 
case  occurs  among  Europeans  living  in  infected  regions. 

Exciting  Cause. — Bacillus  pestis  was  discovered  by  Kitasato.  It 
appears  in  the  form  of  short,  non-motile  rods,  with  rounded  ends,  staining 
readily  and  more  densely  at  the  poles  than  in  the  middle,  and  decolorized 
by  Gram's  method.  This  organism  has  a  characteristic  growth  in  culture. 
It  is  present  in  the  blood  and  lesions  of  the  plague  and  in  the  dust  of  houses 

in  which  cases  have  occurred,  and  in 
the  earth  of  the  floors  and  a^ljacent 
parts.  Dogs  and  cats  and  household 
vermin,  as  rats,  mice,  flies,  and  fleas, 
suffer  from  the  infection,  transmit  it  to 
others  and  to  man,  and  die  infected  by 
its  germ.  Plague  bacilli  are  present  in 
enormous  numbers  in  the  hemorrhagic 
sputum  in  the  pneumonic  form  of  the 
disease,  and  may  be  found  in  the  ordi- 
nary bubonic  form. 

Mode  of  Transmission. — The  plague 
is  not  contagious  in  the  ordinary  sense. 
It  is  dependent  on  the  disease  in  the 
rat,  and  is  transmitted  from  rat  to 
man  by  the  rat  flea.     Cases  common- 
ly occur  singly  in  a  house.     Multiple 
Rat  fleas  are  carried  by  personal 
and  other  fomites.      Insanitary  conditions  except  as  to  rats  have  no 
relation  to  plague. — Plague  Commission,  1908. 

Symptoms. — The  period  of  incubation  varies  from  two  to  five  days. 
The  following  forms  are  described:  1.  Rudimentary  Form;  Pestis 
Minor. — The  patient  is  not  in  all  cases  ill  enough  to  go  to  bed.  There 
is  moderate  fever,  with  enlargement  and  tenderness  of  the  inguinal  glands, 
which  sometimes  undergo  suppuration.  These  cases  constitute  a  danger 
to  the  community  by  the  presence  of  the  bacilli  in  the  discharges.  2.  The 
Ordinary  Form;  Bubonic  Plague. — The  onset  is  sudden,  with  a  chill 
which  is  immediately  followed  by  fever,  headache,  backache,  muscular 
soreness,  great  anxiety,  and  depression  of  spirits.  The  temperature  pro- 
gressively rises  until  the  third  or  fourth  day,  when  there  is  a  more  or  less 
marked  remission,  followed  by  a  further  rise  coincident  with  the  develop- 
ment of  the  buboes,  and  accompanied  by  signs  of  septic  infection,  dry, 
brown  tongue,  delirium,  stupor  and  coUapse  symptoms — secondary  fever. 
Death  frequently  occurs  at  this  stage.  The  swelling  of  the  superficial 
lymph-nodes  occurs  between  the  third  and  fifth  days,  the  inguinal  nodes 
being  involved  in  more  than  half  the  cases,  less  frequently'  those  of  the 


Fig.  258. — Bacillus   pestis.     a,  organism   from 
culture  ;  b,  smear  preparation  from  spleen. 

cases  are  usually  simultaneous. 


MALTA  FEVER.  759 

axilla  or  neck.  The  adenitis  may  undergo  resolution,  suppuration,  or,  in 
rare  cases,  gangrene,  with  the  formation  of  deep  sloughs.  Necrosis  of  the 
subcutaneous  tissue  may  give  rise  to  more  or  less  extensive  carbuncles. 
Enlargement  of  the  spleen  occurs.  Petechi£e  are  common,  and  the  exten- 
sive subcutaneous  hemorrhages  that  characterized  the  disease  in  certain 
epidemics  gave  to  it  in  the  Middle  Ages  the  popular  name  of  the  Black 
Death.  Haemoptysis  and  other  hemorrhages  from  the  mucous  surfaces 
have  been  especially  noted  in  some  outbreaks.  3.  The  Septic  Form. — 
The  symptoms  are  from  the  onset  overwhelming,  and  death  occurs  in  the 
course  of  three  or  four  days  without  the  appearance  of  buboes.  Hemor- 
rhages constitute  a  prominent  feature.  Metastatic  abscesses  are  frequentl)'" 
found  in  the  viscera.  4.  The  Pneumonic  Form. — The  disease  may  appear 
as  a  primary  specific  pneumonia,  with  the  usual  characters  of  infectious 
inflammation  of  the  lungs.  The  type  is  bronchopneumonic,  the  fever  high, 
the  respirations  rapid,  the  sputum  hemorrhagic  and  laden  with  the  bacilli. 
The  attack  lasts  only  a  few  days  and  almost  invariably  terminates  in  death. 

Diagnosis. — Direct. — Cases  imported  during  the  stage  of  incubation 
or  the  first  cases  in  an  outbreak  may  be  readily  overlooked.  In  suspected 
cases  all  uncertainty  can  be  at  once  settled  by  a  proper  laboratory  inves- 
tigation. The  bacteriological  examination  of  the  blood,  pus  from  the 
buboes,  the  urine,  and  the  sputum  yields  positive  results.  If  necessary 
cultures  should  be  made  and  inoculation  experiments  upon  guinea- 
pigs.  The  danger  of  the  importation  of  the  disease  at  the  present  time 
renders  an  efficient  inspection  at  the  quarantine  station  at  every  port 
of  entry  imperatively  necessary,  with  bacteriological  studies  in  the  case 
of  every  suspect. 

Prognosis. — Bubonic  plague  is  the  most  fatal  of  the  acute  infectious 
epidemic  diseases.  In  the  larval  forms  recovery  is  the  rule;  in  the  septic 
and  pneumonic  forms  death;  in  the  ordinary  bubonic  form  a  great  major- 
ity of  the  cases  die.  The  statistics  of  the  Middle  Ages  are  unreliable,  but 
it  is  stated  that  the  Black  Death  of  the  fourteenth  century  destroyed  one- 
fourth  of  the  population  of  Europe. 

XXIV.    MALTA  FEVER. 

Definition. — An  acute  general  infectious  disease,  caused  by  the  Mi- 
crococcus melitensis  and  characterized  by  irregular  fever  of  long  duration 
and  remittent  or  intermittent  type,  with  periods  of  apyrexia,  by  profuse 
sweating,  rheumatoid  pains,  arthritis,  and  enlargement  of  the  spleen. 

Etiology. — Predisposing  Influences. — The  disease  prevails  widely 
upon  the  littoral  and  islands  of  the  Mediterranean  and  is  known  as 
Mediterranean  fever,  rock  fever,  Neapolitan  fever,  Danubian  fever.  It 
has  also  been  encountered  in  China  and  India,  Manila  and  in  the  West 
Indies,  and  imported  cases  have  been  studied  in  this  country.  It  is 
prevalent  in  summer  as  an  endemic  disease,  not  occasionally  in  circum- 
scribed epidemics.  It  is  not  directly  transmissible  from  the  sick  to  the 
well.  Malta  fever  is  especially  a  disease  of  young  adults.  It  has  been 
particularly  studied  by  the  surgeons  of  the  British  Army  stationed  at 
Gibraltar  and  Malta. 


760 


MEDICAL  DIAGNOSIS. 


Exciting  Cause.  —  The  Micrococcus  melitensis  was  first  isolated 
and  studied  by  Brun  in  1887.  This  organism  has  not  been  found  in  the 
circulating  blood,  but  is  present  in  the  spleen  during  life  and  after  death. 
It  is  pathogenic  for  monkeys,  and  cases  of  accidental  infection  in  laboratory 

work  have  been  reported.  The  serum 
of  the  patient  after  the  fifth  day  causes 
agglutination  of  cultures  of  the  organ- 
ism in  dilution  of  1  to  10  or  1  to  50. 

The  milk  supply  at  Malta  is  largely 
derived  from  goats,  and  Zammit,  in 
1905,  made  the  important  discovery 
that  the  goats  of  the  island  are  infected 
with  Micrococcus  melitensis  and  isolated 
this  organism  from  the  milk  and  urine 
of  those  animals. 

Symptoms. — The  period  of  incu- 
bation lasts  from  six  to  ten  days.  The 
onset  is  preceded  by  prodromes  not 
unlike  those  of  enteric  fever.  The 
course  of  the  disease  is  characterized  by 
undulations  of  fever,  102°-104°  F.  (39°-40°  C),  of  distinctly  remittent  type, 
lasting  as  a  rule  from  one  to  three  weeks,  and  separated  by  intervals  of 
incomplete  or  complete  apyrexia  of  two  or  more  days'  duration.  In  rare 
cases  during  the  pyrexial  period  the  fever  conforms  to  the  intermittent  type, 
without,  however,  manifesting  the  regular  periodicity  of  the  malarial  infec- 


FiG.  259. — Micrococcus  melitensis. 


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shown  on  this  chart. 


tions.  This  irregular  fever  is  indefinitely  prolonged,  lasting  from  three 
months,  the  average  time,  to  six  months,  and  being  in  some  instances 
prolonged  by  a  series  of  relapses  to  two  years.  Obstinate  constipation, 
progressive  anaemia,  and  debility  are  common  symptoms;  the  spleen  is 
enlarged  and  tender;  neuralgias,  inflammation  of  the  joints,  with  intra- 


BERI-BERI.  761 

articular  effusion,  painful  inflammatory  conditions  of  certain  fibrous 
structures,  and  orchitis  occur  as  complications.  The  wave-like  range  of 
the  temperature  has  suggested  the  name  "  undulant  fever.  "  A  malignant 
type,  fatal  in  the  course  of  a  week  or  ten  days,  is  recognized,  and  a 
so-called  intermittent  type  with  a  daily  rise  of  temperature  toward 
evening  has  been  described. 

Diagnosis. — Direct. — In  districts  in  which  Malta  fever  is  endemic 
the  direct  diagnosis  is  not  attended  with  difficulty.  It  rests  upon  the  char- 
acter of  the  fever  and  its  protracted  course  with  intervals  of  apyrexia, 
the  tendency  to  relapse,  the  headache,  lassitude,  and  joint  affection. 
Finally,  the  agglutination  test  is  conclusive. 

Differential. — The  true  nature  of  the  disease  may  not  be  apparent 
in  imported  cases.  Malaria  reveals  itself  upon  an  examination  of  the 
blood.  The  temperature  is  higher,  the  periodicity,  as  a  rule,  more  dis- 
tinctly defined.  Joint  pains  are  not  prominent.  The  judicious  use  of 
quinine  is  curative — therapeutic  test.  Enteric  fever  differs  from  Malta 
fever  in  its  temperature  range  and  duration.  If  relapses  occur  they  con- 
stitute a  repetition  of  the  primary  attack  and  like  it  are  attended  by  sub- 
continuous  temperature,  rose  spots,  and  marked  intestinal  and  nervous 
symptoms.  A  positive  Widal  reaction  is  conclusive.  Endemic  and  epi- 
demic influences  are  suggestive.  Dengue  is  a  pandemic  disease  and  spreads 
with  great  rapidity.  The  joint  affection  is  among  the  earliest  and  most 
conspicuous  phenomena.  The  initial  febrile  paroxysm  is  of  short  duration 
and  the  recurrent  paroxysm  is  characterized  by  a  polymorphous  rash. 
Rheumatic  fever  bears  only  a  superficial  resemblance. 

Prognosis. — The  mortality  is  about  2  per  cent.  Death  is  due  to 
the  debility  resulting  from  indefinitely  prolonged  fever,  the  anaemia,  or 
complications.     Convalescence  is  hastened  by  change  of  climate. 

XXV.  BERI-BERI. 

Kakke. 

Definition. — An  endemic  and  epidemic  multiple  neuritis  of  unde- 
termined etiology,  widely  prevalent  in  tropical  and  subtropical  countries 
of  the  East,  and  characterized  by  motor  and  sensory  palsies,  atrophy  of 
the  muscles,  and  dropsy. 

Etiology. — Predisposing  Influences. — This  disease  is  widely  prev- 
alent in  China,  Japan,  the  Philippines,  and  the  Malay  Archipelago.  Local 
epidemics  have  been  observed  in  Australia.  It  is  very  common  in  Brazil 
and  occurs  in  the  West  Indies.  Imported  cases  are  not  uncommon  in  the 
seaport  cities  of  the  United  States,  especially  on  the  Pacific  Coast.  In  a 
few  instances  American  fishermen  have  suffered  from  it,  both  upon  the 
Grand  Banks  and  in  shore  fishing.  In  its  prevalence  as  determined  by 
season  and  locality  it  is  not  unlike  malaria,  being  most  common  in  the  hot 
and  rainy  seasons.  Absence  of  sunlight  and  air,  and  overcrowding  are 
important  favoring  conditions,  hence  beri-beri  is  frequent  in  jails  and 
asylums.  It  is  also  a  common  and  troublesome  disease  on  shipboard, 
both  in  naval  and  commercial  service.     It  is  especially  a  disease  of  fisher- 


762 


MEDICAL  DIAGNOSIS. 


men,  a  fact  attributed  to  exposure  and  wet.  In  districts  where  the  disease 
is  endemic,  and  even  in  epidemics,  the  native  races  chiefly  suffer.  The 
imported  cooUes  are  especially  hable  to  it.  Young  men  from  16  to  30  are 
most  frequently  attacked,  but  no  period  of  life  is  exempt.  Males  suffer 
much  more  often  than  females.  Beri-beri  has  long  been  regarded  as  a 
food  disease  and  attributed  to  rice  which  has  undergone  certain  unknown 
changes,  or  fish  eaten  raw  or  improperly  cooked.  Many  striking  facts 
have  been  adduced  in  support  of  these  opinions,  especially  the  practical 
disappearance  of  the  disease  in  the  Japanese  Navy  after  certain  changes 
in  the  diet,  among  which  was  the  abolition  of  fresh  fish  as  an  article  of  food. 
On  the  contrary,  Hamilton  Wright,  who  has  made  an  especial  study  of  the 
disease,  holds  the  opinion  that  ''no  food  as  food  either  qualitatively  or 
quantitatively  is  a  factor  in  the  production  of  the  disease. " 

Exciting  Cause. — ^The  Dutch  ph3^sicians,  who  have  first-hand  knowl- 
edge of  the  disease  upon  an  extensive  scale,  believe  that  beri-beri  is  an 
infectious  disep.se.     Wright  holds  that.it  is  an  acute  or  subacute  infectious 


Fig.  261. — Atrophic  varietj'  of  beri-beri  showing  muscular  atrophy  and  wrist-drop. —  •Jm/.-nnl  of  Tropical 

Medicine) . — I niernational  Clinics. 


disease,  due  to  a  specific  but  as  j^et  undiscovered  organism,  probably  in- 
gested with  the  food  accidentally  contaminated  by  it.  He  thinks  that 
the  disease  may  be  spread  by  fecal  contamination,  and  regards  this  hy- 
pothesis as  of  great  importance  for  prophylaxis. 

No  specific  bacterium  has  as  yet  been  demonstrated. 

Symptoms. — The  period  of  incubation  is  unknown.  Wright  thinks 
it  is  short.  A  dry  and  wet  form  were  once  recognized.  The  following 
clinical  forms  are  described  but  they  are  not  sharply  differentiated:  1.  Un- 
developed OR  Larval  Form. — The  onset  is  marked  with  catarrhal  phe- 
nomena which  are  followed  by  nervous  symptoms,  such  as  modifications 
of  sensation,  parsesthesias,  hyperaisthesia  and  pain,  and  loss  of  power 
in  the  limbs,  chiefly  in  the  legs  and  feet.  The  muscles  are  not  only 
weak,  they  are  also  tender  upon  pressure.  There  is  in  many  cases  even 
in  this  form  oedema  of  the  feet  and  ankles,  but  it  is  slight.  Cardiac  palpi- 
tation, dyspnoea,  and  abdominal  dis.tress  may  be  present.  This  symptom- 
complex  is  of  variable  duration.  After  a  week  or  two,  or  several  months, 
recovery  takes  place,  but  there  is  a  tendency  to  recurrence.  2.  Atrophic 
Form;  so-called  Dry  Form. — Early  symptoms  are  the  same  as  in  the 
incomplete  form.     There  is,  however,  more  pain,  wasting  of  the  muscles 


TETANUS. 


763 


sets  in  and  progresses  rapidly  so  that  in  a  short  time  paralytic  phenomena 
are  pronounced  and  the  power  of  movement  is  greatly  impaired.  Cardiac 
derangements  and  dropsy  are  not  prominent.  3.  Dropsical,  or  so-called 
Wet  Form. — With  similar  initial 
symptoms  oedema  occurs  early  and 
soon  becomes  general  with  eiTu- 
sions  into  the  serous  sacs.  Muscu- 
lar and  neural  symptoms  are  less 
pronounced  than  in  the  atrophic 
form  and  the  wasting  is  not  appar- 
ent until  after  the  anasarca  sub- 
sides. 4.  Acute  Cardiac,  or 
Pernicious  Form. — The  symp- 
toms which  characterize  the  rudi- 
mentary form  are  followed  by  the 
evidences  of  acute  cardiac  asthe- 
nia, which  may  persist  for  several 
weeks  or  terminate  fatally  in  the 
course  of  a  day  or  two. 

Diagnosis,  —  Direct.  —  In 
countries  in  which  beri-beri  is 
endemic  there  is  little  difficulty 
in  the  diagnosis. 

Differential. — Only  in  an 
isolated  imported  case  could  mul- 
tiple neuritis  from  other  causes, 
as  alcohol,  arsenic,  etc.,  occasion 
difficulty.  Here  the  anamnesis 
is  most  important  and  dropsical 
symptoms  most  suggestive. 

Prognosis. — The  disease  is 
essentially  subacute  and  chronic 
and  lasts  a  varying  time,  meas- 
ured by  days  or  months.  The 
acute  cardiac  forms  usually  be- 
come chronic  after  a  number  of 
days  or  weeks.  Recurrences  are  common,  especially  in  the  wet  season. 
The  mortality  varies  from  2  or  3  to  50  per  cent.,  and  is  very  high 
among  coolie  laborers  imported  into  a  beri-beri  district. 


Fig.  262. — CEdematous  variety  of  beri-beri. —  {Journal 
of  Tropical  Medicine.) — International  Clinics. 


XXVI.  TETANUS. 

Lockjaw. 


Definition. — An  infectious  disease  caused  by  a  bacillus  found  in 
garden  earth  and  in  the  excrement  of  animals,  especially  the  horse,  char- 
acterized by  tonic  spasm  of  the  muscles,  with  paroxysmal  exacerbations. 

Etiology.— Predisposing  Influences. — Tetanus  is  essentially  a 
wound  infection.     The  view  at  one  time  entertained,  that  the  disease  may 


764 


MEDICAL  DIAGNOSIS. 


be  cryptogenic  and  idiopathic,  and  due  to  rheumatism  or  exposure  to  coldr 
is  no  longer  accepted.  Many  cases  arise  in  consequence  of  insignificant 
wounds  which  are  overlooked  or  entirely  healed  at  the  beginning  of  the 
attack.  Internal  injuries  involving  the  mucous  membrane,  which  elude 
observation,  are  to  be  considered  in  this  connection.  Tetanus  occurs  in  all 
latitudes  but  is  much  more  common  in  tropical  than  in  temperate  climates, 
and  among  the  colored  than  the  white  races.  This  is  especially  true  of 
puerperal  tetanus  and  tetanus  of  the  new-born.  In  tropical  America  and  the 
West  Indian  Islands  tetanus  has  prevailed  as  a  veritable  public  scourge. 
Since  the  discovery  of  the  tetanus  bacillus  and  the  diffusion  of  the 
knowledge  of  its  saprophytic  existence  the  prevalence  of  the  disease  has 
greatly  diminished.  Tetanus  occurs  more  frequently  in  the  summer  and 
early  winter  than  at  other  seasons  of  the  year.  It  has  been  attributed  to 
exposure  to  cold  and  to  sleeping  upon  the  damp  ground.  Aside  from  the 
frequency  of  tetanus  among  the  new-born,  age  is  without  influence.  The 
disease  is  said,  however,  to  be  less  common  after  the  sixteenth  year.  Sex 
is  without  influence  except  in  so  far  as  occupation  renders  males  more 
liable  than  females.  Occupation  is  an  important  predisposing  influence. 
All  those  which  involve  liability  to  wounds  of  the  extremities,  with  coin- 
cident fouling  with  earth,  manure,  or  the  excrement  of  animals,  especially 
with  that  of  the  horse,  or  with  dust  or  dirt  containing  such  material,  pre- 
dispose to  tetanus.  Hence  stablemen,  teamsters,  gardeners,  and  soldiers, 
especially  cavalrymen,  are  particularly  liable  to  the  disease.  In  some 
military  campaigns  tetanus  has  contributed  largely  to  the  mortality. 

The  majority  of  cases  occur  after  lacerated  and  crushed  wounds, 
especially  those  involving  large  nerves.  The  disease  is  comparatively 
infrequent  after  incised  wounds.  The  extent  and  severity  of  the  wound 
has  no  direct  relation  to  the  liability  to  tetanus.  The  condition  of  the 
wound  as  regards  its  tendency  to  heal  is  entirely  without  influence;  tetanus 

may  occur  when  a  wound  has  completely 
healed  and  a  cicatrix  has  formed.  The 
disease  may  follow  the  most  trifling 
traumatism — the  extraction  of  a  tooth, 
the  use  of  cupping  glasses,  the  sting  of 
an  insect,  the  application  of  a  blister. 
It  is  far  more  frequent  after  injuries  of 
the  extremities  than  in  other  parts  of  the 
body.  The  disease  has  been  attributed 
to  the  use  of  the  hypodermic  syringe.  At 
one  time  tetanus  was  common  in  hospi- 
tals and  occasionally  became  epidemic 
in  maternity  institutions,  a  large  pro- 
portion of  the  lying-in  women  and  their 
children  dying  of  this  disease. 

Exciting  Cause. — The  tetanus 
bacillus  has  been  found  in  the  cultivated  surface  soil  of  all  countries, 
but  not  beyond  the  depth  of  30  cm.  It  has  also  been  found  in  the 
dust  of  streets  and  in  the  woodwork  of  houses  and  furniture.  It 
is    frequently    present    in    the    excrement    of    animals    and    man.      The 


Fig.  263, — Bacillus  tetani  and  free  spores. 


TETANUS.  765 

comparative  infrequency  of  tetanus  is  in  strong  contrast  with  the 
wide  distribution  of  its  cause. 

Symptoms. — The  period  of  incubation  is  extremely  variable.  In  gen- 
eral the  onset  occurs  between  the  eighth  and  fourteenth  days,  rarely  later 
than  the  fourth  week.  Prodromes  are  infrequent.  They  consist  of  nausea, 
tenderness  in  the  wound  or  scar,  increased  suppuration  or  spontaneous 
reopening  of  the  wound,  accompanied  by  restlessness  and  loss  of  sleep. 

The  attack  is  occasionally  marked  by  shivering  or  an  actual  chill. 
The  characteristic  symptoms  are  continuous  tension  of  the  voluntary 
muscles,  and  the  occurrence  at  irregular  intervals  of  spasms  of  varying 
intensity.  The  tension  and  the  spasms  are  commonly  relaxed  during 
sleep.  In  inoculated  animals,  these  symptoms  usually  commence  in  the 
region  of  the  wound  and  extend  to  other  parts  of  the  body.  In  man  they 
often  first  involve  the  muscles  of  the  neck  and  suggest  an  ordinary  torti- 
collis from  cold.  Tension  and  spasm  of  the  masticatory  muscles — trismus 
— soon  occur  and  may  be  the  earliest  manifestations  of  the  true  condition. 
There  is  inability  to  open  the  mouth  or  protrude  the  tongue — lock]' mo 
— and  efforts  to  perform  these  actions  provoke  more  or  less  persistent 
spasm  of  the  facial  muscles — risus  sardonicus.  Presently  the  abdomen 
is  felt  to  be  hard  and  board-like,  as  in  the  early  stage  of  peritonitis, 
from  contraction  of  the  muscles.  A  sensation  of  oppression  or  pain  in  the 
precordia,  extending  to  the  spine,  is  frequently  experienced,  and  has  been 
attributed  to  spasm  of  the  diaphragm.  The  pain  at  this  time  is  not  usually 
severe  in  proportion  to  the  violence  of  the  spasm;  later  it  becomes  more 
intense.  In  a  short  time  the  spasms  extend  to  the  voluntary  muscles  in  all 
parts  of  the  body  and  affect  them  with  about  equal  severity.  The  dorsal 
and  lumbar  muscles  may  contract  more  violently  than  their  antag- 
onists, giving  rise  to  opisthotonos.  Forcible  contraction  of  the  abdominal 
muscles,  causing  emprosthotonos,  or  of  the  muscles  of  one  side — pleu- 
Tothotonos — are  far  less  common  and  less  marked.  On  the  other  hand, 
transient  or  persistent  rigidity  of  the  trunk  and  limbs — orthotonos — is 
frequently  observed.  The  fingers  are  but  slightly  involved  in  the  general 
stiffness  and  spasmodic  contraction.  The  laryngeal  muscles  may  be  in- 
volved, causing  noisy  respiration,  dyspnoea,  or  fatal  asphyxia.  The  spasms 
may  occur  spontaneously  and  are  apt  to  come  on  when  the  patient  awakes 
from  sleep.  They  are  caused  by  trifling  external  impressions,  as  efforts 
to  move,  the  arrangement  of  the  bedclothing,  or  an  examination  of  the 
pulse  or  heart.  Attempt  to  swallow  frequently  brings  on  violent  general 
spasm.  Viscid  saliva  accumulates  in  the  mouth  and  is  swallowed  with 
difficulty.  Respiration  is  disturbed;  there  may  be  cyanosis;  the  expres- 
sion is  greatly  changed.  The  spasms  are  followed  by  great  exhaustion, 
with  periods  of  quietude,  drowsiness,  and  sleep.  The  duration  of  the  par- 
oxysms is  variable.  The  intellect  as  a  rule  remains  clear  throughout  the 
attack.  In  rare  cases  delirium  has  occurred.  The  pulse  is  increased  in 
frequency  during  the  paroxysms;  in  the  intervals  the  pulse  and  respira- 
tion are  commonly  normal.  The  temperature  is  frequently  normal  until 
toward  the  close  of  the  attack;  in  some  instances  there  is  fever  from  the 
onset,  104°-105°  F.  (40°-40.5°  C).  A  preagonistic  rise  is  usual  and  often 
extreme,    106°-110°   F.    (41.1°-43.5°   C).     Abundant  perspirations  occur 


766  MEDICAL  DIAGNOSIS. 

during  the  paroxysms.  The  urine  is  decreased  in  quantity,  concentrated, 
dark,  and  frequently  albuminous.  Its  toxic  coefficient  is  increased  and  its 
injection  into  animals  has  caused  fatal  tetanus.  The  bowels  are  consti- 
pated. The  sphincters  are  contracted.  The  administration  of  a  clyster 
may  be  difficult  and  catheterization  impossible.  These  procedures  are 
not  only  hindered  by  the  state  of  the  muscles  but  they  also  cause  violent 
general  spasms. 

The  acute  cases  usually  prove  fatal  about  the  third  day.  The  milder 
cases  may  continue  for  two  or  three  weeks  or  even  longer.  Recoveries 
usually  take  place  in  the  prolonged  cases.  The  disease  is  most  severe  and 
quickly  fatal  when  it  develops  shortly  after  the  injury.  Death  occurs 
in  the  acute  cases,  usually  during  the  paroxysm,  from  asphyxia,  oedema  of 
the  glottis,  or  cerebral  hemorrhage;  less  frequently  from  sudden  collapse 
or  coma.  In  the  prolonged  cases  it  may  be  the  result  of  exhaustion  or  of 
inhalation  pneumonia.  If  the  patient  survives  the  fourth  day  the  intensity 
of  the  symptoms  may  gradually  diminish.  Tetanus  neonatorum  is  due  to 
infection  at  the  navel.  The  disease  usually  shows  itself  between  the  first 
and  fifth  days  after  the  separation  of  the  cord.  The  symptoms  are  the 
same  as  those  of  ordinary  traumatic  tetanus.  The  duration  is  variable, 
death  commonly  occurring  about  the  third  or  fourth  day.     Recovery  is  rare. 

The  term  puerperal  tetanus  is  applied  to  those  cases  which  develop 
in  the  lying-in  woman.  It  frequently  occurs  as  the  result  of  abortion  or 
from  neglect  of  antiseptic  precautions  in  confinement.  Tetanus  may  occur 
after  operations  or  injuries  of  the  genitalia  in  non-pregnant  women.  Tet- 
anus bacilli  have  been  found  in  the  uterus  and  vaginal  discharges. 

The  Cephalic  or  Facial  Tetanus  of  Rose  originates  from  a  lacerated 
wound  in  the  region  of  the  facial  nerve  and  is  characterized  by  trismus,  diffi- 
culty in  swallowing,  and  paralysis  of  the  facial  muscles  upon  the  same  side. 

Diagnosis. — Direct. — This  rests  upon  the  occurrence  of  stiffness  in 
the  muscles  of  the  neck,  trismus,  substernal  pain  extending  to  the  back, 
followed  by  risus  sardonicus,  general  tension  of  the  muscles  with  paroxysms 
of  spasm,  and  finally  upon  the  bacteriological  examination.  The  previous 
occurrence  of  trauma  is  most  important.  Courmont  has  shown  that  neither 
spontaneous  nor  experimental  tetanus  develops  any  agglutinating  property 
in  the  blood. 

Differential. — 1.  Torticollis  following  exposure  to  cold — so-called 
rheumatic  torticollis.  A  history  of  trauma  and  the  rapid  development 
of  the  attack  speedily  settle  any  doubt.  2.  Trismus  associated  with 
quinsy.  Parotitis  and  local  abscesses  of  the  jaws  or  teeth  may  suggest 
tetanus,  but  a  careful  examination  and  the  absence  of  general  symptoms 
render  the  diagnosis  clear.  It  is  important  in  this  connection  to  note  that 
the  rigidity  of  the  masticatory  muscles  in  tetanus  is  bilateral.  3.  Strychnia 
Poisoning. — The  spasms  are  very  suggestive  but  trismus  is  rarely  marked, 
and  in  the  intervals  between  the  paroxysms  there  is,  in  stiychnia  poisoning, 
no  rigidity.  4.  Cerebrospinal  Meningitis. — Opisthotonos  is  a  common 
and  prominent  symptom  and  in  rare  cases  general  spasms  may  occur, 
but  the  high  fever  and  grave  mental  derangements  stand  in  contrast  to 
the  absence  of  fever  at  the  beginning  and  the  mental  clearness  in  tetanus. 
5.   Tetany. — Spasm  of  the  extremities,  the  peculiar  position  of  the  wrists 


HYDROPHOBIA.  767 

and  hands  and  the  feet  and  toes,  the  occurrence  of  the  symptom  described 
by  Trousseau  and  that  of  Chvostek,  together  with  the  conditions  under 
which  the  disease  occurs,  usually  render  the  diagnosis  a  simple  matter. 
6.  Hydrophobia. — The  history  of  the  case,  showing  the  bite  of  an  animal 
or  man,  the  long  period  of  incubation,  the  absence  of  trismus,  the  influence 
of  attempts  to  swallow  in  producing  the  spasms,  and  the  great  rest- 
lessness and  jactitation  are  of  diagnostic  importance.  7.  Hysteria. — The 
paroxysms  are  occasionally  attended  by  convulsions  which  suggest  tetanus. 
The  absence  of  antecedent  trauma,  the  neurotic  temperament,  the  inter- 
paroxysmal  state,  the  emotional  manifestations,  the  curious  sensory  dis- 
turbances, the  existence  of  hysterogenetic  areas  render  the  differential 
diagnosis  between  this  condition  and  tetanus  easy. 

Prognosis. — The  worst  days  are  the  first  four.  The  aphorism  of  Hippoc- 
rates still  holds  good:  "The  patient  who  survives  the  fourth  day  may 
recover.  "  Traumatic  tetanus  is  less  frequent  and  less  fatal  in  women  than 
in  men.  The  general  mortality  is  about  80  per  cent.  The  later  the  disease 
shows  itself  after  the  occurrence  of  the  wound  of  infection  the  milder  is 
its  course,  and  the  more  intense  the  initial  symptoms  the  greater  the  danger. 
The  mortality  is  greater  in  children  than  in  adults.  Restriction  of  the 
spasms  to  the  muscles  of  the  neck  and  jaw,  and  the  absence  of  fever  are 
favorable. 

XXVII.   HYDROPHOBIA. 

Rabies;  Lyssa. 

Definition. — An  acute  infectious  disease  of  warm-blooded  animals, 
caused  by  an  unknown  specific  virus  contained  in  the  saliva,  character- 
ized by  convulsive  and  paralytic  symptoms  and  communicated  by 
inoculation   to  man. 

The  terms  ''hydrophobia"  and  "rabies"  denote  prominent  symptoms. 
The  Greek  term  "lyssa"  is  frequently  used.  The  distinction  between 
lyssa  humana  and  lyssa  animalis  is  unnecessary. 

Etiology. — Predisposing  Influences. — A  distinction  was  formerly 
made  between  the  hydrophobia  of  man  and  that  of  animals.  Experi- 
mental medicine  has  established  the  fact  that  the  disease  in  man  and 
animals  is  the  same.  Climate  is  without  influence.  The  disease  occurs  in 
all  parts  of  Europe  and  is  common  in  France,  Holland,  and  England.  At 
one  time  frequent  in  Germany,  it  has  in  recent  years  become  rare  as  a 
result  of  the  strict  enforcement  of  laws  regulating  the  muzzling  and  care  of 
dogs.  It  is  very  common  in  Russia.  In  North  America  it  is  comparatively 
infrequent.  The  greater  number  of  cases  develop  in  the  summer  months, 
a  fact  which  finds  ready  explanation  in  the  out-door  life  and  lighter  clothing 
at  this  season.  Men  and  children  are  affected  more  frequently  than  women 
who  are  less  exposed  and  whose  clothing  affords  some  degree  of  protection. 

Epidemics  among  animals  can  often  be  traced  to  a  single  case.  The 
spontaneous  occurrence  of  the  disease  as  the  result  of  cold,  heat,  thirst,  or 
other  such  cause  has  not  been  established.  It  is  equally  contrary  to  experi- 
ence that  hydrophobia  arises  spontaneously  in  man.  Inoculation  takes 
place  in  the  vast  majority  of  cases  by  the  bites  of  animals  suffering  from 


768  MEDICAL  DIAGNOSIS. 

the  disease.  Not  every  bite  of  an  animal  suffering  from  rabies  produces 
the  disease,  since  the  saliva  may  be  wiped  off  by  the  clothing.  Especially 
dangerous  are  bites  upon  the  face,  hands,  and  the  uncovered  legs  and  feet. 

Rabies  occurs  most  frequently  in  the  dog,  wolf,  and  cat.  Nearly  all 
the  domestic  animals  occasionally  suffer  as  the  result  of  inoculation.  Rats 
and,  in  this  country,  the  skunk  are  particularly  liable.  The  disease  is  com- 
monly propagated  by  the  dog,  which  is  on  the  one  hand  peculiarly  suscep- 
tible and  on  the  other  hand  liable  to  infect  other  animals  and  human  beings, 
the  disposition  to  bite  being  an  especial  manifestation  of  the  attack.  Next 
in  importance  in  disseminating  the  disease  is  the  cat.  The  propagation 
of  hydrophobia  by  other  animals  is  comparatively  rare.  Recent  researches 
show  that  rabbits,  guinea-pigs,  and  other  warm-blooded  animals  in  which 
hydrophobia  was  not  formerly  observed  are  susceptible. 

Exciting  Cause. — The  nature  of  the  poison  is  unknown.  It  is  most 
abundant  in  the  central  nervous  system  and  especially  in  the  medulla 
oblongata.  It  is  present  also  in  the  peripheral  nerves,  though  in  much 
smaller  amounts. 

Symptoms. — The  period  of  incubation  in  man  is  irregular.  Its  aver- 
age duration  is  from  20  to  60  days.  It  may,  however,  be  prolonged  to 
three  months  and  exceptionally  to  six  months. 

The  period  of  incubation  is  influenced  by:  (a)  the  susceptibihty  of  the 
patient — it  is  shorter  in  children  than  in  adults;  (b)  the  animal  communi- 
cating the  infection.  The  incubation  is  shortest  after  the  bite  of  the  wolf 
and  increases  in  the  following  order — the  cat,  the  dog,  and  other  animals, 
(c)  The  amount  of  the  virus  introduced — puncture  wounds  and  extensive 
laceration  wounds  being  followed  by  shorter  periods;  and  (d)  the  part  of 
the  body  upon  which  the  inoculation  takes  place.  Bites  upon  the  face  and 
head  are  followed  by  shorter  periods  of  incubation,  and  next  in  order  are 
bites  upon  the  hands. 

Stage  of  Prodromes.' — There  is  irritation  about  the  scar  or  the  wound, 
together  with  pain.  In  some  instances  the  healed  wound  reopens.  Sensa- 
tions of  numbness  may  occur.  Trembling  and  fibrillary  contraction  of  the 
muscles  of  the  affected  member  have  also  been  observed.  Other  prodromal 
symptoms  consist  of  a  feeling  of  depression,  aching,  and  a  sensation  of 
pressure  in  the  head.  The  patient  becomes  sad,  loses  interest  in  his  sur- 
roundings, and  prefers  to  be  alone.  He  is  unwilhng  to  talk  about  the  injury 
to  which  his  illness  is  attributed.  He  is  restless,  apprehensive,  and  seeks 
relief  from  these  symptoms  in  long  solitary  excursions.  Children  become 
depressed,  lose  interest  in  their  ordinary  play,  and  have  irregular  and 
disturbed  sleep.  There  is  increased  general  sensibility  and  bright  light 
and  noises  are  extremely  distressing.  There  is  laryngeal  irritation  which 
may  show  itself  in  shght  hoarseness  and  occasional  spasmodic  cough. 
There  may  be  difficulty  in  swallowing.  Shivering  may  occur,  which  is 
followed  by  some  elevation  of  temperature  and  increased  pulse-frequency. 
Loss  of  appetite,  nausea,  and  epigastric  pain  occur.  This  stage  commonly 
lasts  from  two  to  eight  days.  It  maj^  however  be  much  prolonged.  In 
some  instances  the  prodromal  symptoms  are  altogether  absent.  Stage 
OF  Excitement. — There  is  an  intense  sensation  of  dyspnoea,  interrupted 
by  sighing  and  accompanied  by  a  feehng  of  oppression  and  precordial 


HYDROPHOBIA.  769 

distress.  Difficulty  in  swallowing  becomes  more  marked  and  it  is  commonly 
on  account  of  these  symptoms  that  the  patient  consults  a  physician.  The 
difficulty  in  swallowing  is  characteristic.  Attempts  to  drink  or  even  to 
swallow  the  saUva  produce  violent  painful  reflex  spasm  of  the  muscles  of 
the  larynx  and  throat,  which  passes  away  to  return  with  renewed  intensity 
upon  further  attempts.  So  distressing  is  this  symptom  that  the  patient 
avoids  taking  fluid  until  compelled  by  the  urgency  of  thirst.  As  the  case 
progresses  any  irritation — a  sound,  a  draught  of  air,  the  sight  of  water 
or  the  mere  suggestion  of  it — may  bring  about  the  spasm.  The  superficial 
and  deep  reflexes  are  increased.  The  pupils  are  usually  slightly  dilated. 
This  stage  is  characterized  also  by  great  excitabiHty  and  restlessness.  The 
patient  is  tormented  by  occasional  hallucinations,  his  speech  is  short  and 
broken,  his  voice  hoarse,  and  during  the  convulsive  attacks  inarticulate 
sounds  may  be  uttered  which  have  been  compared  to  the  barking  of  a  dog. 
In  the  maniacal  excitement  the  patient  sometimes  bites  himself.  Very 
rarely,  however,  does  he  attempt  to  injure  his  attendants.  The  saliva  is 
much  increased.  It  is  frothy  and  discolored  and  freely  expectorated. 
At  the  beginning  of  the  attack  there  is  usually  free  perspiration.  The 
urine  is  diminished  and  of  high  specific  gravity.  Albumin  and  casts  are 
sometimes  present.  Sugar  has  been  observed  and  in  some  cases  hsemo- 
globinuria.  Trembling  of  the  tongue  and  hands  is  common  and  in  some 
instances  there  is  persistent  tremor  of  the  muscles  of  the  face.  Priapism 
occurs.  The  temperature  is  commonly  elevated  and  may  reach  100°  to 
103°  F.  (37.8°-39.5°  C).  In  many  cases  there  is  a  preagonistic  rise.  The 
pulse  is  increased  in  frequency,  irregular  and  intermittent.  The  respirations 
are  irregular  and  shallow  in  the  intervals  between  the  convulsive  paroxysms 
and  sometimes  assume  the  Cheyne-Stokes  rhythm.  The  expression  is 
anxious.  Hallucinations  and  sometimes  furious  maniacal  excitement 
attend  the  convulsive  paroxysms.  In  the  interval  the  mind  is  usually 
clear.  Death  may  occur  from  asphyxia  during  the  paroxysm.  This  stage 
commonly  lasts  from  2  to  3  days.  Paralytic  Stage. — The  spasms  become 
less  frequent  and  less  severe.  There  gradually  develops  muscular  relax- 
ation. Difficulty -in  breathing  disappears  and  it  becomes  possible  to  swal- 
low. The  patient  sinks  into  unconsciousness,  the  heart's  action  becomes 
progressively  more  feeble,  and  death  occurs  in  collapse.  The  paralysis 
may  be  limited  to  certain  groups  of  muscles,  as  the  tongue,  the  facial 
muscles,  or  the  muscles  of  the  eye.  In  other  cases  hemiplegia  or  paraplegia 
may  occur.  In  rats  as  a  rule,  and  occasionally  in  rabbits,  the  stage  of 
excitement  does  not  occur  and  the  onset  of  the  attack  is  marked  by  para- 
lytic symptoms — dumb  rabies.  The  disease  occasionally  assumes  this  form 
in  human  beings.  It  is  apt  to  follow  multiple  and  severe  wounds  inflicted 
by  the  rabid  animal,  and  has  been  attributed  to  proportionally  large  doses 
of  the  virus — an  opinion  supported  by  experimental  investigations. 

Diagnosis.  —  Direct.  —  There  is  nothing  characteristic  about  the 
wound.  It  may  heal  promptly  by  first  intention  or  by  suppuration  and 
granulation  in  the  ordinary  manner.  The  diagnosis  depends  upon  the 
history  of  the  bite  of  an  animal  suspected  or  known  to  be  rabid,  the  occur- 
rence of  irritation  in  the  wound  or  scar,  the  characteristic  spasm  of  the 
muscles  of  deglutition  and  respiration,  the  intense  reflex  excitability,  the 

49 


770  MEDICAL  DIAGNOSIS. 

short  duration  of  the  disease  and  the  fatal  issue.  It  is  important  in  doubt- 
ful cases  to  determine  by  inoculation  the  presence  or  absence  of  the  disease  in 
the  suspected  animal.  A  small  quantity  of  the  substance  of  the  central 
nervous  system  of  a  rabid  animal  inoculated  subdurally  will  produce  in  a 
rabbit  the  paralytic  form  of  rabies  in  the  course  of  fifteen  or  twenty  daj^s. 

Differential. — The  following  diseases  may  present  superficial  resem- 
blances to  hydrophobia  in  the  human  being:  1.  Hysteria. — The  reflex 
irritability  may  suggest  hydrophobia,  but  the  spasms  lack  early  locali- 
zation to  the  muscles  of  the  throat  and  neck  and  the  intensity  of  the 
later  general  convulsions.  The  stigmata  of  hysteria  are  present  and  the 
manifestations  are  indefinitely  prolonged.  2.  Lyssophobia. — The  points  of 
differential  diagnosis  are  those  which  are  to  be  considered  in  hysteria. 
The  symptoms  arise  in  hysterical  and  neurasthenic  persons  who  have 
been  bitten  by  dogs  or  other  animals  and  who  fear  that  they  have  been 
infected  with  hydrophobia.  The  pseudohydrophobic  spasms  are  the 
result  of  autosuggestion.  Cases  of  this  kind  are  doubtless  among  the 
reported  recoveries  from  hydrophobia.  3.  Tetanus. — The  incubation 
period  is  shorter;  the  convulsions  are  tonic;  trismus  is  an  early  and  per- 
sistent symptom,  and  the  disease  follows  indifferent  wounds  and  injuries 
rather  than  the  bites  of  rabid  animals.  4.  Various  diseases — epilepsy, 
poisoning  by  datura  stramonium,  sunstroke,  cerebral  tumor,  acute  mania — 
may  present  symptoms  suggestive  of  hydrophobia  and  give  rise  to  diffi- 
culties in  diagnosis  in  cases  in  which  there  is  the  history  of  the  bite  of  an 
animal  suspected  of  rabies.  The  symptom-complex,  course,  and  termina- 
tion in  these  affections  render  the  diagnosis  as  a  rule  a  comparatively 
easy  matter.  5.  Landry^s  paralysis  presents  sj^mptoms  in  some  respects 
suggestive  of  dumb  hydrophobia.  The  anamnesis  is  of  great  importance. 
Where  there  is  a  history  of  the  bite  of  a  rabid  animal,  or  of  an  animal  sup- 
posed to  be  rabid,  and  the  patient  has  been  subjected  to  the  Pasteur  treat- 
ment, the  differential  diagnosis  between  the  attenuated  form  of  paralytic 
rabies,  which  occasionally  develops  subsequently,  and  Landry's  paralysis 
is  extremely  difficult. 

Prognosis. — Hydrophobia  occurs  in  only  15  or  20  per  cent,  of  individ- 
uals bitten  by  rabid  animals.  The  danger  is  greatest  when  the  wounds  are 
lacerated  or  deep  and  especially  when  they  involve  the  muscles.  It  is  also 
greater  in  bites  of  the  face  and  head  than  in  those  of  the  extremities.  The 
probability  that  the  patient  may  escape  increases  with  the  lapse  of  time. 
From  the  fourth  month  after  the  inoculation  the  danger  rapidly  decreases. 
According  to  Woodhead  the  mortality  of  patients  bitten  by  rabid  animals 
varied  from  5  to  50  per  cent,  prior  to  the  introduction  of  the  Pasteur 
treatment,  and  the  general  mortality  of  those  bitten  by  rabid  animals  was 
16  per  cent.  Bollinger's  statistics  indicate  that  of  patients  bitten  by  dogs 
undoubtedly  rabid  47  per  cent,  suffer  and  die  from  hydrophobia.  Where 
the  wounds  have  not  been  cauterized  83  per  cent,  of  the  cases  succumb; 
where  they  have  been  cauterized  33  per  cent.  die.  When  the  symptoms  in 
the  human  being  are  well  developed  the  prognosis  is  absolutely  unfavor- 
able, death  taking  place  in  a  period  varying  from  12  hours  to  4  days. 
Laveran,  Roux,  and  others  have  reported  cases  in  which  some  symptoms 
of   hydrophobia   have    appeared   in   individuals   undergoing   the    Pasteur 


GLANDERS. 


771 


treatment  who  have  ultimately  recovered.  At  the  Pasteur  Institute  at 
Paris,  of  27,719  cases  of  all  kinds  treated  up  to  January,  1904,  117  died,  a 
mortality  of  0.42  per  cent.  These  figures  do  not  include  a  small  number 
of  cases  in  which  the  disease  appeared  during  or  within  fifteen  days  after 
the  treatments.  Recovery  occasionally  takes  place  in  animals  inoculated 
in  the  laboratories. 


XXVIII.  GLANDERS. 

Farcy. 

Definition. — An  infectious  disease  of  the  horse  caused  by  the  Bacillus 
mallei  and  characterized  by  the  development  of  nodules  in  the  nose  which 
undergo  ulceration — glanders;  nodules  in  the  skin — farcy — and  lymphan- 
gitis.    It  occurs  occasionally  in  man  as  the  result  of  accidental  inoculation. 

Etiology. — Predisposing  Influences. — Among  animals  the  ass  is 
especially  liable  to  glanders.  Mules  and  horses  are  less  so.  Other  animals 
may  contract  the  disease.  Wild  animals  in  confinement,  as  in  menageries, 
frequently  develop  it.  Animals  contract  the  affection  usually  through 
direct  contact  and  commonly  by  the  respiratory  tract.  Glanders  in  man 
occurs  as  a  rule  from  exposure  to  the  disease  in  horses.  Stablemen,  team- 
sters, coachmen,  veterinary  surgeons,  and  cavalrymen  are  especially  liable. 
As  a  rule  the  infection  is  derived  from  chronic  cases  in  the  horse  the  nature 
of  which  for  a  long  time  remains  obscure.  Acute  glanders  in  the  horse  is 
generally  recognized  and  its  further  spread  controlled  by  the  destruction^  of 
the  animal.  The  infection  in  man  usually  occurs  through  some  more  or  less 
trifling  lesion  of  the  skin.  Infection  by  way  of  the  respiratory  surfaces  is  much 
less  frequent.  Infection  may  take  place  by  way  of  the  mucous  membranes. 
The  disease  in  a  pregnant  animal  may  be  communicated  to  the  foetus. 

Exciting  Cause. — The  specific  germ — Bacillus  mallei — morpholog- 
ically resembles  the  tubercle  bacillus  but  is  shorter  and  thicker.  It  is 
chiefly  communicated  from  the  sick  to 
the  well  by  the  discharges,  including 
the  urine  and  milk.  When  the  bacilli 
are  present  in  the  circulating  blood  the 
course  of  the  disease  is  very  rapid.  The 
patient  perishes  with  acute  symptoms. 

Cases  of  glanders  in  animals  have 
been  reported  in  which  recovery  has 
followed  the  repeated  injection  of  small 
but  increasing  doses  of  mallein:  a  sub- 
stance isolated  by  Kalning  and  later  by 
Hellman  from  cultures  of  the  bacilli. 

Symptoms. — For  purposes  of  de- 
scription it  is  convenient  to  make  a 
distinction  between  glanders  and  farcy. 
They  are  due  to  the  same  cause  and 
are  very  often  associated.  Acute  and  chronic  forms  occur.  The  period 
of  incubation  of  acute  glanders  varies  from  three  to  five  days.  Pro- 
dromes are  not  uncommon,  and  consist  of  loss  of  appetite,  nausea,  and 


A^    ^  ^^'  '^^  J  /  / 

Fig.  264.— Bacillus  mallei. 


772  MEDICAL  DIAGNOSIS. 

pain  in  the  head  and  extremities.  In  acute  glanders  the  stage  of  invasion 
is  marked  by  general  febrile  disturbance.  The  mucous  membrane  of  the 
nose  is  swollen  and  respiration  interfered  with.  There  is  a  scanty,  bloody 
secretion  which  rapidly  becomes  more  abundant  and  purulent.  The  nose 
is  reddened  and  swollen.  An  erj'sipelatous  inflammation  may  extend 
over  the  face.  The  nodules  upon  the  nasal  mucous  membrane  rapidly 
break  down,  with  the  development  of  extensive  ulcers  which  may  go  on  to 
necrosis.  The  lymph-nodes  of  the  neck  and  the  salivary  glands  a.re  com- 
monly much  enlarged.  Suppurative  lesions  of  the  skin,  Ij^mphangitis, 
and  an  inflammatory  enlargement  of  the  superficial  lymph-nodes  occur. 
Stage  of  Eruption. — The  eruption  is  sometimes  abundant,  especiall}'  on  the 
face  and  extremities,  particularly^  the  larger  joints.  It  has  been  mistaken 
for  variola.  Only  exceptionallj^  do  the  pustules  show  umbilication.  In 
some  instances  they  are  confluent.  There  is  troublesome  cough  with  abun- 
dant sanguinolent  or  mucopurulent  foul-smelling  expectoration.  Sup- 
purative arthritis  may  occur.  Hemorrhages  into  the  skin  and  mucous 
membranes  have  been  noted.  Colliquative  sweating,  diarrhoea,  stupor, 
convulsions,  and  coma  are  followed  by  death,  which  usually  takes  place  in 
the  course  of  the  second  or  third  week  of  the  attack.  When  an  acute 
attack  develops  in  the  course  of  chronic  glanders  death  may  occur  as  early 
as  the  second  or  third  day. 

Acute  Faecy. — The  infection  in  man  usually  takes  place  from  inoc- 
ulation by  way  of  the  skin.  There  is  intense  inflammatory  reaction  with 
phlegmon  formation  which  rapidly  breaks  down  into  an  ulcer  with  irregular, 
abrupt  edges,  from  which  extend  painful  reddened  lines  marking  the  course 
of  the  lymph  vessels.  The  corresponding  lymphatic  glands  are  swollen, 
tender,  and  painful.  The  swollen  lymphatics  are  known  among  veteri- 
narians as  farcy-pipes;  the  nodular  dilatations  in  their  course  as  farnj- 
buds  or  hnttons.  If  the  lesion  be  situated  upon  one  of  the  extremities  the 
limb  rapidly  becomes  oedematous.  Phlebitis  may  occur  and  abscesses 
form  in  the  subcutaneous  connective  tissue.  In  other  cases  there  are  no 
signs  of  local  inoculation.  The  sickness  begins  with  the  constitutional 
symptoms  characteristic  of  glanders.  In  the  course  of  from  three  to  seven 
days  small  nodules  occur  in  distant  parts  of  the  body  which  rapidly  undergo 
suppuration  with  the  formation  of  deep  ulcers  and  areas  of  gangrene.  The 
joints  may  be  involved  and  abscesses  form  in  the  muscles.  The  constitu- 
tional symptoms  are  those  of  an  acute  infection.  The  attack  frequently 
begins  wdth  a  chill  or  shivering.  The  fever  is  constant  and  may  be  intense. 
It  does  not  conform  to  type.  Remissions  and  intermissions  occur.  The 
mucous  membrane  of  the  nose  may  not  be  involved  and  the  eruption  may 
be  absent.  In  the  acute  cases  the  bacilH  have  been  found  in  the  urine, 
both  in  animals  and  man.  The  termination  is  commonly  in  death  in  the 
course  of  the  second  week. 

Chronic  Forms. — The  disease  develops  insidiously.  Fever  as  a  rule 
is  absent.  If  the  infection  takes  place  through  a  lesion  of  the  skin,  similar 
manifestations  to  those  in  acute  farcy  may  occur,  developing  however 
more  slowly,  and  only  after  some  time  do  symptoms  of  glanders  or  farcy 
appear.  Symptoms  referable  to  the  organs  of  respiration  are  prominent. 
Thev  consist  of  sensations  of  fulness  in  the  nose,  hoarseness,  cough,  an 


ACTINOMYCOSIS.  773 

abundant  nasal  secretion,  and  later  dark,  dry  crusts.  Upon  examination 
catarrhal  inflammation  and  ulceration  are  discovered.  The  condition  is 
often  looked  upon  as  a  chronic  nasal  catarrh.  The  process  may  last  for 
months.  In  some  cases  recovery  has  taken  place.  More  commonly  the 
acute  form  of  the  disease  develops  or  the  patient  dies  of  exhaustion.  In 
chronic  farcy  the  patients  experience  for  some  weeks  pains  in  the  limbs 
and  joints.  At  the  end  of  this  time  subcutaneous  nodules  develop.  These 
undergo  suppuration  and  form  more  or  less  extensive  abscesses  and  ulcers. 
In  some  instances  they  show  a  tendency  to  heal;  in  others  healing  may 
take  place  and  the  scars  after  a  time  break  down.  The  lymph-nodes  are 
not  often  inflamed  and  the  eruption  is  rare.  Chronic  farcy  may  last,  with 
periods  of  rest  and  recrudescence,  for  two  or  three  years  and  end  in  recovery. 
Most  of  the  cases,  however,  terminate  fatally  with  acute  symptoms. 

Diagnosis.  —  Direct.  —  The  diagnosis  of  glanders  or  farcy  depends 
upon  the  occurrence  of  the  foregoing  symptom-complex.  With  a  clear 
history  of  the  case  and  a  knowledge  of  the  occupation  of  the  patient  the 
diagnosis  in  acute  cases  is  not  difficult.  In  chronic  cases  no  suspicion  of 
the  true  nature  of  the  disease  may  be  entertained.  A  positive  diagnosis 
can  be  reached  by  bacteriologic  methods.  Strauss  recommends  for  diag- 
nostic purposes  the  injection  of  cultures  of  the  secretion  into  the  peri- 
toneal cavity  of  a  male  guinea-pig.  After  two  days,  in  positive  cases,  there 
develop  swelling  of  the  testicles  and  granular  inflammation  of  the  tunica 
vaginalis;  later  a  specific  orchitis,  which  undergoes  suppuration.  The 
animal  dies  in  the  course  of  two  or  three  weeks  and  the  visceral  lesions  of 
glanders  are  found.     Mallein  is  frequently  used  for  diagnostic  purposes. 

Differential. — In  the  beginning  of  the  acute  cases  the  symptoms 
and  course  of  the  temperature  may  suggest  enteric  fever,  and  the  joint  pains 
rheumatic  fever.  Later  glanders  is  to  be  distinguished  from  erysipelas 
and  pysemia.  The  urgency  of  the  symptoms,  the  well-defined  local  mani- 
festations, and  the  course  of  the  attack  will  usually  render  the  diagnosis 
a  comparatively  simple  matter.  The  indolent  serpiginous  ulcers  of  chronic 
farcy  may  suggest  tuberculosis  or  syphihs. 

Prognosis. — The  prognosis  is  in  a  high  degree  unfavorable.  Recovery 
takes  place  very  rarely  in  the  acute  cases.  Chronic  glanders  usually  ter- 
minates in  death.  In  chronic  farcy,  recovery  occurs  in  about  50  per  cent, 
of  the  cases. 

XXIX.  ACTINOMYCOSIS. 

Definition. — A  chronic  infectious  disease  caused  by  the  Streptothrix 
actinomj'^ces  or  ray  fungus,  characterized  by  granulomatous  new  forma- 
tions and  multiple  abscesses,  in  the  pus  of  which  are  found  peculiar  bodies 
containing  the  organisms. 

Etiology.  —  Predisposing  Influences.  —  This  disease  occurs  in  all 
parts  of  the  world.  Those  cereals  armed  with  stiff  or  thorny  processes  may 
serve  as  carriers  of  the  fungus.  Barley  and  rye  may  be  especially  named. 
Cattle  are  most  exposed  to  the  danger  of  infection  at  the  time  of  the  second 
dentition  and  in  the  autumn  and  winter.  Low  and  damp  localities  favor 
the  infection.  The  fungus  penetrates  the  tissues  by  way  of  pre-existent 
lesions   of  the   mucous   membranes  or  through  wounds  inflicted  by  the 


774  MEDICAL  DIAGNOSIS. 

spears  of  grain  or  pointed  straws.  The  visual  region  of  infection  both  in 
man  and  animals  is  the  mouth;  less  commonly  the  gastro-intestinal  canal, 
the  lungs,  or  the  wounded  or  abraded  skin.  The  infection  may  be  acquired 
by  drinking  water  contaminated  by  the  discharges  from  the  mouth  of  an 
animal  suffering  from  the  disease.  There  is  no  reason  to  believe  that 
infection  occurs  by  means  of  the  milk  or  flesh  of  diseased  animals. 
Cases  have  occurred  at  all  ages,  from  five  to  seventy  years. .  Men  suffer 
more  frequently  than  women  in  the  proportion  of  5  to  3.  Those 
occupations  which  involve  habitual  contact  with  cattle  and  their  food 
must  be  regarded  as  predisposing  causes. 

Exciting  Cause. — The  parasite  has  been  variously  classified.  Israel 
and  Bostrom  described  it  as  a  cladothrix;  more  recently  it  has  been  re- 
garded as  belonging  to  the  sti^eptothrix  group.  It  appears  in  the  pus  as 
minute  specks,  which  are  yellowish  or  brownish  by  reflected  light — sulphur 

granules — and  often  greenish  by  trans- 
mitted light.  These  granules  vary  in 
diameter  from  one-half  to  two  milli- 
metres and  consist  of  a  central  core  of 
filaments  among  which  are  cocci  in 
varying  numbers  surrounded  by  a  mass 
of  radiating  filaments,  many  of  which 
present  bulbous  or  clubbed  extremities. 
The  earliest  developmental  forms  con- 
sist of  smaller  granules  of  a  gray  color 
and  translucent  appearance  composed 
of  a  thick  mass  of  threads  either  single 
or  branched;  closely  interwoven  at  the 
centre  and  possessing  the  ray -like 
-r,      ..^.     c      .  .-u  ■  arrangement.      The   organism   is   polv- 

FiG.  265. — Streptothrix  actmomyces.  F'  .  '^  i     i       i  i 

morphous.  In  animals  the  club-shaped: 
forms  are  more  common;  in  man  the  filamentous.  Both  threads  and  clubs 
are  present  in  cases  in  which  the  process  is  active.  Ordinary  pyogenic 
bacteria  are  present  in  varying  numbers.  The  ray  fungus  has  been  grown 
upon  artificial  culture  media  and  actinomycosis  has  been  successfully 
inoculated  both  directly  and  by  the  artificially  grown  organism. 

Symptoms. — Actinomj^cosis  is  at  first  a  local  disease.  Its  course  is 
generally  chronic,  and  as  distant  organs  become  involved  it  presents  the 
clinical  picture  of  a  chronic  pyaemia.  In  very  rare  cases  rapid  dissemination 
may  occur  by  way  of  the  blood-vessels,  and  the  disease  run  an  acute  course. 

Gastro-intestinal  Form.  —  The  infection  takes  place  by  way  of 
lesions  in  the  mucous  membrane  of  the  mouth  or  throat  or  through  the 
tonsils.  The  jaw  is  very  commonly  involved  in  cattle,  much  less  frequently 
in  man.  There  is  swelling  of  the  side  of  the  face,  usually  involving  the 
lower,  rarely  the  upper  jaAV.  The  appearance  may  suggest  sarcoma  or  a 
phlegmon.  Sinuses  form  and  the  characteristic  pus  is  discharged.  Bur- 
rowing may  take  place  in  various  directions.  Indolent  ulcers  are  common. 
The  duration  is  variable.  Very  rarely  the  fatal  issue  occurs  as  the  result 
of  secondary  infection  or  embolism  in  a  few  weeks.  The  usual  course  is 
chronic  and  may  extend  over  years.     The  tongue  may  be  involved  either 


ACTINOMYCOSIS.  775 

primarily  or  secondarily.  One  or  more  circumscribed  nodules  form  and  in 
the  course  of  a  few  weeks  undergo  softening  and  may  be  incised.  Intes- 
tinal actinomycosis  commonly  involves  the  region  about  the  caecum  and 
the  appendix,  or  the  sigmoid  flexure  and  the  rectum.  Metastases  are 
common.  Pericsecal  abscesses  have  been  reported.  The  anus  may  be 
involved.  Actinomyces  have  been  found  in  the  stools.  Peritonitis  is  a 
common  termination,  but  the  disease  may  run  a  very  chronic  course  with 
septic  phenomena  and  cachexia. 

Respiratory  Form. — Actinomycosis  of  the  neck  may  directly  involve 
the  larynx  or  may  give  rise  to  laryngeal  cBdema.  The  lungs  may  be  involved 
primarily  or  secondarily.  The  lesions  are  less  characteristic.  In  many 
cases  they  are  merely  those  of  a  chronic  bronchial  catarrh.  In  others 
the  tissue  of  the  lungs  is  studded  with  gray  nodules,  resembling  miliary 
tubercles  and  consisting  of  granulation  tissue  surrounding  masses  of  the 
parasitic  growth.  In  other  cases  the  lesions  are  those  of  chronic  broncho- 
pneumonia with  interstitial  changes  and  a  tendency  to  softening  and  the 
formation  of  cavities.  As  the  process  advances  it  involves  the  pleura, 
which  may  become  adherent  and  greatly  thickened  or  undergo  suppura- 
tive changes  leading  to  circumscribed  empyema.  Fistulous  tracts  are 
formed  which  open  at  the  inner  border  of  the  scapula  or  elsewhere  along 
the  spinal  column.  Erosion  of  the  vertebrae  and  necrosis  of  the  ribs  and 
sternum  may  occur.  The  clinical  phenomena  are  those  of  pulmonary 
tuberculosis  or  fetid  bronchitis.  Actinomycotic  granules  are  not  alwaj^s 
present  in  the  sputa.  As  the  disease  advances  there  are  septic  symptoms 
with  progressive  emaciation  and  night-sweats.  In  rare  instances  the  con- 
dition may  simulate  enteric  fever.  The  duration  varies  from  a  few  weeks 
to  two  or  three  years.     Recovery  is  rare. 

Cutaneous  Form. — Cutaneous  actinomycosis  is  very  rare.  It  appears 
in  the  form  of  circumscribed  tumors  of  a  mottled  purplish  red  and  yellow 
color,  varying  in  diameter  from  1  to  3  or  4  centimetres,  presentmg  one  or 
more  crater-like  ulcerative  openings,  from  which  is  discharged  a  clear  sticky 
fluid  sometimes  containing  the  characteristic  granules.  In  some  instances 
the  ulcerative  process,  while  undergoing  cicatrization  at  the  centre,  advances 
at  the  periphery.     The  condition  is  chronic  and  intractable. 

In  some  few  instances  other  regions  have  been  primarily  involved, 
especially  the  reproductive  organs  in  the  female,  and  the  orbit.  Bollinger 
reported  a  case  of  primary  disease  of  the  brain.  In  the  other  recorded 
cases  the  cerebral  lesions  have  been  the  result  of  metastasis.  The  symp- 
toms are  those  of  cerebral  tumor  or  abscess. 

Diagnosis. — Direct. — This  rests  upon  the  presence  of  the  actino- 
myces  in  the  pus.  Local  tumor  formation  with  a  tendency  to  implication 
of  bone  and  formation  of  multiple  sinuses  should  arouse  suspicion.  Vis- 
ceral actinomycosis  dves  rise  to  obscure  symptoms.  Tumors  involving 
the  lower  jaw  and  the  neck  with  multiple  fistulae  are  very  suggestive. 
In  the  examination  of  the  sputum  some  forms  of  degenerate  epithelium 
and  the  Leptothrix  buccalis  may  present  strong  points  of  resemblance  to 
detached  threads  of  the  ray  fungus. 

Differential. — Actinomycosis  of  the  lungs  may  resemble  forms  of 
chronic  bronchitis  and  tuberculosis.     Tuberculosis  of  the  gastro-intestinal 


776  MEDICAL  DIAGNOSIS. 

tract  maj^  give  rise  to  local  peritonitis,  infiltrations,  abscess  formations, 
and  fistulse,.  which  cannot  in  the  absence  of  the  actinomyces  be  distin- 
guished from  similar  conditions  due  to  other  causes.  Cutaneous  acti- 
nomycosis may  resemble  lupus  and  the  lesions  in  the  tongue  may  be 
mistaken  for  carcinoma,  cysts,   or  syphilitic  gummata. 

Mycetovia  or  Madura  Foot. — This  curious  disease  of  hot  climates 
presents  points  of  resemblance  to  actinomycosis.  It  is  a  chronic  destruc- 
tive local  inflammation  of  the  foot,  or  more  rarely  of  the  hand,  resulting 
in  an  excessive  proliferation  of  connective  tissue.  There  are  two  varieties 
of  the  disease:  the  pale  or  ochroid  form  which  is  characterized  by  yellow- 
ish-white or  brownish  granules  in  the  discharge,  and  the  melanoid  form 
which  is  characterized  by  dark  brown  or  black  masses  of  varying  size. 
The  disease  shows  no  tendenc}^  to  formation  of  visceral  deposits.  It  was 
earlv  described  by  Van  Dyke  Carter  as  a  fungus  disease.  An  organism  has 
been  cultivated  from  the  pale  variety  which  has  been  thought  to  be  closely 
related  but  not  identical  with  actinomyces. 

XXX.  ANTHRAX. 

Wool-Sorter's  Disease;   Malignant  Pustule. 

Definition.  —  An  acute,  infectious,  epidemic  disease  of  vertebrate 
animals,  particularly  sheep  and  cattle,  caused  by  the  Bacillus  anthracis, 
and  occurring  sporadically  in  man  as  the  result  of  accidental  inoculation. 

Etiology. — Predisposixg  Influences. — Anthrax  is  readily  communi- 
cated from  the  domestic  animals  to  man.  Those  occupations  which  involve 
direct  or  indirect  contact  with  living  or  dead  animals  suffering  from  the 
disease  constitute  the  chief  predisposing  cause.  Individuals  especially 
liable  may  be  grouped  as  folloAvs:  1.  Farmers,  shepherds,  drovers,  far- 
riers, and  veterinary  surgeons.  2.  Slaughterers  and  butchers.  3.  Tanners, 
skin  dressers,  rag  sorters,  and  workers  in  wool,  hair,  and  horn.  4.  Those 
who  come  in  contact  with  persons  following  the  foregoing  occupations  or 
who  live  in  their  neighborhood.  5.  Anthrax  may  be  transmitted  from  one 
person  to  another,  and  is  under  certain  circumstances  communicable  from 
the  human  dead  bod}^  to  those  coming  into  contact  with  it. 

Anthrax  is  the  most  widely  spread  and  destructive  of  the  epizootics. 
All  vertebrate  animals  are  susceptible  to  anthrax,  the  herbivora  being 
most  liable,  the  omnivora  less  so,  and  carnivora  only  under  unusual 
circumstances. 

Exciting  Cause.  —  The  Bacillus  anthracis.  This  organism  usually 
finds  access  to  animals  by  way  of  the  gastro-intestinal  tract  from  infected 
fodder  or  infected  pastures  or  water.  Pasteur  held  that  the  earth-worm 
plays  an  important  part  in  bringing  to  the  surface  and  distributing  bacilli 
from  the  buried  carcasses  of  infected  animals.  Certain  localities  thus 
become  permanently  infected.  The  disease  is  directly  inoculable  and  the 
infection  may  take  place  by  the  bites  or  stings  of  insects.  Omnivorous 
animals,  as  the  hog,  dog,  cat,  and  rat,  though  less  susceptible,  sometimes 
contract  the  disease  by  feeding  upon  infected  carcasses.  The  disease 
does  not  spread  by  mere  contact  or  association.     The  danger  of  infection 


ANTHRAX. 


777 


I/.X -^^^ 


Fig.  266. — Bacillus  anthracis 


is  greatly  diminished  if  the  carcasses  of  animals  dead  of  the  disease  are 
buried  unopened.  Occasionally  local  outbreaks  of  anthrax  among  cattle, 
sheep,  and  other  animals,  in  regions  in  which  the  disease  does  not  prevail 
continuously,  have  been  traced  to  imported  hides,  wools,  and  hair.  These, 
not  being  thoroughly  disinfected,  are 
washed,  the  water  being  discharged 
into  streams  and  sewers.  In  some 
instances  the  refuse  from  the  manu- 
facture of  such  articles  is  utilized  for 
manure,  and  farms  and  fields  thus 
become  infected. 

Symptoms.  —  The  cases  may  be 
grouped,  according  to  the  seat  of  the 
IDrimary  lesion  by  which  the  infection 
takes  place,  into  (a)  external  or  cuta- 
neous anthrax,  and  (b)  internal  or 
visceral  anthrax,  of  which  there  are 
pulmonary  and  intestinal  forms. 

(a)  External  or  Cutaneous  Anthrax. 
— 1.  Malignant  Pustule  or  Vesicle. 
— The  term  " malignant  pustule"  is  inappropriate  and  misleading.  The 
condition  is  in  some  cases  not  malignant  and  the  lesion  does  not  sui> 
purate.  Anthrax  is  literally  a  burning  coal.  The  general  condition  is 
known  as  anthracamia.  The  term  charbon  —  coal  —  is  applied  by  the 
French    to    the  local    lesion  of  the  skin,  and  fihrre  charhonneuse  to  the 

general  disease.  The  inoculation 
almost  always  occurs  on  some 
exposed  part,  as  the  arm,  face,  neck, 
or  chest.  The  period  of  incubation 
varies  from  a  few  hours  to  two  or 
three  days.  The  early  symptoms 
are  local  irritation  and  itching.  A 
papule  forms  which  rapidly  becomes 
vesicular.  There  is  surrounding 
redness  and  considerable  brawny 
swelling.  By  the  third  day  the 
vesicle  ruptures,  leaving  a  brown 
base  exuding  serum.  In  the  course 
of  twenty-four  hours  a  black,  dry, 
depressed  eschar  forms,  around 
which  at  a  little  distance  are  several 
small  secondary  vesicles,  sometimes 
discrete,  sometimes  confluent.  The 
oedema  extends  for  some  distance 
and  is  very  tense  and  deep.  The  related  lymph-nodes  are  swollen 
and  tender.  Lesions  upon  the  face  or  neck  cause  extraordinary  swelling 
and  disfigurement.  Implication  of  the  larynx  and  mediastinal  glands 
gives  rise  to  great  difficulty  in  breathing  and  swallowing.  Pus  does  not 
occur  in  favorable  cases  until  the  eschar  begins  to  separate,  usually  toward 


Fig.  267. — .-Vnthrax  pustule;   early  stage. — Royer. 


778 


MEDICAL  DIAGNOSIS. 


the  end  of  the  second  week.  The  severity  of  the  general  symptoms  has  no 
constant  relation  to  the  amount  of  local  disease.  Cases  with  marked 
local  lesions  may  show  but  slight  constitutional  disturbance.  Commonly 
symptoms  of  general  infection  rapidly  follow  the  appearance  of  the  papule, 
or  thejT^  may  be  deferred  for  some  days.  There  is  a  feeling  of  illness,  chilli- 
ness, thirst,  vomiting,  and  restlessness.  In  many  of  the  cases  the  symptoms 
are  those  of  the  internal  affection.  Death  may  take  place  in  from'  three 
to  five  days.  In  favorable  cases  the  constitutional  symptoms  are  slight, 
the  eschar  suppurates,   and  the  wound  heals.     2.  Malignant  Anthrax 

(Edema. — Swelling  appears 

in  the  eyelids  or  elsewhere  on 

,  the   head,   hands,   and   arms. 

Neither  papule  nor  vesicle 
develops  and  there  is  no 
characteristic  eschar.  The 
oedema  may  be  very  exten- 
sive and  occasionally  follows 
the  constitutional  sj^mptoms. 
Extensive  areas  of  gangrene 
may  result,  with  grave  con- 
stitutional symptoms.  A 
remarkable  characteristic  of 
the  external  forms  of  anthrax 
is  the  mental  condition  of  the 
patient.  With  the  gravest 
symptoms  the  mind  may  be 
perfectly  clear  and  the  patient 
manifest  no  indications  of 
anxiety  or  distress  up  to  the 
time  of  death. 

(b)  Internal  or  Visceral 
Anthrax.  —  1.  Pulmonary 
Anthrax  (Wool-sorter's  Dis- 
ease ;  A  nfhraccemia) .  —  This 
form  of  anthrax  occasionally 
develops  in  those  exposed  by 
their  occupations  to  the  inhalation  of  anthrax  spores  in  dust  arising 
from  the  products  of  diseased  animals.  Wool  and  hair  imported  from 
Russia,  Asia,  Egypt,  and  South  America  appear  to  have  been  the  cause 
of  the  disease  in  a  large  proportion  of  the  cases.  The  symptoms  are 
often  indefinite  until  the  approach  of  death.  Prodromes  are  not  com- 
mon. The  onset  is  usually  acute.  The  patient  suddenly  feels  out  of  sorts, 
has  shivering,  chilliness,  uneasiness  about  the  chest  and  stomach,  and 
sensations  of  great  weakness  and  weariness.  In  the  course  of  a  day  or  two, 
without  having  expressed  sensations  of  being  seriously  ill,  the  patient 
may  fall  into  a  condition  of  collapse  which  terminates  a  few  hours  later 
in  death.  The  tongue  is  moist  and  coated,  thirst  is  moderate,  and  there 
may  be  weight  and  uneasiness  at  the  stomach  with  complete  loss  of  appetite. 
Vomiting  and  diarrhoea  also  occur.     Symptoms  referable  to  the  respira- 


FiG.  268. — Anthrax- 


-fifth  day;  oedema  of  neck  and  thorax. 
— Royer. 


ANTHRAX.  779 

tory  system  consist  of  a  feeling  of  oppression,  quickened  respiration, 
cough,  not  commonly  severe,  with  or  without  expectoration.  The  pulse 
is  usually  weak  and  rapid,  out  of  proportion  to  the  severity  of  the  other 
symptoms,  and  toward  the  close  of  the  case  becomes  irregular  and 
uncountable.  The  heart  sounds  are  greatly  enfeebled.  Wandering  or 
active  delirium,  convulsions,  and  coma  have  been  observed.  The  skin  is 
moist.  The  temperature  rises  to  ]02°-103°F.  (38.9°-39.5°  C.)  and  may 
reach  105°-106°  F.  (40.5°-41.1°  C).  It  is  commonly  four  or  five  degrees 
higher  in  the  rectum  than  in  the  axilla.  The  urine  is  scanty,  dark-colored, 
and  of  high  specific  gravity.  Albuminuria  is  common.  2.  Intestinal 
Anthrax  {Mycosis  Intestinalis). — This  form  is  rare  in  man.  Infection 
occurs  by  way  of  the  stomach  and  intestines  in  consequence  of  eating  the 
flesh  or  drinking  the  milk  of  diseased  animals.  The  symptoms  are  those 
of  intense  poisoning,  with  gastro-intestinal  irritation,  and  consist  of  nausea, 
persistent  vomiting,  abdominal  pain,  and  diarrhoea.  There  is  great  weak- 
ness, restlessness,  and  difficulty  in  breathing.  The  pulse  is  small  and  rapid, 
the  surface  of  the  skin  cold  and  moist,  the  face  and  extremities  are  slightly 
cyanotic.  The  rectal  temperature  is  but  slightly  above  normal.  Hemor- 
rhage from  the  mucous  surfaces  may  occur  and  is  sometimes  accompanied 
by  petechise  and  cutaneous  abscesses.  The  spleen  is  enlarged.  The  blood 
is  dark  and  fluid  and  contains  the  bacilli.  Convulsions  and  coma  are 
followed  by  collapse,  and  death  occurs  in  from  two  to  seven  days. 
Instances  have  been  recorded  of  local  outbreaks  in  which  the  symptoms 
have  developed  at  about  the  same  time  in  a  number  of  individuals. 

The  external  form  of  anthrax  may  be  associated  with  both  the  pul- 
monary and  intestinal  forms  of  the  disease.  Eppinger  has  shown  that 
rag-picker's  disease  is  a  local  anthrax  of  the  lung  and  pleura  with  general 
infection,  and  a  consideration  of  the  pathological  anatomy  justifies  the 
conclusion  that  the  intestinal  form  also  begins  as  a  local  process  to  which 
the  constitutional  symptoms  are  secondary. 

Diagnosis.  —  Direct.  —  In  both  the  external  and  internal  forms  of 
anthrax  the  occupation  of  the  patient  is  of  diagnostic  importance.  In 
external  anthrax  the  direct  diagnosis  rests  upon  the  character  of  the  papule 
on  an  uncovered  portion  of  the  body,  the  rapid  development  of  a  vesicle, 
the  redness  and  extensive  brawny  induration  extending  along  the  lym- 
phatics to  the  neighboring  glands.  Microscopical  examination  of  the 
contents  of  the  vesicle  may  show  the  presence  of  anthrax  bacilli.  Cult\u-es 
and  inoculation  experiments  in  a  guinea-pig  or  white  mouse  give  conclu- 
sive results  in  the  course  of  two  days,  the  animal  dying  and  the  internal 
organs  showing  anthrax  bacilli  in  enormous  numbers.  These  organisms 
may  not  appear  in  the  blood  until  shortly  before  death.  The  appearance 
of  the  local  lesion  upon  the  third  or  fourth  day  is  very  characteristic.  The 
central  depressed  eschar,  the  surrounding  vesicles,  redness,  extensive 
oedema,  with  comparatively  little  pain,  are  significant. 

Differential. — An  ordinary  boil  or  carbuncle.  This  rests  upon  the 
absence  of  suppuration  and  of  a  moist  yellow  slough.  Phlegmonous  Ery- 
sipelas and  Cellnlitis. — Anthrax  may  be  distinguished  b}'  the  absence  of 
pain  and  of  marginal  secondary  vesicles  in  the  case  of  slough.  Chancre. — 
The  differential  diagnosis  rests  principally  upon  the  ra])i(lity  of  the  progress 


780  MEDICAL  DIAGNOSIS. 

and  more  serious  constitutional  symptoms  of  anthrax.  Glanders. — There 
is  an  absence  of  the  profuse  purulent  discharge  from  the  nostrils.  The 
direct  diagnosis  of  pulmonary  anthrax  in  the  early  stage  is  impossible. 
Later  the  gravity  of  the  illness  in  connection  with  the  symptoms  above 
described,  in  an  individual  exposed  to  infection  in  his  occupation,  is  highly 
suggestive.  The  direct  diagnosis  can,  however,  be  made  in  some  instances 
by  microscopical  examination  of  the  blood.  If  this  be  negative  inocula- 
tion experiments  should  be  performed.  The  progress  of  the  case  in  intes- 
tinal anthrax  is  so  rapid,  and  the  symptoms  so  closely  resemble  those  of 
gastro-intestinal  poisoning  due  to  other  causes,  that  a  positive  diagnosis 
during  life  is  usually  impossible. 

Prognosis. — Every  case  of  anthrax  may  be  regarded  as  a  grave  ill- 
ness, but  cases  of  spontaneous  recovery  are  not  altogether  uncommon. 
The  mild  cases  are  most  frequent  in  children  and  the  intensity  of  the  attack 
in  man  is  said  to  correspond  to  the  intensity  of  the  disease  in  the  animal 
from  which  the  infection  is  derived.  The  prognosis  is  much  more  favorable 
in  localized  external  anthrax  than  in  the  internal  form.  Malignant  oedema 
of  the  face  or  neck  is  dangerous  to  life,  partly  by  its  extent  and  partly 
through  the  pressure  exerted  upon  the  structures  of  the  neck,  especially 
of  the  great  vessels.  The  prognosis  in  anthrax  oedema  is  by  far  graver 
than  that  of  malignant  pustule.  Inhalation  anthrax — the  rag-picker's 
disease — gives  a  mortality  of  50  per  cent.  The  graver  cases  with  severe 
fever,  rapid  prostration,  and  the  evidences  of  extensive  pulmonary  inflam- 
mation terminate  in  death.  Bell  states  that  "  no  case  demonstrated  during 
life  to  be  intestinal  anthrax  has  ended  in  recovery." 

XXXI.  LEPROSY. 

Lepra;  Elcvhatitiasis  Grcecorum. 

Definition.  —  A  chronic,  infectious,  endemic  disease  caused  by  the 
Bacillus  leprae,  characterized  by  a  disseminated  nodular  infiltrate  in  the 
skin  and  mucous  membranes — tuberculous  leprosy— or  lesions  of  the 
nerves — anaesthetic  leprosy.  In  the  complete  or  generalized  disease  both 
sets  of  lesions  are  present^the  mixed  form. 

Etiology. — Predisposing  Influences. — No  race  is  exempt.  Lep- 
rosy occurs  in  all  latitudes,  in  moist  and  dry  climates,  alike  at  the  sea 
level  and  in  mountainous  settlements.  Congenital  leprosy  is  very  rare; 
in  fact  its  occurrence  is  doubted.  The  disease  sometimes  shows  itself 
in  childhood,  but  the  vast  majority  of  the  cases  develop  in  early  adult 
life.  In  some  instances  it  has  first  appeared  in  extreme  old  age.  Males 
are  affected  in  greater  proportion  than  females.  The  mode  of  life  is 
not  without  influence.  The  poor  suffer  more  frequently  than  the  well- 
to-do,  but  the  latter  do  not  escape.  It  has  been  thought  that  the 
habitual  or  exclusive  use  of  certain  articles  of  diet,  as  vegetables,  salted 
food,  food  without  salt,  fish  or  pork,  predispose  to  leprosy,  either  by 
the  ingestion  of  the  bacilli  or  by  rendering  the  tissues  less  resistant  to 
their  development.  Leprosy  prevails  in  mountainous  districts,  as  Kur- 
distan and  Kashmir,  where  a  fish  diet  is  unknown,  and  among  the  Brahmins 


LEPROSY. 


781 


who  never  taste  fish.  Furthermore  systematic  examinations  of  fish  and 
preparations  of  fish  in  countries  in  which  the  disease  is  endemic  have 
failed  to  reveal  the  presence  of  the  Bacillus  leprae. 

The  Exciting  Cause. — The  Bacillus  lepra  constitutes  the  specific 
infecting  agent.  Nothing  is  known  of  the  distribution  of  the  Bacillus 
leprae  outside  of  the  human  body.  It  has  not  been  found  in  the  tanks  in 
which  lepers  bathe,  nor  in  the  soil  about  the  graves  of  lepers,  although  in 
some  few  instances  it  has  been  discovered  in  the  soil  of  the  paths  and 
banks  surrounding  asylums. 

It  has  been  asserted  that  vaccination  may  be  the  means  of  transmitting 
leprosy.  The  danger  cannot  arise  where  bovine  vaccine  is  used.  The 
majority  of  lepers  have  never  been  vaccinated,  and  in  countries  where 
leprosy  is  steadily  diminishing  vaccination  is  becoming  more  general. 

Until  recently  a  belief  in  the  hereditai'y  transmission  of  leprosy  was 
generall}^  entertained.  The  present 
drift  of  opinion  is  against  this  view. 
The  transmission  of  the  disease  takes 
place  under  conditions  that  are  not 
well  understood.  It  has  been  suggested 
that  the  lepra  bacillus  undergoes  some 
developmental  change  in  an  interme- 
diary host.  It  is  probable  that  the 
bacilli  find  access  to  the  body  through 
the  skin  and  mucous  membranes,  espe- 
cially the  mucous  membrane  of  the  nose. 
When  leprosy  is  carried  by  immi- 
grants into  highly  civilized  countries 
it  rarely  spreads.  In  countries  where 
the  disease  has  been  endemic  its  diffu- 
sion is  largely  influenced  by  the  degiee 
of  association  of  the  lepers  with  the  healthy.  When  the  intercourse 
with  lepers  is  controlled  by  legal  enactments  or  a  general  dread  of  the 
disease,  its  prevalence  is  circumscribed  and  limited.  The  transmission 
of  the  disease  by  the  conjugal  relation  is  rare.  There  are,  however, 
many  recorded  cases  indicating  that  the  communication  has  taken  place 
after  marriage.  Physicians  in  charge  of  hospitals  and  asylums  for  lepers 
rarely  contract  the  disease.  From  9  to  10  per  cent,  of  the  helpers  in 
the  leper  settlement  at  Molokai  have  developed  the  malady.  Prolonged 
exemption  does  not  indicate  permanent  immunity. 

Symptoms. — (a)  Tuberculous  Leprosy. — The  period  of  incubation 
varies  from  a  few  months  to  several  years.  The  prodromal  symptoms 
consist  of  irregular  fever,  weakness  and  prostration,  loss  of  appetite,  and 
impaired  nutrition.  Repeated  epistaxis  is  not  uncommon.  After  a  time 
areas  of  cutaneous  erythema  appear.  These  may  be  sharply  defined  and 
in  some  instances  are  anaesthetic.  Later  they  undergo  pigmentation. 
These  spots  vary  in  size  and  some  of  them  may  disappear.  Aftei  a  time 
pea-sized  or  larger  nodules  appear  which  may  run  together  and  form  large 
tuberculous  masses.  These  tubercles  are  at  first  soft  and  elastic  and 
slightly  tender  upon  pressure;    later  they  become  firmer  and  are  insensi- 


FiG.  269. — Bacillus  of  leprosy;   section  of  skin. 


782 


MEDICAL  DIAGNOSIS. 


tive.  They  may  develop  upon  any  portion  of  the  body.  The  scalp  is, 
however,  usually  exempt.  They  are  most  common  upon  the  face,  the 
dorsal  surfaces  of  the  hands  and  feet,  upon  the  ankles,  wrists,  and  forearms, 
and  the  outer  aspect  of  the  thighs. 

The  lesions  progressively  involve  new  areas  of  skin  with  the  forma- 
tion of  fresh  tuberculous  masses,  and  as  the  older  ones  undergo  ulceration 
areas  of  cicatrization  form.  These  changes  in  the  skin  undergo  their  most 
marked  development  upon  the  face,  producing  the  characteristic  fades 
leonina.  The  superficial  lymphatics  generally  become  enlarged  early  in 
the  course  of  the  disease.  The  eyelashes  and  eyebrows  fall  out  and 
there  is  atrophy  and  loss  of  hair  elsewhere  upon  the  body.  The  hair}^ 
scalp   is    usually  unaffected.      The  mucous    membrane    of  the  upper   air- 


FlG.  270. — Early  stage  of  tuberculous  leprosy 
—  German  Hospital. 


Fig.  2j  1. — Tube-culous  leprosy. 


passages  undergoes  infiltration,  with  the  formation  of  tubercles.  These 
speedily  break  down,  giving  rise  to  painful  ulceration.  Changes  in  the 
voice  occur.  It  becomes  harsh  or  nasal,  or  more  or  less  complete 
aphonia  may  develop. 

As  cicatrization  takes  place  various  deformities  result,  as  stenosis  of 
the  mouth  or  palate,  and  laryngeal  stenosis.  The  process  involves  the 
eyelids  and  extends  to  the  ocular  conjunctiva  and  the  cornea,  resulting  in 
ultimate  destruction  of  vision  in  from  66  to  75  per  cent,  of  the  cases. 

The  duration  of  the  disease  is  indefinite.  The  patient  may  live 
for  years,  becoming  more  and  more  deformed  and  helpless.  Death 
commonly  results  from  exhaustion,  colliquative  diarrhoea,  or  inhalation 
pneumonia;  sometimes  from  stenosis  of  the  larynx  or  trachea  or  laryn- 
geal oedema. 

(b)  An.^sthetic  Leprosy. — The  period  of  incubation  is  commonly 
more  prolonged  than  in  the  tuberculous  form.     The  onset  is  insidious  and 


LEPROSY. 


783 


characterized  by  subjective  cutaneous  symptoms,  as  hypersesthesia,  pruritus, 
and  pain.  Fever  is  not  common.  Persistent  and  troublesome  pains  in 
the  limbs  are  frequent.  Hyperidrosis  may  be  an  early  symptom.  Trophic 
disturbances  may  give  rise  to  the  formation  of  bulla).  Patches  of  erythema 
varying  in  size  from  one  to  several  centimetres,  usually  circular  or  oval  in 
outline,  form  upon  the  trunk  and  limbs.  After  a  time  these  spots  disappear, 
leaving  areas  of  anaesthesia,  but  anaesthetic  patches  may  occur  without 
the  development  of  macules.  The  erythematous  spots  show  a  variety  of 
tints,  from  pinkish-red  to  a  bluish-  or  brownish-red  color,  and  many  of  them 
undergo  pigmentation.  As  the  areas  become  anaesthetic  the  pigment  may 
gradually  disappear,  leaving  well- 
defined  white  or  yellowish  patches 
in  striking  contrast  to  the  surround- 
ing skin.  The  superficial  nerve- 
trunks  are  felt  to  be  enlarged  and 
nodular.  The  hair  of  the  affected 
surfaces  may  become  white  or  fall 
out,  and  as  the  disease  develops 
there  is  complete  suppression  of  per- 
spiration. Similar  lesions  may 
appear  upon  the  face.  They  ma}^ 
remain  discrete  or  become  confluent. 
As  the  disease  advances  they  are 
frequently  the  seat  of  bullse,  some  of 
which  undergo  involution,  with  cica- 
trization, others  break  down,  form- 
ing more  or  less  superficial  ulcers, 
which  on  healing  leave  conspicuous 
scars,  which  are  at  first  dark  but  later 
become  pale,  smooth,  and  shining. 

The  modifications  of  sensibility 
consist  first  of  exaltations  of  sensi- 
bility, such  as  have  been  described; 
second,  of  perversions  of  sensation, 
which  consist  of  dysaesthesias,  formi- 
cation, numbness,  and  delayed  sensa- 
tion; and  third,  abolition  of  sensation,  which  is  more  or  less  complete. 
The  trophic  changes  involve  the  conjunctivae  and  the  mucous  membranes 
of  the  nose,  mouth,  and  throat,  which  may  become  dry  and  red  and  the 
seat  of  areas  of  superficial  ulceration.  The  ulcers  which  form  in  the  anaes- 
thetic patches  developing  in  the  hands  and  feet  may  be  very  destructive, 
giving  rise  to  contracture  and  necrosis,  which  produce  distressing  deformi- 
ties, the  loss  of  fingers  and  toes,  and  the  development  of  perforating  ulcers. 
Spontaneous  resorption  of  bone  may  take  place. 

In  favorable  cases  the  disease  may  last  for  a  long  period  without 
the  development  of  marked  trophoneurotic  changes.  The  average  dura- 
tion of  life  in  this  form  of  lepros}^  is  about  twent}^  years.  In  some 
instances  the  progress  of  the  disease  is  arrested  and  the  patient  may 
reach  an  advanced  age. 


Fig.  272. — Ansesthetic  leprosy. 


784  MEDICAL  DIAGNOSIS. 

(c)  Mixed  or  Complete  Leprosy. — The  lesions  peculiar  to  the  tuber- 
cular and  the  anaesthetic  forms  develop  simultaneously,  or  in  succession.  While 
the  distinction  between  the  two  main  forms  is  in  well-marked  cases  sharply 
defined,  there  are  many  cases  which  must  be  referred  to  the  mixed  form. 

Diagnosis. — The  direct  diagnosis  of  leprosy  in  the  early  stage  may  be 
difficult.  The  erythematous  macules  wath  hypersesthesia,  pain,  and  pig- 
mentation, and  the  subsequent  development  of  tuberculous  nodules  are 
characteristic.  In  the  nervous  form  the  areas  of  persistent  anaesthesia, 
with  bullae,  ulceration,  deformities,  and  necrosis  of  the  hands  and  feet,  are 
important.  A  history  of  residence  in  a  country  in  which  leprosy  prevails, 
even  without  actual  association  with  known  lepers,  justifies  the  suspicion 
of  contagion.  The  bacteriological  examination  of  the  nasal  discbarge,  the 
serum  of  a  blister,  or  of  an  excised  nodule  may  settle  a  doubtful  case. 

The  differential  diagnosis  involves  the  consideration  of  a  great 
number  of  chronic  affections  which  present  resemblances  to  leprosy,  among 
which  may  be  named  especially  syphiHs,  lupus,  multiple  neuritis,  syringo- 
myelia, and  Morvan's  disease. 

Prognosis. — The  experience  of  history  shows  leprosy  to  be  an  incurable 
disease.  Abortive  cases  occur  but  they  are  extremely  rare.  The  prognosis 
as  regards  recovery  or  even  as  regards  the  arrest  of  the  process  is  highly 
unfavorable;  that  as  regards  the  expectancy  of  life  must  be  guarded.  The 
miserable  life  of  the  leper  may  be  prolonged  for  twenty  years  or  more.  The 
outlook  in  the  tuberculous  form  is  less  favorable  than  in  the  anaesthetic  form. 

XXXII.  TUBERCULOSIS. 

Definition. — An  infectious  disease  caused  by  the  Bacillus  tuberculosis, 
and  characterized  histologically  by  the  formation  of  tubercles  and  infiltra- 
tions of  tuberculous  tissue,  which  undergo  caseation  and  necrosis  or  sclerotic 
changes;  anatomically,  by  alteration  and  destruction  of  the  parts  imme- 
diately affected,  and  clinically,  by  local  and  constitutional  symptoms  which 
vary  according  to  the  structures  involved  and  the  extent  of  the  process. 

Etiology. — Predisposing  Influences. — Tuberculosis  is  a  wide-spread 
disease  affecting  both  human  beings  and  animals.  Among  the  latter  the 
domestic  animals  and,  in  particular,  the  bovines  chiefly  suffer.  Wild 
animals  in  captivity  are  peculiarly  liable  to  tuberculosis.  The  liability  of 
the  hog  is  much  less  than  that  of  horned  cattle;  of  the  horse  and  sheep 
very  slight;  of  the  dog  and  cat  even  less,  though  these  animals  housed  as 
pets  with  tuberculous  persons  sometimes  contract  the  disease.  Rabbits 
and  guinea-pigs,  especially  the  latter,  are  peculiarly  susceptible  to  tuber- 
culous infection,  and  are  for  that  reason  much  used  for  the  purposes  of 
laboratory  research.  Avian  tuberculosis  constitutes  a  special  variety  of 
the  disease.  The  wide  prevalence  of  tuberculosis  among  human  beings  is 
due  to  methods  of  living  favorable  to  the  propagation  of  the  infecting 
principle.  It  is  most  prevalent  in  the  centres  of  population  and  in  densely 
peopled  locaHties  in  which  direct  sunHght,  fresh  air,  and  cleanliness  are 
little  known.  About  one-seventh  of  all  deaths  are  caused  by  tuberculous 
disease.  Climate  has  little  influence  as  a  predisposing  cause.  Tubercu- 
losis is  more  common  in  proportion  to  the  population  in  temperate  than 


TUBERCULOSIS.  785 

in  tropical  or  extreme  northern  regions.  xUtitiide  is  important.  The  great 
plateaus  of  the  United  States  and  Mexico,  the  settlements  of  the  high 
regions  of  the  Alps,  the  Andes,  and  the  Himalayas  are  remarkably  free  from 
tuberculous  affections.  Soil  and  Locality. — Tuberculous  diseases  and 
especially  phthisis  have  been  shown  to  be  more  prevalent  in  wet,  badly 
drained  districts  than  in  dry  uplands  with  a  porous,  sandy  soil.  The 
influence  of  soil  in  this  respect  consists  in  an  increased  liability  to  catarrhal 
affections  and  hence  general  increase  in  susceptibility.  Mode  of  Life. — 
Tuberculosis  is  fostered  by  darkened  houses  and  unventilated  sleeping 
rooms.  Habitual  life  in  the  open  air  is  unfavorable  to  it  alike  in  the  individ- 
ual and  in  the  community.  Like  other  readily  transmissible  infections, 
it  spreads  with  great  rapidity  when  introduced  among  aboriginal  peoples 
previously  free  from  it.  Race. — The  influence  of  racial  susceptibility  is 
much  less  than  that  exerted  by  the  mode  of  life.  It  is  difficult  to  separate 
these  factors.  The  American  Indian,  the  negro,  and  the  immigrant  peasant 
fiom  Ireland  and  Southeastern  Europe  suffer  in  this  country  from  an 
especial  liability.  There  is  an  apparent  relative  immunity  arnong  the 
Jews.  Personal  Predisposition. — The  phthinoid  or  pterygoid  chest  is  not 
only  seen  in  phthisical  individuals  but  it  is  also  characteristic  of  those 
who  manifest  a  peculiar  susceptibility  to  phthisis.  On  the  other  hand  a 
very  large  proportion  of  those  who  contract  the  disease  have  well-developed 
chests  and  every  evidence  of  perfect  health.  Now  that  tuberculosis  is 
known  to  be  an  infection  to  which  the  liability  is  wide-spread,  less  attention 
than  formerly  is  paid  to  the  so-called  diathetic  states.  Age. — Tuberculous 
infection  may  occur  at  any  age.  Eai'ly  adult  life,  from  twenty  to  thirty- 
five,  is  attended  with  a  peculiar  liability.  The  susceptibility  of  the  various 
tissues  and  organs  varies  with  different  periods  of  life.  In  infancy  the 
intestines,  glands,  and  meninges,  in  childhood  and  adolescence  the  bones 
and  lymph-nodes,  and  later  the  lungs,  other  viscera,  and  the  skin  are  more 
commonly  affected,  but  any  form  of  tuberculosis  may  occur  at  any  period 
of  life.  Sex. — Women  become  tuberculous  in  slightly  higher  proportion 
than  men.  Occupation. — Those  who  work  in  a  confined  and  dust}'  atmo- 
sphere are  very  liable  to  contract  pulmonary  consumption.  From  this 
point  of  view  phthisis  merits  a  place  among  the  occupation  diseases. 
Previous  Disease. — Catarrhal  affections  predispose  to  tuberculosis.  It  is 
to  this  fact  that  must  be  ascribed  the  frequency  of  pulmonary  tuberculosis 
after  the  acute  diseases  in  which  bronchial  catarrh  plays  a  prominent 
part,  as  pertussis  and  measles.  The  marked  predisposition  to  tuberculosis 
of  the  lymph-nodes  on  the  part  of  young  children  is  due  to  their  liability 
to  catarrhal  processes  in  the  upper  respiratory  passages  and  bronchi. 
I  am  not  disposed  to  think  that  tuberculous  infection  is  especially  favored 
by  entei'ic  fever.  Influenza  and  variola  are  regarded  as  predisposing  influ- 
ences. In  such  cases  the  development  of  the  disease  nuiy  be  either  the 
result  of  direct  infection  upon  a  soil  prepared  by  the  antecedent  malady  or 
of  the  lighting  up  of  a  latent  tuberculous  focus.  Tabes  mesenterica  is 
doubtless  in  most  cases  the  result  of  infection  by  way  of  the  lesions  of  a 
catarrhal  enterocolitis.  Among  chronic  diseases  syphilis  and  diabetes 
are  very  often  followed  by  pulmonary  tuberculosis,  and  the  latter  affection 
is  a  common  terminal  condition  in  chronic  bronchitis,  disease  of  the  heart, 
50 


786 


MEDICAL  DIAGNOSIS. 


cirrhosis  of  the  Kver,  and  chronic  nephritis.  Cases  of  tabes  and  other  forms 
of  spinal  scleiosis  often  terminate  m  pulmonary  tuberculosis.  In  cases  of 
chronic  antecedent  disease,  whether  the  tuberculous  process  be  frank  or 
latent,  the  final  event  is  an  acute  miliary  tuberculosis.  A  blow  or  injury 
is  very  often  followed  by  tuberculous  disease  of  the  part.  In  the  case 
of  meningitis,  or  bone  or  joint  disease,  it  is  necessary  to  assume  an 
antecedent  latent  tuberculosis;  when  pleural  or  pulmonary  tuberculosis 
follows  a  contusion  of  the  chest  in  the  absence  of  fracture  of  a  rib  or 
laceration  of  the  pleura  or  lung,  we  may  assume  that  the  resistance 
of  the  part  has  been  impaired  by  the  injm-y,  and  infection  thus  ren- 
dered possible.  Much  more  commonly,  careful  inquiry  will  elicit  a 
history  of  previous  symptoms  of  tuberculosis.  The  danger  of  a  surgical 
operation  m  local  tuberculosis  is  always  to  be  considered.     Latent  trouble 

elsewhere    may    be    lighted    up,    or    an 
acute  miliary  process  develop. 

The  Pathogenic  Organism. — The 
demonstration  by  Koch  of  the  tubercle 
bacillus  and  the  etiological  unity  of  the 
tuberculous  diseases  constitutes  one  of 
the  most  remarkable  and  beneficent 
achievements  of  modern  medicine  and 
ranks  in  importance  with  .Tenner's 
great  work. 

The  bacilli  are  present  in  varying 
abundance  in  all  the  lesions  of  tuber- 
culosis. They  are  very  numerous  in 
active  lesions,  but  scanty  in  the  sluggish 
processes  of  chronic  glandular  or  bone 
disease.  When  a  tuberculous  focus,  as 
a  softened  lymph-node,  discharges  its 
contents  into  a  vein  or  lymph  vessel,  the  bacilli  are  swept  on  with  the  current 
to  effect  new  lodgement  and  produce  new  tubercles  at  various  points  in  the 
body.  When  not  found  in  the  effusions  of  serous  tuberculous  inflammation, 
as  pleurisy,  or  in  sections  of  chronic  or  obsolescent  lesions,  the  nature  of  the 
process  may  frequently  be  demonstrated  bj'  culture  or  inoculation.  Rosen- 
berger,  as  the  result  of  the  examination  of  the  thoracic  ducts  in  subjects 
dead  of  tuberculosis,  and  the  examination  of  the  blood  by  a  special  technic 
(see  p.  245)  in  120  cases  of  tuberculosis,  including  advanced  and  incipient 
cases  and  the  miliary  variety,  has  reached  the  conclusion  that  tuberculosis 
in  all  its  forms  is  a  bactersemia.  His  investigations  also  lead  him  to  regard 
termxinal  mixed  infections  as  uncommon.  The  bacilli  are  thrown  off  by 
way  of  the  discharges,  the  sputum  in  laryngeal  and  pulmonary  tuber- 
culosis, the  urine,  faeces,  vaginal  discharges  and  rarely  the  semen  in  the 
genito-urinary  forms,  and  tuberculous  sinuses,  abscesses,  and  ulcerated 
surfaces  in  various  parts  of  the  body.  They  retain  their  vitality  outside 
the  body  for  an  undetermined  period. 

The  chief  source  of  infection  is  the  sputum.  Beside  this  all  others 
fall  into  insignificance.  The  principal  vehicle  of  transmission  as  shown 
by  Cornet  is  the  atmospheric  dust. 


Fig.  273. — Spread  of  sputum  showing  Bacillus 
tuberculosis. 


TUBERCULOSIS.  787 

Modes  of  Infection.  —  (a)  Heredity.  —  Clinical  and  experimental 
evidence  are  alike  against  transmission  from  the  male  by  means  of  the 
spermatozoids.  The  hypothesis  that  transmission  may  occur  from  the 
tuberculous  mother  by  way  of  the  ovum  has  some  experimental  support. 
Transmission  b}"  way  of  the  blood,  the  bacilli  penetrating  the  placenta, 
is  supported  by  clinical  and  laboratory  facts.  The  placenta  under  such 
circumstances  is  usually  tuberculous,  but  in  some  instances  it  has  been 
apparently  normal.  The  number  of  reported  cases  of  congenital  tuber- 
culosis in  man  is  limited. 

The  difficulties  in  determining  the  part  played  by  heredity  in  individual 
cases  arise  from  the  uncertainty  in  regard  to  the  transmission  of  individual 
susceptibility  from  the  affected  forebears  to  the  offspring,  the  absence  as 
yet  of  definite  conclusions  as  to  the  prolonged  latency  of  tubercle  bacilli 
in  the  tissues  of  an  apparently  healthy  child  of  a  tuberculous  parent,  and 
the  fact  that  tuberculosis  is  at  the  outset  a  distinctl}''  local  process,  which 
may,  when  acquired  by  postnatal  infection,  become  circumscribed  or 
obsolescent,  and  remain  latent  in  the  tissues  (lymph-nodes,  for  example) 
for  an  indefinite  period,  to  become  again  active  under  various  circumstances, 
as  traumatism,  acute  disease,  or  softening  and  rupture  of  a  gland-capsule. 
The  mere  fact  that  a  parent,  grandparent,  or  collateral  relation  in  a  pre- 
vious generation  suffered  from  tuberculosis  no  more  proves  the  hereditary 
nature  of  the  disease  than  the  occurrence  of  scarlet  fever  in  them  would 
render  it  hereditar}^  Yet  the  assumption  in  regard  to  the  one  disease  might 
with  the  same  indifference  to  scientific  accuracy  be  made  of  the  other. 

(b)  Inoculation. — Tuberculosis  in  man  has  been  in  rare  instances 
produced  by  inoculation.  Those  who  work  in  the  post-mortem  room 
frequently  contract  local  skin  tuberculosis,  the  nature  of  which  has  been 
demonstrated  both  microscopically  and  by  inoculation  in  animals — post- 
mortem warts.  These  lesions  are  discrete,  small  nodules  and  are  almost 
always  situated  upon  the  backs  of  the  hands  or  fingers.  Inoculation  may 
also  take  place  in  various  accidental  ways;  among  these  are  circumcision, 
cuts  from  the  broken  spit-cup  of  a  consumptive,  and  the  bite  of  a  tuber- 
culous person.  There  is  no  evidence  to  support  the  assertion  of  the  anti- 
vaccinationist  that  consumption  is  transmitted  in  the  vaccine  virus,  beyond 
the  fact  that  in  a  very  limited  number  of  cases  lupus  has  developed  at  the 
site  of  the  vaccine  pock.  In  point  of  fact,  the  lesion  almost  always  remams 
local  at  the  seat  of  inoculation. 

(c)  Inhalation. — The  vehicle  is  atmospheric  dust  to  which  bacilli  are 
attached.  This  dust  in  rooms  occupied  by  the  consumptive  and  around 
his  person  is  made  up  of  the  dried  pulverized  sputum.  An  obvious  measure 
of  prophylaxis  is  to  keep  the  sputum,  discharged  into  suitable  receptacles, 
moist  and  disinfected  until  it  can  be  destroyed  by  fire  or  otherwise  effect- 
ually disposed  of.  In  some  instances  direct  infection  takes  place  by  the 
inhalation  of  tubercle  bacilli  contained  in  the  fine  particles  of  moist  sputum 
ejected  by  the  patient  in  the  act  of  coughing  or  even  m  conversation,  and 
remaining  for  a  time  suspended  in  the  air  in  his  immediate  neighborhood. 
Among  the  facts  that  lend  support  to  the  hypothesis  of  infection  by  inhala- 
tion are  the  frequency  with  which  the  early  lesions  involve  the  larynx, 
lungs,  and  bronchial  glands;    the  prevalence  of  the  disease  in  cloisters, 


788  MEDICAL  DIAGNOSIS. 

asylums,  prisons,  and  other  similar  institutions,  and  the  remarkable 
investigations  of  Flick,  who  showed  that  not  only  certain  localities  but 
also  particular  houses  become  infected,  and  that  members  of  different 
families   successively  occupying  such  houses  succumb  to  the  disease. 

The  degree  of  intimacy  of  association  with  the  consumptive  plays 
an  important  part  in  the  danger  of  the  transmission  of  the  disease.  It  is 
no  uncommon  thing  for  a  woman  who  has  nursed  a  consumptive  daughter 
or  sister  to  contract  the  disease  and  die  of  it  in  the  course  of  some  months. 
This  occurrence  is  infrequent  among  nurses,  whose  attendance  is  less  close 
and  hours  are  less  prolonged.  The  latter  have  also  an  advantage  in  their 
technical  knowledge  of  the  dangers  and  in  habits  of  prophylaxis.  In  the 
case  of  husband  and  wife  this  danger  of  the  transmission  of  pulmonary 
tuberculosis  is  abundantly  established  by  common  observation  and  the 
results  of  statistical  inquiries. 

(d)  Infection  hy  Food. — The  milk  of  tuberculous  cows,  and  milk  foods, 
including  butter  made  from  it,  have  been  shown  to  be  capable  of  giving 
rise  to  the  disease.  Tuberculous  lesions  of  the  udder  are  not  necessary, 
the  milk  of  animals  healthy  in  this  respect  having  been  shoAvn  to  be  infec- 
tious. Bovine  tuberculosis  constitutes  a  positive  danger  to  the  human 
race.  The  frequency  of  tuberculosis  of  the  intestines  and  mesenteric  glands 
in  young  children  finds  a  ready  explanation  in  infected  milk. 

The  meat  of  tuberculous  animals  is  not  without  clanger.  It  has  been 
shown  experimentally  to  be  infective  to  guinea-pigs.  Thorough  cooking 
probably  destroys  the  infecting  principle;  uncooked  meats,  smoked  beef 
and  similar  articles  may  convey  the  disease.  Legal  enactments  against 
the  exposure  for  sale  of  the  flesh  of  tuberculous  animals  are  well  founded. 

A.    Acute  Miliary  Tuberculosis. 

Tubercle  bacilli  find  their  way  into  the  blood  from  a  focus  of  tuberculous 
endangitis  or  the  perforation  of  the  vessel  wall  by  a  softening  caseous  mass. 

Varieties. ^ — Three  clinical  forms  occur:  (a)  the  general  or  so-called 
typhoid,  characterized  by  the  symptoms  of  an  acute  general  infection; 
(b)  the  pulmonary,  in  which  the  symptoms  are  chiefly  referable  to  the 
lungs,  and  (c)  tuberculous  meningitis. 

(a)  Generalized  Miliary  Tuberculosis. — Miliary  nodules  are  thickly 
disseminated  throughout  the  various  organs  of  the  body. 

Symptoms. — -The  symptoms  are  those  of  an  acute  general  infection, 
and  the  condition  presents  many  of  the  features  of  enteric  fever,  for  which 
it  is  often  mistaken.  The  signs  of  local  disease  are  rarely  marked.  The 
onset  is  gradual  after  a  period  of  rapidly  failing  health.  In  some  of  the 
cases  the  onset  is  abrupt.  Nose-bleeding  is  not  common.  The  pulse  is 
rapid  in  proportion  to  the  fever,  not  often  dicrotic,  and  shows  remarkable 
variations  in  frequency  within  short  periods  of  time.  The  fever  increases, 
the  temperature  being  very  irregular,  usually  much  higher  in  the  evening 
than  in  the  morning  and  often  reaching  104°  F.  (40°  C.)  or  more  with 
remissions  of  three  or  four  degrees.  In  some  of  the  cases  the  range  is  dis- 
tinctly intermittent.  Inverse  temperatures  are  occasionally  observed. 
There  is  profound  asthenia  with  rapid  loss  of  flesh.    Pulmonary  symptoms. 


TUBERCULOSIS.  789 

increased  respiration  frequency,  especially  early  in  the  attack,  and  dyspnoea 
with  faint  cyanosis,  are  common.  Diffuse  rales,  the  signs  of  a  bronchitis 
not  unlike  that  of  enteric  fever,  are  heard,  and  in  some  of  the  cases  there 
may  be  dulness  at  an  apex,  or  patches  of  subcrepitant  and  crepitant  rales 
at  various  parts  of  the  chest.  In  a  group  of  cases  there  is  no  fever  or  the 
temperature  does  not  exceed  subfebrile  ranges,  and  the  true  nature  of  the 
disease  is  revealed  only  upon  post-mortem  examination.  Delirium  is  less 
common  than  somnolence  and  stupor,  which  deepen  to  coma,  terminating 
in  death.  Toward  the  last  there  may  be  an  intensification  of  the  lung 
symptoms,  or  the  evidences  of  involvement  of  the  meninges.  Cheyne- 
Stokes  respiration  is  common. 

Diagnosis. — The  direct  diagnosis  of  this  form  of  acute  miliary  tuber- 
culosis rests  upon  the  signs  of  a  profound  toxaemia,  irregularity  of  the 
temperature,  the  occurrence  in  some  cases  of  an  inverse  range,  the  rapidity 
and  irregularity  of  the  pulse,  and  the  absence  of  the  signs  which  character- 
ize the  other  specific  infections  and  septic  processes.  If  there  be  localized 
pulmonary  signs,  the  history  of  glandular  or  bone  tuberculosis,  or  menin- 
geal symptoms,  the  diagnosis  becomes  more  probable.  Choroid  tubercles, 
or  tubercle  bacilli  in  the  fluid  obtained  by  lumbar  puncture,  or  in  the  blood, 
render  it  positive  and  final. 

The  DIFFERENTIAL  DIAGNOSIS  between  general  miliary  tuberculosis  and 
enteric  fever  very  often  taxes  the  art  of  medicine  to  its  utmost.  This  is 
particularly  the  case  when  the  onset  is  marked  by  bronchitis  of  some  sever- 
ity, attended  by  dyspnoea  and  faint  cyanosis,  with  little  cough.  Under 
these  circumstances  great  rapidity  and  irregularity  of  respiration  and 
pulse,  and  in  general  terms  a  correspondence  in  their  frequency,  irregularity 
of  the  temperature  and  conformity  to  the  remittent  or  intermittent  rather 
than  the  subcontinuous  type,  signs  of  deficient  oxygenation  of  the  blood, 
constipation,  only  slight  enlargement  of  the  spleen,  herpes,  the  absence  of 
rose  spots,  and  a  leucoc3^tosis  are  in  favor  of  miliary  tuberculosis.  The 
following  facts  must  receive  due  consideration.  There  are  cases  common 
in  childhood  and  not  extremely  rare  in  adult  life  in  which  the  fever  curve 
of  enteric  fever  is  remittent  throughout.  Constipation  is  by  no  means  rare 
in  enteric  fever,  and  diarrhoea  may  occur  in  miliary  tuberculosis.  Enlarge- 
ment of  the  spleen  occurs  in  both  diseases,  but  is  neither  so  early  nor,  except 
occasionally  in  children,  so  decided  in  tuberculosis.  Herpes,  though  rare, 
has  been  observed  in  enteric  fever.  Rose  spots  occur  in  tuberculosis,  but 
they  are  rare  and  appear  singly  rather  than  in  crops,  and  do  not  present 
the  appearance  nor  run  the  course  of  the  eruption  which  characterizes  enteric 
fever.  Leucocytosis  is  common  in  miliary  tuberculosis;  leucopenia  the 
rule  in  enteric  fever.  But  leucocytosis  occurs  in  enteric  fever  compHcated 
by  inflammatory  and  suppurative  processes.  Albuminuria  and  the  diazo 
reaction  may  occur  in  both  diseases.  The  Widal  reaction  may  not  be  con- 
clusive, since  it  may  occur  in  an  individual  who  has  passed  through  an 
attack  of  enteric  fever  and  subsequently  become  tuberculous.  Nor,  for  the 
same  reason,  is  the  presence  of  Bacillus  typhosus  in  the  urine  conclusive. 
If  that  organism  is,  however,  found  in  blood  cultures  the  diagnosis  of 
enteric  fever  may  be  made.  The  two  conditions  may  coexist  and  the 
lesions  of  both  diseases  have  been  present  upon  post-mortem  examination. 


790  MEDICAL  DIAGNOSIS. 

(b)  The  Pulmonary  Form. — The  acute  phenomena  develop  in  persons 
who  suffer  from  persistent  cough  or  are  known  to  have  chronic  pulmonary 
tuberculosis,  or,  especially  in  children,  may  follow  an  infectious  disease, 
as  measles  or  whooping-cough. 

Symptoms. — The  onset  is  like  that  of  an  acute  bronchitis  or  broncho- 
pneumonia. Troublesome  cough,  mucopurulent  expectoration,  sometimes 
rusty  sputum  or  blood  spitting,  dyspnoea,  slight  cyanosis,  and  a  dusky 
flushing  of  the  cheeks  are  among  the  symptoms  that  attract  attention. 
In  children  especially,  but  sometimes  also  in  adults,  there  are  patch}-  areas 
of  dulness  at  the  bases  posteriorly,  with  areas  of  tympanitic  resonance, 
the  sign  of  collateral  emphysema.  Rales  of  larger  size,  both  sibilant  and 
sonorous,  may  be  heard;  but  much  more  commonly  they  are  fine  or  coarse 
crepitant.  A  grazing  friction  scarcely  to  be  distinguished  from  the  finest 
subcrepitant  or  crepitant  rales  is  the  sign,  as  established  by  post-mortem 
observations,  of  a  miliary  tuberculosis  of  the  pleura.  Bronchial  breathing 
of  high  pitch  is,  in  children,  often  heard  at  the  bases  and  opposite  the  root 
of  the  lung.  The  temperature  is  not  usually  very  high,  102°-103°  F.  (38.9°- 
39.5°  C),  often  irregular,  and  may  be  of  inverse  type.  The  pulse  is  irregular. 
The  spleen  is  usually  enlarged.  Toward  the  end  cerebra'  symptoms  some- 
times develop,  the  pulse  grows  more  feeble  and  rapid,  coarse  rales  obscure 
the  finer  respiratory  signs,  and  Cheyne-Stokes  breathing  occurs.  The 
duration  of  the  disease  varies  from  a  fortnight  or  more  in  the  acute  to 
several  months  in  the  chronic  cases. 

Diagnosis. — The  direct  diagnosis  is  not  usually  attended  with  diffi- 
culty. In  children  this  form  of  miliary  tuberculosis  very  often  follows 
measles  and  whooping-cough  and  constitutes  the  principal  danger  in  those 
diseases.  The  history  of  chronic  tuberculosis,  pulmonary,  glandular,  or 
joint,  is  of  diagnostic  importance.  Tubercle  in  the  choroid,  when  found, 
establishes  the  diagnosis,  but  the  proportion  of  cases  in  which  it  occurs  is 
limited.  The  occurrence  of  meningeal  symptoms  is  important.  Tubercle 
bacilh  are  often  absent  from  the  sputum  upon  repeated  examination;  when 
found  their. significance  is  positive. 

Differential  Diagnosis. — This  relates  to  non-tuberculous  broncho- 
pneumonia. The  anamnesis  is  very  important.  A  history  of  tuberculous 
disease  in  any  of  its  forms,  even  a  chronic  cough  without  impairment  of 
general  health,  merits  careful  consideration.  The  degree  of  dyspnoea  and 
cyanosis,  tubercle  bacilli,  haemoptysis,  and,  above  all,  the  persistence  of  the 
fever  and  other  symptoms  are  of  diagnostic  value. 

(c)  The  Meningeal  Form. — Acttte  Tuberculous  Meningitis. — An  acute 
miliary  tuberculosis  in  which  the  membranes  of  the  brain,  less  commonly 
also  those  of  the  cord,  are  chiefly  implicated.  As  the  membranes  of  the 
base  are  the  common  seat  of  the  process,  the  affection  is  sometimes  spoken 
of  as  basilar  meningitis.  This  form  is  especially  common  between  the 
second  and  fifth  years  of  hfe.  It  is  rare  during  the  first  year  and  relatively 
infrequent  in  adult  life.  A  primary  tuberculous  depot  may  usually  be 
discovered,  most  frequently  in  the  bronchial  or  mesenteric  glands.  It  may 
be  in  the  lungs,  the  middle  ear,  the  bones,  or  genito-urinary  organs.  In  a 
small  proportion  of  the  cases  the  most  careful  autopsy  fails  to  reveal  the 
local  source  of  the  infection. 


TUBERCULOSIS.  791 

Symptoms.— There  are  frequently  prodromal  symptoms.  These  consist 
of  gradual  loss  of  appetite  and  weight,  irritability,  fretfulness,  and  change 
of  disposition.  There  may  be  a  history  of  recent  measles  or  whooping- 
cough,  or  of  a  fall. 

Stage  of  Irritation. — The  onset  may  be  attended  with  a  severe 
general  convulsion,  or  with  the  usual  triad  of  meningeal  symptoms — 
headache,  vomiting,  and  retraction  of  the  muscles  of  the  back  of  the  neck, 
the  last  being  less  marked  than  in  cerebrospinal  fever.  Fever  is  present, 
usually  moderate  but  gradually  increasing  to  102°-103°  F.  (39° -39.5°  C.)! 
The  pain  is  intense  and  paroxysmal,  and  the  exacerbations  are  accompanied 
by  a  short  sudden  scream — hydrocephalic  cry.  The  child  holds  its  hand  to 
its  head,  and  sometimes  screams  continuously  for  hours  at  a  time.  The 
vomiting  is  without  apparent  cause  and  is  repeated  from  time  to  time. 
The  bowels  are  usually  constipated.  The  retraction  of  the  neck  may  be 
slight  at  first  and  only  manifest  when  the  head  is  bent  forward  or  rotated. 
The  respiration  frequency  remains  normal,  but  the  pulse,  at  first  rapid, 
becomes  irregular  and  slow.  Sleep  is  restless  and  accompanied  by  muscular 
twitchings  and  sudden  starts  and  cries.  The  pupils  are  as  a  rule  con- 
tracted, and  very  often  to  a  greater  degree  upon  one  side  than  upon  the 
other.     Kernig's  sign  is  present. 

Transitional  Stage. — The  signs  of  irritation  gradually  and  irreg- 
ularly subside.  The  vomiting  ceases,  the  belly  becomes  retracted  and 
scaphoid,  and  constipation  is  stubborn.  Headache  is  replaced  by  dulness, 
stupor,  and  occasional  delirium.  The  retraction  of  the  neck  continues, 
the  pupils  are  dilated  and  irregular,  and  strabismus  is  common.  There 
may  be  convulsions,  or  rigidity  of  various  muscle  groups.  The  respiration 
is  at  times  sighing  and  irregular,  and  when  disturbed  the  child  utters  the 
sudden,  shrill  cry  so  often  heard  in  the  disease.  The  temperature  is  irreg- 
ular and  atypical.  Irregular  patches  of  erythema  are  noted,  and  if  the 
skin  is  tapped  with  the  finger-tip,  or  the  nail  drawn  across  it,  a  vivid  red 
spot  or  line  shortly  appears  and  only  slowly  fades — tache  cerebrale — a 
sign  of  little  diagnostic  value  since  it  occurs  in  enteric  fever,  hysteria,  and 
other  conditions  in  which  there  is  relaxation  of  the  peripheral  vessels. 

Stage  of  Paralysis. — The  stupor  deepens  to  coma  and  the  patient 
cannot  be  aroused.  Muscular  spasms  occur  and  there  ma}^  be  general 
convulsions.  The  pupils  are  dilated  and  irresponsive  to  light;  there  is 
paralysis  of  ocular  muscles,  and  ophthalmoscopic  examination  reveals 
optic  neuritis.  Tubercles  in  the  choroid  are  by  no  means  always  seen. 
Tetanoid  contractions,  cataleptic  states,  tremor,  and  athetoid  movements 
occur,  and  in  some  cases  there  are  hemiplegias  or  monoplegias.  Aphasia 
may  occur.  The  pulse  now  becomes  rapid  and  feeble,  and  the  symptom- 
complex  known  as  the  typhoid  state,  with  dry  tongue,  muttering  delirium, 
involuntary  discharges,  and  subnormal  temperature,  develops.  The  dura- 
tion of  the  attack  varies  from  two  to  four  or  five  weeks.  There  is  sometimes 
a  pre-agonistic  rise  of  temperature. 

A  moderate  leucocytosis  is  usually  present  during  the  whole  course 
of  the  attack.  There  are  cases  which  begin  with  great  abruptness  and 
intensity,  in  persons  apparently  in  good  health,  and  run  their  course  in  a 
few  days;  on  the  other  hand  there  are  cases  which  run  a  chronic  course, 
with  anomalous  symptoms  suggestive  of  tumor  of  the  brain. 


792  MEDICAL  DIAGNOSIS. 

Diagnosis. — The  direct  diagnosis  of  tuberculous  meningitis  rests  upon 
the  presence  of  the  signs  of  a  local  tuberculous  process,  the  mode  of 
onset,  which  differs  from  that  of  cerebrospinal  fever,  the  course  of  the 
disease,  and  the  results  of  lumbar  puncture.  The  fluid  withdrawn  is  usually 
turbid  and  often  contains  tubercle  bacilli.     It  is  sometimes  sterile. 

Differential  Diagnosis. — For  the  details  of  the  differential  diagnosis 
between  tuberculous  meningitis  and  pneumococcus  and  streptococcus 
meningitis  and  cerebrospinal  fever  see  Cerebrospinal  Fever. 

B.  Tuberculosis  of  the  Lymph=nodes — Scrofula. 

Tuberculosis  of  the  lymph-nodes  is  more  common  in  children  than 
in  adults,  but  it  occasionally  occurs  in  middle  life  and  infrequently  in  per- 
sons of  advanced  age.  Catarrhal  inflammation  of  mucous  membranes, 
by  which  their  resistance  is  impaired,  is  probably  the  most  important 
predisposing  factor  in  this  form  of  tuberculous  disease.  Tonsillitis  and 
nasopharyngeal  catarrh  doubtless  stand  in  a  causal  relation  to  the  cervical 
adenitis  so  common  in  childhood;  measles,  pertussis,  and  recurrent  attacks 
of  catarrhal  bronchitis,  to  tuberculosis  of  the  bronchial  glands;  and  the 
intestinal  diseases  to  which  infants  are  prone  afford  the  gateway  of  infec- 
tion of  the  mesenteric  glands. 

Glandular  tuberculosis  is  very  commonly  a  local  form  of  the  disease. 
There  is  a  remarkable  tendency  to  encapsulation  and  latency.  The  deposi- 
tion of  lime  salts  is  common.  A  long  quiescent  bronchial  gland  may  become 
the  source  of  a  local  or  general  tuberculous  process. 

Varieties.— (a)  Generalized,  and  (b)  local  tuberculosis  of  the 
lymph-nodes  are  to  be  considered. 

(a)  The  Generalized  Form.— A  form,  of  the  disease  in  children  char- 
acterized by  the  successive  implication  of  groups  of  glands,  and  terminat- 
ing in  a  general  tuberculous  cachexia  or  in  meningitis  has  been  described. 

(b)  Local  Tuberculous  Adenitis. — The  groups  usually  affected  are, 
in  the  order  of  their  frequency,  the  cervical,  the  tracheobronchial,  and  the 
mesenteric.  The  cervical  glands  are  very  frequently  involved.  The  chil- 
dren of  the  poor,  and  especially  the  negro,  mostly  suffer,  but  those  living 
in  affluence  do  not  wholly  escape.  Chronic  rhinitis,  tonsillitis,  otitis  media, 
eczema  capitis  vel  faciei,  conjunctivitis,  or  keratitis  may  afford  the  port  of 
entry  for  the  infection. 

Cervical  Glands. —  Symptoms. — The  submaxillary  glands  are  most  fre- 
quently and  usually  first  involved.  The  posterior  cervical  chain,  the 
glands  above  the  clavicle,  and  the  axillary  glands  are  also  affected  in 
many  cases.  The  disease  may  affect  one  or  both  sides;  when  both,  to  a 
much  greater  extent  on  one  than  the  other.  The  bronchial  glands  may 
also  be  tuberculous.  Infection  of  the  pleurae  or  lungs  may  subsequently 
take  place.  The  enlarged  glands  may  at  first  be  felt  as  discrete,  smooth, 
firm,  and  somewhat  elastic  tumors,  over  which  the  skin  is  freely  movable. 
They  rapidly  enlarge  and  coalesce,  forming  large  disfiguring  masses  to 
which  the  overlying  skin  becomes  adherent,  with  subsequent  inflamma- 
tion and  suppuration.  If  the  resulting  abscess  be  not  opened,  it  breaks, 
leaving  a  sinus  which  heals  slowly,  followed  by  a  characteristic,  retracted. 


TUBERCULOSIS. 


793 


unsightly  scar.  Fever  is  usually  present  during  the  active  stage  of  the 
process  and  the  patient  is  anaemic.  The  process  is  slow,  but  many  of  the 
cases,  especially  in  children,  ultimately  recover. 

Diagnosis. — Direct. — Indolent  glandular  enlargements  in  the  neck 
and  axillary  region,  more  marked  on  one  side  than  the  other,  becoming 
adherent  and  slowly  softening  with  abscess  formation,  are  usually  tuber- 
culous, especially  in  children  who  suffer  from  local  catarrhal  or  inflam- 
matory diseases  of  the  upper  air-passages,  otitis  media,  eczema  of  the 
head  or  face,  chronic  conjunctivitis  or  keratitis,  or  tuberculous  disease  in 
other  parts  of  the  bod}'. 

Differential. — Slight  cervical  adenitis  occurs  in  connection  with  various 
catarrhal  processes  and  the  exanthemata.  As  a  rule  these  enlargements 
gradually  undergo  resolution  as  the 
primary  disease  subsides.  Sometimes 
they  suppurate.  This  shorter  course  of 
the  process,  the  association  with  acute 
disease,  and  the  slighter  degree  of  en- 
largement are  of  diagnostic  importance. 

Hodgkin's  disease  may  at  first  be 
very  difficult  to  recognize.  The  greater 
frequency  of  tuberculous  adenitis  in 
children,  the  early  implication  of  the 
glands  in  the  submaxillary  region,  the 
slow  development,  the  tendency  to 
inflammatory  adhesions  among  the 
glands  themselves  and  to  the  skin,  and 
to  suppuration  and  abscess  formation, 
are  in  favor  of  the  tuberculous  nature 
of  the  process.  Limitation  to  a  group 
of  glands,  as  the  cervical  or  axillary,  or  to  one  side,  is  much  more 
common   in   tuberculous   adenitis  than  in   Hodgkin's  disease. 

Tracheobronchial  Glands. — This  form  of  tuberculosis  is  very  common 
in  young  children,  and  particularly  so  in  the  inmates  of  foundling  asylums, 
orphanages,  and  similar  institutions.  The  glands  may  attain  large  size. 
The  trachea  and  bronchi  may  be  flattened,  and  pressure  may  be  exerted 
upon  the  superior  cava,  the  pulmonary  artery,  and  the  azygos  vein. 
The  softening  caseous  contents  of  the  glands  may  perforate  into  the 
bronchi  or  trachea  and  cause  asphyxia;  into  the  great  vessels  with  gen- 
eral infection  of  the  blood  stream,  or  very  rarely  into  the  oesophagus. 
Pulmonary  infection  very  often  occurs  either  by  contiguity  of  tissue  or 
along  the  root  of  the  lung.     Pericardial  tuberculosis  may  occur. 

Symptoms. — Pressure  symptoms  occur,  but  they  are  less  common  and 
less  urgent  than  the  anatomical  conditions  suggest.  The  enlarged  mass 
constitutes  one  of  the  forms  of  mediastinal  tumor.  Dyspnoea,  paroxysmal, 
brassy  cough  from  pressure  on  the  recurrent  laryngeal  nerves,  cyanosis  and 
puffiness  of  the  face  from  pressure  on  the  superior  cava,  dysphagia  from  com- 
pression of  the  oesophagus,  are  occasional  symptoms.  In  the  majority  of 
cases  the  mechanical  disturbance  is  slight  or  absent  altogether.  Nor  are  defi- 
nite physical  signs  common.    Impaired  resonance  upon  light  percussion  over 


Fig.  274. — Chronic  cervical  adenitis. 


794  MEDICAL  DIAGNOSIS. 

the  manubrium  sterni  may  be  noted,  and  slight  relative  dulness  along  the 
spine  in  the  upper  dorsal  region.  These  physical  signs  are,  however,  neither 
so  constant  nor  so  well  marked  as  to  serve  a  useful  purpose  in  the  diagnosis. 

Mesenteric  QIands — Tabes  Mesenterica. — A  slight  enlargement  is  com- 
mon and  may  not  give  rise  to  special  symptoms.  As  a  rule  the  enlargement 
is  general  and  attains  considerable  size.  The  retroperitoneal  glands  are  often 
coincidently  involved.  Caseation  and  softening  occur.  Resorption  of  the 
fluid  portions  and  the  deposition  of  lime  salts  sometimes  take  place.  The 
tuberculosis  may  be  primary,  infection  having  arisen  by  way  of  the 
lesions  of  intestinal  catarrh,  or  it  may  be  secondary  to  tuberculous  lesions 
of  the  bowel. 

Symptoms. — Tabes  mesenterica  is  common  in  very  young  children. 
The  belly  is  enlarged  and  tympanitic;  the  enlarged  glands  cannot  always 
be  felt;  there  is  diarrhoea  with  thin,  watery,  and  offensive  stools.  The 
nutrition  is  deranged  and  the  little  patients  are  anaemic,  puny,  and  wasted. 
The  superficial  abdominal  veins  are  often  enlarged  and  conspicuous.  There 
is  fever  of  hectic  type.  In  a  group  of  cases  there  is  an  associated  tuber- 
culous peritonitis,  the  belly  is  distended,  firm,  or  doughy,  and  nodular 
tumors  may  be  felt.  Massive  tuberculous  enlargement  of  the  mesenteric 
and  retroperitoneal  glands  occasionally  occurs  in  adults. 

Diagnosis. — laired. — In  young  children  the  diagnosis  is  commonly 
attended  with  no  great  difficulty.  The  appearance  of  the  child  is  sug- 
gestive. Sometimes  the  enlarged  glands  are  palpable.  Tuberculous 
adenitis  elsewhere,  or  the  evidence  of  tuberculous  disease  of  the  lungs,  is 
of  diagnostic  importance. 

Differential. — The  diagnosis  of  the  essential  character  of  circum- 
scribed tuberculous  glandular  masses  in  the  abdomen,  especially  when  they 
are  of  considerable  size,  and  in  the  adult  without  tuberculous  disease  of 
the  intestines,  peritoneum,  or  lungs,  is  often  attended  with  difficulty.  The 
differential  diagnosis  can  in  many  of  the  cases  only  be  reached  by  exclu- 
sion and   may  even   then   remain   in  doubt.      Tuberculin   may  be   used. 

C.  Tuberculosis  of  the  Serous  Membranes. 

General  Tuberculosis  of  Serous  Membranes. — The  process  may  be 
general,  the  pleurae,  pericardium,  and  peritoneum  being  involved  simul- 
taneously or  in  rapid  succession.  There  may  be  an  acute  miliary  tuber- 
culosis; a  more  chronic  form  with  agglomeration  of  tuberculous  material, 
with  caseation  and  inflammatory  and  suppurative  lesions;  and  finally  a 
chronic  proliferative  process  with  firm  tuberculous  nodules,  fibroid  lesions, 
great  thickening  of  the  membranes,  and  the  absence  of  exudate.  The 
pericardium  is  less  frequently  involved  than  the  pleurae  and  peritoneum. 

Tuberculous  Pleurisy. — The  pleurisy  may  be  acute,  with  fibrinous, 
serofibrinous,  purulent,  or  hemorrhagic  exudate;  or  it  may  be  chronic. 
It  is  very  often  latent.  Secondary  and  terminal  forms  occur.  A  rare  form 
of  acute  tuberculous  pleurisy  with  ulceration  and  necrosis  of  the  j^leura 
has  been  described.  Subacute  cases  with  a  serofibrinous  exudate  are  very 
common.  They  are  almost  constantly  associated  with  circumscribed 
tuberculous  disease  of  the  lungs,  or  with  tracheobronchial  adenitis.     The 


TUBERCULOSIS. 


795 


exudate  may  become  purulent.  There  are  cases  in  which  no  signs  of  tuber- 
culous disease  can  be  found,  in  which  after  a  period  of  latency  varying  from 
a  few  weeks  to  many  years,  with  excellent  health,  pulmonary  or  acute 
miliary  tuberculosis  supervenes.  The  visceral  pleura  is  always  involved 
in  pulmonary  tuberculosis  extending  to  the  periphery  of  the  lung.  Adhesions 
with  more  or  less  thickening  result.  In  the  absence  of  protecting  adhesions 
a  caseating  mass  in  the  lung  may  perforate  the  visceral  pleura  and  cause 
pyopneumothorax.  Finally  there  is  a  chronic  adhesive  pleurisy  with  great 
thickening  and  involvement  of  the  interlobar  pleura  and  the  lung  itself. 
For  the  S3^mptomatology  and  diagnosis  of  tuberculous  pleurisy  see  Pleurisy. 
Tuberculosis  of  the  Pericardium. — The  process  may  be  part  of  a  gen- 
eral miliary  tuberculosis,  or  latent  in  cases  of  chronic  tuberculosis  or  other 
chronic  disease,  or  it  may  cause  a  chronic  adhesive  pericarditis  analogous 
to  the  more  common  chronic  adhesive  pleurisy.  There  are  acute  cases 
with  fibrinous  or  plastic,  serofibrinous,  hemorrhagic,  or  purulent  exudate, 
and  the  ordinary  symptoms  of  pericarditis,  in  which,  in  the  absence  of 
tuberculous  disease  elsewhere,  the  true  nature  of  the  process  cannot  be 
recognized  intra  vitarn.     (See  Pericarditis.) 


Fig.  275. — Tuberculous  peritonitis.   Outline  indicates  a  hard  mass  which  was  found  on  operation  to  consist 
of  areas  of  nodules  matting  together  the  intestines. — Rotch. 

Tuberculosis  of  the  Peritoneum.  —  There  may  be  diffuse  miliary 
tuberculosis  or  circumscribed  areas  corresponding  to  tuberculous  ulcera- 
tion of  the  intestine,  acute  miliary  tuberculosis  with  serofibrinous  or 
bloody  exudate,  chronic  tuberculosis  with  agglomerations  of  tuberculous 
tissue  undergoing  caseation  and  necrosis,  chronic  proliferative  or  fibroid 
peritonitis  with  extensive  adhesions  and  thickening  of  the  capsule  of  the 
liver  and  spleen.  The  infection  takes  place  by  way  of  the  intestines,  espe- 
cially in  children,  and  in  adults  is  propagated  from  the  Fallopian  tubes  or 
the  seminal  vesicles,  prostate,  or  testicle.  In  by  far  the  largest  proportion 
of  cases  infection  of  the  peritoneum  is  secondary  to  tuberculosis  of  the 
lungs  or  pleura.  Tuberculous  peritonitis  has  been  known  to  follow  contu- 
sion of  the  abdomen;  it  sometimes  has  its  starting  point  in  the  hernial  sac 
and  often  constitutes  a  terminal  condition  in  chronic  visceral  disease, 
especially  cirrhosis  of  the  liver. 

Symptoms. — Tuberculosis  of  the  peritoneum  presents  peculiar  clinical 
phenomena  which  serve  to  distinguish  it  from  peritonitis  due  to  other  causes. 

The  disease  may  be  latent  and  discovered  only  upon  operation,  or 
post  mortem.  In  other  cases  the  onset  may  be  sudden  with  urgent  symp- 
toms, as  fever,  vomiting,  pain,  and  tenderness.  There  are  cases  in  which 
the  onset  and  early  symptoms  suggest  enteric  fever. 


796  MEDICAL  DIAGNOSIS. 

Fever  occurs  in  the  acute  cases  and  the  temperature  often  reaches 
104°  F.  (40°  C.)  or  more;  in  many  of  the  cases  the  rise  is  only  to  sub- 
febrile  ranges — 100°  F.  (37.8°  C).  In  the  chronic  cases  fever  is  absent 
and  subnormal  temperatures  often  occur.  The  pulse  is  variable  and,  in 
the  absence  of  fever,  of  moderate  frequency.  Tympanitis  is  common  in  the 
acute  cases,  but  in  the  chronic  form  the  belly  may  be  small  and  doughy. 
Ascites  of  small  amount  is  common;  it  is  usually  serous,  but  may  be 
purulent  or  hemorrhagic,  and  is  sacculated  from  the  beginning,  or  soon 
becomes  so.  A  diffuse  pigmentation  of  the  skin  may  suggest  Addison's 
disease.  Irregular  attacks  of  pain  associated  with  fever  and  digestive  dis- 
turbance occur,  and  tenderness  upon  pressure  is  a  more  or  less  continuous 
symptom.  Dense  infiltration  of  the  omentum  with  tubercles  and  fibrinous 
exudation  may  convert  that  structure  into  a  thick,  cord-like  mass  adherent 
to  the  transverse  colon  and  extending  across  the  abdomen.  This  tumor- 
like omental  thickening  may  b^  recognized  upon  palpation.  Similar  masses 
may  be  felt  in  other  parts  of  the  abdomen.  Sacculated  fluid  exudates  con- 
fined by  adhesions  among  the  abdominal  or  pelvic  organs,  the  mesentery, 
and  the  walls,  form  cyst-like  tumors  which  suggest  ovarian  or  other  cysts 
and  often  lead  to  errors  in  diagnosis. 

Less  frequently  the  mesentery  of  the  small  intestine,  the  root  of  which 
extends  in  an  oblique  direction  from  the  lumbar  vertebrae  to  the  right  sacro- 
ihac  symphysis,  undergoes  thickening  and  retraction, which  is  associated  with 
great  shortening  of  the  intestine  and  thickening  of  its  walls  in  such  a  manner 
that  the  bowel  is  drawn  together  into  a  tumor-like  mass  occupying  the  right 
side  of  the  abdomen.  These  changes  may  be  so  extensive  as  to  involve  the 
bowel  in  its  entire  length.  Massive  enlargement  of  the  mesenteric  glands  is 
very  often  present  in  tuberculous  peritonitis,  especially  in  children. 

Diagnosis. — The  direct  diagnosis  of  tuberculosis  of  the  peritoneum  is 
attended  with  much  difficulty  in  the  acute  cases  with  sudden  onset,  great 
pain  and  tenderness,  rigidity  of  the  abdominal  muscles,  vomiting,  and 
fever.  The  presence  of  tuberculous  lesions  elsewhere,  and  in  particular  at 
the  apex  of  one  lung,  in  the  pleurae,  bones,  or  genito-urinary  tract,  is  of 
great  diagnostic  importance.  In  this  group  of  cases  prompt  operative 
measures  are  indicated,  not  only  in  order  to  clear  up  the  uncertainty  as  to 
the  causal  conditions — surgical  diagnosis — but  also  as  the  only  curative 
measure  which  yields  promise  of  relief  in  several  of  the  conditions,  as  per- 
foration of  the  bowel  or  other  hollow  viscus,  or  the  rupture  of  an  abscess  or 
cyst,  which  cause  acute  peritonitis  with  precisely  the  same  symptoms. 
In  the  subacute  forms  the  direct  diagnosis  cannot  always  be  made.  Per- 
sistent abdominal  symptoms  in  a  tuberculous  individual  constitute  suffi- 
cient ground  for  a  provisional  diagnosis,  which  the  subsequent  course  of 
the  case  will  frequently  confirm.     Many  of  the  subacute  cases  are  latent. 

The  diagnosis  in  the  chronic  forms  depends  upon  the  presence  of  the 
general  symptoms  of  chronic  peritonitis,  the  recognition  of  tuberculous 
foci  in  other  parts  of  the  body,  encysted  fluid  exudate,  or  irregular  tumor- 
like masses  within  the  abdomen,  the  tuberculin  test,  which  may  be  used  in 
any  doubtful  case  unattended  by  fever  or  with  fever  of  only  moderate  range, 
and  the  finding  of  tubercle  bacilli  in  the  fluid  obtained  by  paracentesis, 
or  a  positive  reaction  to  the  injection  of  such  fluid  into  guinea-pigs. 


TUBERCULOSIS.  797 

Differential. — The  points  of  discrimination  between  peritonitis 
due  to  other  causes  and  tuberculous  peritonitis  have  been  indicated 
in  the  foregoing  paragraphs.  Non-tuberculous  neoplasms  are  usually 
more  local,  circumscribed,  and  definite  in  their  relation  to  the  viscera,  as 
the  kidneys,  spleen,  or  hver.  Fever  is  less  apt  to  occur.  But  more  impor- 
tant still  are  the  absence  of  prior  or  concurrent  evidences  of  tuberculosis 
elsewhere,  and  negative  results  of  bacteriological  tests. 

The  omental  and  intestinal  tumors  which  occur  in  the  chronic  forms 
are  fairly  distinctive  and  only  lead  to  uncertainty  in  the  case  of  malignant 
disease.  The  differential  diagnosis  rests  upon  the  anamnesis,  the  more  rapid 
wasting  in  cancer,  and  the  differences  in  the  cachexia  of  the  two  conditions. 

Ovarian  Cysts. — Errors  of  diagnosis  are  common.  In  some  of  the 
cases  of  tuberculous  peritonitis  with  encysted  exudate  the  general  health 
is  fairly  well  preserved.  The  physical  signs  may  be  similar  in  both  condi- 
tions. The  contour  in  tuberculous  pseudocysts  is  less  regular;  areas  of 
dulness  upon  percussion,  or  palpable  nodular  masses  may  be  demonstrable. 


Fig.  276. — Tympany  due  to  tuberculous  peritonitis. — German  Hospital. 

and  changes  in  form  or  position  may  arise  with  variations  in  the  amount  of 
gas  in  the  coils  of  intestines.  Depression  of  the  vault  of  the  vagina  occurs 
in  both  conditions.  Tubal  disease  and  nodular  masses  in  one  or  both 
ovarian  regions  are  suggestive.  Febrile  outbreaks  are  common  in  tuber- 
culosis, but  rarely  occur  in  non-inflammatory  ovarian  cysts. 

Cirrhosis  of  the  Liver. — If  the  ascites  is  so  great  as  to  interfere  with 
the  palpation  of  the  liver  in  a  doubtful  case,  paracentesis  is  necessar}^  for 
diagnostic  purposes.  A  hemorrhagic  fluid  may  be  present  in  tuberculosis  or 
carcinoma.  This  occurrence,  together  with  thickening  of  the  peritoneum  or 
demonstrable  tumors,  or  the  evidence  of  tuberculosis  or  carcinoma  in  distant 
organs  is  diagnostic.  In  a  considerable  proportion  of  the  cases  of  hepatic 
cirrhosis,  tuberculosis  of  the  peritoneum  occurs  as  a  terminal  condition. 

D.  Tuberculosis  of  the  Alimentary  Canal. 

Tuberculous  lesions  of  the  structures  forming  the  digestive  tract, 
with  the  exception  of  the  liver  and  intestines,  are  rare. 

Lips,  Tongue,  and  Mouth. — Tuberculous  ulcers  of  these  organs  occur 
in  rare  instances,  mostly  in  association  with  laryngeal  or  pulmonary  disease. 
Upon  the  lips  they  are  liable  to  be  mistaken  for  chancre  or  epithelioma. 
Tuberculous  ulcers  upon  the  tongue  occur  in  the  form  of  deep  circumscribed 


798  MEDICAL  DIAGNOSIS. 

lesions,  with  well-defined  but  irregular  borders  and  a  caseous  base.  They 
resist  treatment,  not  being  influenced  by  the  iodides,  and  tend  to  spread. 
The  glands  at  the  angle  of  the  jaws  are  not  enlarged.  The  salivary  glands 
are  very  rarely  the  seat  of  tuberculous  infection.  Tuberculosis  of  the  hard 
and  soft  ]3alate  in  rare  instances  is  the  result  of  the  invasion  of  these  struc- 
tures from  adjacent  parts.  The  tonsils  are  frequently  infected.  There 
may  be  superficial  ulceration  or  diffuse  infiltration  with  miliary  tubercle. 
Caseous  depots  may  be  present.  Infection  may  take  place  by  means  of 
tuberculous  milk  or  other  food,  dust,  or  by  the  sputum  in  pulmonary 
disease.  The  frequency  of  tuberculous  cervical  adenitis,  especially  in 
children,  finds  an  explanation  in  tonsillar  disease.  In  ulcers  of  doubtful 
character  upon  the  lips  and  tongue,  or  elsewhere  in  the  mouth,  a  portion  of 
the  tissue  may  be  excised  for  examination,  or  inoculations  may  be  made. 
In  a  suspicious  ulcer  of  the  tongue  failure  of  the  iodides  and  absence  of 
glandular  involvement  are  against  a  diagnosis  of  syphihs. 

Pharynx  and  CEsophagus. — In  lar3'ngeal  and  chronic  pulmonary 
tuberculosis  miliary  tubercles  and  superficial  ulceration  frequently  invade 
the  oropharynx.  The  latter  condition,  when  associated  with  ulceration 
of  the  epiglottis,  is  attended  with  great  pain  upon  deglutition,  and  consti- 
tutes a  most  distressing  condition  in  laryngeal  phthisis.  Adenoid  vegeta- 
tions of  the  nasopharynx  are  in  some  instances  infected.  An  extension 
from  the  larynx  may  invade  the  upper  part  of  the  oesophagus.  Rare  cases 
of  tuberculous  ulceration  have  been  reported. 

Stomach  and  Intestines. — Ulceration  of  the  wall  of  the  stomach  is 
a  recognized  pathological  condition  but  the  diagnosis  cannot  be  made 
during  life,  since  the  symptoms  are  the  same  as  in  ordinary  peptic  ulcer. 
It  has  occasionally  been  observed  post  mortem  in  tuberculous  subjects, 
but  non-tubercidous  peptic  ulcer  is  more  liable  to  occur  in  those  debili- 
tated and  rendered  anaemic  by  tuberculous  disease.  The  probability  that 
a  peptic  ulcer  may  become  tuberculous  is  to  be  considered.  Intestinal 
tuberculosis  may  be  primary,  especially  in  children,  and  is  then  usually 
followed  by  infection  of  the  mesenteric  glands  or  peritoneum.  Primary 
tuberculosis  of  the  intestine  in  the  adult  is  exceedingly  rare. 

Symptoms. — Irregular  diarrhoea,  colicky  pains,  and  moderate  fever 
occur.  Intestinal  hemorrhage  may  be  the  initial  symptom.  Emaciation 
and  signs  of  tuberculosis  of  the  lungs  or  elsewhere  suggest  the  actual  patho- 
logical condition.  There  are  cases  in  which  the  tuberculosis  begins  in  the 
csecal  region,  and  the  symptoms  are  circumscribed  tenderness,  slight 
irregular  fever,  and  diarrhoea  alternating  with  constipation.  When  these 
symptoms  subside  and  recur  after  quiet  intervals  of  varying  duration,  the 
condition  simulates  a  chronic  appendicitis.  Hemorrhage  occurs  and  necrosis 
may  take  place,  causing  peri-appendicular  abscess  or  jDerforation  into  the 
peritoneum.     Thickening  of  the  intestinal  wall  forms  part  of  the  process. 

Secondary  lesions  are  much  more  common.  The  lower  portion  of  the 
ileum  and  the  large  bowel  are  usually  involved.  Infection  occurs  by  means 
of  the  swallowed  sputum,  and  the  intestinal  disease  gives  rise  to  trouble- 
some and  distressing  symptoms  in  the  later  stages  of  many  cases  of  phthisis. 
The  lymphatic  glands  are  early  involved  and  there  is  frequently  extensive 
ulceration  of  the  mucous  membrane  of  the  small  and  large  bowel.    There 


TUBERCULOSIS.  799 

may  be  ovoid  ulcers  in  the  ileum,  corresponding  to  Peyer's  patches,  but  as 
a  rule  the  tuberculous  ulcer  is  transverse  and  in  many  cases  annular.  Its 
borders  and  floor  are  thickened  from  the  infiltration  of  tubercle,  which 
shows  caseation  at  various  points.  The  muscular  coat  is  often  involved, 
patches  of  recent  tubercles  are  seen  upon  the  corresponding  serosa,  local 
adhesions  occur,  forming  knot-like  masses  among  the  intestinal  coils,  and 
in  rare  instances  perforation  takes  place.  Sclerotic  changes  often  proceed 
side  by  side  with  caseation  and  necrosis,  and  lead  to  cicatrization,  irregular 
puckering,  and  stenosis.  These  lesions  are  sometimes  localized  in  the 
caecum  and  appendix,  and  form  dense  sausage-shaped  tumors  in  the  right 
lower  quadrant  of  the  abdomen,  slightly  or  not  at  all  movable,  painful 
upon  palpation,  and  suggestive  of  carcinoma.  More  extensive  adhesions 
and  infiltration  in  this  region  sometimes  occur,  and  in  rare  instances  a  fecal 
fi-stula.  Fistula  in  Ano — Anal  Fistula. — This  condition  is  in  a  large  pro- 
portion of  the  cases  tuberculous  and  associated  with  pulmonary  tuber- 
culosis which  is  sometimes  latent  or  obsolescent.  Operation  is  occasionally 
followed  by  a  flaring  of  the  lung  trouble  into  activity,  whether  post  hoc  or 
propter  hoc  cannot  always  be  determined.  This  fact  does  not  militate 
against  effectual  operation  by  excision,  since  it  is  better  to  suffer  from  one 
focus  of  tuberculosis  than  from  two. 

Secondary  tuberculous  ulceration  of  the  intestine  manifests  itself 
by  a  group  of  abdominal  symptoms  superadded  to  those  of  the 
pre-existing  disease,  usually  pulmonary.  Less  frequently  the  intestinal 
lesions  are  secondary  to  tuberculosis  of  the  peritoneum,  the  primary  infec- 
tion being  in  the  lymph-nodes  in  children,  or  the  genito-urinary  tract  in 
adults  of  either  sex.  Abdominal  pain,  tenderness,  loss  of  elasticity  with 
local  doughiness  or  tumor  formation,  particularly  in  the  right  iliac  region, 
diarrhoea  often  alternating  with  constipation,  and  later  the  signs  of  stenosis 
of  the  bowel,  namely,  local  bloating,  smooth  sausage-shaped  tumors  indicat- 
ing the  contour  of  the  distended  gut,  and  stormy  peristalsis,  make  up  the 
clinical  picture.  In  the  rare  cases  in  which  the  obstruction  becomes  com- 
plete the  ominous  characteristic  symptoms  of  occlusion  of  the  bowel 
(q.v.)  appear. 

Diagnosis. — The  direct  diagnosis  of  primary  tuberculosis  of  the 
intestine  cannot  always  be  made  even  in  children.  It  depends  upon  heredi- 
tary predisposition,  the  possibility  of  feeding  upon  the  milk  of  tuberculous 
cows,  irregular  high  fever,  rapid  emaciation  and  loss  of  strength,  and  the 
presence  in  the  stools  of  many  tubercle  bacilli  upon  repeated  examination. 
Secondary  lesions  may  be  diagnosticated  when  persistent  abdominal  symp- 
toms, not  yielding  to  treatment,  come  on  in  the  course  of  pulmonary  con- 
sumption or  local  tuberculosis  in  other  parts  of  the  body,  and  in  particular 
when  there  are  also  localized  physical  signs  indicative  of  intestinal  thickening, 
kinking,  or  obstruction.  If  fecal  fistula  develops  and  tubercle  bacilli  are 
found  in  the  discharge  as  well  as  in  the  stools,  the  diagnosis  is  positive. 

Differential.  —  The  discrimination  between  intestinal  tuberculosis 
and  the  conditions  which  resemble  it  cannot  in  all  cases  be  made.  Two 
topics,    however,  demand   especial  mention — carcinoma   and   appendicitis. 

Cachexia  and  pain  occur  as  in  carcinoma  elsewhere.  Fever  is  not  a 
prominent  symptom.    The  temperature  is  on  the  contrary  often  subnormal. 


800  MEDICAL  DIAGNOSIS. 

Ribbon-shaped  stools,  foul-smelling  stools  in  which  blood,  pus,  and  necrotic 
fragments  of  the  neoplasm  are  found,  and  the  general  symjjtoms  of  stenosis 
are  suggestive  of  cancer.  Absence  of  tuberculosis  elsewhere,  negative 
findings  as  to  bacilli,  and  failure  of  the  temperature  rise  after  the  injection 
of  tuberculin  are  of  great  diagnostic  importance. 

There  are  rare  cases  of  tuberculosis  of  the  caecum  in  which  the  process 
invades  the  lymphoid  tissue  of  the  appendix — tuberculous  appendicitis. 
Primary  attacks  of  appendicitis  are  so  well  characterized  that  the  question 
of  tuberculosis  does  not  enter  into  their  consideration.  The  acute  or  sub- 
acute character  of  the  early  symptoms  even  in  the  chronic  cases  would 
appear  in  the  anamnesis.  Of  diagnostic  importance  are  other  diffuse 
abdominal  symptoms,  pain,  tenderness,  diarrhoea  preceding  the  local 
phenomena,  and  the  coincidence  of  tuberculosis  in  other  organs.  It  is  not 
to  be  forgotten  that  an  attack  of  non-specific  appendicitis  may  develop 
in   a  tuberculous  individual. 

E.  Tuberculosis  of  the  Brain  and  Spinal  Cord. 

Tuberculosis  occurs  as  an  acute  meningitis  which,  while  chiefly  basilar, 
is  almost  always  also  spinal,  and  constitutes  one  of  the  manifestations  of 
the  acute  form  of  general  or  disseminated  infection — acute  miliary  tuber- 
culosis (q.v.);  as  a  chronic  meningo-encephalitis  due  to  the  development 
of  multiple  tubercles,  usually  within  circumscribed  limits;  and  finally  as 
solitary  tubercles  (see  p.  1260). 

F.  Tuberculosis  of  the  Qenito=urinary  Organs. 

Tuberculosis  of  the  genito-urinary  tract  is  frequent  and  important. 
Lesions  have  been  observed  in  the  foetus,  and  the  occurrence  of  tuberculous 
orchitis  in  very  young  children  suggests  the  possibility  of  hereditary 
transmission.  In  the  preponderating  majority  of  instances  the  disease  is 
secondary  to  disease  of  some  distant  organ,  especially  the  lungs,  and  the 
infection  must  be  ascribed  to  transmission  by  way  of  the  blood.  In  a 
considerable  proportion  infection  takes  place  from  the  peritoneum.  Tubal 
and  vesical  tuberculosis  have,  however,  been  observed  in  cases  of  intestinal 
tuberculosis  in  which  no  evidence  of  the  implication  of  the  peritoneum 
could  be  found.  Less  frequently  the  disease  arises  by  direct  infection  from 
the  rectum  to  the  bladder,  or  to  the  uterus  or  vagina,  in  consequence  of 
adhesions  and  fistula  formation.  Tuberculous  abscesses  in  the  pelvis  may 
be  the  source  of  infection  of  any  of  the  genito-urinary  organs.  Vertebral 
tuberculosis  may  implicate  the  kidney  by  direct  extension.  The  possi- 
bility of  primary  tuberculosis  as  the  result  of  direct  infection  in  sexual 
intercourse  appears  very  great.  Whether  or  not  accidental  infection  by 
way  of  the  vagina  or  urethra  may  take  place  from  other  sources,  as  infected 
instruments  or  syringes,  suppositories,  or  in  digital  examination,  or  by 
transmission  from  the  rectum  by  way  of  the  clothing  has  not  been  fully 
estabhshed.  The  infection  may  involve  any  of  the  tissues  of  the  genito- 
urinary system.  It  often  extends  rapidly,  and  in  some  cases  there  are 
manifestations  of  the  disease  at  different  points  at  the  same  time. 


TUBERCULOSIS.  801 

Tuberculosis  of  the  Kidneys. — The  disease  may  be  secondary.  In 
acute  general  tuberculosis  scattered  tubercles  are  present  in  the  substance 
and  upon  the  surface  of  the  kidneys.  In  pulmonary  tuberculosis  there 
may  be  scattered  nodules,  or  pyelitis.  Primary  tuberculosis  of  the  kidney 
also  occurs.  In  many  of  the  cases  the  lesions  are  at  the  same  time  present 
in  the  kidneys,  extending  to  the  pelvis  and  uterus,  and  in  the  bladder, 
prostate,  and  seminal  vesicles,  and  the  seat  of  primary  invasion  is  uncertain. 
Renal  tuberculosis  is  most  frequent  in  middle  life  but  may  be  met  with  at 
any  age.     Males  suffer  much  more  frequently  than  females. 

Symptoms. — The  urine  contains  pus  in  varying  amounts.  There  is 
increased  frequency  of  micturition.  These  symptoms  often  go  on  for 
years  without  abnormal  subjective  sensations  and  with  maintenance  of 
the  general  health.  There  may  be  tenderness  upon  firm  pressure.  In 
exceptional  cases  the  kidney  may  be  greatly  enlarged,  or  there  may  be 
a  pyonephrosis.  Under  such  circumstances  there  may  be  a  palpable 
abdominal  tumor.  The  urine  is  albuminous,  and  in  addition  to  pus-cells 
contains  epithelium  and  granular  debris.  Tube-casts  are  not  very  common. 
Tubercle  bacilli  are  present.  Hemorrhage  may  occur.  As  the  disease 
advances  the  other  kidney  becomes  involved,  and  a  tuberculous  cachexia 
with  chills,  irregular  fever,  sweating,  and  emaciation  and  progressive 
asthenia  ensues.  The  lungs  are  implicated  and  an  acute  disseminated 
miliary  tuberculosis  occurs  as  a  terminal  event.  Encysted  caseous  or 
calcareous  masses  in  the  kidney  are  occasionally  found  in  the  post-mortem 
room  and  point  to  the  possibility  of  spontaneous  cure. 

Diagnosis. — Direct. — The  above  symptoms,  associated  with  the 
evidence  of  tuberculosis  in  the  testicle  or  prostate,  or  in  the  tubes  or 
ovaries,  the  presence  of  tubercle  bacilli  in  the  urine,  and  a  positive  reac- 
tion to  the  tuberculin  test,  justify  a  positive  diagnosis.  The  differentiation 
of  the  urine  by  catheterization  of  the  ureters  renders  possible  a  diagnosis 
of  the  kidney  affected.  The  urine  may  contain  bacilli  from  tuberculous 
lesions  in  the  bladder  or  elsewhere  in  the  genito-urinary  tract,  and  the  fact 
that  the  morphological  and  tinctorial  characters  of  the  smegma  bacillus 
are  practically  the  same  as  those  of  the  tubercle  bacillus  is  to  be  borne  in 
mind.  The  specimen  for  examination  in  a  doubtful  case  must  be  obtained 
by  catheterization  under  the  strictest  precautions  against  contamination, 
and  the  possibility  that  even  then  smegma  bacilli  may  be  accidentally 
present  must  not  be  forgotten.  Inoculation  tuberculosis  caused  by  the 
urinary  sediment  is  proof  positive  of  genito-urinary  tuberculosis,  but  not 
necessarily  of  tuberculosis  of  the  kidney. 

Differential. — It  may  be  difficult  to  difTerentiate  tuberculous  pye- 
lonephritis from  calculous  pyehtis.  A  history  of  attacks  of  renal  colic, 
various  forms  of  crystalline  sediment  and  blood-cells  in  the  urine,  or  actual 
hemorrhage,  are  in  favor  of  the  latter.  Hemorrhage  is  much  less  common 
in  tuberculosis  of  the  kidneys. 

Suprarenal  Capsules. — Tuberculosis  of  the  adrenals  with  fibrocaseous 
lesions  is  the  most  common  anatomical  change  found  in  Addison's  disease, 
and  may  manifest  itself  by  the  symptoms  of  that  disease  (q.v.). 

Tuberculosis  of  the  Ureters  and  Bladder. — The  symptoms  of  renal 
tuberculosis  are  those  of  cystitis,  and  infection  of  the  bladder  is  usually 
secondary  to  infection  of  the  kidneys  on  the  one  hand,  or  of  the  testes, 

51 


802  MEDICAL  DIAGNOSIS. 

prostate,  or  seminal  vesicles  on  the  other.  The  process  very  often  invades 
the  ureters  from  the  pelvis  of  the  kidney.  Primary  tuberculosis  of  the 
bladder  is  a  rare  affection. 

Tuberculosis  of  the  Prostate  and  Seminal  Vesicles. — These  organs 
are  frequently  the  seat  of  tuberculous  growths  and  caseous  nodules.  The 
prostate  is  often  found  upon  digital  examination  to  be  enlarged  and  nodular. 
It  is  sometimes  tender.  There  is  great  irritabihty  of  the  bladder,  vesical 
tenesmus,  frequent  micturition  or  retention  of  urine,  in  which  case  the  use 
of  the  catheter  is  attended  with  great  pain.  Tuberculosis  of  the  urethra 
is  rare.     It  may  present  the  symptoms  of  stricture. 

Tuberculosis  of  the  Testes.— The  diagnosis  is  usually  unattended  with 
difficulty  because  the  organ  is  accessible  and  the  changes  are  somewhat  char- 
acteristic. The  disease  occurs  in  infants  as  well  as  in  adults.  One  or  both 
testicles  may  be  involved.  It  may  be  primary,  but  in  most  cases  is  second- 
ary to  pulmonary  or  other  visceral  or  bone  tuberculosis.  It  is  frequently 
associated  with  tuberculous  peritonitis.  The  tuberculous  testicle  may  be 
recognized  by  the  enlargement  which  principally  affects  the  epididymis, 
pain,  tenderness,  and  only  a  moderately  uneven  surface. 

The  DIFFERENTIAL  DIAGNOSIS  between  tuberculous  and  syphilitic  dis- 
ease of  the  testicle  may  be  attended  with  uncertainty.  In  the  latter,  pain 
and  tenderness  may  be  absent,  the  testicle  itself  rather  small,  the  epididymis 
involved,  and  the  surface,  owing  to  the  agglomeration  and  various  size  of 
the  gummata,  is  more  nodular  and  uneven. 

Tuberculosis  of  the  Fallopian  Tubes  and  Ovaries. — The  tubes  are 
very  frequently  affected.  The  disease  is  often  primary.  There  is  enlarge- 
ment with  great  thickening  and  infiltration  of  the  walls,  upon  which,  in 
some  cases,  irregularities  of  the  surface  ma}^  be  felt.  It  may  occur  in  chil- 
dren and  young  girls,  and  is  usually  bilateral.  The  ovaries  are  secondarily 
involved.  Abscess  formation  and  the  extension  to  the  peritoneum  are 
common.     Implication  of  the  uterus  is  extremely  rare. 

Diagnosis. — Direct. — This  rests  upon  the  local  findings,  such  as  enlarge- 
ment and  irregular  thickening  of  the  tubes,  evidences  of  adhesions,  s  gns  of 
peritoneal  tuberculosis  or  pulmonary  phthisis,  anaemia,  loss  of  M^eight,  fever 
in  the  evening  upon  moderate  exertion  and  at  the  menstrual  period. 

Differential.  —  Gonorrhceal  salpingitis  may  be  present  without 
serious  derangement  of  the  general  health.  The  enlargement  of  the 
tubes  is  not  attended  with  the  same  degree  of  infiltration  or  irregularity 
of  the  surface,  the  anamnesis  is  suggestive,  and  the  presence  of  gonococci 
in  the  discharges  conclusive. 

Tuberculosis  of  the  Liver,  Spleen,  Myocardium,  Endocardium,  and 
Arteries  cannot  be  recognized  with  certainty  during  life.  These  forms  of  vis- 
ceral tuberculosis  are  therefore  rather  of  anatomical  than  of  clinical  interest. 

G.  Tuberculosis  of  the  Lungs. 

Pulmonary  Tuberculosis;  Phthisis;  Consumption. 

Varieties. — (a)  Acute  pneumonic  phthisis;  (b)  chronic  ulcerative 
phthisis,  and  (c)  fibroid  phthisis. 


TUBERCULOSIS.  803 

(a)    ACUTE  PNEUMONIC  PHTHISIS. 

According  to  the  distribution  of  the  lesions  two  types  are  recognized, 
the  pneumonic  and  the  bronchopneumonic. 

The  Pneumonic  Form.  —  A  single  lobe  or  an  entire  lung  may  be 
involved.  This  form  is  much  more  common  in  adults  than  children,  and 
in  males  than  females. 

Symptoms. — The  onset  is  usually  abrupt,  with  a  chill  followed  by 
high  fever,  pain  in  the  side,  cough,  and  expectoration,  at  first  scanty  and 
mucoid,  later  more  abundant,  often  frothy  and  blood-stained.  The  attack 
frequently  occurs  in  the  midst  of  apparent  health;  occasionally  during  the 
course  of  an  apparently  ordinary  mild  influenza  or  "cold,"  and  some- 
times in  an  individual  who  has  a  tuberculous  lesion  regarded  as  obsolescent. 
The  respiration  is  rapid  and  dyspnoea  may  be  urgent;  the  pulse  is  frequent 
and  variable.  The  physical  signs  are  those  of  croupous  pneumonia,  feeble 
vesicular  murmur,  with  crepitus,  later  dulness,  increased  vocal  fremitus, 
and  bronchial  breathing.  They  correspond  to  the  limits  of  a  lobe  or  to  a 
whole  lung,  and  when,  as  is  often  the  case,  they  are  also,  in  the  course  of 
some  days,  found  upon  the  opposite  side  the  clinical  picture  is  that  of  a 
double  pneumonia. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  course  of  the  attack 
and  the  finding  of  tubercle  bacilli  in  the  sputa.  The  latter  have  been 
observed  as  early  as  the  fourth  day.  As  a  rule  their  presence  is  not  noted 
until  later.  Fibres  of  elastic  tissue  constitute  the  signs  of  necrosis  of  the 
pulmonary  structure.  The  following  clinical  manifestations  are  suggestive 
and  should  arouse  a  suspicion  as  to  the  character  of  the  process:  hereditary 
predisposition  to  tuberculous  infection;  individual  history  of  tuberculous 
infection  which  may  have  remained  subacute  or  become  quiescent;  physical 
depression  preceding  the  outbreak,  especially  if  accompanied  by  cough 
and  expectoration;  an  irregular  temperature  range  conforming  rather  to 
the  remittent  than  the  continuous  type;  recurrent  chills;  circumscribed 
patches  of  high-pitched,  ringing,  coarse  crepitant  rales  persisting  for 
several  days  with  but  little  change;  a  mucopurulent  greenish  expectora- 
tion, and  extremely  feeble  breath  sounds  over  the  affected  region. 

The  DIFFERENTIAL  DIAGNOSIS  between  acute  pneumonic  tuberculosis 
and  croupous  pneumonia  cannot  be  made  in  a  large  proportion  of  the  cases 
during  the  first  week.  There  is,  in  truth,  usually  no  suspicion  that  the  case 
is  not  one  of  ordinary  pneumonia  until  even  a  longer  time  has  elapsed. 

Prognosis. — The  outlook  is  in  the  highest  degree  unfavorable.  Death 
has  occurred  as  early  as  the  sixth  day,  more  commonly  after  three  or  four 
weeks,  or  as  late  as  the  second  or  third  month.  In  a  limited  number  of 
cases  the  acute  symptoms  gradually  subside  and  the  case  becomes  one  of 
chronic  phthisis. 

The  Bronchopneumonic  Form. — The  lesions  are  those  of  an  acute  case- 
ous bronchopneumonia.  Groups  of  lobules  are  affected,  with  crepitant  tissue 
intervening,  but  extensive  areas  or  even  an  entire  lobe  may  be  involved. 

A  second  form  is  due  to  the  aspiration  of  blood  and  the  contents  of 
tuberculous  cavities  into  the  finer  bronchial  tubes  during  haemoptysis 
— tuberculous  aspiration  pneumonia.      This  condition  may  follow  early 


804  MEDICAL  DIAGNOSIS. 

haemoptysis,   which    has   not    been    preceded    by   marked    symptoms,   or 
occur  after  hgemoptysis  in  the  course  of  a  chronic  tuberculosis. 

In  a  third  form  the  caseous  bronchopneumonia  involves  lobules  at 
both  apices  and  in  other  parts  of  the  lungs,  causing  patches  of  consolida- 
tion varying  in  diameter  from  1  to  3  or  4  cm.  and  sometimes  scattered 
uniformly  throughout  both  lungs. 

Symptoms. — These  are  the  forms  which  constitute  a  majority  of  the 
cases  of  acute  pulmonary  tuberculosis — phthisis  Jiorida  or  galloping  con- 
sumption. They  are  common  in  adults  but  far  more  common  in  children. 
The  clinical  picture  varies  greatly.  In  adults  the  disease  may  develop  in 
persons  apparently  well  or  in  those  who  have  been  failing  in  weight  and 
strength.  The  onset  is  rapid  but  not  abrupt.  There  are  irregular  chills, 
fever  of  hectic  type,  sweating,  loss  of  appetite,  cough,  and  expectoration 
which  is  usually  slight.  Blood  spitting  is  sometimes  the  first  event  to 
attract  attention.  The  pulse  and  respiration  frequency  are  high,  and  loss  of 
weight  and  strength  is  rapid  and  progressive.  The  physical  signs  may  be 
at  first  obscure,  but  presently  diminished  expansion,  patchy  dulness, 
especially  at  an  apex,  vesiculobronchial  respiration,  and  moist  crepitant 
and  small  mucous  rales  occur.  The  disease  affects  one,  more  commonly 
both  lungs.  Tubercle  bacilli  and  fibres  of  elastic  tissue  are  present  in  the 
sputa,  often  at  an  early  date.  The  symptoms  become  more  intense,  and  in 
the  course  of  two  or  three  weeks  in  the  more  acute  cases  the  patient  falls 
into  the  so-called  typhoid  state,  with  stupor,  delirium,  dry  tongue,  and 
high  fever.  Meanwhile  the  physical  signs,  more  extensive  dulness,  bronchial 
breathing,  high-pitched  and  coarser  rales,  indicate  the  extension  and  prog- 
ress of  the  lesions.  In  some  cases,  however,  the  signs  are  obscured  by  the 
development  of  areas  of  collateral  emphysema.  Softening  may  occur  with 
cavity  formation  and  corresponding  changes  in  the  physical  signs.  In 
children  this  form  of  pulmonary  tuberculosis  may  arise  as  an  independent 
disease.  Much  more  commonly  it  follows  an  acute  infection,  especially 
measles  and  pertussis.  In  a  majority  of  the  cases  the  bronchopneumonia 
which  occurs  as  a  sequel  to  diseases  of  this  group  is  tuberculous. 

Diagnosis. — The  direct  diagnosis  of  acute  bronchopneumonic  phthisis 
rests  upon  the  association  of  the  foregoing  symptoms  and  physical  signs 
with  the  presence  of  elastic  fibi*es  and  tubercle  bacilli  in  the  sputa. 

The  DIFFERENTIAL  DIAGNOSIS  between  tuberculous  and  non-tuberculous 
bronchopneumonia  is,  in  the  early  stages  of  the  disease,  and  especially  in 
children,  often  impossible.  Later  the  presence  of  elastic-tissue  elements 
and  tubercle  bacilli  are  decisive.  Meanwhile  the  anamnesis  is  important. 
A  hereditary  predisposition,  association  with  individuals  who  are  tuber- 
culous, or  dwelling  in  an  infected  house,  or  enlarged  superficial  lymphatics, 
or  a  history  of  symptoms  or  signs  indicative  of  enlarged  bronchial  glands 
is  important.  The  signs  of  marked  apical  lesions  are  highly  suggestive 
of  tuberculous  disease,  but  diffuse  tuberculous  bronchopneumonia  may 
occur  without  marked  apex  consolidation. 

Prognosis. — The  outlook  is  in  the  highest  degree  unfavorable.  In  adults 
death  may  occur  in  the  course  of  three  or  four  weeks;  in  children  within  a 
few  days.  There  are  cases,  however,  in  which  the  disease  runs  a  somewhat 
more  protracted  course,  and  a  limited  number,  both  in  adults  and  children,  in 


TUBERCULOSIS.  805 

which  after  the  gravest  symptoms  the  condition  of  the  patient  undergoes 
some  improvement  and  the  case  gradually  passes  into  one  of  chronic  phthisis. 

(b)  CHRONIC  ULCERATIVE  PHTHISIS. 

This  is  the  common  form  of  chronic  pulmonary  tuberculosis. 

The  lesions  vary  greatly  in  kind,  distribution,  and  extent.  They 
comprise  nodular  and  miliary  tubercles,  tuberculous  bronchopneumonia, 
pneumonic  inflammation  of  the  vesicular  structure  surrounding  the  tuber- 
cles, frequently  presenting  the  appearance  of  ordinary  red  hepatization, 
sometimes  the  more  uniform  diffuse  tuberculous  infiltration,  cavities  of 
various  size,  together  with  collateral  emphysema  and  changes  in  the 
bronchi  and  bronchial  glands  and  in  the  pleura,  with  firm,  thick  adhesions 
or  effusion,  which  may  be  serofibrinous,  purulent,  or  hemorrhagic.  The 
tendency  is,  (a)  to  caseation,  softening,  ulceration,  necrosis,  and  cavity 
formation,  and  (b)  to  sclerosis.  The  latter  process  may  result  in  the  forma- 
tion of  a  limiting  membrane,  by  which  the  lesion  is  encapsulated,  or,  when 
extensive,  in  traction  deformities  of  the  chest,  and  bronchiectasis. 

The  fact  that  the  primary  lesion  or  lesions  in  pulmonar}'-  tuberculosis  of 
the  chronic  ulcerative  type  are  local  and  circumscribed  is  of  the  greatest  prac- 
tical importance  both  in  diagnosis  and  prognosis;  first,  because  it  underlies 
the  clinical  division  of  the  cases  into  incipient  and  advanced,  and  second; 
because  cases  referable  to  the  first  group  are  mostly  amenable  to  treatment. 

The  distribution  of  the  lesions  is  in  a  majority  of  the  cases  as  follows: 
The  earliest  lesions  are  situated,  not  at  the  extreme  apex  of  the  lung,  but  2 
to  4  cm.  below  it  and  nearer  the  posterior  and  lateral  surfaces  than  the 
anterior  surfaces.  Extension  from  this  point  is  downward  and  forward, 
the  upper  lobe  being  progressively  involved  in  regions  corresponding  to 
the  first,  second,  and  third  interspaces,  and  spreadmg  upon  both  sides  of 
the  midclavicular  line.  Less  commonly  the  primary  lesion  is  found  in  the 
upper  lobe  at  a  point  corresponding  to  the  first  and  second  interspaces 
below  the  outer  third  of  the  clavicle.  As  the  process  extends  downward, 
the  anterolateral  region  of  the  lobe  is  involved.  Invasion  of  the  middle 
lobe  of  the  right  lung  is  usually  by  extension  from  the  upper  lobe.  Second- 
ary implication  of  the  lower  lobe  begins  at  a  point  2  to  4  cm.  below  its 
apex  at  the  level  of  the  fifth  dorsal  spine,  and  extends  downward  and  out- 
ward in  a  line  roughly  corresponding  to  the  inner  border  of  the  scapula 
when  the  patient's  hand  is  placed  upon  the  opposite  shoulder  and  the  elbow 
raised  as  high  as  possible.  In  the  course  of  time  the  upper  lobe  of  the 
opposite  lung  usually  becomes  involved,  the  earliest  lesions  appearing  a 
short  distance  below  the  actual  apex  and  rapidly  becoming  diffused.  The 
right  upper  lobe  is  first  involved  somewhat  more  commonly  than  the  left. 
Primary  implication  of  the  base  is  rare. 

In  advanced  cases  miliary  tuberculosis,  visceral  tuberculosis  involving 
various  organs,  amyloid  disease,  and  fatty  liver  occur. 

The  extension  of  the  lesions  is,  (a)  peripherally  by  the  direct  invasion 
of  contiguous  tissue;  (b)  radially  by  means  of  the  lymph  current;  (c) 
by  conveyance  along  the  bronchial  system,  (i)  in  the  direction  of  adjacent 
or  distant  vesicular  structures — inhalation,  insufflation;   (ii)  in  the  direction 


806  MEDICAL  DIAGNOSIS. 

of  the  upper  air-passages — laryngeal  ulceration;  (d)  by  transference;  e.g., 
to  the  digestive  tract— secondary  pharyngeal,  hngual,  or  intestinal  tuber- 
culosis; by  dissemination,  as  in  the  case  of  the  rupture  of  a  gland  or  other 
encapsulated  focus  into  a  serous  cavity,  or  a  blood-vessel — acute  miliary 
tuberculosis. 

The  progress  of  the  lesions  is  variable.  On  the  one  hand,  infiltration, 
caseation,  softening,  ulceration,  necrosis,  proceeding  at  different  rates  in 
different  foci;  while,  on  the  other  hand,  sclerotic  changes  encapsulate  and 
limit  the  advance  of  the  disease  and  tend  to  circumscribe  the  process. 

Symptoms. — As  the  primary  infection  is  local,  there  is  usually  a  period 
of  latency.  The  patient  is  tuberculous  before  he  is  consumptive,  and,  in  the 
fortunate  cases,  he  may  be  tuberculous  without  ever  becoming  consumptive. 

The  MODE  OF  ONSET  is  determined  by  the  degree  of  activity  of  the 
tuberculous  process  and  the  nature  of  the  reaction  of  the  infected  individ- 
ual. It  may  be  characterized  by  latency,  with  indefinite  symptoms  not 
suggestive  of  pulmonary  disease,  or  masked  by  the  symptoms  of  grave 
disease  in  other  organs,  tuberculous  or  non-tuberculous. 

G astro-intestinal  Symptoms. — Loss  of  appetite,  gastric  irritability  and 
vomiting,  acid  eructations  frequently  precede  the  pulmonary  symptoms 
for  a  considerable  time.     The  cough  is  regarded  as  "a,  stomach  cough." 

Anaemia. — In  children  and  adolescents,  especially  young  girls,  there 
is  early  chloro-ansemia  with  pallor,  progressive  weakness,  palpitation  and 
headache  upon  exertion,  and  slight  afternoon  fever.  Menstrual  irregular- 
ities, especially  amenorrhoea,  are  suggestive. 

Ague-like  Fever. — Constitutional  symptoms,  recurring  chills,  fever,  and 
sweating  characterize  the  onset  in  a  considerable  group  of  cases.  When 
such  paroxysms  recur  with  regularity  and  with  only  shght  cough  and 
expectoration,  especially  in  a  malarious  region  or  in  an  individual  who 
has  previously  suffered  from  ague,  a  false  diagnosis  may  readily  be  made. 

Pleurisy. — The  early  phenomena  may  be  those  of  a  persistent  dry 
pleurisy,  the  signs  of  which  are  sometimes  restricted  to  the  apex,  sometimes 
more  extended.  In  other  cases  the  impairment  of  health  begins  with  pleural 
effusion.  The  resorption  or  aspiration  of  the  fluid  is  sooner  or  later  followed 
by  the  signs  of  consohdation  in  an  upper  lobe,  and  the  symptoms  of  phthisis. 
Many  of  these  cases  are,  in  fact,  pleurogenous,  with  secondary  pulmonary 
infection,  and  the  early  dry  cough  is  that  of  pleural  irritation.  In  some 
cases  the  lung  lesions  rapidly  develop;  in  others  an  interval  of  weeks, 
months,  or  even  years  may  occur. 

Hcemoptysis. — Blood  spitting  may  be  the  first  indication  of  the  disease. 
An  abundant  hemorrhage  is  sometimes  followed  by  the  rapid  develop- 
ment of  the  signs  of  a  diffuse  tuberculosis.  In  other  cases  haemoptysis 
recurs  from  time  to  time  before  the  positive  physical  signs  of  pulmonary 
disea  e  can  be  recognized.  It  is  probable  that  the  local  lesions  almost 
always  antedate  the  pulmonary  hemorrhage. 

Bronchitis. — The  great  majority  of  cases  begin  with  the  signs  of  a 
catarrhal  bronchitis.  The  patients  often  suffer  from  nasopharyngeal 
catarrh  and  manifest  an  especial  tendency  to  "catch  cold."  At  length 
the  cough  becomes  persistent,  there  is  habitual  expectoration,  especially 
in  the  morning,  and  upon  examination  the  rales,  which  are  heard  widely 


Tuberculosis.  807 

over  the  chest,  are  found  to  be  more  abundant  and  moist  and  of  higher 
pitch  over  the  upper  part  of  one  lung,  where  there  is  also  relative  dulness 
and  deficient  expansion. 

Chronic  Bronchitis  a7id  Emphysema.- — The  terminal  tuberculosis  so 
common  in  these  conditions  is  usually  masked  for  a  considerable  time  by 
the  symptoms  and  signs  of  the  primary  condition.  This  is  especially  the 
case  when  there  are  asthmatic  symptoms. 

Laryngitis. — The  symptoms  of  pulmonary  phthisis  are  frequently 
preceded  by  hoarseness,  occasional  aphonia,  and  a  laryngeal  cough.  It  is 
probable  that,  in  the  majority  of  these  cases,  tuberculous  lesions  already 
exist  in  the  lungs. 

Tuberculosis  of  the  cervical  and  axillary  .lymph-glands  may  precede  the 
development  of  pulmonary  tuberculosis  for  a  long  time,  or  coexist  with 
quiescent  lesions  in  the  lungs. 

Stages. — The  attempt  to  divide  the  course  of  the  attack  into  a  stage 
of  the  growth  and  development  of  tubercles,  a  stage  of  caseation  and 
softening,  and  a  stage  of  cavity  formation  has  fortunately  been  abandoned. 
In  the  first  place,  as  new  foci  of  disease  are  constantly  forming  in  advancing 
cases,  all  three  of  these  anatomical  conditions  are  frequently  present  at  the 
same  time;  secondly,  they  do  not  correspond  with  definite  clinical  periods, 
and,  finally,  a  patient  in  the  so-called  third  stage,  with  signs  of  cavit}'' 
formation,  is  often  in  a  more  favorable  condition,  with  better  prospect 
for  the  arrest  of  his  disease,  than  another  in  the  first  stage,  with  extensive 
and  rapidly  advancing  infiltration  or  diffuse  foci. 

The  following  schema  was  adopted  by  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis  in  1905: 

Slight  initial  lesion  in  the  form  of  infiltration  limited  to  the 
apex  or  a  small  part  of  one  lobe. 

No  tuberealous  complications.  Slight  or  no  constitutional 
S5"mptoms  (particularly  including  gastric  or  intestinal  dis- 
turbance or  rapid  loss  of  weight). 

Slight  or  no  elevation  of  temperature  or  acceleration  of 
pulse  at  any  time  during  the  twenty-four  hours,  especially 
after  rest. 

Expectoration  usually  .small  in  amount  or  absent. 

Tubercle  bacilli  may  be  present  or  absent. 

C  No  marked  impairment  of  function  either  local  or  constitu- 
tional. 
Moderately  advanced  J  Localized  con.solidation  moderate  in  extent  with  Httle  or 

I      no  evidence  of  destruction  of  tissue  ; 

I  Or  disseminated  fibroid  deposits. 
[  No  serious  complications. 

f  Marked  impairment  of  function,  local  and  constitutional. 

Far  advanced       J  Localized  consolidation  intense  ; 

I  Or  disseminated  areas  of  softening  ; 
[  Or  .serious  complications. 

Acute  miliary  tuberculo.sis 

Unimproved All  e.ssential  symptoms  and  signs  unabated  or  increased. 

f  Constitutional  symptoms  lessened  or  entirely  absent;  physi- 

Improved j      qh\  .signs  improved  or  unchanged  ;  cough  and  expectora- 

l     tion  with  bacilli  usually  present. 

IAb.sence  of  all  con.stitutional  symptoms  :  expectoration  and 
bacilli  may  or  may  not  ht  present ;  i)hysical  signs  .station- 
ary or  retrogressive ;  the  foregoing  conditions  to  have 
existed  for  at  least  two  months. 

f  All  constitutional  svmptoms  and  expectoration  with  bacilli 

Apparently  cured J      absent  for  a  period  of  three  months  ;  the  i)hysical  .signs  to 

t     be  those  of  a  healed  lesion. 

_  C  All  constitutional  symptoms  and  expectoration  with  bacilli 

'^'^^" —  i      absent  for  a  period  of  two  years  under  ordinary  conditions 

I     of  life. 


Incipient  (favorable) 


808  MEDICAL  DIAGNOSIS. 

Trudeau's  classification  is  as  follows: 

1.  Incipient. — Cases  in  which  both  the  physical  and  rational  signs  point  to  but  slight 
local  and  constitutional  involvement. 

2.  Advanced. — Cases  in  which  the  localized  disease  process  is  either  extensive  or  in  an 
advanced  stage,  or  where,  with  a  comparatively  slight  amount  of  pulmonary  involvement, 
the  rational  signs  point  to  grave  constitutional  impairment  or  to  some  complication. 

3.  Far  Advanced. — Cases  in  which  both  the  rational  and  physical  signs  warrant  the  term. 

4.  Apparently  Cured. — Cases  in  which  the  rational  signs  of  phthisis  and  the  bacilli  in 
the  expectoration  have  been  absent  for  at  least  three  months  or  who  have  no  expectora- 
tion at  all;  any  abnormal  physical  signs  remaining  being  interpreted  as  indicative  of  a 
healed  lesion. 

5.  Arrested. — Cases  in  which  cough,  expectoration,  and  bacilli  are  still  present,  but  in 
which  all  constitutional  disturbance  has  disappeared  for  several  months;  the  physical 
signs  being  interpreted  as  indicative  of  a  retrogressive  or  arrested  process, 

"Closed"  and  ''Open"  Pulmonary  Tuhercidosis.  —  Too  much  stress 
has  been  laid  upon  the  importance  of  tubercle  bacilli  in  the  sputa  in  the 
early  diagnosis.  These  organisms  do  not  appear  until  after  the  caseation 
and  softening  of  a  tuberculous  lesion  situated  near  a  bronchus  or  bron- 
chiolus,  into  which  tuberculous  material  finds  its  way  by  the  necrosis  of 
the  intervening  tissue.  The  period  prior  to  this  event,  which  may  extend 
over  weeks  or  months,  or,  in  extreme  cases,  over  years,  is  known  as  the 
"closed  period";  that  which  follows  as  the  "open  period."  The -general 
recognition  of  this  distinction  is  desirable. 

Symptoms  of  Incipient  Pulmonary  Tuberculosis. — The  greater  number 
of  these  have  already  been  described  under  the  heading  "mode  of  onset." 
The  association  of  haemic,  circulatory,  digestive,  and  nervous  derangements 
is  especially  important. 

The  ptdse  is  either  persistently  frequent  but  regular,  or  subject  to 
abnormal  acceleration  upon  physical  effort  or  mental  excitement.  The 
temperature  shows  slight  elevation  upon  exertion,  after  meals,  and  before 
and  during  menstruation.  The  observations  must  be  taken  every  two 
hours  during  the  day,  while  the  patient  is  in  repose.  Subfebrile  ranges — 
99.5°  F. — are  significant.  Chest  pains  are  common.  They  are  of  two 
kinds,  pleural  pain  over  the  seat  of  a  lesion,  and  a  dull  shoulder  pain  extend- 
ing down  the  arm  and  sometimes  mistaken  for  rheumatism.  The  cough  is 
frequently  short  and  dry,  a  troublesome  hacking  brought  on  by  exertion 
or  excitement  or  changes  of  external  temperature.  Very  often  it  occurs 
only  on  rising  in  the  morning  and  persists  in  paroxj^sms  until  a  small, 
tough  mucoid  mass  is  expectorated,  after  which  it  is  absent  for  the  rest  of 
the  day.  The  Sputum. — There  is  little  characteristic  in  the  expectorated 
material.  It  is  usually  at  this  stage  of  the  disease  merely  a  grayish  sago- 
like mucus,  containing  alveolar  cells  which  have  undergone  the  myelin 
degeneration.  In  the  closed  stage  tubercle  bacilli  are  absent,  though  one 
or  two  may,  in  rare  instances,  be  found  as  the  result  of  inhalation.  Repeated 
examinations  are  necessary.  Their  continuous  presence  in  the  sputum  is 
the  positive  sign  of  tuberculosis  in  the  open  stage.  The  examination  may 
yield  negative  results  for  long  periods  in  cases  of  quiescent  limited  upper 
lobe  lesions,  and  then,  after  an  attack  of  some  acute  affection,  as  influenza, 
or,  in  the  midst  of  apparent  health,  bacilli  may  appear  suddenly  and  last 
a  short  time — transient  open  tuberculosis.  Elastic  fibres  are  not  often 
encountered  in  the  incipient  stages. 


TUBERCULOSIS.  809 

Hcemoptysis. — This  accident  occurs  in  about  70  per  cent,  of  all  cases 
of  phthisis  at  some  period  in  the  course  of  the  disease.  The  haemoptysis 
which  occurs  in  the  incipient  stage  differs  from  that  in  the  advanced  stages 
in  being,  as  a  rule,  slight,  recurrent,  and  due  to  oozing  from  patches  of 
acute  congestion  surrounding  closed  tuberculous  foci,  or  to  superficial 
erosions  of  bronchial  mucosa.  In  advanced  phthisis  the  bleeding  is  due  to 
the  erosion  of  a  vessel  in  the  wall  of  a  cavity,  or  the  rupture  of  an  aneurism 
of  a  branch  of  the  pulmonary  artery.  It  is  usually  profuse  and  not  rarely 
fatal.  The  expectorated  blood  in  early  haemoptysis — closed  tuberculosis — 
does  not  usually  contain  tubercle  bacilli;  that  in  the  advanced  stages  is 
often  followed  by  expectoration  containing  those  organisms.  Large  initial 
blood  spittings  may,  in  rare  instances,  usher  in  the  open  stage  and  be 
associated  with  bacillary  sputum. 

General  Nutrition  and  Weight. — The  toxins  which  give  rise  to  anaemia, 
vasomotor  derangements,  pseudodyspepsia,  fever,  and  nervous  erethism 
interfere  with  nutritive  processes  and  cause  loss  of  weight  which  is  often 
rapid  and  striking. 

Associated  Diseases. — The  patients  are  especially  prone  to  catarrhal  and 
other  inflammatory  outbreaks.  Coryza,  laryngitis,  bronchitis,  pneumonia, 
and  pleurisy  are  common  and  may  recur  repeatedly  in  the  same  patient. 

Hoarseness,  due  to  subacute  laryngeal  catarrh  with  slight  abductor 
paresis,  may  be  an  early  symptom.  Actual  paralysis  of  the  recurrent  is 
less  common.  It  may  be  due  to  pleural  adhesions  or  to  pressure  upon  the 
recurrent  by  tuberculous  lymph-glands.  It  much  more  frequently  occurs 
upon  the  left  side.  Phenomena  of  inferior  importance  are  unequal  dilata- 
tion of  the  pupils,  a  reddish  or  bluish  gingival  hne,  slight  or  transient  enlarge- 
ment of  the  thyroid  gland,  and  albuminuria. 

The  Physical  Signs  in  Incipient  Pulmonary  Tuberculosis.  —  Inspection 
reveals  very  early  a  retarded  and  shghtly  diminished  respiratory  excursus 
in  the  infraclavicular  region  of  the  affected  side.  This  sign  may,  in  some 
cases,  be  earlier  detected  by  palpation.  The  vocal  fremitus  may  also  be 
slightly  increased.  Percussion  may  show  quite  early  relative  dulness,  often 
slight  but  recognizable  by  the  higher  pitch  and  shorter  duration  of  the 
sound,  and  a  slightly  tympanitic  quality.  Auscultation  yields  even  more 
suggestive  signs.  There  is  an  early  deviation  from  the  normal  type  of 
breathing.  The  first  change  consists  in  the  development  of  the  quality 
described  as  rough.  The  inspiratory  murmur  is  enfeebled.  Cog-wheel 
or  interrupted  breathing  is  occasionally  heard  in  the  region  imme- 
diately adjacent  to  and  below  the  portion  of  the  lung  involved.  This 
may,  however,  occur  in  other  conditions.  Moist  crepitant  and  small  mucous 
rales  are  early  signs,  but  in  many  cases  they  remain  long  absent.  Rales, 
not  heard  upon  full  inspiration,  even  full  inspiration  after  coughing,  may 
in  some  cases  be  ehcited  by  a  full  inspiration  followed  by  forced  expiration, 
with  cough  at  the  end  of  the  latter.  The  rough  breathing  is  presently 
replaced  by  vesiculobronchial  respiration  which,  as  the  lesion  progresses, 
becomes  bronchovesicular  and,  later,  as  consolidation  becomes  complete — 
advanced  stage — bronchial.  Pleural  friction  sounds  of  varjang  quality 
and  intensity  may  often  be  heard  over  the  affected  region.  They  are  some- 
times transient,  sometimes  persistent.    Basal  friction  sounds  are  also  occa- 


810  MEDICAL  DIAGNOSIS. 

sionally  heard  in  the  incipient  stage.  Less  frequent  but  very  suggestive 
when  present,  is  a  subclavian  systolic  murmur,  more  common,  as  a  rule, 
upon  inspiration,  though  occasionally  heard  with  expiration.  This  loud 
systolic  whiff,  due  to  traction  upon  the  vessel  wall  by  pleural  adhesions,  is 
a  very  striking  phenomenon.  Extension  of  the  absolute  cardiac  dulness 
to  the  right  or  left,  as  the  case  may  be,  constitutes  an  important  sign. 

The  Diagnosis  of  Incipient  Pulmonary  Tuberculosis.  —  Direct  Diagnosis. 
— In  the  absence  of  cough  and  expectoration  a  positive  diagnosis  can 
rarely  be  made.  When  these  phenomena  are  present,  and  especially  when 
tubercle  bacilli  are  found,  the  question  as  to  the  nature  of  the  process 
is  at  once  settled.  From  the  standpoint  of  therapeutics  the  recognition  of 
phthisis  in  the  closed  stage  is  of  such  importance  that,  in  a  suspected  case, 
a  provisional  diagnosis  constitutes  a  motive  for  immediate  and  systematic 
treatment.  This  provisional  diagnosis  rests  not  upon  any  single  rational 
symptom  or  physical  sign  of  the  stage  of  incipiency,  but  upon  the  associa- 
tion of  several  of  them  in  an  individual  in  whom  no  other  pathological 
process  by  which  to  explain  them  can  be  demonstrated.  The  anamnesis 
is  important.  Family  predisposition,  close  habitual  association  with  tuber- 
culous persons,  an  unfavorable  occupation,  an  unhygienic  life  may  appear 
as  etiological  factors,  but  their  absence  has  only  a  negative  value. 

The  bodily  conformation  may  be  misleading.  The  classical  habitus 
phthisicus — the  phthinoid  or  paralytic  chest — is  symptomatic  of  advanced, 
not  of  incipient  phthisis.  Recurrent  hoarseness,  bronchitis,  anaemia, 
dyspepsia,  loss  of  weight,  fever,  and  haemoptysis  are  symptoms  of  great 
moment.  Among  the  physical  signs,  diminished  and  retarded  respiratory 
excursus  of  that  part  of  the  chest  corresponding  to  the  limited  lesions, 
diminished  resonance  with  a  faint  tympanitic  quality,  rough  or  vesiculo- 
bronchial respiration,  and  a  few  moist,  clicking  rales  or  a  prolonged  whizzing 
rale  at  the  end  of  the  first  two  or  three  inspirations  are  highly  significant. 
It  is  to  be  remembered  that  in  slowly  advancing  lesions  the  signs  may  be 
obscured  by  collateral  emphysema.  Not  less  significant  is  the  localization 
of  those  signs  in  an  infraclavicular  or  axillary  region.  The  variation  of 
auscultatory  signs  must  be  remembered — the  fact  that  rales  are  sometimes 
heard  only  after  cough,  the  frequent  temporary  disappearance  of  crepitus 
after  several  deep  inspirations,  the  tendency  of  rales  to  disappear  late  in 
the  day  and  in  dry  weather,  and  the  intensification  of  auscultatory  phe- 
nomena during  menstruation.  Rosenberger  claims  that  tubercle  bacilli 
can  be  found  in  the  blood  even  when  absent  in  the  sputum.  In 
any  case  in  which  the  symptoms  and  signs  warrant  a  provisional  diagnosis, 
the  patient  milst  be  carefully  instructed  as  to  his  mode  of  life,  the  necessity 
of  keeping  himself  under  systematic  observation,  and  the  importance  of 
the  repetition  of  the  examination  at  stated  intervals. 

Differential  Diagnosis. — The  mode  of  onset  is  to  be  considered. 
The  patient  is  in  failing  health;  has  he  the  symptoms  and  signs  of  phthisis, 
latent  or  marked?  Are  his  symptoms  those  which  the  toxins  of  tubercu- 
losis cause?  Superficial  examination  and  hasty  observation  will  not  dis- 
cover the  answer  to  these  questions.  Above  all,  the  practitioner  must 
avoid  the  delusion  that  every  paroxysmal  fever  is  malarial  and  every  cough 
in  a  dyspeptic  a  "stomach  cough."     Pleurisy  is  highly  suspicious.     Prob- 


TUBERCULOSIS. 


811 


ably  two-thirds  of  the  cases  of  persistent  fibrinous  pleurisy  or  pleural 
effusion  ultimately  become  tuberculous.  Malaria  may  be  recognized  by  the 
blood  examination.  Hcevioptysis  is  common  in  mitral  disease,  especially 
stenosis,  and  many  cases  of  valvular  disease  of  the  heart  are  diagnosticated 
phthisis.  This  error  may  be  avoided  b}^  a  routine  physical  examination, 
which  must  in  every  case  include  the  heart.  Cervico-axillary  adenitis  may 
long  coexist  with  a  fair  degree  of  health.     It  is  well,  however,  to  watch  the 


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Fig.  277. — Subcutaneous  tuberculin  test.    Positive  reaction. 

infraclavicular  regions,  especially  upon  the  side  in  which  the  tuberculous 
glands  are  situated.  Laryngitis. — Persistent  hoarseness  with  swelling  of  the 
arytenoids  and  slight  adductor  paresis  is  frequently  the  phenomenon  of 
pulmonary  phthisis.  Recurrent  catarrhal  and  inflammatory  affections  in  the 
respiratory  tract  are  ominous,  especially  when  there  are  hereditary  or  per- 
sonal predisposing  factors  to  tuberculous  infection.  Infraclavicular  or  axil- 
lary localizations  are  highly  suggestive.  The  patient  should  be  forewarned 
and  placed  under  treatment.  Such  reassuring  phrases  as  "  local  bronchitis'^ 
and  "spot  on  the  lung"  are  worse  than  obsolete;  they  are  dishonest. 


812  MEDICAL  DIAGNOSIS. 

The  Tuberculin  Test. — If  a  case  remains  doubtful,  or  if,  for  personal 
reasons,  delay  must  be  avoided,  tuberculin  may  be  employed.  To  the 
objection  as  to  danger,  it  may  be  affirmed  that  in  the  hands  of  innumerable 
careful  observers  its  cautious  use  has  not  been  followed  by  untoward 
effects.  To  the  objection  as  to  results,  it  is  to  be  admitted  that  it  has  some- 
times failed  in  cases  of  demonstrated  tuberculosis,  and  that  some  degree 
of  reaction  has  occurred  in  non-tuberculous  cases.  No  one,  however,  has 
reported  an  intense  reaction  to  tuberculin  in  a  healthy  person  or  in  other 
diseases.  The  mode  of  procedure  is  as  follows:  The  patient  is  kept  in  bed 
and  the  temperature  taken  every  two  hours  from  8  a.m.  to  10  p.m.  for  two 
days.  At  the  end  of  this  period  and  in  the  early  morning,  at  first  .5,  then  2 
and  finally,  if  required,  5  mg.  of  Koch's  old  tuberculin  are  injected  at  inter- 
vals of  three  days.  In  children  the  dose  is  .10  to  .5  mg.,  according  to  the 
age.  The  temperatures  are  taken  at  intervals  of  two  hours  as  before. 
The  constitutional  reaction  shows  itself  in  fever  which  rises  rapidly — 102° 
to  104°  F.  (39°-40°  C.)— and  only  gradually  subsides.  So  long  as  it  con- 
tinues the  patient  must  be  kept  in  bed.  Local  reaction  is  frequently  mani- 
fest in  the  suspected  chest  area  in  the  form  of  fine  moist  rales.  As  this 
may  occur  in  the  absence  of  the  febrile  reaction,  auscultation  must  be 
performed  twice  daily.  Sputum  previously  absent  may  be  ejected  during 
or  after  the  reaction  and  may  contain  bacilli.  In  other  cases  intense 
general  and  local  reaction  may  occur  without  expectoration. 

The  Ophthalmotuberculin  Test. — The  method  proposed  by  Cal- 
mette  and  Wolff- Eisner  consists  in  the  instillation  of  a  drop  of  a  1  per  cent, 
tuberculin  solution  into  the  eye,  which  is  followed  by  a  conjunctival  hyjDer- 
^^^  ^^  semia  in  infected  individuals,  while 

in  non-tuberculous  individuals  no 
signs  of  irritation  follow. 

Fig.  278.— Eye-dropper  with  throttle  for  measured  In    Baldwin's    cHnical   StudieS    & 

filtered  sterile  normal  saline  solution 
of  two  strengths  and  a  measured  drop  (0.025  c.c.)  were  employed,  the  latter 
to  insure  accuracy  of  dosage.  A  throttled  eye-dropper  with  a  calibrated 
mark  to  0.025  c.c.  was  used,  the  throttle  permitting  the  control  of  the 
liquid  when  filled  to  the  mark.     The  technic  is  as  follows: 

"The  two  solutions  of  0.33  per  cent,  and  0.5  per  cent.,  respectively, 
were  employed  successively  in  each  eye.  When  the  first  failed  to  react  the 
stronger  was  instilled  into  the  other  eye  after  forty-eight  hours.  By  this 
method  severe  reactions  may  be  avoided  in  cases  of  suspected  tuberculosis, 
though  if  time  failed  the  stronger  solution  might  be  used  without  serious 
discomfort  being  anticipated  should  a  marked  reaction  follow.  In  order 
to  avoid  any  danger  of  contamination  the  solutions  were  sealed  in  glass 
tubes  containing  three  or  four  drops  and  then  boiled.  These  can  easily 
be  broken  in  a  piece  of  gauze  or  cotton  at  a  file  mark.  The  eye-dropper  is 
then  inserted,  after  being  cleansed  with  alcohol  and  sterile  saline  solution. 
Care  is  used  to  prevent  the  introduction  of  spicules  of  glass.  The  solution 
should  be  warmed  in  cold  weather. 

"  The  lid  of  one  eye  is  pulled  down  and  the  measured  drop  instilled  as  with 
any  other  fluid  by  holding  the  eye-dropper  parallel  to  the  eye,  but  care  should 
be  observed  that  it  does  not  overflow  on  the  cheek;  this  is  easily  accom- 
plished by  holding  the  hd  down  until  the  drop  is  distributed  about  the  sac." 


TUBERCULOSIS. 


813 


Baldwin's  Scheme  for  Recording  Reactions. 

Negative. — No  difference  in  color  when  lower  eyelids  are  pulled  down 
and  compared. 

Doubtful.      Slight  difference  with  redness  of  caruncle. 
Positive.       +  =  Distinct  palpebral  redness  with  secretion. 

"  +  +  =  Ocular    and    palpebral    redness    with    secretion  well 

marked. 
•'*       +  4-  +  =Deep  injection  of  entire  conjunctiva  with  oedema  of 
lids,  photophobia,  and  secretion. 

TABLE  SHOWING  RESULT  IN  137  CASES— Baldwin. 


I.  Pulmonary    tuberculosis. 
No.  cases,  45. 

II.  Pulmonary  or  other  tuber- 
culosis ;  healed  from  1  to 
17  years.    No.  cases,  9. 


III.  Pulmonary  or  other  tuber- 
culosis suspected.  No. 
cases,  26. 


IV.  Apparently   healthy    per- 
sons.   No.  cases,  57. 


Reacted .  . 
Doubtful  . 
Negative  .  . 

Reacted.  . 
Doubtful  . 


.42 
.  1 
.    2     (1  miliary  and  1  tuberculin-treated). 


1     (17  years). 


(a)  From  history  (14  cases) J   Doubtful  '.  '. 

I  Negative  . . 

(b)  From  symptoms  (8  cases) /  Reacted .  .  . 

I.  Negative  .  , 


(c)  From  physical  signs  (4  cases) . 


f  Reacted  .  .  , 
1  Negative  .  . 


(d)   With  family  history  of   tubercu-  |  g^tibtiJi  ". ! 
losis  (18  cases).  I  Negative  .  , 


(e)  Constantly  associated  with  tuber- 

culous doctors,  nurses,  husbands 
and  wives  of  invalids  (18  cases). 

(f)  With    no    family   history  or   ex-  f 

posure  (21  cases).  { 


Reacted ....    6 
Negative  ...  12 


Reacted . 
Negative 


.    2 
.19 


Contraindications. — These  include  diseases  of  the  conjunctiva,  eyelids, 
and  cornea,  and  of  the  internal  structures  of  the  eye.  Undue  exposure  to 
dust,  smoke,,  or  strong  light  should  be 
avoided  during  the  test.  The  test  is 
superfluous  when  the  diagnosis  can 
be  made  b}-  physical  or  microscopic 
examination.  The  repetition  of  the 
test  is  not  unattended  with  danger 
due  to   sensitization. 

Cutaneous  Tuberculin  Reac- 
tion.— Von  Pirquet,  M^ho  suggested 
this  test,  employed  at  first  a  25  per 
cent,  solution  of  old  tuberculin,  but 
subsequentl}^  used  the  undiluted  old 
tuberculin.  The  inoculation  is  per- 
formed on  the  forearm  with  a  chisel- 
.shaped  in.strument,  the  skin  having 
been  previously  thoroughly  cleansed 
with  ether.  Any  suitable  instrument 
may,  however,  be  employed,  and  any  convenient  part  of  the  body  selected. 

Positive  Reaction. — If  a  papule  of  at  least  5  millimetres  in  diameter 
develops  at  the  point  of  vaccination  in  twenty-four  hours,  the  patient  may 


Fig.  279. — V  Pirquet's  method. 


814  MEDICAL  DIAGNOSIS. 

be  regarded  a&  infected  with  tuberculosis.  As  a  general  rule  the  more 
active  the  tuberculous  process  the  more  intense  and  extensive  the  cutaneous 
reaction.  Very  intense  reactions  occur  in  glandular  tuberculosis  and  in 
these  cases  inflammatory  changes  in  the  skin  beyond  the  borders  of  the 
papule  often  occur — scrofulous  reaction.  The  signs  of  reaction  occur  in 
periods  varying  from  two  or  three  hours  to  several  days  and  are  later  in 
proportion  to  the  degree  of  dilution  of  the  tuberculin.  No  direct  information 
as  to  the  period  at  which  the  infection  has  taken  place,  namely,  as  to  whether 
it  is  old  or  recent,  its  situation  in  the  body  or  the  extent  of  the  lesions,  is 
afforded  by  the  cutaneous  test. 

Negative  Reaction. — Failure  may  be  due  to  absence  of  tuberculous 
infection  or  to  various  causes,  among  which  von  Pirquet  especially  enumer- 
ates the  following:     (1)  relative  insusceptibility,  which  is  rare  in   early 


Fig.  280. — Petruschky's  method:    a,  lower  vaccination  1:10  negative,  upper  two  1:0  positive;   b,  lower 

vaccination  1:10  and  upper  two  1:0  negative. 

childhood  but  not  infrequent  in  older  persons  having  circumscribed  lesions 
which  are  encapsulated;  (2)  failure  of  the  capacity  for  reaction  in  the  last 
stages  of  tuberculosis;  (3)  loss  of  the  capacity  to  react  in  immunity  pro- 
duced by  tuberculization,  either  by  progressively  increasing  doses  or  by  a 
recent  single  dose  of  larger  amount;  (4)  temporary  disappearance  of 
the  capacity  of  reaction  during  an  attack  of  measles. 

In  a  considerable  proportion  of  cases  the  failure  of  the  test  is,  therefore, 
due  to  relative  insusceptibility,  and  it  has  been  shown  that  well-marked  "  sec- 
ondary positive  reaction"  may  be  obtained  upon  the  repetition  of  the  test  in 
these  cases.  A  primary  reaction  is,  however,  the  sign  of  an  active  tuberculous 
process.  Petruschky  makes,  on  the  upper  arm  with  the  point  of  a  cannula, 
cross-lined  vaccinations  with  old  tuberculin  in  dilutions  of  1  to  10,  1  to  5,  or 
1  to  0.  He  finds  no  reaction  in  fully  cured  cases,  and  that  the  test  is  without 
danger  and  does  not  give  rise  to  any  important  symptoms  in  any  case. 
Petruschky  regards  this  procedure  as  an  important  means  of  early  diagnosis. 


TUBERCULOSIS.  815 

Tuberculin  Inunction — Moro's  Test. — This  diagnostic  procedure, 
described  as  "  a  diagnostic  measure  without  rupture  of  continuity  of  the 
skin,"  consists  in  the  inunction  into  the  skin  of  the  chest  or  abdomen, 
over  an  area  of  4  square  inches,  of  a  mass  about  the  size  of  a  pea  of  an 
ointment  composed  of  5  c.c.  of  Koch's  old  tuberculin  rubbed  up  with  5 
grammes  of  anhydrous  wool  fat.  Absorption  takes  place  slowly,  and  on 
the  following  day,  or,  more  commonly,  not  until  the  second  day,  in  cases 
of  previous  or  present  tuberculous  infection,  a  positive  reaction  shows  itself 
in  the  appearance  of  small  papules  in  the  area  of  inunction  or  its  immediate 
vicinity.  These  lesions  vary  in  number  and  color  from  a  few  pale  papules 
to  a  numerous,  thick-set  crop  that  are  very  red.  The  skin  may  be  reddened 
and  the  seat  of  some  itching.  These  cutaneous  lesions  wholly  disappear  in  the 
course  of  a  week.  They  are  not  attended  by  other  local  or  constitutional  phe- 
nomena.    The  test  is  negative  when  the  skin  shows  no  changes  of  any  kind. 

The  Opsonic  Method. — A.  E.  Wright  and  S.  T.  Reid,^  in  a  communi- 
cation "  On  the  Possibility  of  Determining  the  Presence  or  Absence  of 
Tuberculous  Infection  by  the  Examination  of  a  Patient's  Blood  and  Tissue 
Fluids,"  have  arrived  at  the  following  conclusions: 

"  (1)  Conclusions  which  can  be  arrived  at  when  we  have  at  disposal 
the  results  of  a  series  of  measurements:  (a)  Where  a  series  of  measure- 
ments of  the  opsonic  power  of  the  blood  reveals  a  persistently  low  opsonic 
power  with  respect  to  the  tubercle  bacillus,  it  may  be  inferred,  in  the  case 
where  there  is  evidence  of  a  localized  bacterial  infection  which  suggests 
tuberculosis,  that  the  infection  in  question  is  tubercular  in  character, 
(b)  Where  repeated  examination  reveals  a  persistently  normal  opsonic 
power  with  respect  to  the  tubercle  bacillus,  the  diagnosis  of  tubercle  may, 
with  probability,  be  excluded." 

''  (2)  Conclusions  which  may  be  arrived  at  where  we  have  at  disposal 
the  result  of  an  isolated  blood  examination:  (a)  Where  an  isolated  blood 
examination  reveals  that  the  tuberculo-opsonic  power  of  the  blood  is  low, 
we  may — according  as  we  have  evidence  of  a  localized  bacterial  infection 
or  of  constitutional  disturbance — infer  with  probability  that  we  are  deal- 
ing with  tuberculosis — in  the  former  case  with  a  localized  tubercular 
infection,  in  the  latter  with  an  active  systemic  infection,  (b)  Where  an 
isolated  blood  examination  reveals  that  the  tuberculo-opsonic  power  of 
the  blood  is  high,  we  may  infer  that  we  have  to  deal  with  a  systemic  tuber- 
culous infection  which  is  active,  or  has  recently  been  active,  (c)  Where 
the  tuberculo-opsonic  power  is  found  normal,  or  nearly  normal,  while  there 
are  symptoms  which  suggest  tuberculosis,  we  are  not  warranted,  apart 
from  the  further  test  described  below,  in  an-iving  at  a  positive  or  a 
negative  diagnosis." 

The  further  criterion  to  which  reference  was  made  in  the  preceding 
paragraph  is  the  following:  When  a  serum,  after  it  has  been  heated  to  60°  C. 
for  ten  minutes,  is  found  to  retain,  in  any  considerable  measure,  its  power  of 
inciting  phagocytosis,  we  may  conclude  that  "incitor  elements"  have  been 
elaborated  in  the  organism,  either  in  response  to  autoinoculations  occurring 
spontaneously  in  the  course  of  tubercular  infection,  or,  as  the  case  may  be, 
under  the  artificial  stimulus  supplied  by  the  inoculation  of  tubercle  vaccine. 

1  Proceedings  of  the  Royal  Society,  B  Vol.  LXXVII,  1906. 


816  MEDICAL  DIAGNOSIS.. 

Iodine  Test. — The  iodine  salts,  and  especially  potassium  iodide  in 
moderate  doses,  may  produce  the  physical  signs  of  a  local  catarrh  over  a 
suspected  area  (Striker).  The  signs  of  consolidation  may  also  become 
more  definite.  In  the  expectoration,  which  almost  always  follows,  tubercle 
bacilli  are  frequently  found. 

X-RAY  Examination. — The  results  obtained  are  less  definite  than 
in  the  advanced  stages  of  the  disease.  The  complicated  apparatus  and 
great  technical  skill  required  also  stand  in  the  way  of  the  general  employ- 
ment of  this  method  in  the  diagnosis  of  pulmonary  tuberculosis  in  the 
incipient  stage. 

The  pulmonary  tuberculosis  which  so  often  occurs  as  a  terminal  condi- 
tion in  pneumonoconiosis,  chronic  bronchitis,  and  emphysema  is  not  usually 
recognizable  in  the  incipient  stage — masked  tuberculosis.  The  symptoms 
of  the  primarj^  disease  are  not  so  much  altered  as  intensified.  As  the  process 
advances  tubercle  bacilli  previously  absent  may  be  found  in  the  sputa. 

Symptoms  of  Moderately  and  Far  Advanced  Pulmonary  Tuberculosis. — 
There  is  no  definite  border-line  between  the  stages.  The  difficulties  in 
diagnosis  disappear.  The  symptoms  and  signs  become  definite  and  char- 
acteristic.    Any  tyro  can  interpret  the  clinical  picture. 

1.  Pulmonary  Symptoms. — Cough  may  be  slight  but  is  usually  promi- 
nent and  annoying.  After  cavity  formation  it  is  commonly  paroxysmal; 
with  laryngeal  involvement,  husky  and  brassy.  Sputum. — The  expectora- 
tion is  variable.  There  may  be  little  or  none,  even  when  cough,  fever,  and 
rapid  wasting  are  associated  with  the  physical  signs  of  extensive  consolida- 
tion. The  mucoid  expectoration  of  the  early  period  presently  shows  scat- 
tered grayish  or  grayish-green  purulent  masses  in  which  tubercle  bacilli 
and  elastic  fibres  may  be  found.  With  softening  the  expectoration  becomes 
more  profuse  and  distinctly  purulent.  Nummular  sputa  are  often  present 
after  cavities  have  formed.  The  sputa  sometimes  contain  calcareous 
masses  varying  in  diameter  from  1  mm.  to  1  or  2  cm.,  often  of  irregular 
shape.  They  are  the  result  of  the  deposition  of  lime  salts  in  circumscribed 
caseous  masses.  They  find  their  way  into  a  bronchus  by  the  ulceration 
and  necrosis  of  the  intervening  tissue.  Hcemoptysis. — The  amount  varies 
from  a  trace  to  500-750  c.c.  In  a  majority  of  the  attacks  it  does  not 
exceed  15  c.c.  It  is  in  many  cases  repeated,  and  a  hemorrhagic  form  of 
phthisis  has  been  described.  Hemorrhage  into  a  lai'ge  cavity  may  prove 
fatal  without  any  blood  being  expectorated.  Bacilli  and  elastic  fibres  may 
sometimes  be  discovered  in  the  clots.  After  a  day  or  two  small  black  clots 
and  blood-casts  of  the  smaller  bronchi  are  often  coughed  up  and  an  access 
of  fever  may  occur.  Dyspncea. — The  respiration  is  not  usually  increased 
except  upon  exertion. 

2.  Constitutional  Symptoms. — Fever  is  an  important  initial  symp- 
tom. It  may  be  remittent  in  tj^pe,  or  intermittent  and  paroxysmal,  with 
ague-like  perlodicit5^  The  temperature  is  an  important  indication  of  the 
progress  of  the  disease.  The  periods  of  quiescence  are  afebrile  and  marked 
by  gain  in  weight,  while  those  of  activity  are  accompanied  by  fever  and 
loss  of  flesh.  There  are,  however,  rare  cases  in  which,  with  advancing 
lesions,  pyrexia  is  absent.  The  fever  of  the  incipient  stage  is  sometimes 
continuous,  with  slight  daily  remissions  and  exacerbations;    that  of  the 


TUBERCULOSIS.  817 

moderately  advanced  stage  corresponds  to  the  activity  of  the  process, 
and  when  present  is  of  remittent  or  intermittent  type,  tending  to  subside 
altogether  when  the  patient  is  kept  at  rest;  while  that  of  the  far  advanced 
period  of  the  disease,  with  ulceration,  necrosis,  and  the  formation  of  cavi- 
ties, is  septic  in  character, — so-called  hectic, — the  range  of  temperature 
being  subnormal— 95°-96°  F.  (35°-35.5°  C.)— in  the  morning  between  10 
A.M.  and  noon,  and  steadily  rising  to  a  maximum  of  104°-105°  F.  (40°- 
40.5°  C.)  between  6  and  11  p.m.  Colliquative  sweating  frequently  attends 
the  morning  fall  of  temperature.  The  measurements  should  be  made  at 
two-hourly  periods  in  order  to  ascertain  the  actual  minima  and  maxima. 
Inverse  temperatures  are  sometimes  observed.  Sweating.— Froiuse  sweats 
may  occur,  not  only  toward  morning,  but  at  any  time  at  which  the  patient 
sleeps.  They  may  occur  early  but  are  much  more  common  in  the  far  ad- 
vanced cases.  Circulation. — The  pulse-frequency  is  increased  and  variable. 
It  usually  rises  with  the  fever.  The  pulse  is  often  large,  soft,  and  compres- 
sible. As  the  sign  of  vasomotor  paresis,  capillary  and  venous  pulsation  may 
sometimes  be  seen.  Loss  of  weight  is  a  marked  symptom.  It  is  often  rapid 
and  extreme — consumption;  phthisis.  During  periods  of  quiescence  it  is 
often  arrested,  and  in  favorable  cases  weight  is  regained.  In  rare  cases 
increase  of  weight  occurs  in  the  absence  of  other  signs  of  improvement. 
Anorexia,  vomiting,  intractable  diarrhoea,  osdema  of  the  legs  and  feet  with  or 
without  albuminuria,  are  common  in  the  stadium  ultimum.  Peripheral 
neuritis,  showing  itself  in  extensor  palsy  of  the  wrists,  more  commonly  the 
feet,  sometimes  occurs.  The  mental  condition  in  the  terminal  dyscrasia 
is  often  remarkable— spes  phthisica.  The  patients  up  to  the  very  last  busy 
themselves  with  plans  for  the  future,  new  methods  of  treatment,  different 
climates,  business  schemes,  and  the  confident  expectation  of  recovery. 

Physical  Signs  in  Advanced  Pulmonary  Tuberculosis. — Inspection. — The 
thorax  undergoes  deformities  corresponding  to  the  progressive  diminu- 
tion in  the  volume  of  the  lungs.  It  tends  to  assume  permanently  the 
expiratory  form. 

Palpation.- — Diminished  expansion  at  the  apex  may  be  determined 
in  the  following  manner:  The  examiner  stands  behind  the  patient,  who  is 
seated,  and  gently  grasps  the  shoulders  with  his  hands,  the  tips  of  the 
fingers  being  in  the  infraclavicular  spaces,  the  thumbs  resting  upon  the 
upper  part  of  the  scapula?.  The  patient  then  slowly  draws  a  deep  breath; 
to  study  the  expansion  at  the  bases  the  hands  grasp  the  two  sides  of  the 
chest  in  a  similar  manner  in  the  lower  axillary  regions.  Lagging  and 
limitation  of  the  excursus  are  signs  of  great  significance.  The  vocal  fremitus 
is  increased  over  areas  of  consolidation;  over  vomicae  it  may  be  increased 
or  diminished.    It  is  usually  enfeebled  over  thickened  pleurae. 

Percussion. — In  doubtful  cases  percussion  should  be  performed  dur- 
ing quiet  breathing  and  upon  full-held  inspiration,  as  minor  differences  in 
the  sounds  upon  the  two  sides  then  become  more  marked.  Slight  relative 
dulness  may  be  recognized  by  the  elevation  of  pitch  which  accompanies  it. 
Light  percussion  above,  beneath,  and  over  the  clavicle  should  be  practised. 
The  supraspinous  fossae  and  the  points  corresponding  to  the  apices  of  the 
lower  lobes  are  important  regions.  Dulness  over  consolidation  and  tym- 
pany over  vomicae  is  the  rule;    but  scattered  small  tuberculous  foci  with 

62 


818  MEDICAL  DIAGNOSIS. 

intervening  air-containing  vesicular  structure,  especially  when  there  is 
collateral  emphysema,  yields  resonance  with  a  tympanitic  quality,  and  a 
cavity  filled  with  fluid  will  often  yield  a  dull  or,  upon  very  nice  percussion, 
a  flat  percussion  sign.  Over  large  cavities,  situated  near  the  periphery 
of  the  lung,  the  cracked-pot  sound  may  be  obtained. 

Auscultation. — In  the  incipient  stage  the  vesicular  murmur  is  usually 
enfeebled,  sometimes  scarcely  audible.  Rough  breathing  is  an  early  sign. 
Cog-wheel  inspiration  is  often  present,  but  it  occurs  in  other  conditions. 
With  advancing  lesions  vesiculobronchial,  bronchovesicular,  and  bronchial 
respiration  succeed  each  other,  to  be  finally  replaced,  as  softening  occurs 
and  vomicae  form,  by  cavernous  or  amphoric  breathing.  Rales  of  all 
kinds,  from  the  crepitus  of  the  beginning  lesion  to  the  gurgling  of  cavities, 
attend  the  process.  Rales  are  due  largely  to  the  accompanying  bronchitis, 
and  vary  in  kind  and  number  according  to-  the  character  of  the  secretion 
and  the  activity  of  the  process  in  different  parts  of  the  lung.  Puerile  respi- 
ration may  be  heard  over  the  adjacent  unaffected  lobes  or  over  the  opposite 
lung.  The  vocal  resonance  is  increased  and  bronchophony  and  pectoriloquy 
may  be  elicited  over  areas  of  dense  consolidation  and  cavities.  Whispering 
pectoriloquy  is  an  important  sign  of  large  superficial  cavities.  Pleural 
friction  sounds  are  an  important  early  sign  and  occur  from  time  to  time 
during  the  progress  of  the  case.  At  first  usually  near  the  apex,  they  occur 
over  advancing  lesions  in  all  points  of  the  chest.  Pleural  friction  at  the  left 
anterior  border  of  the  lung,  and  especially  over  the  lingula,  frequently  has 
the  cardiac  rhythm — pleuropericardial  friction.  The  signs  of  cavities  are 
very  variable.  Situated  superficially,  a  cavity  may  cause  a  distinct  shal- 
low depression  in  one  or  two  intercostal  spaces.  A  rapidly  formed  cavity, 
or  several  small  cavities  without  much  surrounding  condensation  or  pleural 
thickening,  may  yield  a  full,  clear  resonance  in  which  the  only  modification 
is  a  slightly  tympanitic  quality — vesiculotympanitic  resonance.  Tym- 
panitic and  amphoric  resonance  are  usual.  The  pitch  may  be  modified  by 
opening  and  closing  the  mouth — Wintrich's  sign — or  upon  change  of 
posture — Gerhardt's  sign.  The  cracked-pot  sound  can  be  brought  out  only 
over  fairly  large  cavities  with  thin  walls  and  superficially  situated,  and 
disappears  for  a  time  after  it  has  once  or  twice  been  heard.  Cavernous 
respiration  is  usually  soft  and  low  pitched.  It  may,  however,  be  tubular 
or  amphoric.  Gurgling  rales  are  common  over  large  cavities  and  sometimes 
have  a  ringing  or  metallic  quality,  especially  during  coughing.  Increased 
vocal  resonance  and  whispering  pectoriloquy  are  valuable  signs.  Over 
large  cavities  in  the  upper  lobes  the  heart  sounds  and  sometimes  a  trans- 
mitted systolic  murmur  are  occasionally  heard,  and  in  rare  cases  sharp, 
splashing  rales  having  the  cardiac  rhythm.  Over  a  layer  of  dense,  con- 
solidated lung  extending  to  a  large  bronchus  there  may  be  signs — circum- 
scribed tympanitic  percussion  note,  amphoric  respiration,  and  coarse  moist 
rales — which  closely  simulate  those  of  a  cavity.  Light  percussion,  the 
pitch  of  the  sound  not  being  raised  by  opening  the  mouth  or  change  of 
posture,  and  the  absence  of  the  cracked-pot  sound  may  be  of  use  in  the 
recognition  of  the  actual  condition. 

Diagnosis  of  Advanced  Pulmonary  Tuberculosis. — The  direct  diagnosis 
rests    upon   the   physical   signs    and    the   presence   of   tubercle  bacilli  in 


TUBERCULOSIS.  819 

the  sputa.  The  symptoms  are  variable  and  acquire  diagnostic  value  only 
in  proportion  as  they  correspond  with  the  signs  of  the  lesions  and  their 
distribution  and  evolution. 

The  spirometer  has  deservedly  fallen  into  disuse  in  the  diagnosis  of 
incipient  tuberculosis  of  the  lungs,  and  its  use  is  attended  with  danger 
in  the  advanced  cases.  The  expectations  raised  by  the  publications  of 
Arloing  and  Courmont  in  regard  to  the  use  of  tuberculous  serum — agglu- 
tination— in  the  diagnosis  of  tuberculous  disease  have  not  been  realized. 

Prognosis  in  Chronic  Ulcerative  Phthisis. — When  proper  treatment  is 
instituted  in  the  stage  of  incipiency  and  rigorously  carried  out,  the  pros- 
pect of  a  cure  is  good.  The  frequency  with  which  limited  obsolescent, 
even  healed  tuberculous  lesions  are  found  post  mortem  in  the  lungs  of 
individuals  dead  of  other  diseases  or  by  accident,  bears  ample  testimony 
to  the  intrinsic  tendency  to  recovery.  It  has  been  said  that  more  people 
recover  from  pulmonary  tuberculosis  without  being  aware  that  they  have 
had  it  than  die  of  it. 

The  prognosis  in  the  advanced  cases  is  unfavorable  and  in  the  far 
advanced  cases  hopeless.  In  individual  cases,  the  early  recognition  of  the 
disease,  a  good  family  history,  limited  local  lesions,  slight  constitutional 
reaction,  and  the  disposition  and  means  to  make  a  business  of  getting  well 
are  favorable  conditions  in  the  prognosis.  The  pleurogenous  cases  often 
run  a  slow  and  relatively  favorable  course.  The  cases  characterized  by 
recurrent  blood  spitting  are  unfavorable.  Only  in  the  worst  cases  is  the 
course  of  the  disease  relentlessly  progressive.  As  a  rule  there  are  periods 
varying  from  weeks  to  months  in  which  the  lesions  remain  quiescent,  the 
symptoms  subside,  the  general  health  improves,  and  there  is  a  gain  in  weight. 
The  duration  varies  from  some  months  to  several  years,  the  average  being 
about  two  and  a  half  years.  A  remarkable  decrease  in  the  death-rate 
from  consumption  has  taken  place  in  recent  years.  This  is  to  be  ascribed 
to  the  discovery  of  the  tubercle  bacillus,  the  recognition  of  the  fact 
that  tuberculosis  is  an  acquired  rather  than  an  inherited  disease,  and  the 
dissemination  among  the  people  of  the  knowledge  by  which  its  spread  can 
be  restricted. 

(c)   FIBROID  PHTHISIS. 

This  term  is  used  to  designate  a  very  chronic  tuberculous  process  in 
the  lungs,  with  relatively  slight  ulceration  and  much  development  of 
fibrous  tissue.  It  may  begin  as  a  tuberculous  bronchopneumonia  or  fol- 
low an  ordinary  ulcerative  phthisis.  In  a  large  proportion  of  the  cases  it 
begins  as  a  chronic  tuberculous  pleurisy.  The  anatomical  and  clinical 
condition  is  practically  that  of  pulmonary  cirrhosis.  One  or  both  lungs 
may  be  affected;  if  both,  one  to  a  much  greater  extent  than  the  other. 
There  are  vomicae  at  the  apex,  surrounded  by  dense  fibroid  tissue,  and  bron- 
chiectatic  cavities  elsewhere.  The  pleura  is  greatly  thickened,  and  encap- 
sulated cheesy  masses,  with  patches  of  recent  tubercle,  and  enlarged 
bronchial  glands  are  present.  Am5^1oid  disease  of  the  liver,  spleen,  and 
intestines  develops  in  the  advanced  cases. 

Symptoms. — Cough,  often  paroxysmal  and  more  common  in  the  morn- 
ing, purulent  expectoration,  sometimes  fetid,  and  dyspnoea  upon  exertion 


820  MEDICAL  DIAGNOSIS. 

constitute  the  symptom-complex.  Blood  spitting  occurs.  The  patients 
are  thin,  but  frequently  have  fair  health.    Fever  is  not  a  common  symptom. 

Physical  Signs. — The  chest  is  flat,  the  shoulders  lower,  and  the  clav- 
icles prominent.  The  vocal  fremitus  is  diminished.  Resonance  is  greatly 
impaired  and  has  the  tympanitic  quality.  At  the  apex  cavernous,  at  the 
base  bronchial,  respirations  are  heard.  Rales  are  not  common,  but  coarse 
moist  and  gurgling  rales  may  be  present  when  fluid  collects  in  the  cavities 
or  dilated  bronchi.  The  superficial  area  of  cardiac  dulness  is  increased, 
the  impulse  may  be  seen  and  felt  in  two  or  more  interspaces,  and  the  heart 
is  displaced  toward  the  affected  side. 

Diagnosis. — Direct. — This  rests  upon  the  symptoms  and  physical 
signs  as  detailed  above. 

Differential. — The  distinction  between  tuberculous  and  non-tubercu- 
lous pulmonary  cirrhosis  cannot  in  all  cases  be  made  intra  vitam.  The 
presence  of  tubercle  bacilli  in  the  sputum  is  positive.  When  not  found  during 
life  they  are  often  present  in  the  lesions  after  death.  Atrophic  emphy- 
sema presents  some  points  of  resemblance  to  fibroid  phthisis,  but  differs 
from  it  in  being  a  symmetrical  affection  and  occurring  only  in  aged  persons. 

Prognosis. — The  outlook  is  favorable  as  to  life,  unfavorable  as  to 
recovery.  The  disease  is  chronic,  lasting  from  ten  to  twenty  or  twenty- 
five  years.  The  patient  is  usually  able  to  attend  to  his  affairs.  There  are 
cases  characterized  by  recurrent  hemorrhages,  and  death  sometimes  occurs 
from  haemoptysis. 

Turban  has  suggested  the  following  scheme  for  uniform  records  for 
comparative  statistics  in  tuberculosis  of  the  lungs: 

r      I.  Disease  of  slight  severity,  affecting  at  most  one  lobe 
1    o*   J-   „  i      .        J     «  or  two  half  lobes. 

1.  Stadium  =  extent  and   se-  J     jj    Disease  of  slight  severity,  more  extensive  than  I,  but 

lunL  Q'sease  m  tne  i  affecting  at  most  two  lobes  ;  or  severe,  and  affecting 

^'  at  most  one  lobe. 

L  III.  All  cases  of  greater  extent  and  severity  than  II. 

2.  Disease  quiescent  or  pro- 

gressing. 

o    T« tu  „f  *;^„o-„„^ „„+    /To  date  from  first  occurrence  of  symptoms,  such  as  per- 

3.  Length  of  time  smce  onset.  |  ^-^^^^^  ^^^^^^^  haemoptysis,  or  pleurisy. 

4.  General  condition f  Satisfactory. 

(.  Unsatisfactory. 

5.  Digestion f  Normal. 

(.  Abnormal. 

6.  Pulse-frequency To  be  taken  in  morning  during  repose. 

(Daily  maxima  over  101.3°. 
Daily  maxima  between  99.7°  and  101.3°. 
Temperature  normal  with  two-hourly  rectal  temperature 
(mouth  temperature  0.4°-0.5°  lower). 

'•  ^tUltl^'''''  ^°'  "'^^'  I  Tubercle  baclBI  aTsl^t^' 
infection.  "j^  j^j.^^^  infection. 

9.  Tubercular  complications.      Name  of  affected  organ. 
10.  Other  complications /  Name  of  disease  :  serious  complications  such  as^heart  dis- 


ease, nephritis,  or  diabetes  are  to  be  noted. 
Full,  undiminished. 

lost. 


,,„..-  ,  f  Full,  undiminishe 

11.  Capacity  for  work J  slightly  reduced. 

L  Much  reduced  or 

12.  Result  of  treatment i  N^f  Improved. 

I  Died. 

Nos.  1-10  are  filled  up  on  admission  or  commencement  of  treatment. 
Nos.  11  and  12  on  discharge. 


SYPHILIS.  821 

XXXIII.    SYPHILIS. 

Definition. — A  chronic  specific  infection,  propagated  by  inoculation 
and  characterized  by,  (a)  a  pecuhar  initial  lesion — the  chancre;  (b)  con- 
stitutional symptoms  with  mucous  and  cutaneous  lesions  and  enlargement 
of  the  superficial  lymph-nodes;  and  (c)  the  development  of  granulomatous 
lesions  in  the  various  tissues  of  the  body.  These  effects  of  the  infection  are 
consecutive,  and  constitute  (a)  the  primary  stage,  (b)  the  secondary  stage, 
and  (c)  the  tertiary  stage.  Syphilis  is  frequently  transmitted  from  the 
parent  to  the  child — hereditary  syphilis. 

Etiology. — Predisposing  Influences. — Syphilis  is  a  venereal  disease 
and  is  usually  acquired  by  illicit  sexual  intercourse.  When  acquired  by  an 
innocent  person  in  the  marital  relation  or  by  accidental  means,  it  is 
described  as  syphilis  insontium.  Individual  susceptibility  is  universal 
and  affects  all  periods  of  life.  Accidental  infection  is  common  among 
medical  men.  The  fingers  are  usually  the  site  of  the  primary  lesion.  Chan- 
cres upon  the  lip  or  tongue  may  result  from  the  conveyance  of  the  virus 
by  kissing,  the  use  of  drinking  utensils,  the  pipe,  and  other  indirect  methods. 
The  infection  is  active  in  the  oral  and  pharyngeal  lesions — mucous  patches. 
Unnatural  vices  are  responsible  for  a  certain  proportion  of  the  primary 
sores  about  the  mouth.  A  nurse  suckling  a  syphilitic  infant  may  be  inocu- 
lated upon  the  nipple  and  is  also  liable  to  accidental  inoculation  upon  the 
lip,  finger,  or  elsewhere.  Local  epidemics  of  syphiHs  among  infants  from 
arm-to-arm  vaccination  have  been  reported.  Such  accidents  are  no  longer 
possible.  Syphilis  has  been  transmitted  in  tattooing.  Hereditary  trans- 
mission may  take  place  from  the  father,  the  mother  presenting  no  evidence 
of  infection — sperm  inheritance,  paternal  heredity.  In  rare  instances  a 
child  begotten  by  a  father  in  the  active — secondary — stage  has  shown  no 
evidence  of  syphilis.  In  equally  rare  cases  the  child  of  a  father  who,  after 
thorough  treatment,  has  shown  no  signs  of  the  disease  has  developed 
congenital  syphilis.  There  are  usually  unknown  factors  in  problems  of  this 
nature.  After  vigorous  systematic  treatment,  and  the  lapse  of  three  years 
after  the  entire  disappearance  of  symptoms,  a  man  may  be  allowed  to  marry 
and  is  not  Hkely  either  to  infect  his  wife  or  to  beget  infected  children. 

Transmission  from  the  mother  is  called  germ  inheritance — maternal 
heredity.  A  woman  suffering  from  syphihs  in  the  active  stage  is  liable, 
when  conception  occurs,  to  bear  a  syphilitic  child.  As  a  rule  both  parents 
are  syphilitic,  the  one  having  infected  the  other.  A  very  remarkable  fact 
is  set  forth  in  Colles's  law,  which,  briefly  stated,  is  this:  A  child  that  is 
affected  with  hereditary  syphilis,  its  mother  showing  no  signs  of  the  disease, 
will  not  infect  the  mother.  Such  a  child  will  infect  its  nurse  or  others,  but 
the  mother  appears  to  have  acquired  an  immunity  without  manifesting 
any  of  the  usual  phenomena  of  the  disease.  In  the  case  of  the  mother 
becoming  infected  after  conception,  the  child  may  show  the  signs  of  con- 
genital syphilis  or,  less  frequently,  it  may  escape.  A  parent  or  parents  in 
the  stage  of  tertiary  syphilis  may  have  non-syphilitic  children. 

Exciting  Cause.  —  Many  organisms  have  been  described  in  the 
course  of  the  last  twenty-five  years.  Recent  observations  have  estab- 
lished the  fact  that  the  spirochaeta  described  by  Schaudinn  in  1905,  and 


822 


MEDICAL  DIAGNOSIS. 


Fig.  281. — Treponema  pallidum  in  a  chancre. 


named  by  him  Spirochceta  pallida,  is  the  cause  of  the  disease.  This  organism 
is  very  deHcate,  closely  coiled,  having  pointed  ends,  and  motile.  A  larger 
spiral  organism  found  in  association  with  it  upon  the  surface  of  syphilitic 
sores,  and  also  upon  the  ulcerated  surfaces  of  non-syphilitic  lesions,  and  in 
smegma  from  healthy  men  and  women,  he  named  Spirochseta  refringens. 
S.  pallida- — Treponema  pallidum. — has  been  found  with  great  frequency  in 
syphilitic  lesions  at  various  stages  of  the  disease,  as  well  as  in  the  organs 

of  congenital  syphilis  and  the  placenta, 
and  in  greater  numbers  in  the  active 
lesions.  It  has  been  found  in  the  syph- 
ilitic lesions  of  inoculated  monkeys. 
It  has  not  yet  been  grown  in  culture. 


(a)  ACQUIRED  SYPHILIS. 

The  Primary  Stage. — A  period  of 
incubation  varying  from  two  to  four 
weeks,  exceptionally  longer,  elapses 
between  the  inoculation  and  the  appear- 
ance of  the  initial  sore.  This  lesion 
consists  of  a  small  red  papule,  which 
gradually  enlarges  and  breaks  down  in 
the  centre,  forming  a  circumscribed, 
superficial  ulcer,  with  a  pecuhar  hard,  gristly,  or  cartilage-like  movable 
base,  which  still  further  increases  in  size  and  is  known  as  the  indurated  or 
hard  chancre.  This  initial  lesion  may  remain  small  and  readily  elude 
observation  when  just  within  the  urethra  or  in  the  female  genitalia.  In 
the  other  localities  it  usually  appears  as  a  conspicuous  and  characteristic 
sore.  In  the  course  of  a  week  or  two  the  associated  lymph-nodes  "undergo 
a  painless  and  indolent  enlargement. 

The  Secondary  Stage.  —  The  earliest  indications  of  constitutional 
infection  are  usually  manifest  within  a  period  varying  from  six  to  twelve 
weeks.  They  consist  of  the  following  phenomena:  Fever,  usually  so  mild 
as  to  attract  little  attention,  101°  F.  (38.5°  C),  sometimes  marked,  less 
frequently  severe.  In  type  it  may  be  subcontinuous,  remittent,  or  inter- 
mittent; in  duration  indefinite,  sometimes  onl}^  subsiding  upon  the  vigor- 
ous use  of  antisyphilitic  treatment.  It  may  not  appear  until  late  in  the 
course  of  the  disease.  The  recognition  of  syphilitic  fever  is  of  great  diag- 
nostic importance.  It  may  simulate  malaria  or  the  symptomatic  fever  of 
advanced  pulmonary  tuberculosis,  or  hectic  fever  due  to  other  causes. 

Anamia. — The  erythrocytes  often  fall  rapidly  to  3,000,000  and  occa- 
sionally lower.  There  is  pallor  with  a  sallow  or  muddy  tinge  of  the  skin.  The 
superficial  lymph-nodes,  especially  the  suboccipital  and  epitrochlear  glands, 
become  enlarged  and  tender.  Lassitude,  headache,  rhachialgia,  and  the  vague 
pains  of  a  general  infection  are  common.  The  designation  syphilitic  cachexia 
has  been  applied  to  cases  in  which  this  symptom-group  is  pronounced. 

Cutaneous  Lesions — Syphilodermata. — The  earliest  eruption  is  usually 
macular  or  roseolar.  The  individual  spots  are  irregularly  oval,  of  large 
size  and  often  run  together.     They  are  symmetrically  distributed  upon 


SYPHILIS.  823 

the  trunk  and  anterior  surfaces  of  the  arms  and  thighs.  In  color  they  are 
reddish-brown,  often  so  faint  as  to  be  scarcely  observed,  sometimes  vivid 
or  coppery.  This  exanthem  usually  fades  in  the  course  of  some  weeks,  but 
sometimes  recurs  at  subsequent  periods  in  the  course  of  the  disease.  Later 
a  papular  eruption  may  appear  upon  the  face  and  trunk,  not  unlike  acne. 
This  syphilide  occasionally  appears  upon  the  forehead  just  below  the 
edge  of  the  hair — corona  veneris.  Frequently  associated  with  it  is  a  pustular 
eruption,  suggestive  of  the  variolous  rashes.  This  combination  of  papules 
and  pustules  appearing  upon  the  head  and  trunk,  especially  when  syphilitic 
fever  is  present,  may  give  rise  to  an  erroneous  diagnosis  of  smallpox.  Still 
later  squamous  rashes  appear,  much  like  psoriasis  but  less  scaly,  coppery 
in  color,  and  often  confined  to  the  palms  and  soles.  Papulosquamous 
lesions  are  by  no  means  rare.  These  eruptions  frequently  appear  in  the 
above  order,  but  sometimes  in  a  different  succession,  and  two  or  more  are 
often  present  at  the  same  time.  Symmetry  and  polymorphism  are  char- 
acteristic of  the  syphilodermata  in  the  secondary  stage.  Flat  Condy- 
lomata.— About  the  vulva  and  anus,  upon  the  perineum,  at  the  corners  of 
the  mouth,  occasionally  at  the  umbilicus,  and  in  the  folds  of  the  armpits 
and  groins,  and  elsewhere  where  the  skin  is  constantly  moist  or  there  are 
opposing  cutaneous  folds,  there  sornetimes  appear,  but  not  in  all  cases, 
flat  warty  growths,  slightly  elevated,  with  distinct  borders  and  a  moist, 
grayish  surface.  The  secretion  causing  these  lesions  is  inoculable  and  they 
are  in  the  highest  degree  characteristic  of  syphilis.  Alopecia  Syphilitica. — 
Not  rarely  the  hair,  and  often  the  eyebrows  and  lashes,  fall  out  during  the 
secondary  stage.  The  loss  of  hair  may  be  in  patches,  like  those  of  alopecia 
areata,  or  there  may  be  a  general  thinning.  Onychia  Syphilitica. — The  nails 
are,  in  some  cases,  affected  by  a  syphilitic  inflammation  involving  the 
matrix,  and  are  lost  or  become  deformed. 

Lesions  of  the  Mucous  Membranes. — The  oral  mucosa  is  chiefly  affected. 
About  the  time  of  the  appearance  of  the  rash  the  throat  and  mouth  become 
sore.  There  is  a  general  erythematous  angina,  more  intense  than  else- 
where, upon  the  tonsils  and  pharynx,  where  are  frequently  visible  small, 
superficial  ulcers  with  well-defined,  scalloped  borders  and  grayish-white 
surfaces — mucous  patches.  These  patches  are  also  common  on  the  tongue, 
the  lips,  and  the  buccal  mucosa.  They  are  characteristic  of  syphilis  and  the 
secretion  from  their  surface  is  highly  inoculable.  Whitish  patches  upon 
the  tongue — leucomata — sometimes  occur,  especially  in  smokers.  Papillary 
hypertrophy  of  the  mucosa  about  the  vulva  or  at  the  verge  of  the  anus 
may  give  rise  to  warty  excrescences  of  considerable  size — condylomata. 

Other  lesions  of  diagnostic  importance  are  iritis,  which  is  often  encountered 
early  in  the  secondary  stage  and  tends  to  recur;  much  less  frequently  cho- 
roiditis and  retinitis,  and  deafness  from  otitis  media  or  labyrinthine  disease. 
Abortion  and  miscarriage  are  common  and  repeated  interrupted  pregnancies 
are  very  suggestive.  Periostitis  is  a  border-line  lesion  marking  the  late  sec- 
ondary or  early  tertiary  stage.  It  especially  involves  the  tibia,  clavicles, 
cranial  bones,  and  less  frequently  the  sternum.  It  is  usually  circumscribed 
and  often  associated  with  nodes.  Upon  palpation  the  surface  of  the  long 
bones  is  rough,  and  nodular  bosses  may  be  felt  upon  the  bones  of  the  skull. 
There  is  tenderness  upon  pressure,  and  pain,  which  is  usually  worse  at  night. 


824  MEDICAL  DIAGNOSIS. 

The  Tertiary  Stage. — There  is  no  distinct  time  between  the  secondary 
and  tertiary  stages.  Tertiary  lesions  are  sometimes  present  shortly  after 
infection;  sometimes  they  make  their  appearance  along  with  the  phenom- 
ena which  are  characteristic  of  the  secondary  stage;  more  commonly  they 
do  not  appear  until  a  longer  or  shorter,  often  a  remote,  period  after  the 
lesions  of  that  stage  have  subsided.  The  third  stage  of  syphilis  is  character- 
ized by  certain  lesions  of  the  skin,  the  development  of  gummata,  disease 
of  the  bones,  and  amyloid  degenerations.  Cutaneous  Lesions. — Circum- 
scribed nodular  lesions  are  common.  They  appear  in  groups,  which  are 
irregular,  asymmetrical,  and  characterized  by  the  formation  of  deep, 
rounded  ulcers  which  involve  the  deeper  layers  of  the  skin  and  tend  to 
coalesce,  healing  at  one  point  and  spreading  at  another,  and  leaving  deep 
scars  as  they  heal.  Rupia,  a  deep  ulcerating  tertiary  lesion  covered  by 
stratified,  oyster-shell-like  crusts,  is  much  less  common  than  formerl}^ 

Gummata. — These  lesions  are  circumscribed  and  vary  in  size  from 
minute  bodies  to  tumors  sometimes  reaching  five  centimetres  in  diameter. 
They  develop  in  the  skin,  subcutaneous  tissue,  mucous  membranes,  internal 
organs,  muscles,  and  bones.  In  the  bones  they  form  dense,  hard,  hemi- 
spherical, subperiosteal  masses  called  nodes.  Gummata  of  the  skin  and 
subcutaneous  tissue  tend  to  break  down  and  form  deep  ulcers,  which  heal 
slowly  and  leave  deep,  disfiguring  scars.  Under  treatment  they  are  fre- 
quently absorbed.  Gummata  of  the  mucous  membranes  are  especially 
common  in  the  mouth,  nose,  and  pharynx.  They  involve  underlying  struc- 
tures and  often  give  rise  to  extensive  and  deep  ulceration  and  necrosis  of 
cartilage  and  bone.  Perforation  of  the  nasal  septum,  destruction  of  the 
nasal  bones,  perforation  and  more  or  less  extensive  destruction  of  the  hard 
and  soft  palate,  and  adhesions  of  the  uvula  or  soft  palate  to  the  pharyn- 
geal wall  are  common  effects.  Ulceration  and  necrosis  of  the  cartilages  of 
the  larynx  also  occur.  Stricture  of  the  rectum  is  one  of  the  results  of  gum- 
matous infiltration  and  ulceration.  Syphilomata  are  common  in  the  internal 
organs.  They  sometimes  form  agglomerations  of  large  size.  Their  usual 
course  is  to  undergo  fibroid  metamorphosis  w'th  puckering  and  deformity. 
Syphilitic  nodes  and  periostitis  have  already  been  described.  Further 
lesions  are  extensive  and  deep  necrosis,  which  may  become  perforating, 
as  in  the  bones  of  the  cranium,  the  formation  of  exostoses  which  may 
cause  serious  and  obscure  pressure  symptoms,  as  in  the  brain  or  spinal 
cord  or  the  articulations.  Syphilitic  dactylitis,  often  followed  by  per- 
manent deformity,  is  the  manifestation  of  gummatous  infiltration  and 
periostitis  of  the  bones  of  the  fingers  and  toes.  Much  less  common 
are  gummata  of  the  muscles  and  myositis  syphilitica.  Amyloid  degen- 
eration is  common  in  syphilis  even  in  the  absence  of  chronic  sup- 
puration. It  occurs  especially  in  neglected  cases  of  the  acquired 
disease  and  is  rare  in  the  congenital  form. 

(b)  HEREDITARY  SYPHILIS. 

The  infant  may  show  the  characteristic  symptoms  at  birth  or  may 
present  the  appearance  of  health.  In  the  latter  case  the  evidences  of 
infection  appear  in  the  course  of  one  or  two  months. 


SYPHILIS.  825 

1.  Symptoms  at  Birth. — The  child  is  undersized  and  usually  wasted 
and  wrinkled.  Bullae  may  be  present  on  the  wrists  and  ankles  and  scaly 
patches  upon  the  palmar  and  plantar  surfaces.  Mucous  patches  upon  the 
nasal  and  oral  mucous  membrane,  rhagades  at  the  angles  of  the  mouth  and 
at  the  anus  are  characteristic.  There  is  enlargement  of  the  liver  and  spleen. 
Nodular  thickening  of  the  bones  and,  in  some  cases,  separation  of  the  epiphy- 
ses occur.  Such  children  snuffle,  are  extremely  feeble,  are  difficult  to 
feed,  and  usually  perish  within  a  short  time.  Hemorrhage  is  occasionally 
encountered.  It  is  more  common  at  the  navel  but  may  be  subcutaneous, 
or  there  may  be  bleeding  from  the  mucous  surfaces. 

2.  Early  Symptoms.  —  When  born  without  symptoms,  syphilitic 
children  are  often  plump  and  well  nourished  and  remain  so  until  some 
time  between  the  third  and  eighth  weeks.  The  earliest  symptoms  are 
usually  those  of  a  syphilitic  endorhinitis,  namely,  impeded  nasal  respira- 
tion, difficulty  in  nursing,  snuffling,  and  a  mucopurulent,  sometimes  bloody 
discharge.  In  severe  cases  necrosis  of  the  nasal  bones  may  occur,  followed 
by  characteristic  deformity  of  the  face.  Involvement  of  the  Eustachian 
tubes  and  middle  ear  results  in  deafness.  Such  cases  constitute  one  of  the 
groups  of  deaf-mutes.  Cutaneous  lesions  appear  about  the  same  time. 
They  consist  of  a  certain  general  muddy  sallowness,  in  sharp  contrast  to 
the  fresh  rosy  skin  of  a  healthy  infant,  patchy  erythema  or  eczema,  or 
large,  irregular  coppery  patches  with  well-defined  borders.  These  erup- 
tions are  frequently  first  seen  upon  the  buttocks,  but  may  invade  other 
regions.  A  papular  syphilide  is  common.  Rhagades  upon  the  lips  and 
especially  at  the  corners  of  the  mouth  and  at  the  anus  are  of  diagnostic 
importance.  Mucous  patches  develop  and  are  highly  contagious.  The 
secretion  from  these  lesions  usually  constitutes  the  means  of  infection  in  wet- 
nurses  and  others.  Alopecia,  onychia,  dactylitis  also  frequently  occur  as  the 
case  goes  on.  A  general  adenopathy  is  not  common,  but  the  lymph-nodes 
in  relation  to  local  lesions  of  the  skin  often  undergo  an  indolent  enlarge- 
ment. The  spleen  is  enlarged;  the  liver  less  constantly  and  to  a  less  extent. 
The  large  relative  size  of  the  liver  in  the  new-born  is  to  be  kept  in  mind. 

3.  Later  Symptoms.  —  Children  suffering  from  congenital  syphilis 
may  regain  the  appearance  of  health  under  judicious  management.  Very 
frequently  they  remain  undersized  and  badly  nourished  and  look  pre- 
maturely old.  The  facies  and  cranial  development  are  very  often  char- 
acteristic. The  skull  is  frequently  asymmetrical,  the  forehead  prominent, 
the  bridge  of  the  nose  in  some  cases  depressed,  the  lips  pouting,  with 
radiating  linear  scars,  especially  at  the  corners  of  the  mouth.  At  the 
second  dentition  and  at  puberty  the  symptoms  of  hereditary  syphilis 
frequently  reappear. 

Hutchinson  Teeth — Notched  Teeth. — The  upper  central  incisors  are  peg- 
shaped,  shorter,  and  narrower  than  normal,  and  especially  narrower  at  the 
cutting  edge  than  at  the  neck.  The  enamel  is  usually  well  formed,  not 
pitted  and  thinned  as  after  prolonged  non-specific  sickness  in  infancy, 
and  there  is  at  the  cutting  edge  a  single  notch  of  varying  depth  in  which 
the  enamel  is  deficient  and  the  dentin  exposed. 

Other  symptoms  are  interstitial  keratitis,  iritis,  deafness  of  laby- 
rinthine origin,  bone  lesions,  and,  in  particular,  a  gummatous  periostitis 


826  MEDICAL  DIAGNOSIS. 

which  gradually  causes  marked  thickening  and  deformity  and  which  shows 
an  especial  tendency  to  affect  the  tibiae.  The  nodes  of  late  hereditary 
syphilis  are  usually  symmetrical  and  are  sometimes  mistaken  for  rickets. 
They  may  first  appear  in  adolescence.  There  may  be  enlargement  of  the 
spleen  and  visceral  gummata. 

The  question  of  the  transmission  of  syphilis  to  the  third  generation 
remains  undecided. 

(c)   VISCERAL    SYPHILIS. 

1.  Syphilis  of  the   Central   Nervous  System    (see    Diseases   of  the 

Nervous  System). 

Para-  or  Metasyphilitic  Diseases. — The  term  parasyphilitic  was  sug- 
gested by  Fournier  to  designate  a  group  of  affections  not  directly  due  to 
syphiKs,  but  much  more  common  in  those  who  have  had  that  disease 
than  in  others.  This  category  includes  tabes,  paresis,  certain  types  of 
epilepsy,  and  forms  of  arteriosclerosis.  They  are  not  curable  by  mercury 
and  the  iodides. 

2.  Syphilis  of  the  Lungs. — Pulmonary  syphilis  is  a  very  rare  condition. 
The  following  forms  are  described:  (a)  White  Pneumonia  of  the  Fatus. — 
The  process  may  involve  extensive  portions  of  a  lobe  or  an  entire  lung. 
The  affected  tissue  is  heavy,  airless,  and  of  a  grayish-white  color.  The 
alveoli  are  filled  with  desquamated  epithelium  and  their  walls  are  thick- 
ened and  infiltrated,  (b)  Gummata  irregularly  scattered  throughout  the 
lung,  especially  in  connection  with  the  bronchi  and  more  abundantly  about 
the  root  than  elsewhere.  There  is  an  associated  bronchopneumonia,  (c) 
Fibrous  interstitial  pneumonia  beginning  at  the  root  of  the  lung  and  extend- 
ing along  the  bronchi  and  vessels.  This  sclerotic  process  may  begin  in  the 
pleura  and  involve  the  connective-tissue  framework,  especially  in  the 
interlobar  tissue.  It  principally  affects  the  portions  of  the  lung  adjacent 
to  the  root.  It  is  encountered  in  individuals  with  a  syphilitic  history  or  in 
whom  there  are  other  forms  of  visceral  syphilis,  and  is  sometimes  associated 
with  gummata.  As  in  other  forms  of  pulmonary  sclerosis,  bronchiectasis 
is  often  present. 

Symptoms.  —  The  clinical  manifestations  are  those  of  pulmonary 
tul:)erculosis  or  pulmonary  sclerosis.  In  the  former  case  the  absence  of 
tubercle  bacilli  upon  repeated  examination,  and  the  absence  of  signs  of 
destructive  lesions,  as  elastic  tissue,  are  suggestive;  in  the  latter  the  signs 
of  chronic  interstitial  pneumonia  and  of  bronchiectasis  are  present.  The 
acute  syphilitic  pneumonia  and  chronic  syphilitic  phthisis  of  French  authors 
are  not  generally  recognized  as  clinical  entities. 

3.  Syphilis  of  the  Liver. — The  following  forms  are  described:  (a) 
Diffuse  Syphilitic  Hepatitis. — This  is  common  in  congenital  syphilis.  The 
organ  is  large  and  firm  and  shows  the  presence  of  minute  and  larger  gummata 
and  extensive  connective-tissue  hj^perplasia.  (b)  Gummata. — In  congenital 
syphilis  gummata  of  various  sizes  may  occur  at  any  period.  In  the  acquired 
disease  they  are  usually  among  the  later  manifestations  of  the  acute  process. 
They  are  commonly  multiple  and  may  attain  the  size  of  an  orange.  They 
undergo  fibroid  changes  with  contraction  and  cause  remarkable  deform- 
ities of  the  organ;   in  rare  cases  softening  takes  place  with  the  formation 


SYPHILIS.  827 

of  one  or  more  fluctuating  tumors,  (c)  Syphilitic  Perihepatitis. — Glisson's 
capsule  and  the  connective  tissue  along  the  portal  canals  are  thickened. 
Great  vein  obstruction  may  occur  when  the  connective-tissue  proliferation 
extends  along  the  large  venous  trunks,  (d)  Amyloid  Liver. — This  change 
is  very  common  in  syphilis.  Gummata  may  be  present  or  a  consecutive 
diffuse  hepatitis  may  occur. 

Symptoms.  —  The  clinical  phenomena  are  by  no  means  constant. 
Congenital  syphilitic  hepatitis  can  scarcely  be  diagnosticated  with  preci- 
sion even  when  suspected.  The  organ  is  enlarged  and  firm.  There  may 
be  jaundice.  In  the  adult  the  symptom-complex  of  atrophic  cirrhosis  is 
frequently  present.  The  symptoms  are  sallowness  or  slight  jaundice, 
digestive  disturbances,  loss  of  weight,  and  ascites. 

Irregularity  in  the  outline  of  the  liver  dulness  occurs  in  many  of  the 
cases.  The  evolution  and  involution  of  gummata  cause  progressive  and 
retrogressive  deformities  of  the  liver  which  are  of  great  importance  in  diag- 
nosis. These  syphilitic  tumors  are  less  dense  in  consistence  than  the 
surrounding  tissue  in  hepatitic  or  amyloid  disease,  and  can  in  some  cases 
be  differentiated  from  it  upon  palpation.  In  syphilitic  perihepatitis  an 
audible  and  palpable  friction  rub  may  sometimes  be  recognized;  jaundice 
is  present  in  one-third  of  the  cases  and  may  be  intense.  Pains  in  the 
hepatic  region  occur  and  the  signs  of  ascites  and  of  splenic  enlargement  are 
by  no  means  rare.  In  amyloid  liver  the  symptoms  of  amyloid  disease  in 
other  organs  are  usually  present.  The  liver  is  enlarged,  smooth,  and  firm, 
Its  outline  may  be  irregular.  There  is  commonly  also  enlargement  of  the 
spleen.  Anaemia,  polyuria  with  albumin  and  casts,  and  a  tendency  to 
dropsy  are  present. 

4.  Syphilis  of  the  Digestive  Tract. — The  oesophagus  and  stomach  are 
very  rarely  involved.  Ulceration  of  the  small  intestine  is  likewise  uncom- 
mon. The  rectum  is  far  more  often  affected.  Rectal  syphilis  is  more 
common  in  women.  The  lesions  are  due  to  gummata  in  the  submucous 
tissue  above  the  internal  sphincter,  which  undergo  ulcerative  changes  which 
become  chronic  and  on  healing  cause  stenosis.  There  may  be  tenesmus, 
discharge  of  bloody  pus  with  the  stools,  and  pain  on  defecation.  Later 
the  symptoms  are  those  of  stenosis. 

5.  Syphilis  of  the  Circulatory  System. — The  Heart. — Valvular  lesions 
are  exceedingly  infrequent.  Both  vegetations  and  gummata  have,  however, 
been  observed.  Mural  lesions  are  common.  They  comprise  gummata, 
fibroid  induration,  amyloid  degeneration,  and  endarteritis  obliterans. 
Changes  in  the  blood-vessels  of  the  heart  occur  both  in  the  congenital  and 
the  acquired  diseabe.  Valvular  lesions  give  rise  to  definite  murmurs. 
Syphilis  of  the  myocardium  may  be  present  without  symptoms;  those 
characteristic  of  myocarditis  are  usual.      Sudden  death  may  occur. 

The  Arteries. — There  are  two  forms  of  syphilitic  arteritis,  an  obliter- 
ating endarteritis  which  is  not  distinctive,  and  a  gummatous  periarteritis 
which  involves  especially  the  smaller  arteries  of  the  brain  and  the  branches 
of  the  coronary  arteries,  and  is  specific.  Syphilitic  changes  in  the  arteries 
are  etiologically  related  to  arteriosclerosis  and  aneurism. 

6.  Syphilis  of  the  Kidneys. — Gummata  and  amyloid  degeneration 
constitute  the  common  changes.     The  former  cannot  be  recognized  intra 


828  MEDICAL  DIAGNOSIS. 

vitam;  the  latter  presents  the  usual  symptoms.  An  acute  syphilitic 
nephritis^   without  specific  characters,   has  been  described. 

7.  Syphilis  of  the  Testicles. — Gummata  in  the  substance  of  the  testis 
is  not  uncommon.  It  may  be  mistaken  for  tuberculosis.  It  is  usually 
painless  and  does  not  tend  to  invade  the  skin  or  to  undergo  softening  or 
suppuration.  An  interstitial  orchitis  may  develop  as  a  slowly  progressive 
affection  unattended  with  pain  and  resulting  in  induration  and  atrophy. 
One  testis  is  usually  affected  to  a  greater  extent  than  its  fellow. 

Diagnosis. — 1.  General  Diagnosis  of  Syphilis. — (a)  The  Primary  Le- 
sion.— The  surgeon  is  more  frequently  consulted  than  the  medical  man. 
In  a  suspicious  sore  the  following  points  are  of  importance:  a  history  of 
exposure  within  a  month  or  six  weeks;  induration;  movability;  sluggish 
ulceration;  scanty  secretion;  slight  painless  enlargement  of  the  inguinal 
glands.  These  traits  belong  equally  to  the  chancre  upon  the  genitalia  and 
elsewhere.  The  history  of  exposure  may,  however,  be  in  default.  The 
patient  may  prefer  to  conceal  the  actual  fact  at  the  risk  of  his  future  health 
as  well  as  his  character  for  veracity;  or  the  inoculation  may  have  occurred 
in  marital  intercourse  or  otherwise  by  non-genital  infection.  The  initial 
lesion  may  not  have  attracted  the  patient's  attention.  This  is  especially 
liable  to  occur  in  women.  In  man  the  lesion  is  sometimes  inconspicuous 
and  may  be  mistaken  for  preputial  herpes  or  an  abrasion;  or  it  may  be 
masked  by  coincident  chancroids,  or,  when  at  the  meatus  or  in  the  urethra, 
by  a  gonorrhoea,  or  finally  an  extragenital  chancre,  even  when  well  char- 
acterized, may  fail  to  arouse  the  suspicion  of  the  practitioner  as  to  its  true 
nature.  There  is  only  one  diagnostic  rule,  namely,  to  preserve  a  guarded 
and  discreet  openness  of  mind  in  all  doubtful  cases  and  carefully  watch  for 
subsequent  developments. 

(b)  The  Seconbary  Stage.  —  Consecutive  events  are  important. 
The  history  of  exposure,  especially  when  doubtful,  and  the  history  of  a 
subsequent  sore,  however  doubtful,  are  of  great  diagnostic  value.  Sore 
throat  and  roseola  are  usually  the  first  symptoms  which  attract  the  patient's 
attention.  A  painful  erythematous  angina,  with  tonsillar  ulceration  and 
mucous  patches,  with  a  symmetrical,  faint,  brownish-red  macular  rash 
upon  the  trunk,  and  painless  enlargement  of  the  inguinal,  suboccipital, 
and  epitrochleal  lymph-nodes,  especially  when  associated  with  fever, 
constitutes  a  symptom-complex  upon  which  a  direct  diagnosis  may  be  made. 
Later  polymorphous  rashes,  corona  veneris,  alopecia,  irregular  fever,  and 
anaemia  are  confirmatory. 

Justus  found  that  after  the  beginning  of  treatment  by  mercurial 
inunction  or  hypodermically  in  cases  of  syphilis  not  previously  treated 
there  was  a  haemoglobin  reduction  of  from  10  to  20  per  cent.,  followed  by 
a  rise  as  the  treatment  was  continued.  Later  observations  have  not 
confirmed  the  diagnostic  value  of  this  test  in  doubtful  cases. 

The  Wasserman  Test. — This  serum  test  requires  a  very  careful  technic 
and  is  exposed  to  many  sources  of  error.  It  therefore  should  only  be 
undertaken  by  trained  laboratory  workers.*  During  the  two  years  that 
have  elapsed  since  it  was  first  published  the  reliability  of  this  diagnostic 
method  has  been  fully  established.     In  a  recent  publication  Wasserman 

1  Consult  Immune  Sera:  C.  F.  Bolduan,  third  edition,  1908. 


SYPHILIS.  829 

has  given  the  results  of  3000  tests,  of  which  1010  were  upon  cases  surely 
non-syphilitic  and  used  as  controls.  In  1982  syphilitic  cases  about  90 
per  cent,  gave  positive  results.  In  cases  without  manifest  symptoms  at 
the  time,  "latent  syphilitis, "  about  50  percent,  gave  positive  reactions. 
The  chief  value  of  this  test  is  in  cases  with  symptoms  suggestive  of  syphilis 
but  a  questionable  anamnesis. 

The  Noguchi  Butyric  Acid  Test. — This  depends  upon  the  fact  that  in 
cases  of  secondary  syphilis,  untreated  or  but  slightly  treated,  an  increased 
globulin  content  in  the  serum  can  be  demonstrated  by  the  precipitation 
produced  upon  the  addition  of  acid.  The  serum  is  mixed  with  half  satu- 
rated solution  of  ammonium  sulphate,  the  precipitate  separated  by  centrif- 
ugating,  and  the  supernatant  fluid  poured  off.  The  precipitate,  redissolved 
in  ten  volumes  of  normal  salt  solution,  is  then  treated  by  a  10  per  cent, 
solution  of  butyric  acid  in  salt  solution.  In  normal  sera  a  slight  opalescent 
precipitate  results,  but  in  the  sera  of  secondary  syphilis  the  increased  globu- 
lin content  is  shown  by  a  distinct  flocculent  precipitate  which  forms  within 
two  hours.    The  spinal  fluid  may  be  employed  instead  of  blood-serum. 

(c)  The  Tertiary  Stage. — The  anamnesis  is  here  also  of  great  impor- 
tance. It  is  often  defective.  Sometimes  discretion  suggests  a  very  guarded 
investigation  of  the  past  history  of  the  patient.  Inquiry  should  be  made 
concerning  persistent  rashes  and  falling  of  the  hair.  Careful  inspection 
of  the  throat  and  skin  should  be  made  for  the  signs  of  past  lesions. 
Scars  in  the  groins  are  insufficient  evidence.  Suppurating  buboes  are 
usually  due  to  chancroids,  not  syphilis.  Slowly  progressive  ulcerating  lesions 
of  the  skin,  advancing  in  one  direction  and  healing  in  another, — serpigin- 
ous,— gumma  and  gummatous  ulceration,  perforation  of  the  nasal  septum, 
of  the  hard  or  soft  palate,  necrosis  of  the  nasal  or  cranial  bones,  the  signs 
of  iritis,  the  presence  of  nodes,  irregular  periosteal  thickening  or  exostosis, 
especially  upon  the  clavicles,  tibiae,  or  bones  of  the  skull,  particularly  when 
two  or  more  of  them  are  associated,  constitute  diagnostic  data  of  final 
importance  in  the  direct  diagnosis.  But  these  lesions  are  often  wholly 
absent  and  the  sufferer  from  tertiary  syphilis,  and  particularly  the  sufferer 
from  nervous  syphilis,  may  be  entirely  free  from  the  gross  or  visible 
external  manifestations  of  the  disease.  In  many  cases  of  nervous  syphilis 
it  is  impossible  to  elicit  a  history  of  marked  secondary  signs. 

2.  Diagnosis  of  Hereditary  Sypliilis. — Repeated  miscarriages  are,  in 
connection  with  any  of  these  phenomena,  of  diagnostic  value.  The  efflo- 
rescence of  the  characteristic  rash  associated  with  snuffles,  mucous  patches, 
and  rhagades  within  the  first  three  months  justifies  the  direct  diagnosis. 
At  subsequent  periods  of  life  the  characteristic  facies,  infantile  develop- 
ment, symmetrical  nodes,  notched  teeth,  and  interstitial  keratitis  tell  their 
own  story  and  may  solve  the  problem  of  diagnosis  in  obscure  nervous  or 
visceral  disease. 

3.  Diagnosis  of  Visceral  Syphilis. — The  anamnesis  and  the  presence 
of  the  signs  of  former  lesions  are  of  primary  importance.  In  the  male 
careful  search  should  always  be  made  for  vestiges  of  the  primary  sore. 
It  is  to  be  remembered  that  the  manifestations  of  visceral  syphilis  are 
usually  not  in  themselves  different  from  those  of  lesions  due  to  other 
pathological  processes,  and  that  their  true  nature  can  be  recognized  only 


830  MEDICAL  DIAGNOSIS. 

by  the  history  of  infection,  the  presence  and  association  of  characteristic 
external  phenomena,  or  the  therapeutic  test. 

1.  Syphilis  of  the  Brain  and  Cord  (see  Diseases  of  the  Nervous  System). 

2.  Syphilis  of  the  Lung. — The  clinical  diagnosis  of  this  rare  condition 
in  any  of  its  forms  can  seldom  be  made  with  precision.  Chronic  interstitial 
pneumonia  with  the  signs  of  bronchiectasis,  or  chronic  bronchopneumonia 
in  a  person  with  a  history  of  syphilis  or  presenting  well-characterized 
lesions  in  other  parts  of  his  body,  may  be  of  syphilitic  origin.  Tuber- 
culosis of  the  lungs  and  gummata  may  coexist. 

3.  Syphilis  of  the  Liver. — The  diagnosis  is  most  important,  as  it  is 
essential  to  the  choice  of  treatment.  The  irregularly  enlarged  liver,  with 
soft  circumscribed  gummata,  may  suggest  cyst,  abscess,  or  malignant 
tumor.  Under  such  circumstances  an  unnecessary  surgical  operation  might 
be  performed.  A  history  of  infection,  collateral  lesions,  and  fair  general 
heailth  "Suggests  syphilis.  The  diagnosis  in  gummata  forming  large  con- 
glomerate tumor  masses  in  the  right  or  left  lobe  in  absence  of  collateral 
evidence  must  remain  obscure.  In  cirrhosis  and  perihepatitis  recovery 
under  specific  treatment  is  often  the  only  sign.  Irregularity  of  outline, 
which,  when  there  is  ascites,  can  only  be  determined  after  paracentesis, 
is  very  suggestive.  Amyloid  disease  of  the  liver  is  commonly  associated 
with  similar  visceral  changes  elsewhere. 

4.  Syphilis  of  the  Digestive  Organs. — The  history  affords  presumptive 
evidence  in  disease  of  the  oesophagus.  Syphilis  of  the  stomach  cannot  be 
positively  diagnosticated.  The  chronic  course  of  syphilis  of  the  rectum, 
the  symptoms  of  gradual  stenosis  of  the  gut,  and  the  results  of  digital 
examination  by  which  a  firm  fibrous  annular  contraction  is  usually  felt, 
quite  unlike  the  irregular,  ragged  surface  of  ulcerating  cancer,  are  essential 
diagnostic  criteria. 

5.  The  clinical  diagnosis  of  syphilitic  disease  of  the  heart  and  arteries 
must  be  a  provisional  one.  Cardiovascular  changes,  in  no  respect  differ- 
ing in  symptomatology  from  those  occurring  in  syphilitic  subjects,  are 
often  due  to  other  causes. 

6.  The  diagnosis  of  renal  syphilis  cannot  be  made  during  life. 

7.  Syphilis  of  the  Testes. — The  recognition  of  syphilis  in  these  organs 
may  be  of  great  importance  in  obscure  visceral  disease.  Syphilis,  tuber- 
culosis, and  cancer  are  to  be  differentiated.  Gummata  involve  the  body  of 
the  testicle  and  give  rise  to  irregular  conglomerated  masses,  unattended 
with  pain  and  showing  no  tendency  to  invade  the  skin  or  undergo  soften- 
ing. Tubercle  more  commonly  affects  the  epididymis  and  is  often  associ- 
ated with  tHe  signs  of  tuberculous  disease  elsewhere.  Malignant  disease 
runs  a  more  rapid  course,  attains  a  larger  size,  is  attended  with  pain,  and 
tends  to  involve  the  skin  and  undergo  ulceration. 

Therapeutic  Diagnosis. — Symptomatic  treatment  by  mercury  and  the 
iodides  under  suitable  conditions  will  frequently  cause  the  disappearance 
of  symptoms.  Intermittent  courses  of  treatment,  repeated  during  long 
periods  of  time,  usually  prevent  the  recurrence  of  symptoms,  arrest  the 
tendency  to  abortion,  and  may  be  followed  by  the  birth  of  healthy  children 
in  whom  neither  the  early  nor  the  late  manifestations  of  syphilis  occur. 
Obscure  skin  eruptions  fade  if  of  syphilitic  origin. 


GONORRHCEA. 


831 


With  reference  to  visceral  syphilis  the  following  facts  are  important: 
The  symptoms  of  nervous  syphilis  may,  in  early  cases,  disappear  after  the 
use  of  antisyphilitic  remedies;  in  pulmonary  sj^^hilis  the  results  are  incon- 
clusive; syphilis  of  the  liver  in  certain  of  its  forms  is  amenable  to  treat- 
ment and  in  some  cases  the  improvement  is  rapid  and  permanent;  syphilis 
of  the  heart  and  arteries  shows  retardation  rather  than  cure  and  here  the 
therapeutic  test  is  useless.  The  symptoms  of  the  secondary  stage  yield 
promptly,  while  in  the  tertiary  stage  the  gummatous  lesions  yield  more 
or  less  gradually  and  the  sclerotic  lesions  are  but  slightly  if  at  all  influenced. 
The  so-called  parasyphilitic  diseases  are  not  cured  by  antisyphilitic  treat- 
ment. Finally  there  are  rare  cases  of  acute  malignant  syphilis  which  run 
a  rapidly  fatal  course  wholly  uninfluenced  by  treatment. 

Prognosis. — Under  early,  systematic  treatment,  repeated  from  time 
to  time  in  courses  of  proper  duration  for  a  period  of  three  or  four  years, 
an  apparent  cure  is,  in  the  majority  of  cases,  established  and  maintained. 


XXXIV.  GONORRHCEA. 

Definition.  —  A  contagious  catarrhal  inflammation  of  the  genital 
mucous  membrane,  chiefly  propagated  by  impure  sexual  intercourse,  and 
due  to  the  gonococcus  of  Neisser. 

This  wide-spread  venereal  infection  is  scarcelj^  inferior  in  importance 
to  syphilis.  In  truth,  when  we  take  into  consideration  the  facts  that  syphilis 
is  much  less  virulent  than  formerly  in  its  early  and  late  constitutional 
effects,  and  that  it  gives  rise  to  symptoms  which  compel  the  most  ignorant 
and  inexperienced  to  seek  professional 
advice  at  a  period  when  it  is  still 
amenable  to  treatment,  and  that  gonor- 
rhoea, while  retaining  all  its  capacity  for 
immediate  and  late  harmfulness,  is  too 
often  regarded  as  a  trifling  local  dis- 
order, the  very  existence  of  which  may 
be  unsuspected  by  the  female  patient, 
we  may  even  question  whether  gonor- 
rhcEa  is  not  the  more  serious  disease 
of  the  two. 

The  gonorrhoeal  infection  may 
limit  itself  to  the  mucous  membrane 
of  the  genitalia — (1)  the  primary  local 
infection;  it  may  invade  the  genito- 
urinary organs  by  direct  continuity 
of  structure — (2)  secondary  local  infection;  or  finally,  it  may  be  swept 
into    the    blood    stream    and    give    rise    to    (3)    constitutional    infection. 

With  reference  to  the  spread  of  the  infection  in  the  genito-urinary  tract, 
it  is  a  question  of  extent.  Every  case  in  the  male  is  at  first  an  infection  of 
the  anterior  urethra.  With  reference  to  systemic  effects,  it  is  a  question  of 
degree;  any  case  is  liable  to  systemic  disturbance,  and  malaise,  feverishness, 
head  and  back  pains,  and  other  symptoms  of  constitutional  infection  are 
often  present  at  the  onset  or  later  in  the  course  of  the  attack.  The  fever 
associated  with  the  initial  symptoms  is  due  to  the  absorption  of  toxins. 


Fig.  282. — Spread  of  pus  containing  gonococci. 


832  MEDICAL  DIAGNOSIS. 

The  Primary  Local  Infection. — It  is  necessary  for  the  purposes  of 
medical  diagnosis  to  bear  in  mind  the  fact  that  the  gonococcus  may 
persist  in  a  shght  urethral  discharge  capable  of  giving  rise  to  the  disease 
for  long  periods  after  the  patient  has  thought  himself  cured,  and  that 
innocent  women  frequently  become  infected  upon  marriage.  It  is  also  to 
be  remembered  that  the  existence  of  a  urethral  stricture  bears  a  causal 
relation  to  cystitis,  pyelitis,  persistent  rhachialgia,  lassitude,  general 
disability,  and  neurasthenia,  and  that  in  acute  disease  it  may  be  the  cause 
of  urinary  retention. 

Secondary  Local  Infection. — The  gradual  extension  of  the  specific 
inflammation  from  the  mucous  membrane  primarily  involved  gives  rise,  in 
the  male,  to  posterior  urethritis,  epididymitis,  prostatitis,  periurethral 
abscess;  in  the  female  to  abscess  of  the  vulvovaginal  glands,  metritis,  sal- 
pingitis, inflammation  of  the  ovary,  and,  in  rare  cases,  to  acute  peritonitis; 
in  both  sexes  to  cystitis  and  pyelitis,  usually  mixed  infections. 

Constitutional  Qonorrhoeal  Infection. — Gonorrhceal  Sepsis — Septi- 
coPYiEMiA. — The  presence  of  the  gonococcus  in  the  blood  has  been 
demonstrated.  There  are  cases  of  rapidly  fatal  general  infection,  usually 
associated  with  suppurative  lesions  in  the  urinary  tract.  The  symptoms 
are  chill,  high  temperature  of  irregular  range,  profuse  sweats,  muttering 
delirium,  and  stupor  deepening  to  coma. 

Cardiac  and  Articular  Localizations — Gonorrhceal  Endocar- 
ditis.— This  localization  is  of  frequent  occurrence  in  gonococcus  septicaemia. 
Gonococci  have  been  isolated  from  the  blood  during  life,  and  the  vegeta- 
tions upon  the  valves  after  death.  The  endocarditis  is  often  of  the  malig- 
nant type.  In  a  majority  of  the  cases  the  endocarditis  has  followed  an 
arthritis,  but  it  may  occur  in  the  absence  of  the  joint  affection  or  the 
latter  may  follow  it.  Pericarditis  may  occur,  and  an  acute  gonorrhcEal 
myocarditis  has  been  observed. 

Gonorrhceal  Arthritis. — The  designation  gonorrhceal  rheumatism  is 
erroneous  and  misleading  and  should  be  abandoned.  This  localization  has 
been  observed  in  infants  in  connection  with  ophthalmia  neonatorum  and 
in  young  children  in  whom  gonorrhoea  is  common  as  the  result  of  accidental 
infection  by  towels  or  clothing,  or  of  vicious  practices.  It  is  most  common 
between  twenty  and  thirty.  Males  suffer  from  the  joint  affection  more 
frequently  than  females.  It  may  occur  at  any  time  during  the  course  of 
the  urethral  discharge.  Most  commonly  the  arthritis  begins  during  the 
acute  stage  and  is  followed  by  a  subsidence  of  the  discharge,  which  is, 
however,  usually  only  temporary.  It  may  occur  after  discharge  has  greatly 
diminished  or  not  for  several  weeks  after  the  beginning  of  the  attack. 
A  single  joint  may  be  affected;  more  commonly  two  or  even  three  are 
involved.  Polyarthritis  is  rare  and  the  migratory  form  characteristic  of 
acute  rheumatism  does  not  occur.  The  joints  remain  inflamed  and  only 
slowly  get  well.  The  ankles,  knees,  and  wrists  are  especially  liable  to  gonor- 
rhceal inflammation  and  the  temporomaxillary,  sternoclavicular,  vertebral, 
and  sacro-iliac  articulations  are  frequently  attacked.  The  inflammation 
is  endo-  and  periarticular.  In  the  latter  case  the  exudate  sometimes  extends 
along  the  sheaths  of  the  tendons.  The  effusion  into  the  joints  is  that  of  a 
serous  synovitis.     It  may  be  seropurulent.     The  gonococcus  may  be  iso- 


EPHEMERAL  FEVER.  833 

lated  from  the  endo-  and  the  periarticular  exudates.     In  some  cases  the 
results  are  negative.    Mixed  infections — staphylococci,  streptococci — occur. 

Gonorrhceal  arthritis  tends  to  become  chronic.  Relapses  are  frequent; 
disorganization  or  disabling  ankylosis  may  result.  Among  the  compli- 
cations are  iritis,  endocarditis,  pericarditis,  and  pleurisy. 

Diagnosis. — Direct.— The  anamnesis  is  most  important.  Caution  is  to 
be  exercised  in  questioning  young  girls  and  married  persons  of  both  sexes. 
The  existence  of  a  mucopurulent  urethral  discharge  is  not  positively  con- 
clusive. A  young  person  suffering  from  gonorrhoea  may  also  contract 
rheumatic  fever.  In  the  female  a  vaginal  discharge  should  be  examined 
for  gonococci.  Clinically,  a  limited  number  of  joints  involved,  the  persist- 
ence of  the  inflammation  without  migration,  the  association  of  endocar- 
ditis of  the  malignant  form,  and  implication  of  the  temporomaxillary, 
sternoclavicular,  or  vertebral  articulations  are  of  diagnostic  value. 

Differential. — Rheumatic  Fever. — The  evanescent — migratory — char- 
acter of  the  arthritis,  the  number  of  joints  involved, — 'polyarthritis, — the 
frequent  rapid  and  complete  resolution  of  the  inflammation,  a  history  of  ■ 
exposure  to  cold  or  wet,  of  previous  attacks,  of  heredity,  and  the  com- 
monly lower  intensity  of  an  endocarditis,  when  present,  are  in  favor 
of  rheumatic  fever.  Pycemic  or  Septic  Arthritis. — The  presence  of  a  sup- 
purative focus,  caries,  osteomyelitis  with  toxaemic  phenomena,  as  irregular 
chills,  high  fever  of  irregular  remittent  or  intermittent  type,  profuse  sweat- 
ing, rapidly  developing  anaemia,  the  implication  of  a  single  joint  or,  at  most, 
two  or  three,  and  the  evidences  of  large  intra-articular  effusion,  are  in 
favor  of  septic  arthritis.  Goiit. — If  the  patient  be  a  middle-aged  male, 
energetic  and  self-indulgent,  the  attack  be  sudden,  the  great  toe,  ankle, 
knee,  or  wrist  involved,  the  swelling  tense,  the  surface  livid  and  glossy, 
and  tophi  be  present  around  the  small  joints  or  in  the  helix  of  the  ear,  a 
diagnosis  of  gout  may  safely  be  made.  I  have  seen  a  calculus  impacted 
in  the  urethra  cause  a  free  purulent  discharge,  followed  by  an  attack  of 
gout.  Arthritis  Deformans. — There  are  cases  in  which,  for  a  time,  the  joint 
affection,  whether  arthralgic,  polyarthritic,  or  monarthritic,  cannot  be  dis- 
tinguished at  the  time  of  acute  exacerbations  from  gonorrhceal  arthritis. 
No  question  arises  in  regard  to  the  differential  diagnosis  except  in  cases  of 
recent  or  chronic  urethritis  in  the  male  or  leucorrhoea  in  the  female. 

Prognosis. — Gonorrhoeal  infection  in  its  systemic  form  is  always  a 
serious  matter.  The  virulent  septic  cases  prove  fatal  in  a  few  days  or  a 
week  or  two;  the  endocarditis  frequently  assumes  the  malignant  type; 
the  arthritis  is  commonly  rebellious  to  treatment  and  not  rarely  is  followed 
by  lasting,  even  permanent  disability.    Salicin  and  the  salicylates  are  useless. 

XXXV.  EPHEMERAL   FEVER— FEBRICULA-SIMPLE 
CONTINUED   FEVER. 

Definition. — Fever  of  short  duration,  occurring  in  the  absence  of  defi- 
nite lesions  or  known  specific  cause,  and  characterized  by  elevation  of 
temperature  and  the  derangements  of  function  which  commonly  attend  it. 
Fever  lasting  twenty-four  or  forty-eight  hours  and  ceasing  completely  is 
designated  ephemeral  fever;  an  attack  of  three  or  four  days'  duration. 
fehricula;   and  one  lasting  a  week  or  more,  simple  continued  fever. 

53 


834  MEDICAL  DIAGNOSIS. 

Etiology. — Children  and  neurotic  individuals  are  more  liable  to 
transient  febrile  attacks  than  others — a  fact  due  to  the  instability  of  the 
heat-regulating  mechanism.  Several  groups  of  cases  are  described:  (a) 
symptomatic,    (b)  toxic,  and  (c)  infectious. 

(a)  In  many  cases  the  fever  is  doubtless  due  to  unrecognized  local 
lesions,  as  in  angina  tonsillaris  or  catarrhal  bronchitis  of  the  larger  tubes, 
with  little  or  no  cough  and  no  rales;  or  to  slight  injury  such  as  results  from 
a  fall  upon  the  head. 

(b)  Among  the  toxic  cases  are  those  which  arise  from  indigestion  or 
gastro-intestinal  catarrh  with  the  absorption  of  fever-producing  substances. 
The  fever  sometimes  follows  prolonged  mental  or  physical  effort,  exposure 
to  damp  and  cold  without  definite  lesions,  exposure  to  the  sun  but  not  to 
a  degree  sufficient  to  cause  thermic  fever,  and  the  inhalation  of  the  con- 
centrated emanations  from  decomposing  organic  matter.  There  are 
instances  in  which  a  number  of  persons  have  been  at  the  same  time  taken 
ill,  with  nausea,  vomiting,  fever,  and,  in  some  instances,  collapse  symptoms 
after  being  present  at  a  very  offensive  post-mortem  examination  or  the 
opening  of  an  obstructed  sewer  or  of  a  mortuary  vault. 

(c)  Mild  or  abortive  cases  of  the  infectious  diseases  have  been  regarded 
as  febricula.  Stille  called  attention  to  the  occurrence  of  cases  of  cerebro- 
spinal fever  so  mild  that  they  can  "  only  be  recognized  by  the  lurid  light  of 
the  epidemic."  The  true  nature  of  the  mildest  form  of  enteric  fever — 
typhus  levissimus — may  be  readily  overlooked,  and  there  are  cases  of  scarlet 
fever,  measles,  and  rheumatic  fever  without  distinctive  symptoms  beyond 
a  transient  fever  for  two  or  three  days — larval  cases  of  the  infectious  diseases. 
In  view  of  these  facts,  it  is  evident  that  the  more  closely  the  cases  of 
transient  fever  without  obvious  symptoms  are  studied,  the  fewer  will  be 
encountered  that  are  really  neither  symptomatic  nor  specific,  and  there  is  a 
tendency  to  do  away  with  this  group  of  fevers  altogether  as  a  nosological 
entity.  On  the  other  hand,  every  practitioner  occasionally  encounters  cases 
for  which  no  other  place  in  the  classification  of  diseases  can  be  found. 

Symptoms. — The  onset  is  usually  abrupt;  exceptionally  gradual  with 
lassitude  and  languor.  The  usual  symptoms  of  febrile  infection  are  present. 
In  rare  instances,  especially  in  children,  there  may  be  chilHness  or  a  con- 
vulsion. Defervescence  takes  place  by  crisis  between  the  second  and  the 
fourth  days;  if  later,  usually  by  rapid  lysis. 

A  direct  diagnosis  may  be  made  from  the  abrupt  onset  of  the  fever, 
its  short  course  and  the  critical  termination  in  the  absence  of  local  lesions  and 
cutaneous  rashes.    The  prognosis  is  invariably  and  essentially  favorable. 

XXXVI.  ROCKY  MOUNTAIN  SPOTTED  FEVER. 

Tick  Fever. 

Definition. — An  acute  infectious  endemic  disease,  prevalent  in  the 
northwestern  mountainous  regions  of  the  United  States,  and  due  to  the 
bite  of  a  tick.  It  is  characterized  by  the  gradual  onset  of  symptoms  com- 
mon in  the  acute  infections,  a  papular  or  petechial  eruption,  and  an  irregular 
fever  of  variable  duration  terminating  by  lysis. 


ROCKY  MOUNTAIN  SPOTTED  FEVER.  835 

This  disease,  tong  known  under  designations  sucli  as  "  mountain  fever,  " 
"black  fever,"  and  "spotted  fever,"  iias  recently  been  made  the  subject 
of  scientific  investigation  under  the  auspices  of  the  Montana  State  Board 
of  Health  (1902),  the  PubUc  Health  and  Marine  Hospital  Service  (1903), 
and  the  American  Medical  Association  (1906-1907),  and  is  now  recog- 
nized as  a  nosological  entity. 

Etiology. — Predisposing  Influences. — Certain  districts  in  the  Rocky 
Mountains  are  the  exclusive  regions  in  which  the  disease  occurs.  The  great 
majority  of  the  reported  cases  have  been  observed  in  April,  May,  and  June. 
A  few  have  occurred  in  March  and  July.  No  period  of  life  affords  exemp- 
tion. The  disease  has  been  noted  as  early  as  the  second  and  as  late  as  the 
seventy-fourth  year.  Ranchmen,  lumbermen,  engineers,  and  prospectors 
have  supplied  the  greater  number  of  cases. 

Exciting  Cause. — Despite  various  hypotheses,  the  infecting  organism 
has  not  yet  been  demonstrated.  It  is  inoculated  by  the  bite  of  a  tick — 
Dermacentor  andersoni.  Tick  fever  may  be  caused  in  monkeys  and  guinea- 
pigs  by  the  inoculation  of  the  defibrinated  blood  of  human  beings  suffer- 
ing from  the  disease.  Some  observers  have  attributed  the  disease  to  the 
inoculation  of  the  infecting  principle  by  mosquitoes. 

Symptoms. — The  average  duration  of  the  period  of  incubation  appears 
to  be  about  seven  days.  The  onset  is  attended  by  nausea  and  vomiting, 
muscular  pains,  malaise,  headache,  and  epistaxis,  chilhness  or  a  distinct 
chill.  The  temperature  rises  abruptly  to  103°-104°  F.  (39.5°-40°  C.)  and 
its  range  may  be  subcontinuous  or  intermittent.  At  the  expiration  of  from 
sixteen  to  twenty  days  defervescence  takes  place,  followed  by  subnormal 
temperatures  for  a  few  days.  In  fatal  cases  the  temperature  usually 
remains  high,  but  a  preagonistic  fall  sometimes  occurs.  The  eruption  shows 
itself  about  the  third  or  fifth  day,  first  appearing  upon  the  ankles,  wrists, 
and  forehead,  and  gradually  spreading  over  the  whole  body.  It  remains, 
however,  more  abundant  upon  the  extremities  than  upon  the  trunk.  It 
is  at  first  maculopapular  and  disappears  upon  pressure.  In  the  course  of 
a  few  days  it  becomes  more  distinctly  papular  and  does  not  disappear  upon 
pressure  or  when  the  skin  is  made  tense.  Many  of  the  spots  become  petechial 
and  in  the  severer  cases  more  or  less  extensive  ecchymosis  occurs.  The 
intervening  skin  is  congested,  slightly  cyanotic,  and  jaundiced.  In  favor- 
able cases  the  eruption  fades  with  the  defervescence  and  its  disappearance 
is  followed  by  desquamation.  Gangrene  of  the  penis  or  scrotum  or  of 
the  toes  has  been  reported.  In  mild  cases  the  rash  may  not  appear. 
Gastro-intestinal  symptoms  are  prominent.  The  liver  and  spleen  are 
enlarged.  The  urine  is  diminished  in  volume,  of  high  color  and  specific 
gravity,  and  contains  albumin  and  casts  of  all  kinds.  The  blood 
shows  a  moderate  secondary  anaemia  and  in  some  cases  a  moderate 
leucocytosis — 13,000. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  endemic  occurrence 
of  a  disease  having  the  above  sj'^mptom-complex  in  particular  localities 
and  at  certain  seasons  of  the  year,  a  history  of  tick  or  mosquito  bites, 
sudden  onset,  chilliness  or  high  continued  or  intermittent  fever,  the  appear- 
ance of  the  maculopapular  eruption  upon  the  third,  fourth,  or  fifth  day, 
petechise,  ecchymosis,  and  defervescence  followed  by  desquamation. 


836  MEDICAL  DIAGNOSIS. 

Prognosis. — Rocky  ]\Iountaiii  spotted  fever  is  a  very  fatal  disease. 
According  to  several  observers  the  mortality  varies  from  70  to  90  per  cent. 
In  some  seasons  the  cases  are  mild  and  most  of  them  have  terminated  in 
recovery.  Among  the  phenomena  which  in  individual  cases  render  the 
outlook  especially  unfavorable  are  deep  jaundice,  extensive  hemorrhage 
into  the  skin,  delirium,  and  exhaustion. 


XXXVII.  ICTERUS  IXFECTIOSUS. 

Weil's  Disease;  Acute  Febrile  Icterus. 

Definition. — An  acute  infectious  disease  characterized  by  sudden 
onset  with  chill,  followed  hj  high  fever  and  jaundice. 

Etiology.— Predisposing  Influences. — The  clinical  picture  suggests 
the  severer  cases  of  catarrhal  jaundice  and  various  febrile  forms  of  gastro- 
intestinal disease  that  may  run  their  course  with  or  without  jaundice. 
It  corresponds  very  closely  to  the  disease  observed  by  Griesinger  in  Cairo, 
and  Kartulis  in  Alexandria,  and  described  under  the  designation  bilious 
typhoid  or  typhus  biliosus.  Many  cases  reported  as  Weil's  disease  clearly 
do  not  belong  to  that  category,  such  as  santonin  poisoning,  septica?mia, 
abortive  enteric  fever,  and  the  so-called  hepatic  form  of  enteric  fever. 
The  view  that  AA'eil's  disease  is  a  form  of  rheumatic  fever  complicated  by 
a  resorption  icterus  is  not  generally  accepted.  Some  etiological  considera- 
tions support  the  assumption  that  the  disease  is  the  manifestation  of  a 
specific  infectious  process.  Among  these  are  the  following:  The  cases 
which  correspond  to  AYeil's  description  usually  occur  sporadicall}',  but  not 
rarely  thev  appear  in  groups  in  circumscribed  localities,  and  during  the 
hot  season.  Males  are  more  affected  than  females — 90  per  cent.  Certain 
occupations  exert  a  predisposing  influence,  butchers,  tanners,  and  laborers 
in  sewers  being  especially  liable  to  the  disease.  It  has  been  attributed  to 
the  drinking  of  contaminated  water,  and  epidemics,  especially  among 
soldiers,  have  been  ascribed  to  the  swallowing  of  such  water  during  bathing. 
The  disease  is  most  frequent  between  the  twenty-fifth  and  the  fortieth 
5'ears  of  life.     It  is  uncommon  in  childhood,  and  rare  after  fifty. 

Exciting  Cause. — The  researches  of  Jager  render  it  probable  that 
an  organism  cultivated  from  the  urine  of  living  cases  and  from  the  organs 
of  a  case  dead  of  the  disease — Proteus  fluorescens — is  the  infecting  agent. 

Symptoms. — The  attack  begins  abruptly,  usually  without  prodromes 
and  often  with  a  chill.  Headache,  vertigo,  pain  in  the  back  and  limbs  occur. 
There  is  great  lassitude.  The  temperature  rises  rapidly  to  104°  F.  (40°  C.) 
or  higher,  and  is  remittent  in  type.  It  lasts  from  eight  to  fourteen  days. 
There  are  recurrences  of  the  fever,  and  in  a  considerable  proportion  of  the 
cases  relapses  occur.  Stupor  and  delirium  occur,  and  the  resemblance  of 
some  of  the  cases  to  enteric  fever  may  be  striking — a  resemblance  increased 
by  the  early  development  of  splenic  enlargement.  Jaundice  makes  its 
appearance  between  the  third  and  fifth  days  and  is  of  variable  intensity, 
being  in  a  considerable  proportion  of  the  cases  deep  and  attended  by 
clay-colored  stools.  The  liver  is  increased  in  size  and  tender  upon  pressure. 
The  urine  is  commonly  albuminous,  with  hyahne  and  epithelial  casts,  and 


GLANDULAR  FEVER.  837 

sometimes  contains  red  blood-corpuscles.  Haematuria  is  not  very  uncom- 
mon. In  the  fatal  cases  deep  stupor,  delirium,  and  coma  precede  death. 
There  is  rapid  wasting  during  the  attack.  Muscular  pains  persist  after  the 
defervescence  and  are  among  the  last  symptoms  to  disappear.  Angina 
tonsillaris  is  occasionally  an  early  complication.  Herpes  faciahs  and  other 
cutaneous  lesions,  as  erythema  and  hemorrhage  into  the  skin,  have  been 
observed.  A  group  of  the  graver  cases  are  hemorrhagic.  Parotid  bubo 
is  a  rare  complication.  The  duration  of  the  attack  varies  from  two  to  four 
weeks,  and  the  convalescence  is  slow. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  occurrence  of  jaundice 
with  the  symptoms  of  an  acute  severe  infection,  quite  unhke  ordinary 
catarrhal  icterus  on  the  one  hand,  and  without  the  phenomena  of  the  specific 
infections  on  the  other.  The  age,  sex,  and  occupation  of  the  patient  are  to 
be  considered.  It  is  probable  that  some  of  the  local  epidemics  reported  as 
catarrhal  jaundice  of  severe  type  have  been  outbreaks  of  Weil's  disease. 

Prognosis. — The  death-rate  is  low,  most  of  the  cases  terminating  in 
recovery. 

XXXVIII.  GLANDULAR   FEVER. 

Definition. — An  infectious  disease  of  children,  characterized  by  sud- 
den onset,  erythematous  angina,  enlargement  of  the  tonsils,  high  fever  of 
short  duration,  and  swelling  and  tenderness  of  the  lymph-nodes  of  the 
neck,  particularly  those  along  the  posterior  border  of  the  sternocleido- 
mastoid muscles. 

Etiology. — Predisposing  Influences. — Certain  individuals,  particu- 
larly in  childhood,  exhibit  a  peculiar  irritability  of  the  superficial  lymphatic 
glands,  some  of  which  become  enlarged  and  painful  in  almost  any  disease, 
however  trifling.  Enlargement  of  the  lymph-nodes  is  characteristic  of 
measles,  rotheln,  tuberculosis,  syphilis,  and  many  other  diseases,  and,  when 
acute,  is  commonly  attended  with  some  degree  of  fever.  Glandular  fever — 
Driisenfieber  of  Pfeiffer — is  a  definite  nosological  entity,  the  predisposing 
influences  to  which,  except  that  it  is  almost  exclusively  a  disease  of  child- 
hood, are  wholly  unknown.     It  occurs  sporadically  and  in  epidemics. 

The  EXCITING  CAUSE  has  not  yet  been  determined. 

Symptoms. ^The  onset  is  sudden,  with  a  rise  of  temperature  to  101°- 
103T.  (3S.5°-39.5°C.).  There  is  pain  on  moving  the  head  and  neck, 
together  with  nausea,  vomiting,  and  abdominal  pain.  The  angina  is  not  as 
a  rule  intense  nor  of  long  duration.  The  adenopathy  shows  itself  upon  the 
second  or  third  day,  the  glands  becoming  enlarged  in  varying  degree  to 
the  size  of  a  walnut,  painful  and  tender  to  the  touch.  There  is  slight  peri- 
glandular oedema,  but  no  general  swelling  or  redness,  and  but  little  diffi- 
culty in  swallowing.  In  a  limited  proportion  of  the  cases  sul)sternal 
uneasiness  and  an  unproductive,  paroxysmal  cough  are  the  signs  of  impli- 
cation of  the  tracheal  and  peribronchial  glands.  The  axillary,  inguinal, 
and  mesenteric  glands  are  sometimes  involved.  The  fever  is  of  short  dura- 
tion but  the  enlarged  glands  only  slowly  undergo  involution.  Suppuration 
has  been  noted. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  presence  of  the  foregoing 
symptom-complex.     The  differential  diagnosis  must  be  made  by  exclusion. 


838  MEDICAL  DIAGNOSIS. 

Prognosis. — Recovery  is  the  rule.  The  occurrence  of  suppuration  in 
some  of  the  affected  glands,  otitis  media,  retropharyngeal  abscess,  and 
severe,  even  hemorrhagic  nephritis  may  protract  the  illness  or  cause  it 
to  terminate  in  death;    but  these  accidents  are  infrequent. 


XXXIX.  MILIARY  FEVER. 

Sweating  Sickness. 

Definition. — An  acute  infectious  disease,  characterized  by  fever,  profuse 
sweating,  and  an  eruption  of  miliary  vesicles. 

Miliary  fever,  or  the  sweating  sickness,  prevailed  extensive!}'  in  Eng- 
land in  the  fifteenth  and  sixteenth  centuries.  Outbreaks  have  occurred 
within  recent  years  in  France,  Italy,  and  Austria.  They  have  sometimes 
extended  over  wide  areas;  more  frequently  they  have  been  limited  to 
districts  or  villages.  These  epidemics  have  lasted  in  some  instances  three 
or  four  weeks;  in  others  they  have  run  their  course  in  a  week  or  ten  days. 
When  the  disease  shows  itself  it  attacks,  like  influenza  and  dengue,  a  large 
number  of  persons  in  a  very  short  time. 

Etiology. — Nothing  is  known  of  the  pathogenic  principle  which  gives 
rise  to  miliary  fever. 

Symptoms. — After  prodromal  symptoms  of  short  duration,  the  attack 
sets  in  suddenly  with  moderate  fever,  profuse  sweating,  and  epigastric  dis- 
tress. These  symptoms  are  followed  by  an  erythematous  rash  and  the  copious 
eruption  of  miliary  vesicles,  most  abundant  upon  the  neck  and  trunk.  In  the 
more  severe  cases  the  symptoms  of  an  intense  infection — high  fever,  profound 
depression,  hemorrhage,  and  delirium — are  present.  Desiccation  and  desqua- 
mation occur.     The  duration  of  the  disease  varies  from  one  to  four  weeks. 

Diagnosis. — Direct. — This  rests  upon  the  development  of  an  acute 
Illness,  characterized  by  the  above  symptoms,  in  a  large  proportion 
of  the  inhabitants  of  a  locality  in  rapid  succession,  and  the  absence  of  the 
symptoms  of  influenza,  dengue,  or  other  infectious  maladies. 

Differential. — The  sweating  might  suggest  malaria,  but  the  orderly 
succession  of  chill,  fever,  and  sweat  which  characterize  the  ague  fit  in 
the  regularly  recurring  forms,  the  well-defined  periodicity,  the  effects 
of  quinine,  and  the  presence  of  Laveran's  parasite  in  the  blood  would 
settle  any  doubt.  Influenza  bears  a  strong  resemblance  to  miliary  fever. 
Its  pandemic  prevalence,  the  prominence  of  catarrhal  symptoms,  the 
frequency  of  high  fever,  and  the  absence  of  the  vesicular  rash  determine 
the  question  of  diagno.sis.  Dengue  differs  from  miliary  fever  in  its  geo- 
graphical distribution,  being  a  disease  of  tropical  and  subtropical  climates; 
in  its  mode  of  onset  and  course;  in  its  early  arthropathy; in  its  eruptions; 
and  in  the  fact  that  profuse  sweating  and  a  copious  vesicular  eruption  are 
uncommon.  Rheumatic  fever  might  suggest  miliary  fever  by  the  abundant 
perspirations  which  are  common;  but  the  prominence  and  migratory  char- 
acter of  the  arthritis,  the  higher  fever,  and  the  sporadic  or  endemic  occur- 
rence would  at  once  dispel  any  uncertainty  in  regard  to  the  diagnosis. 

Prognosis. — In  the  more  malignant  forms  death  occurs  in  the  course 
of  several  hours.  The  mortality  in  the  early  course  of  epidemics  is  high. 
In  some  of  the  recent  outbreaks  the  death-rate  has  been  low. 


FOOT-AND-MOUTH  DISEASE.  839 

XL.  FOOT-AND-MOUTH   DISEASE. 

Aphthous  Fever. 

Definition. — An  acute  infectious  disease  of  cattle,  sheep,  and  pigs, 
but  also  met  with  less  frequently  in  other  domestic  animals,  characterized 
by  fever,  salivation,  and  a  vesicular  eruption  upon  the  mucous  membrane 
of  the  mouth,  nose,  and  conjunctiva,  less  frequently  also  upon  that  of  the 
vulva  and  upon  the  udder  and  teats.  In  the  sheep,  goat,  and  pig  the  affec- 
tion manifests  itself  particularly  about  the  hoof,  while  in  the  horse  only 
the  oral  mucous  membrane  is  involved.  This  disease,  whica  occurs  in 
widespread  epizootics,  is  readily  transmissible  to  man,  and  numerous 
epidemics  have  been  described.     It  is  more  common  as  a  sporadic  affection. 

Etiology. — Predisposing  Influences. — All  those  occupations  which 
involve  contact  with  animals  suffering  from  the  disease,  their  fodder  or 
manure,  or  the  stables  in  which  they  are  housed,  predispose  to  the  disease. 

Exciting  Cause. — The  infecting  principle  has  not  been  isolated. 
Its  presence  in  the  contents  of  the  vesicles  and  in  the  saliva,  milk,  and 
urine,  has  been  demonstrated  by  intravenous  and  intraperitoneal  injec- 
tion. It  retains  its  virulence  in  stalls,  fodder,  and  dung  heaps  for  a  period 
of  several  months,  and  is  capable  of  transportation  to  indefinite  distances 
by  fomites.  The  most  common  source  of  infection  m  man  is  by  the  raw 
milk  of  infected  animals.  Herbwig's  experiments  upon  himself  and  his 
assistants  demonstrated  this  mode  of  transmission  beyond  doubt.  The 
cream  also  contains  the  virus,  as  well  as  butter,  curds,  and  cheese  made 
from  the  infected  milk.  The  possibility  of  acquiring  the  disease  bj^  hand- 
ling the  meat  of  infected  animals  is  to  be  considered,  though  prolonged 
cooking  may  render  it  innoxious  as  an  article  of  food. 

Symptoms. — In  man,  after  an  incubation  period  of  from  three  to 
five  or  eight  days,  the  disease  begins  with  lassitude  and  pains  in  the  head, 
back,  and  limbs.  These  symptoms  are  associated  with  dryness  of  the  mouth, 
difficulty  in  swallowing,  and  nervous  symptoms,  such  as  vertigo  and 
insomnia.  Complete  loss  of  appetite,  vomiting,  and  fever  ensue.  The  last 
is,  however,  by  no  means  a  constant  symptom.  In  some  cases  there  is 
nose-bleeding.  If  the  infection  has  occurred  by  way  of  the  oral  mucosa 
there  are  seen,  in  the  course  of  a  day  or  more,  vesicles  which  come  out  in 
successive  crops  and  are  preceded  by  a  more  or  less  diffuse  and  very  painful 
inflammation.  In  the  course  of  a  short  time  the  vesicles  increase  in  size 
and  then  rupture,  leaving  superficial  ulcers  which  graduall}^  heal  with 
scars.  There  is  salivation,  great  pain  in  eating,  and  a  fetid  breath.  Urti- 
caria and  roseolous  and  scarlatiniform  rashes  appear,  and  in  some  cases  crops 
of  vesicles  resembling  the  vesicles  upon  the  mucous  membrane  of  the  mouth. 
The  last  gradually  undergo  desiccation  and  healing  without  ulceration. 
When  infection  takes  place  by  way  of  lesions  upon  the  skin,  constitutional 
symptoms  develop  first,  vesicles  appear  near  the  seat  of  infection,  the 
above-described  rashes  follow,  and  sometimes,  but  by  no  means  invariably, 
the  vesicles  subsequently  develop  in  the  mouth. 

Diagnosis. — Direct. — This  rests  upon  the  presence  of  the  foregoing- 
symptoms    in    an   individual    who    has    been   exposed    to    the   danger  of 


840  MEDICAL  DIAGNOSIS. 

contact  with  infected  animals  or  their  surroundings,  or  of  eating  infected 
food  products.  In  a  doubtful  case,  experimental  inoculation  should  be 
practised  and  for  this  purpose  the  calf,  on  account  of  its  greater  suscepti- 
bility, should  be  selected. 

Differential. — The  ordinary  form  of  aphthous  stomatitis  is  not 
attended  by  the  constitutional  symptoms  of  a  severe  infection,  nor 
accompanied  by  cutaneous  rashes.  The  vesicles  run  their  course  so  rapidly 
that  they  are  seldom  seen  prior  to  the  formation  of  the  circumscribed  painful 
ulcers,  with  sharp  edges  and  yellow  bases,  to  which  they  give  rise.  The 
acute  exanthemata  may  be  suggested  by  the  constitutional  symptoms 
and  the  buccal  and  cutaneous  eruptions.  Varicella,  however,  usually  lacks 
the  fever  and  lassitude  of  foot-and-mouth  disease;  measles  is  character- 
ized by  catarrhal  symptoms  not  present  in  the  affection,  and  scarlet  fever 
by  a  diffuse  non-vesicular  angina  and  generalized  erythema  developing 
within  forty-eight  hours  after  an  abrupt  onset.  Diphtheria,  which  may  be 
suggested  by  the  appearance  of  the  ulceration  in  the  mouth  in  certain 
cases,  reveals  its  pathological  identity  by  the  Klebs-Loffler  bacillus.  In 
any  suspicious  case  the  etiological  factor  in  diagnosis  is  important. 

Prognosis. — In  a  majority  of  the  cases  in  adults  recovery  takes  place 
in  two  or  three  weeks.  Owing  to  the  difficulty  in  taking  food,  and  the 
serious  nature  of  the  gastro-intestinal  derangements  in  children,  the  out- 
look is  far  more  serious,  and  progressive  emaciation  and  debility  are  fre- 
quently followed  by  death.  Septic  infection  by  way  of  the  mucous  and 
cutaneous  lesions  may  prolong  the  illness. 

XLI.  ERYSIPELOID  OF   ROSENBACH. 

Erythema  Migrans;   Erythema  Serpens. 

Definition. — An  erythematous  inflammation  of  the  fingers,  due  to 
the  inoculation  of  an,  as  yet,  undetermined  pathogenic  principle,  associated 
with  putrescent  animal  matter,  and  characterized  by  swelling,  tension, 
dark  red  or  purplish  discoloration,  well-defined  edges,  and  a  tendency  to 
advance  from  the  point  of  origin,  with  moderate  pain,  some  itching  and 
burning,   and  the  absence  of  constitutional  symptoms. 

Etiology. — Predisposing  Influences. — Erysipeloid  is  a  compara- 
tively rare  disease.  It  has  been  especially  studied  by  Rosenbach  in  Germany 
(1887),  and  Gilchrist  (1904)  and  Jopson  (1908)  in  this  country.  Occupa- 
tion constitutes  the  most  important  predisposing  influence.  The  affection 
occurs  almost  without  exception  among  those  who  are  engaged  in  handling 
dead  animal  matter  under  conditions  which  render  it  liable  to  putrefaction, 
as  dealers  in  fish  (especially  shell-fish),  game,  and  poultry,  and  butchers 
and  cooks.  Medical  students,  laboratory  workers,  and  taxidermists  are  also 
liable  to  the  infection.  Those  who  handle  crabs  are  especially  exposed  to 
the  danger  of  contracting  erysipeloid,  which  is  sometimes  spoken  of  as 
"crab  cellulitis." 

Exciting  Cause. — Rosenbach  and  others  have  described  a  cladothrix, 
but  subsequent  investigators  have  failed  to  obtain  such  an  organism. 
The  manner  of  inoculation,  the  nature  of  the  lesions,  the  constant  cHnical 


ERYTHEMA  INFECTIOSUM.  841 

course  of  the  disease,  and  the  pathological  findings,  which  are  those  of 
an  inflammation  of  the  entire  corium,  and,  to  some  extent  also,  of  the 
subcutaneous  tissue,  are  suggestive  of  a  specific  infection.  No  specific 
organism  has,  however,  been  demonstrated. 

Symptoms. — The  infection  results  from  an  injury  to  the  skin.  There 
may  be  a  number  of  small  wounds.  The  period  of  incubation  varies  from 
a  few  hours  to  several  days,  being  commonly,  however,  about  forty-eight 
hours.  The  inflamed  skin  is  tense,  livid,  elevated  above  the  level  of  the 
adjacent  surface,  and  characterized  by  a  sharply  defined  border  which 
advances  toward  the  hand  and  may  invade  the  palm,  the  dorsum  of  the 
hand,  and  other  fingers  than  the  one  first  affected.  As  the  border  advances 
resolution  takes  place  in  the  part  first  attacked.  Suppuration  does  not 
occur  nor  do  vesicles,  as  a  rule,  develop.  Complete  recovery  takes  place  in 
a  period  varying  from  two  or  three  to  ten  or  fifteen  days.  Fever  and 
other  constitutional  symptoms  do  not  occur. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  foregoing  characters 
and  may  usually  be  made  without  difficulty.  The  differential  diagnosis 
from  the  cellulitis  caused  by  pyogenic  organisms  rests  upon  the  mode  of 
infection  in  the  latter,  the  occurrence  of  suppuration,  and  the  presence  of 
pus-producing  bacteria  in  the  exudate;  and  from  erysipelas  by  the  absence 
of  constitutional  symptoms  and  the  trifling  nature  of  the  erysipeloid 
affection.     The  prognosis  is   uniformly  favorable. 

XLII.   ERYTHEMA  INFECTIOSUM. 

In  1896  Escherich  described  a  feebly  contagious  disease  of  childhood 
characterized  by  a  rose-colored  maculopapular  rash  with  trifling  subjec- 
tive symptoms,  among  which  a  mild  erythematous  sore  throat  is  mentioned. 
The  incubation  period  varies  from  six  to  fourteen  days  and  the  rash 
appears  first  upon  the  face  and  consists  of  maculopapules,  in  some  instances 
sharply  marginate,  in  others  gradually  fading  into  the  healthy  sldn.  It 
disappears  momentarily  upon  pressure.  In  the  course  of  twenty-four 
hours  it  invades  other  parts  of  the  body,  sometimes  presenting  the  appear- 
ance of  urticaria.  It  is  especially  marked  upon  the  extensor  and  outer 
surfaces  of  the  extremities.  It  lasts  from  six  to  ten  days,  fading  first 
upon  the  face,  where  it  first  appeared,  and  is  not  followed  by  desquama- 
tion. The  superficial  lymph-nodes  are  not  enlarged.  The  attack  does  not 
confer  immunity  from  scarlet  fever,  measles,  or  rubella.  No  outbreaks 
have  been  observed  in  America.  The  direct  diagnosis  rests  upon  the  char- 
acter of  the  rash  and  its  distribution,  the  absence  of  constitutional  symp- 
toms, and  mild  transmissibility.  The  differential  diagnosis  from  these 
diseases  depends  upon  the  absence  respectively  of  their  specific  etiologic 
and  clinical  manifestations.  Erythema  infectiosum  bears  only  the  most 
remote  resemblance  to  scarlet  fever,  measles,  rubella,  urticaria,  and  certain 
drug  rashes. 


842  MEDICAL  DIAGNOSIS. 


II- 

THE  DIAGNOSIS  OF  DISEASES  CAUSED  BY  ANIMAL  PARASITES. 

A.     DISEASES   DUE   TO   PROTOZOA, 
i.  Psorospermiasis. 

This  term  is  applied  to  the  diseases  produced  by  the  sporozoa  other 
than  hsemospiridia — protozoa  that  only  live  parasitically  in  the  cells,  tumors, 
or  organs  of  other  animals.  They  are  mostly  cytozoa.  This  class  includes 
Gregarinida  and  Coccidiidea.  The  latter  is  the  cause  of  a  disease  common 
in  the  rabbit  in  which  the  liver  is  the  seat  of  small  whitish  nodules,  seen 
upon  section  to  be  dilatations  of  biliary  ducts.  Coccidia  are  found  in  the 
epithelial  cells  lining  these  cyst-like  dilatations.  Rainey's  corpuscles  or 
tubes  are  ovoid  bodies  containing  sickle-shaped,  unicellular  organisms — 
Sarcocystis  miescheriana — found  within  the  sarcolemma  of  various  ani- 
mals, especially  the  hog. 

Visceral  Psorospermiasis;  Coccidiosis. — Infection  takes  place  by 
swallowing  the  spores  or  oocj^sts  containing  spores.  The  gastric  juice 
causes  the  spores  to  open  and  frees  the  sporocytes,  which  by  way  of  the 
common  duct  reach  the  biliary  ducts  and  penetrate  the  epithelial  cells. 
A  limited  number  of  cases  has  been  observed  in  man. 

Symptoms. — Those  of  severe  infection:  fever  (sometimes  intermittent), 
dry  tongue,  nausea,  diarrhoea,  and  tenderness  over  the  liver  and  spleen, 
which  are  enlarged.  The  parasites  have  also  been  found  in  the  ureters 
and  kidneys.     The  diagnosis  during  life  has  not  been  made. 

ii.   Amoebic   Dysentery. 

Definition. — A  colitis  caused  by  Amoeba  dysenterige  and  character- 
ized by  pain,  tenesmus,  and  frequent  stools  containing  mucus  and  blood. 
Dysentery  occurs  as  an  acute  and  chronic  disease.    Liver  abscess  is  common. 

Etiology. — Predisposing  Influences. — Dysentery  is  more  prevalent 
in  tropical  countries.  In  Egypt  and  India  it  is  endemic,  frequently  epi- 
demic. It  occurs  sporadically  in  all  temperate  climates.  It  is  a  water- 
borne  disease  and  infection  may  take  place  by  drinking  contaminated  water, 
or  eating  raw  vegetables  washed  with  it. 

Exciting  Cause. — Amoeba  dysenterire,  first  described  by  Lambl  in 
1859,  later  by  Losch  in  1875,  is  classed  among  the  Rhizopoda.  This  organ- 
ism frequently  exhibits  the  differentiation  betw^een  the  hyaline  ecto-  and 
the  granular  endosarc  very  clearly,  especially  in  the  pseudopodia.  It 
contains  a  vesicular  nucleus  and  contracting  vacuoles.  Amoebse  are  seen 
in  great  numbers  in  the  stools,  being  found  especially  in  the  shreds  of 
mucus  or  pus,  in  the  pus  of  liver  abscess  and  abscess  in  other  positions 
which  occasionally  occur,  and  in  the  purulent  expectoration  in  hepatic 
abscess  discharging  by  way  of  a  pulmonary  fistula.    An  amoeba  frequently 


DISEASES  DUE  TO  PROTOZOA.  843 

contains  red  blood-corpuscles.  They  can  be  grown  in  cultures  from  the 
stools  and  intestinal  ulcers  but  not  readily  alone,  a  symbiotic  organism 
being  required.  Amoeba  coli  has  been  found  in  the  stools  of  healthy  per- 
sons.   There  may  be  different  varieties,  of  which  some  are  non-pathogenic. 

The  lesions  to  which  this  organism  gives  rise  are  situated  in  the  large 
bowel,  sometimes  reaching  as  high  as  the  lower  part  of  the  ileum.  They 
consist  of  an  inflammatory  infiltration  of  the  submucosa,  followed  by 
necrosis  and  sloughing  of  the  mucous  membrane,  which  results  in  the 
formation  of  circumscribed  round,  oval,  or  irregular  ulcers  with  overhanging 
borders.  The  base  of  the  individual  ulcer  consists,  according  to  stage  of 
development,  of  the  submucous,  muscular,  or  serous  coat  of  the  gut.  There 
is  a  remarkable  tendency  to  extend  by  undermining  the  mucous  mem- 
brane with  the  formation  of  deep, 
serpiginous  ulcerating  tracts  or  fis-  ^^s^ 

tula.      In    severe    cases    the    entire  I^O-"-'''  ,__  ^y,         WJ 

intestine   is   greatly   thickened    and  "■^'       ^  ^-^  'l|j|ID"^'--: 

extensively    ulcerated.      When    the  \  ■^, 

process  is  less  extensive,  the  rectum,         "-   \^'^''  .  ^ 

the  hepatic  and  sigmoid  flexures,  and         '        -   v''    ', ',     '  " 
the  caecum  are  points  of  selection. 

Healing  leads  to  extensive  new  form-  - 

ation  of  fibrous  tissue  and  constric-  ^'3'  ..  ;>C''^"""^^  ■ 

tion  of  the  bowel. 

The  lesions  of  the  liver  consist 
of,  (a)  local  necrosis  of  hepatic  tissue 

in  scattered  patches,  and  (b)  abscess      -. .  ^g,     %'t^  If^'v 

formation.      The    abscess    may    be 
multiple   and  scattered  throughout 
the  organ,  or  single.     The  latter  are 
usually  situated  in  the  right  lobe  and      '  ^Ty'' 
under  the  convex  or  diaphragmatic     i    .-..         .      .•  .    _  [■^T^"^] 

surface;     less    frequently    near    the  Fig.  283.— Amceba  dysenterite. 

concave  intestinal  surface.     In  the 

former  case  rupture  frequently  takes  place  into  the  lung  or  pleura. 
Less  commonly,  according  to  its  location,  the  abscess  may  rupture  into 
the  inferior  vena  cava,  pericardium,  peritoneum,  stomach,  intestine,  or 
the  portal  or  hepatic  vein. 

Symptoms. — AcL'TE  Form. — This  form  is  characterized  by  sudden 
onset,  pain,  tenesmus,  frequent  stools  containing  blood  and  mucus.  Large 
sloughs  may  be  passed.  There  is  fever,  not  often  intense.  Rapid  emaciation 
occurs  and  the  patient  maj^  die  in  the  course  of  a  week  or  two.  Hemorrhage 
of  the  bowels  may  take  place  or  perforation  with  peritonitis.  Recovery 
is,  however,  the  rule.  In  a  considerable  proportion  of  the  cases  the  disease 
becomes  chronic.     There  is  a  moderate  leucocytosis — 9000  to  16,000. 

Chronic  Form. — The  disease  may  be  insidious  in  onset.  There  are  sub- 
acute d5''senteric  attacks  with  pain,  frequent  stools,  mucus  and  blood,  and  slight 
fever.  These  spells  alternate  with  periods  of  constipation.  The  patients  may 
have  fairly  good  health,  but  are  liable  to  indigestion,  and  the  attacks  are 
readily  brought  on  by  errors  of  diet,  over-fatigue,  sudden  chilling  and  the  like. 


■^^^" 


844 


MEDICAL  DIAGNOSIS. 


Diagnosis. — Direct. — The  intestinal  symptoms — pain,  tenesmus,  fre- 
quent stools  with  blood  and  mucus — justify  a  diagnosis  of  dysentery;  the 
presence  of  amoebae  in  the  discharges,  a  diagnosis  of  amcebic  dysentery, 
alike  in  the  acute  and  chronic  cases. 

Hepatic  abscess  maybe  entirely  latent.  More  commonly  there  is  enlarge- 
ment of  the  liver  at  its  upper  or  lower  aspect  with  recurrent  chills,  fever,  sweat- 
ing, local  pain,  and  oedema.  The  leucocytosis  is  high.  With  the  establishment 
of  a  pulmonary  fistula  there  is  dark  expectoration  containing  amoebae. 

Differential. — Bacillary  Dysentery. — The  diagnosis  rests  upon  the 
absence  of  amoebae  and  the  agglutinating  power  of  the  blood-serum  for 
the  bacilli,  and  the  more  pronounced  toxaemia.  Proctitis. — Tenesmus  and 
mucohemorrhagic  stools  may  suggest  dysentery,  but  the  slight  and 
transient  nature  of  the  attack  and  its  manifest  local  character  are  of  diag- 
nostic importance. 

Prognosis. — Many  cases  recover  but  the  tendency  to  recurrence  is  marked. 
The  mortality  is  about  25  per  cent.  Hepatic  abscess  adds  greatly  to  the  grav- 
ity of  the  outlook. 

iii.  Trypanosomiasis. 

Sleeping  Sickness. 

Definition. — A  chronic  disease  caused  in  man  by  Trypanosoma 
gambiense  and  characterized   by  undulant  fever,  rapid  pulse,  weakness, 

_^     loss  of  flesh,  and  frequently  a  pro- 
tracted lethargy. 

Etiology.  —  Predisposing  In- 
fluences.— As  a  disease  of  horses 
and  cattle  trypanosomiasis  is  known 
as  siirra  in  India  and  the  Philippines 
and  is  prevalent  in  South  Africa. 
Africa  has,  in  fact,  no  less  than  six 
trypanosomal  diseases,  all  of  them 
very  important:  nagana,  dourine, 
galziekte,  zouspana,  Gambian  horse 
disease,  and  human  trypanosomiasis. 
Human  trypanosomiasis  is  widely 
distributed  in  Uganda  and  the  West 
Coast  of  Africa.  It  is  conveyed  by 
the  tsetse  fly. 

Exciting  Cause. — This  flagel- 
late protozoon  was  first  discovered 
by  Gruby  in  the  blood  of  the  frog 
in  1843.  The  organism  is  a  unicel- 
lular, elongated  body  having  an 
undulating  fold  or  membrane  upon 
the  dorsal  edge  which  terminates 
in  a  flagellum  of  varying  length. 
Stained  specimens  show  a  large  nucleus  and  a  small  chromatin  mass  near  one 
pole.     It  has  recently  been  grown  by  Novy  on  artificial  media  in  the  labo- 


fit-rofti 


Fig.  284. — Trypanosoma  gambiense. — After  Bruce 
and  Nabarro. 


DISEASES  DUE  TO  PROTOZOA.  845 

ratory.  It  was  later  noted  to  be  a  common  blood  parasite  in  birds  and  fishes. 
It  was  found  in  1878  by  Lewis  in  the  rat  and  subsequently  in  cattle  and 
horses  by  Evans  (1880)  and  Bruce  (1895).  Dutton  first  recognized  trypano- 
somes  in  the  blood  of  human  beings  in  1902.  Trypanosomes  have  been 
observed  with  great  frequency  in  the  sleeping  sickness  or  African  lethargy 
and  have  a  causal  relation  to  that  disease. 

Symptoms. — As  in  the  case  of  rats  and  other  animals,  trypanosome 
infection  may  be  latent  in  human  beings.  Trypanosome  Fever. — The 
symptoms  consist  of  irregular  fever,  rapid  pulse,  weakness,  swelling  of  the 
lymph-nodes  and  spleen,  and  oedema  of  the  feet.  This  form  of  the  disease 
has  been  produced  in  monkeys  by  inoculation.  Sleeping  Sickness. — The 
period  of  latency  may  be  extremely  prolonged,  in  some  instances  reaching 
five  years.  In  a  case  of  Manson's,  symptoms  developed  in  a  fortnight. 
The  early  symptoms  are  dulness,  apathy,  headache,  fever,  difficulty  in 
walking,  tremor  of  the  hands,  and  mumbling  speech.  The  fever  and 
drowsiness  increase,  the  patient  has  to  be  aroused  to  take  food  and  finally 
cannot  be  aroused  at  all.  Death  usually  results  from  some  complication, 
as  septic  meningitis. 

Diagnosis. — Direct. — Exposure  in  an  infected  region,  the  history  of 
an  insect  bite  (especially  by  the  African  tsetse  fly,  Glossina  palpalis),  the 
varying  but  prolonged  period  of  latency,  the  peculiar  symptom-complex 
(especially  the  progressively  deepening  lethargy),  and  the  presence  of  try- 
panosomes in  the  blood  and  cerebrospinal  fluid  are  characteristic. 

Prognosis. — Sleeping  sickness  is  a  very  fatal  disease.  The  duration 
after  distinctive  symptoms  have  occurred  varies  from  three  to  twelve 
months.     Recoveries  have  followed  treatment  by  atoxyl. 

iv.  Dum=dum   Fever. 

Kala-azar. 

Definition. — A  chronic  disease  of  the  East  due  to  a  protozoon  of 
the  flagellate  type  and  characterized  by  irregular  fever,  pulmonary  con- 
gestion, anaemia,  recurrent  oedema  of  the  feet,  enlargement  of  the  spleen 
and  liver,  and  occasionally  subcutaneous  hemorrhages.  This  disease 
is  identical  with  tropical  cachexial  fever  and  has  been  called  Leishman- 
Donovan  disease. 

Etiology. — Predisposing  Influences. — Dum-dum  fever  is  prevalent 
in  Oriental  countries  and  occurs  in  Egypt.    The  European  races  rarely  suffer. 

Exciting  Cause. — The  bodies  discovered  by  Leishman  in  1900  and 
independently  by  Donovan  in  1903,  and  regarded  by  Laveran  and  Mesnil 
as  a  new  species  of  Piroplasma,  have  been  found  in  the  liver  and  spleen 
by  puncture  during  life  and  also,  in  the  majority  of  cases,  in  the  circulating 
blood.  They  have  been  found  in  the  mesenteric  glands,  intestinal  ulcers, 
and  bone-marrow.  In  stained  smears  of  the  fluid  from  the  spleen  and  liver 
they  appear  as  elongated  oval  or  circular  bodies  with  a  spherical  nucleus 
against  the  capsule  and  a  rod-like  body  on  the  other  side.  They  occur  singly 
and  in  pairs  and  packed  in  phagocytic  cells  in  the  juice  of  the  liver  and 
spleen  and  in  zoogloea  masses  in  the  lung.    Malarial  parasites  are  not  found. 


846 


MEDICAL  DIAGNOSIS. 


Symptoms. — Constant  enlargement  of  the  spleen;  usual  but  not 
invariable  enlargement  of  the  liver;  moderate  anemia;  leucopenia;  irreg- 
ular fever  prolonged  for  many  months  with  occasional  remissions;  hemor- 
rhages, subcutaneous  and  from  mucous  surfaces,  especially  the  gingival 
and  nasal  mucosa;  transitory  oedemas,  particularly  of  the  legs  and  feet; 
and  more  or  less  marked  pallor  and  pigmentation  of  the  skin — these  consti- 
tute the  clinical  picture.  Dysenterj'  and  various  secondary  infections  occur. 
Prognosis. — Two  forms  of  the  disease  are  encountered,  an  intense  form 
with  recurrent  attacks  of  high  fever  and  rapidly  developing  cachexia, 
which  terminates  fatally  in  a  few  months,  and  a  much  milder  form  both 

as  regards  fever  and  cachexia, 
which  runs  a  protracted 
course,  death  usually  resulting 
from  some  intercurrent  dis- 
ease. The  mortality,  according 
to  Leishman,  varies  from  70 
to  96  per  cent. 


V.   Malarial  Fevers. 

Definition. — A  group  of 
infectious  diseases  caused  by 
the  Hsemosporidia  (Plasmo- 
dia) described  by  Laveran 
and  transmitted  to  man  by 
the  bite  of  the  similarly  infected 
mosquito,  comprising,  (a)  regu- 
larly intermitting  periodical 
fever  of  tertian  or  quartan 
type,  (b)  irregular  fever  of 
remittent  or  continued  type, 
and    (c)    a    chronic    cachexia 


Fig.  285. — Leishman-Donovan  bodies.  1,  three  par- 
asites showing  chromatin  masses;  2,  3,  4,  5,  parasites  showing 
fission. — After  Christophers,  a,  parasite  from  spleen;  6,  c,  d, 
e,  large  parasites  from  cultures;  f,g.h,  bodies  showingflagella; 
i.  j,  k,  forms  exhibiting  unequal  longitudinal  fission;  I,  two 
spirillar  forms  separated  from  parasite. — After  Leishman. 


-The    geographical    distribu- 


and  pernicious  fever,  often  rapidly  fatal, 
with  anaemia  and  enlargement  of  the  spleen. 
Etiology. — Predisposing  I^FLUENCES 
tion,  formerly  wide,  is  becoming  more  restricted.  The  conditions  necessary 
for  the  breeding  of  the  mosquito,  namely,  heat  and  moisture,  are  every- 
where predisposing  factors  to  malaria.  Regions  of  special  prevalence  are 
found  in  tropical  and  subtropical  countries,  as  Panama,  Central  America, 
India,  and  Northern  Africa,  especially  along  the  coasts  and  in  the  river 
basins.  In  Europe,  Southern  Russia  and  Lower  Italy  are  still  highly 
malarious.  Germany  and  France  are  almost  free,  while  the  prevalence  of 
the  disease  in  Holland  and  England  has  practically  ceased.  In  the  United 
States  the  malarial  fevers  have  steadily  diminished  since  the  colonial  period. 
At  the  time  of  the  first  settlement  of  the  country  the  prevalent  fevers  were 
malarial;  as  clearings  Avere  made  and  the  soil  tilled  and  drained,  malarial 
fevers  and  enteric  fever  prevailed  side  by  side  until  at  length  malarial 
fevers  disappeared  and  enteric  fever  became  predominant.  Malarial  fever 
has  almost  disappeared  from  New  England  and  New  York.  It  is  now  com- 
paratively infrequent  in  Eastern  Pennsylvania,  New  Jersey,  and  Maryland. 


DESCRIPTION  OF  PLATE  XIII. 

The  Parasite  of  Tertian  Fever.   (Drawn  b}'  Mr.  Br5del  for  Thayer  and  Hewetson's  paper,  The  Malarial 
Fevers  of  Baltimore,  Johns  Hopkins  Hospital  Reports,  Volume  V.    We  copy  the  original  legend.) 

1.  Normal  red  corpuscle. 
2,  3,  4.  Young  hyaline  forms.    In  4,  a  corpuscle  contains  three  distinct  parasites. 
5,  21,  Beginning  of  a  piginentatiou.  The  parasite  was  observed  to  form  a  true  ring  by  the  confluence 
of  two  pseudopodia.    During  observation  the  body  burst  from  the  corpuscle,  which  became 
decolorized  and  disappeared  from  view.     The  parasite  became,  almost   immediately, 
deformed  and  motionless,  as  shown  in  Fig.  21. 
6,  7,  8.  Partly  developed  pigmented  forms. 

9.  Full  grown  body. 
10-14.  Segmenting  bodies. 

15.  Form  simulating  a  segmenting  body.    The  significance  of  these  forms,  several  of  which  have 
been  observed,  is  not  clear  to  the  writers,  who  have  never  met  with  similar  bodies  in  stained 
specimens  so  as  to  be  able  to  study  the  structure  of  the  individual  segments. 
16, 17.  Precocious  segmentation. 
18, 19,  20.  Large  swollen  and  fragmenting  extra-cellular  bodies. 
22.  Flagellate  body. 
23,  24.  "Vacuolization. 

The  Parasite  op  Quartan  Fever. 

25.  Normal  red  corpuscle. 

26.  Young  hyaline  form. 

27-34.  Gradual  development  of  the  intra-corpuscular  bodies. 

35.  Full  grown  body.  The  substance  of  the  red  corpuscle  is  no  more  visible  in  the  fresh  specimen. 
36-39.  Segmenting  bodies. 

40.  Large  swollen  extra-cellular  forms. 

41.  Flagellate  body. 

42.  Vacuolization. 


PLATE  XIII. 


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DISEASES  DUE  TO  PROTOZOA.  847 

It  still  prevails  in  many  regions  of  the  South,  especially  on  the  Gulf  Coast. 
The  Northwestern  States,  the  Pacific  Coast,  and  the  regions  north  of  the 
St.  Lawrence  are  practically  free  from  it. 

Season. — In  the  tropics  the  maximum  prevalence  corresponds  to  the 
rainy  season,  the  minimum  to  the  dry.  In  temperate  climates  there  are 
a  few  cases  in  the  spring,  usually  relapses — vernal  intermittent.  The  greater 
number  of  cases  occur  in  the  early  autumn — primary  infection. 

Locality. — Genera  of  the  subfamily  Anophelina,  the  only  mosquitoes 
in  which  the  malarial  parasite  of  man  develops,  are  distinctly  rural  insects, 
breeding  in  small,  shallow  pools  and  stagnant  waters,  in  contradistinction 
to  Culicinse,  which  prefer  human  habitations  and  cities  and  deposit 
their  ova  in  tanks  and  cisterns.  Hence  malarial  diseases  prevail  more 
extensively  outside  of  cities. 

Exciting  Cause. — To  Laveran,  a  French  Army  surgeon,  is  due  the 
credit  of  having  discovered  in  1880,  in  Algiers,  in  the  blood  of  patients 
suffering  from  malarial  fever,  the  hsematozoon  which  he  recognized  as 
parasitic  and  regarded  as  the  cause  of  the  disease.  A  great  number  of 
observers  have  contributed  to  our  knowledge  of  the  subject.  Among  the 
most  important  steps  in  the  development  of  that  knowledge  are  the  follow- 
ing: that  the  febrile  paroxysm  coincides  with  the  sporulation  or  segmen- 
tation of  a  group  of  parasites;  that  the  tertian,  quartan,  and  pernicious 
fevers  are  due  to  different  parasites;  that  infection  takes  place  by  the  bite 
of  the  mosquito,  species  of  the  subfamily  Anophelinse;  that  the  infecting 
mosquito  must  itself  be  previously  infected  by  the  blood  of  an  individual 
suffering  from  malaria;  and  that  the  malarial  parasites  of  man  require 
two  different  hosts  for  their  complete  development — the  asexual  cycle 
taking  place  in  the  blood  of  man,  the  intermediate  host,  and  the  sexual 
cycle  in  Anophelinffi,  the  definitive  host.  So  far  as  our  present  knowledge 
of  the  life  history  of  the  malarial  parasites  goes  they  exist  only  in  the 
mosquito  and  man. 

The  parasite  belonging  to  the  class  Sporozoa,  order  Hsemosporidia, 
has  received  many  different  names.  It  was  designated  Plasmodium  malarice 
by  Marchiafava  and  Celli,  and  this  term,  although  unsuitable  according  to 
the  rules  of  zoological  nomenclature,  has  remained  in  general  use. 

The  Parasite  in  Man. — Schizogonous  Cycle. — Three  species  are  recog- 
nized, differing  morphologically  and  in  the  form  of  fever  which  they  cause. 
They  are  (a)  the  tertian  (Plasmodium  vivax),  (b)  the  quartan  (Plasmodium 
malarise),  and  (c)  the  estivo-autumnal  (Plasmodium  immaculatum). 

Tertian  Parasite  (Plasmodium  vivax). — This  species  is  the  cause 
of  tertian  fever.  Its  cycle  of  development  occupies  forty-eight  hours. 
It  appears  first  in  the  red  blood-corpuscles  as  a  round  or  irregular  unpig- 
mented  body  which  gradually  increases  in  size.  In  the  course  of  a  few 
hours  it  has  become  ring-shaped  and  shows  fine  melanin  granules.  It 
contains  a  large  nuclear  body  in  which  there  is  a  small  chromatin  mass. 
There  are  now  active  amoeboid  movements  which  do  not  cease  upon  expo- 
sure to  the  temperature  of  the  room.  .The  affected  blood-corpuscles  become 
enlarged  and  lose  their  color.  The  pigment  increases  in  amount.  Toward 
the  end  of  forty-eight  hours  the  full-grown  parasite  occupies  the  greater 
part  of  the  swollen  corpuscle.    At  this  time  many  of  the  parasites  undergo 


848  MEDICAL  DIAGNOSIS. 

the  process  known  as  segmentation  or  sporulation,  in  which  the  melanin 
granules  are  collected  into  a  compact  mass  and  the  protoplasm  divides 
into  spores,  numbering  from  15  to  20,  mostly  collected  into  an  irregular 
heap  around  the  pigment  mass,  sometimes  having  a  radial  arrangement. 
The  spores — merozoites — which  represent  the  sexually  undifferentiated 
individuals,  finally  separate  from  the  central  mass  of  pigment  granules 
and  from  each  other,  pass  into  the  blood-serum,  and,  attacking  fresh  blood- 
corpuscles,  cause  subsequent  paroxysms  of  fever.  Some  of  the  full-grown 
tertian  parasites  do  not  undergo  this  process  of  sporulation,  but,  attaining 
a  size  larger  than  the  reel  corpuscles,  show  abundant  coarse  pigment 
granules  in  active  commotion  and  represent  the  sexually  differentiated 
forms — gametocytes. 

Quartan  Parasite  (Plasmodium  malarice). — This  species  is  the 
■cause  of  quartan  fever.  Its  cycle  of  development  is  seventy-two  hours. 
It  appears  abruptly  after  the  paroxysm  in  the  form  of  a  small,  unpigmented 
body  with  sluggish  amoeboid  movements  on  the  surface  of  the  red  corpuscle. 
As  it  increases  in  size  it  penetrates  within  the  corpuscle,  where  it  presents 
an  appearance  very  much  like  that  of  the  tertian  parasite,  but  smaller. 
At  the  end  of  twenty-four  hours  melanin  granules,  coarser  than  those  of 
the  tertian  parasite  and  mostly  situated  at  the  periphery,  begin  to  form. 
As  the  pigment  increases  and  the  parasite  develops  the  amoeboid  movements 
become  more  sluggish  and  finally  cease.  Forty-eight  hours  after  the  attack 
the  parasites  have  attained  a  diameter  of  one-half  to  two-thirds  that  of 
the  corpuscle.  In  sixty  hours  they  completely  fill  the  corpuscles,  of  which 
only  a  narrow  rim  of  a  yellowish-green  or  brassy  tint  remains,  which  in 
turn  presently  disappears.  The  melanin  grains  assume  a  radial  arrange- 
ment and  move  toward  the  centre,  while  the  periphery  now  becomes  pig- 
mentless  and  shows  the  indication  of  commencing  segmentation,  which 
about  the  expiration  of  the  third  day  is  complete,  each  parasite  separating 
into  nine  to  twelve  spores,  a  process  corresponding  to  a  fresh  attack  of 
fever.     Sexually  differentiated  parasites — gametocytes — persist. 

EsTivo-AUTUMNAL  Parasite  (Plasmodium  immaculatum;  Plasmo- 
dium prcBcox). — This  parasite  is  the  cause  of  estivo-autumnal  fever  and 
the  various  forms  of  malarial  fever  designated  tropical,  pernicious,  and 
malignant.  It  is  very  small,  not  exceeding  when  fully  developed  one-third 
to  one-half  the  diameter  of  the  red  blood-corpuscle.  It  is  very  active; 
its  pigment  is  colored,  scanty,  and  finely  granular.  The  affected  corpuscles 
are  frequently  shrunken,  crenated,  and  brassy.  Its  cycle  of  development 
is  forty-eight  hours,  but  the  processes  of  pigment  accumulation  and  develop- 
ment are  not  often  seen  in  the  peripheral  blood  since  they  take  place  in 
the  spleen,  liver,  bone-marrow,  and  cerebral  capillaries.  The  spores  are 
smaller  than  in  the  other  species,  arranged  radially,  and  range  in  number 
from  7  to  12.  After  the  illness  has  lasted  some  days — never  at  first — larger, 
crescentic,  ovoid,  and  round  bodies,  highly  refractive  and  containing  central 
masses  of  coarse  pigment,  are  seen.  The  crescentic  and  ovoid  bodies  do  not 
undergo  sporulation  and  represent  gametocytes.  If  the  disease  continues 
these  bodies  increase  rapidly  and  finally  may  be  the  only  form  present. 

These  sexually  differentiated  forms — gametocytes — are  incapable  of 
further  development  within  the  human  host,  but  in  the  abstracted  blood 


DESCRIPTIOX  OF  PLATE  XIY. 

The  Parasite  of  Aestivo-Autujinal  Fever.  (Drawn  by  Mr.  Brodel  for  Thayer  and  Hewetson's  paper, 
The  Malarial  Fevers  of  Baltimore,  Johns  Hopkins  Hospital  Reports,  Vol.  V.  We  copy  the  original 
legend.) 

1,  2.  Small  refractive  ring-like  bodies. 
3-6.  Larger  disc-Like  and  amoeboid  forms. 
7.  Ring-like  body  with  a  few  pigment  granules  in  a  brassy,  shrunken  corpuscle. 
8,  9,  10,  12.  Similar  pigmented  bodies. 

11.  Amceboid  body  with  pigment. 

13.  Body  with  a  clump  of  pigment  in  a  corpuscle,  showing  a  retraction  of  the  haemoglobin-con- 
taining substance  about  th«  parasite. 
14r-20.  Larger  bodies  with  central  pigment  clumps  or  blocks. 

21-24.  Segmenting  bodies  from  the  spleen.    Figs.  21-23  represent  one  body  where  the  entire  process 

of  segmentation  was  observed.  The  segments,  eighteen  in  number,  were  accurately  comited 

before  separation  as  in  Fig.  23.  The  sudden  separation  of  the  segments,  occurring  as  though 

some  retaining  membrane  were  ruptured,  was  observed. 

2.5-33.  Crescents  and  ovoid  bodies.    Figs.  30  and  31  represent  one  body  which  was  seen  to  extrude 

slowly  and,  later,  to  withdraw  two  rounded  protrusions. 
34,  35.  Round  bodies. 

36.  "Gemmation,"  fragmentation. 

37.  Vacuolization  of  a  crescent. 

38-40.  Flagellation.  The  figures  represent  one  organism.  The  blood  was  taken  from  the  ear  at  4.15 
p.m.;  at  4117  the  body  was  as  represented  in  Fig.  38.  At  4.27  the  fiagella  appeared  ;  at  4.33 
two  of  the  fiagella  had  already  broken  away  from  the  mother  body. 

41-19.  Phagocytosis.    Traced  by  Dr.  Oppenheimer  with  the  camera  lucida. 


PLATE   XIV. 


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DISEASES  DUE  TO   PROTOZOA. 


849 


upon  the  slide  or  in  the  intestine  of  Anopheles  the  male  elements — 
microgametocytes — form  actively  moving  flagella  —  viicrogametes — which 
detach  themselves  and  penetrate  into  the  coarsely  granular  female  forms 
— macrogametes — which  they  fecundate. 

The  independence  of  the  three  species  of  malarial  parasites,  dis- 
tinguished by  their  morphologic  and  pathologic  characters,  has  been  fully 
established  by  the  results  obtained  by  the  experimental  inoculation  of 
the  blood  of  patients  suffering  from  malaria  into  the  veins  of  healthy 
persons.     After  a  period  of  latency,  varying  with  the   particular  species 


i^HumanCyclem  IMosquito  Cy  cb 


Fig.  286. — Diagram  of  the  complete  life-cycle  of  the  estivo-autumnal  malaria  parasite.  1-7,  stages 
in  the  development  of  the  asexual  cycle  (schizogony) ;  8,  spores  or  merozoites;  b  b',  c  c',  d  d',  gameto- 
cytes  in  blood  of  man,  sexual  cycle  ;  e',  macrogamete  ;  e,  microgametocyte  ;  /,  macrogamete  penetrated  by 
microgamete  ;  g,  h.  i,  motile  zygote,  vermicule,  or  ookinete  ;  j-o,  stages  of  development  in  the  stomach  wall 
(sporogony);  p,  mature  oocyst  showing  sporozoi'tes  ;  q,  sporoid. — Based  upon  the  plates  of  Grassi. 


under  investigation,  the  inoculated  individuals  have  developed  malarial 
fever,  always  of  the  same  type  as  that  of  the  patient  from  whom  the 
blood  was  obtained. 

The  Parasite  in  the  Mosquito. — The  common  genera  of  mosquito  in 
temperate  climates  are  Culex  and  Anopheles.  Of  each  there  are  many 
species.  The  Culex  appears  to  play  no  part  in  malarial  infection,  but 
wherever  there  is  malaria  the  Anopheles  is  to  be  found.  If  the  Anopheles 
has  not  been  infected  by  sucking  the  blood  of  a  human  being  suffering 
from  malaria,  it  is  of  course  incapable  of  communicating  the  disease  b}^  its 
bite,  and  the  parasite  does  not  develop  in  cold  climates.  These  two  facts 
serve  to  explain  the  presence  of  Anopheles  in  regions  not  malarious.  Of 
the  many  species  of  Anopheles  described,  it  is  probable  that  in  temperate 
54 


850  MEDICAL  DIAGNOSIS. 

cHmates  the  A.  maculipennis  is  most  active  in  the  diffusion  of  malaria. 
The  distinction  between  Culex  and  Anopheles  under  ordinal-}*  condi- 
tions within  a  house  is  an  easy  matter  and  depends  upon  the  following  facts: 

Culex:  The  Mature  Insect. — The  palpi  in  the  female  are  short,  pro- 
jecting only  a  Httle  distance  beyond  the  base  of  the  proboscis.  The  wings 
show  no  special  markings.  Resting  upon  the  wall  or  ceiling  Culex  holds 
its  posterior  pair  of  legs  turned  up  over  its  back,  and  its  body,  unless 
dragged  down  by  the  weight  of  blood,  is  nearly  j^arallel  to  the  wall  or  ceiling. 

AxoPHELES. — The  palpi  in  the  female  are  of  nearlj^  the  same  length  as 
the  proboscis.  The  wings  of  different  species  show  distinct  mottlings, 
hence  the  names  of  species — A.  maculopennis,  A.  punctipennis.  The  pos- 
terior pair  of  legs,  when  the  insect  is  resting,  rest  upon  the  wall  or  ceiling 
or  hang  down,  and  the  body  is  held  at  an  angle  of  forty-five  degrees  with 
the  surface  upon  which  it  rests.  The  sex-ripe  forms  of  the  malarial  para- 
site, when  taken  into  the  stomach  of  Anopheles,  rapidly  mature  with 
flagellation  and  fecundation.  The  resulting  motile  fusiform  body  bores 
into  the  wall  of  the  mosquito's  stomach  and  there  rests,  undergoing  a 
definite  cycle  of  development,  with  the  formation  of  oocysts  at  first  oval, 
later  globular.  The  nuclei  within  these  cysts  divide  into  a  great  number 
of  daughter  nuclei,  which  form  sporoblasts,  from  wdiich  sporozoites  develop. 
The  mature  oocysts  burst  and  discharge  their  sporozoites  into  the  body  of 
the  host.  Circulating  in  the  blood  these  accumulate  in  the  course  of  a  few 
hours  within  the  cells  of  the  venenosalivary  glands  and  are  inoculated 
with  the  saHva  by  the  bite  of  the  insect.  They  are  transformed  in  the 
blood  of  the  human  host  into  the  amoeboid  form  of  the  parasite  and  multiply 
by  sporulation  (schizogony)  until  they  attain  sufficient  numbers  to  produce 
the  paroxysm  of  fever.  The  early  generations  of  parasites  in  the  human 
host  are  asexual,  sexual  differentiation  occurring  later. 

The  asexual  forms  serve  as  the  means  of  prolonging  the  infection  in 
the  human  host;  the  sexual  forms,  sterile  so  long  as  they  remain  in  the 
human  host,  become  fertile  in  the  mosquito  and  maintain  the  life  and 
dissemination  of  the  parasite. 

Symptoms. — The  cases  may  be  grouped  into  the  regularly  intermitting 
fevers,  the  irregular,  remittent,  or  continued  fevers,  and  malarial  cachexia. 

(a)  The  Regularly  Intermitting  Fevers  ;  the  Agues. — 1 .  Tertian  Fever. 
2.  Quartan  Fever. — The  period  of  incubation  varies  from  a  few  days  to 
a  fortnight.  Latent  malarial  infection,  not  attended  by  symptoms,  may  be 
called  into  activity  by  removal  from  a  malarious  district,  other  change 
of  climate,  or  by  an  attack  of  illness. 

The  Paroxysm. — The  febrile  paroxysm,  known  as  the  '"chill"  or 
"  ague  fit,"  may  be  divided  into  three  stages:   cold,  hot,  and  sweating. 

Cold  Stage.— There  are  usually  premonitory  symptoms,  consisting  of 
lassitude,  yawning,  epigastric  distress,  sometimes  nausea  and  vomiting, 
and  headache.  Shivering  occurs  and  quickly  passes  into  a  full}^  developed 
rigor  with  chattering  teeth,  violent  shaking  of  the  whole  body,  and  dis- 
tressing sensations  of  cold.  The  face  is  cyanotic,  the  body  and  limbs 
covered  with  goose-flesh,  cold  to  the  hand,  and  showing,  when  tested  by 
the  surface  thermometer,  a  subnormal  temperature.  At  the  same  time  the 
rectal  temperature  is  high— 105°-106°  F.  (40.5°-41°  C).    During  this  stage 


DISEASES  DUE  TO  PROTOZOA. 


851 


nausea,  vomiting,  and  headache  may  occur.  The  pulse  is  small,  frequent, 
and  tense.  The  duration  of  the  stage  varies  from  ten  or  fifteen  minutes 
to  an  hour  or  more.  The  danger  of  the  attack  lies  in  the  prolongation 
of  the  cold  stage. 

Hot  Stage. — The  sensations  of  cold  are  replaced  by  those  of  heat; 
pallor  and  cyanosis  give  way  to  flushing,  and  the  appearance  of  collapse 
is  followed  by  that  of  more  or  less  intense  fever,  with  bounding  pulse, 
headache,  and  sometimes  delirium.  The  rectal  temperature  does  not  rise, 
having  as  a  rule  reached  its  maximum  about  the  conclusion  of  the  cold 
stage.  There  is  urgent  thirst  and  the  patient  is  distressed  by  subjective 
sensations  of  heat.  The  duration  of  this  stage  varies  from  thirty  minutes 
to  three  or  four  hours. 

Sweating  Stage. — Perspiration  starts  in  drops  upon  the  forehead  and  face 
and  soon  covers  the  entire  body  profusely.  In  some  cases  the  sweating  is 
moderate.  The  duration  of  this  stage  is  variable.  At  its  conclusion  the  patient 
commonly  falls  into  a  sleep  from  which  he  awakes  refreshed  but  weak. 


Fig.  287. — Tertian  fever. — Craig.    (Inter national  Clinics.) 

The  duration  of  the  entire  paroxysm  varies  from  an  hour  or  two,  asr 
is  common  among  the  inhabitants  of  malarious  districts,  to  six  or  eight 
hours.  The  cold  stage  is  sometimes  slight  and  transient  and  occasionally 
not  followed  by  a  hot  stage.  A  more  common  variation  from  type  consists 
in  the  hot  stage  alone,  followed  by  very  slight  sweating.  During  the 
paroxysm  the  spleen  is  usually  tender  and  palpable,  herpes  labialis  occurs, 
and  there  are  the  rational  symptoms  and  physical  signs  of  a  mild  bronchitis, 
which  passes  off  with  the  sweating  stage. 

In  the  intervals  between  the  paroxysms  the  patient  commonly  feels 
well  and  regards  himself  as  in  his  usual  health.  The  paroxysm  is  the 
result  of  a  haemodyscrasia,  at  once  morphological  and  toxic,  produced  by 
the  segmentation  of  the  parasites. 

1.  Tertian  Fever. — In  this  type,  caused  by  the  presence  in  the 
blood  of  the  tertian  parasite,  the  paroxysms  recur  every  forty-eight 
hours  or  every  third  day.  Hence  the  name  tertian.  If  two  groups 
of  parasites,  reaching  maturity  and  undergoing  segmentation  every  alter- 
nate day,  are  present,  there  are  daily — quotidian — paroxysms,  and  the 
type  is  double  tertian. 


852 


MEDICAL  DIAGNOSIS 


2.  Quartan  Fever. — The  paroxysm  caused  by  sporulation  of  the 
quartan  parasites  recurs  about  the  end  of  seventy-two  hours,  or  every 
fourth  day,  and  is  for  this  reason  known  as  quartan.  If  two  groups  of 
parasites  are  present,  maturing  upon  different  days,  paroxysms  occur  upon 
successive  days  followed  by  a  free  day — double  quartan;  if  three  groups 
are  present  the  paroxysms  occur  daily — triple  quartan,  likewise  quotidian. 


Fig.  288. — Double  tertian  fever. — Craig.    (International  Clinics.) 

The  course  of  the  regularly  intermittent  malarial  fevers  is  greatly 
influenced  by  circumstances.  Mild  cases  frequently  recover  without  treat- 
ment, especially  if  removed  from  the  opportunity  of  further  infection  and 
kept  in  bed.  Untreated  cases  are,  however,  liable  to  relapse.  The  attacks 
yield  promptly  to  proper  treatment  by  quinine.  Repeated  reinfection  or 
the  persistence  of  the  disease  results  in  ansemia  and  haemolytic  jaundice, 
ultimately  in  malarial  cachexia. 


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Fig.  289. — Quartan  fever. — Craig.    (International  Clinics.) 

(b)  The  Irregular,  Remittent,  Continued,  and  Pernicious  Fevers.— This 
type  of  fever  prevails  in  Southern  Italy  and  Russia,  tropical  countries, 
and  the  Gulf  Coast  of  the  United  States.  Its  milder  forms  occur  in  tem- 
perate climates,  chiefly  in  the  latter  part  of  summer  and  in  the  autumn, 
hence  the  term  estivo-autumnal  fever.  It  is  associated  with  the  presence 
in  the  blood  of  the  parasite  of  the  same  name  and  is  characterized  by  irregu- 


DISEASES  DUE  TO  PROTOZOA. 


853 


larity  and  intensity.  The  irregularity  is  due  to  the  fact  that  the  parasite, 
which  has  a  cycle  of  development  of  apparently  forty-eight  hours,  is  sub- 
ject to  great  variations  in  this  respect  and  occurs  in  multiple  groups  which 
do  not  tend  to  mature  upon  certain  definite  days;  the  intensity  is  due 
to  the  virulence  of  the  toxins  produced  by  the  organisms  at  the  time  of 
sporulation,  and  their  predilection  for  the  cerebral  capillaries  and  peri- 
vascular spaces. 

The  symptoms  are  most  variable.  Some  of  the  cases  begin  as  irregular 
intermittent  with  prolonged  paroxysms,  which  may  occur  without  chills 
or  chilliness.  Another  peculiarity  is  that  the  temperature  rise  is  gradual 
and  the  defervescence  by  lysis.  The  tendency  to  anticipation  of  the  par- 
oxysm is  marked,  and  this  feature  with  prolongation  rapidly  converts  inter- 
mittent into  a  remittent  or  continued  fever.  In  other  cases  there  is  fever 
of  continued  type  without  marked  paroxysms,  and  the  clinical  picture  is 
suggestive  of  enteric  fever.    There  is  severe  headache,  flushed  face,  a  bound- 


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Fig.  290. — Estivo-autumna)  fever. — Craig.    {International  Clinics.) 


ing  but  not  dicrotic  pulse,  and  enlargement  of  the  spleen.  The  tempera- 
ture range  is  very  often  102°-104°  F.  (38.9°-40°  C.)  with  remissions  and 
exacerbations  like  those  of  enteric  fever.  Intestinal  symptoms  are  not 
often  prominent.  The  frequent  association  of  a  moderate  bronchitis  with 
the  foregoing  symptoms,  together  with  moderate  enlargement  and  tender- 
ness of  the  spleen,  adds  to  the  clinical  resemblance.  Delirium  may  occur. 
It  is  usually  mild  but  may  be  active.  Subicteroid  discoloration  of  the 
skin  is  common  and  begins  early,  and  in  a  group  of  cases — bilious  remittent 
of  the  older  writers — deep  jaundice  is  associated  with  nausea  and  vomiting 
and  intense  headache.  The  inappropriate  and  misleading  designation, 
typhomalarial  fever,  at  one  time  applied  to  this  group  of  malarial  fevers, 
has  fortunately  passed  into  disuse. 

The  course  of  the  estivo-autumnal  fevers  is  extremely  variable,  (a) 
Mild  Forms. — In  the  mildest  cases  the  attack  may  run  its  course  with 
moderate  fever  and  indefinite  symptoms.  The  clinical  picture  suggests 
simple  continued  fever  or  the  mildest  form  of  enteric  fever — typhus  levissi- 
mus.  (b)  Severe  Forms. — Other  cases  are  more  severe.  The  fever  is 
characterized  by  marked  remissions  and  exacerbations.  There  is  intense 
headache,  flushed  face,  delirium,  jaundice,  and  vomiting,  with  enlargement 


854  MEDICAL  DIAGNOSIS. 

of  the  spleen  and  liver  and  epigastric  tenderness — bilious  remittent  fever. 
(c)  Pernicious  Fevers. — The  important  types  are  (i)  the  algid,  (ii)  the 
comatose,  and  (iii)  the  hemorrhagic. 

(i)  Algid  Form. — The  attack  may  begin  T\ath  a  prolonged  chill. 
More  commonly  there  are  merely  subjective  sensations  of  cold.  Gastric 
symptoms,  nausea,  vomiting,  epigastric  distress,  are  prominent.  Extreme 
prostration  occurs  and  is  associated  with  a  feeble,  small  pulse  and  rapid, 
shallow  respiration.  Frequent  diarrhoea,  in  some  instances  attended  with 
rice-water  discharges  like  those  of  cholera,  may  be  present  and  with  it  great 
diminution  of  the  urine.  Fever  is  at  first  absent,  the  temperature  being,  as 
a  rule,  subnormal.  Later  irregular  febrile  exacerbations  may  occur.  In 
default  of  energetic  treatment  death  takes  place  in  the  course  of  a  few  days 
with  the  evidences  of  profound  asthenia.  -Sudoral,  syncopal,  cardialgic, 
and  choleraic  varieties  are  described. 

(ii)  Comatose  Foryn. — The  attack  begins  abruptly  with  cerebral  symp- 
toms, as  intense  headache  with  acute  delirium  or  stupor  deepening  to  coma. 
In  some  cases  the  seizure  may  be  apoplectiform.  A  chili  may  mark  the 
onset,  but  this  is  not  invariably  the  case.  There  is  a  hot,  dry  skin  witk 
high  temperature.  The  patient  may  die  without  regaining  consciousness; 
or  he  may  recover  consciousness  in  the  course  of  twelve  or  twenty-four 
hours.     The  second  or  third  attack  is  usually  fatal. 

(iii)  Hemorrhagic  Form. — This  form  is  also  designated  hsemoglobinuria 
and  is  identical  with  the  African  black-water  fever.  It  is  rare  in  tem- 
perate climates,  its  chief  distribution  being  on  the  Gulf  Coast  of  the  United 
States,  Central  America,  Lower  Italy,  and  Africa.  The  disease  is  malarial, 
but  whether  it  is  due  to  a  special  parasite  or  not  remains  to  be  settled.  As 
a  rule  the  patients  have  suffered  from  repeated  attacks  of  malarial  fever  and 
are  in  poor  health.  Parasites  have  been  found  in  the  blood  prior  to,  and  in 
a  more  limited  number  of  cases  at  the  onset  of,  the  attack.  Later  they  are 
not  found  in  a  majority  of  the  cases.  The  evidence  that  malarial  haemo- 
globinuria  is  caused  by  quinine  is  not  conclusive.  The  attack  begins  with 
fever,  to  which,  in  the  course  of  a  short  time,  hsemoglobinuria  supervenes. 

(c)  Malarial  Cachexia. — Prolonged  exposure  in  a  malarious  district 
with  repeated  infection  by  way  of  the  parasites  is  frequently  followed  by 
the  development  of  an  ansemia  of  high  grade  with  enlargement  of  the 
spleen.  Emaciation,  a  muddy  complexion  with  general  cutaneous  pig- 
mentation, subcutaneous  and  retinal  hemorrhages,  breathlessness  upon 
exertion,  oedema  of  the  ankles,  are  usual  symptoms.  There  is  irregular 
temperature  varying  from  normal  to  subfebrile  ranges  with  occasional 
exacerbations— 102°-103°  F.  (.39°-39.5° C).  The  splenic  enlargement  is 
often  massive,  constituting  the  tumor  known  in  the  Southern  States  as 
''ague  cake.''     Hsematemesis  occasionally  occurs  and  may  be  fatal. 

Diagnosis. — Direct. — The  recognition  of  the  essential  nature  of  the 
malarial  fevers  is  not  usually  attended  with  difficulty.  The  two  important 
tests  are  the  presence  of  the  blood  parasite  and  the  curative  effect  of  quinine. 
A  history  of  exposure,  the  well-defined  periodicity  of  the  regularly  inter- 
mitting tertian  and  quartan  fevers,  enlargement  of  the  spleen,  herpes,  and 
the  absence  of  tuberculosis,  syphilis,  sepsis,  or  other  causes  of  period- 
ical fever  are  diagnostic  criteria  of  secondary  importance. 


DISEASES  DUE  TO  FLUKES. 


855 


Differential. — The  estivo-autumnal  form  often  closely  simulates 
enteric  fever.  On  the  one  hand  the  malarial  parasite  and  control  by  qui- 
nine, on  the  other  the  Widal  reaction  and  the  power] essness  of  any  drug  to 
arrest  the  course  of  the  attack,  are  positive  tests.  The  parasites  may  be 
demonstrated  in  fresh  blood  taken  a  few  hours  before  the  expected  chill. 
In  doubtful  cases  a  carefully  prepared  cover-slip  preparation  of  the  blood 
may  be  stained  for  examination.  The  intermittent  pyrexia  which  refuses 
to  yield  to  quinine  in  daily  doses  of  15  to  20 
grains — gramme  1  to  1.3— properly  admin- 
istered by  the  mouth  or  hypodermically  is 
not  malarial.  The  masked  intermittents — 
dumb  ague — blurred  types — which  occur  in 
persistent  infections  or  after  inadequate  treat- 
ment manifest  themselves  by  indefinite  symp- 
toms and  attacks  of  irregular  fever  or  an 
afebrile  temperature  with  an  occasional  chill. 
Here  the  therapeutic  test  is  conclusive.  In 
septic  states  wdth  intermittent  pyrexia,  abscess, 
malignant  endocarditis,  hepatic  fever,  and  the 
like  a  study  of  the  blood  is  important,  since 
leucocytosis,  which  does  not  often  occur  in 
uncomplicated  malaria,  is  usually  present  in 
these  conditions. 

Prognosis. — The  malarial  fevers  of  the 
regularly  intermitting  forms  and  the  estivo- 
autumnal  fevers  of  temperate  climates  yield 
readily  to  treatment  by  quinine.  If  neglected 
or  when  reinfection  occurs  they  recur  from 
year  to  year  with  vernal  or  autumnal  relapses. 
Malarial  cachexia  may  thus  develop.  The 
prognosis  in  the  tropical  forms  of  estivo- 
autumnal  fever  is  grave.  Life  can  be  saved 
in  many  of  the  cases  only  by  the  prompt, 
skilful,  and  judicious  administration  of  quinine  Sect  "o/q^hlhll"'— cirmin  HospuS* 
in  sufficient  doses,  and  the   removal   of  the 

patient  from  the  danger  of  reinfection.  The  prognosis  in  malarial 
cachexia  is  fairly  good.  Health  may  be  regained  by  proper  treatment 
sufficiently  prolonged.     The  main  indication  is  the  avoidance  of  reinfection. 


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B.   DISEASES  DUE  TO   FLUKES-DISTOMIASIS. 

The  parasitic  trematodes  are  wddely  distributed  among  vertebrate 
animals.  These  are  important  in  man:  (1)  Fasciola  hepatica — Distomum 
hepaticum;  (2)  Paragonimus  westermani — Distoma  pulmonis;  (3)  Fascio- 
lopsis  (Distoma)  buski;  and  (4)  Schistosomum  haematobium — Bilharzia 
hsematobia.   The  following  clinical  forms  of  distomiasis  are  to  be  considered. 

\.  Hepatic  Distomiasis. — Several  species  of  liver  flukes  have  been 
observed  in  man,  of  which  the  most  important  is  Opisthorchis  sinensis, 
widely  distributed  in  the  East,  especially  in  Tonquin,  China,  and  Japan. 


856 


MEDICAL  DIAGNOSIS. 


Imported  cases  have  been  encountered  in  the  United  States.  This  para- 
site is  10-14  mm,  long  by  2.4-3.9  mm.  broad.  The  eggs  are  oval  with  a 
well-defined  operculum  at  the  pointed  pole.  They  measure  0.027-0.030 
by  0.015-0.0175.  The  parasite  infests  the  gall-bladder  and  gall-ducts  of 
domestic  dogs  and  cats  and  human  beings.  They  have  also  been  found  in 
the  pancreas  of  human  beings.  Their  number  is  sometimes  enormous. 
The  changes  produced  in  the  gall-ducts  are  local  dilatations  with  sac- 
culation  and  proliferation  of  the  connective  tissue  of  the  wall,  and  in 

the  liver  interstitial  hepatitis 
followed  by  atrophy. 

Symptoms.  —  Intermit  t  ent 
diarrhoea,  sometimes  bloody;  en- 
largement of  the  liver,  with  pain, 
and  jaundice  which  is  intermittent; 
and  slight  fever.  After  two  or  three 
years  oedema  of  the  feet  occurs, 
followed  by  anasarca  and  ascites. 
The  ova  are  found  in  the  stools. 
Recovery  takes  place,  but  relapses 
occur.  The  mortality  is  about 
14   per   cent. 

2.  Pulmonary  Distomiasis. — 
Paragonimus  (Distoma)  westermani 
has  been  observed  in  China,  Korea, 
Formosa,  and  Japan.  Imported 
cases  have  been  studied  in  the 
United  States.  The  body  is  red- 
dish-brown in  color  and  plump.  It 
is  8-10  mm.  in  length,  4-6  mm.  in 
breadth.  The  eggs  are  oval,  brown- 
ish-yellow, thin-shelled,  and  have 
approximate  average  diameters  of 
0.09  mm.  in  length  by  0.06  mm.  in 
breadth.  They  are  found  in  large 
numbers  in  the  sputum. 

Symptoms.  — There  is  cough  and 
blood  spitting  but  the  symptoms 
are  usually  slight.  The  patients  are  able  to  follow  their  occupations. 
Copious  haemoptysis  sometimes  occurs.  Males  are  principally  affected; 
women  and  children  rarely.    The  mode  of  infection  has  not  been  discovered. 

3.  Intestinal  Distomiasis. — Fasciolopsis  (Distoma)  buski  has  only 
been  observed  in  the  intestine  of  man.  The  cases  have  occurred  in  East- 
ern and  Southern  Asia.     Seven  cases  only  have  been  reported  (Braun). 

4.  Haemic  Distomiasis — Bilharziasis. — A  parasitic  disease  endemic  in 
Egypt,  Abyssinia,  The  Sudan,  and  in  many  other  districts  of  Africa.  There 
appears  to  be  a  centre  of  infection  in  Arabia.  Elsewhere  beyond  the 
borders  of  Africa  it  is  encountered  in  imported  cases.  The  parasite — 
Schistosomum  haematobium — was  discovered  by  Bilharz  in  1852.  Unlike 
the  other  flukes  the  sexes  are  separate  and  the  male  carries  the  female  in 


Fig.  292. — 1.  Fasciola  hepatica. — After  Glaus.  2.  Egg 
of  parasite. — After  Braun. 


DISEASES  DUE  TO  FLUKES. 


857 


a  gynsecophorous  canal.  The  male  is  of  a  whitish  color  and  12-14  mm.  in 
length,  varying  from  1  mm.  to  0.4-0.5  mm.  in  diameter.  The  dorsal  surface 
of  the  posterior  part  of  the  body  is  covered  with  spinous  papillae.  The 
female  is  filiform,  pointed  at  the  ends,  about  20  mm.  in  length,  and  0.25  mm. 
in  diameter.  The  eggs  are  oval,  of  a  transparent  yellow  color,  thin-shelled, 
and  provided  with  a  terminal  spine.  They  vary  greatly  in  size.  They 
hatch  in  water.  The  development  of  the  embryo  has  not  been  worked  out. 
Whether  infection  takes  place  by  the  mouth,  the  urethra,  or  through  the 
skin  in  bathing  is  unknown.  The  young  specimens  are  found  in  the  portal 
vein,  the  sexes  separate.     Hence  the  males  bearing  the  females  penetrate 


Fig.  293. — 1.  Paragonimus  westermani. — After  Leukart.     2.  Egg  of  parasite. — After  Katsurada. 

to  the  venous  plexus  of  the  pelvis,  from  which  they  reach  the  wall  of  the 
bladder  and  rectum,  the  ova  being  deposited  in  the  tissues  but  wandering 
by  means  of  the  spine  and  being  voided  with  the  fseces  and  urine.  They 
are  easily  found  in  the  latter,  especially  in  the  flakes  of  mucus  present. 
Many  remain  in  the  tissues,  causing  inflammatory  irritation,  fibroid  thick- 
ening, and  papillomatous  growths.  Others  collecting  within  the  bladder 
perish  and  undergo  calcification,  thus  forming  the  nuclei  of  the  vesical 
calculi  so  common  in'  bilharziasis.  The  ova  may  be  transported  to  distant 
parts  by  the  blood  stream,  and  have  been  found  in  all  the  organs,  though 
in  small  numbers. 

Symptoms.  ^The  infection  is  sometimes  latent,  the  parasites  giving 
rise  to  no  symptoms.  This  is  especially  the  case  while  they  remain  in  the 
portal  vein.     Early  symptoms  are  catarrh  of  the  bladder,  with  pain  in  the 


858  MEDICAL  DIAGNOSIS. 

bladder  and  rectum  and  in  the  lumbar  region.  The  urine  is  at  first  normal 
in  appearance,  but  after  a  time  there  is  tenesmus  with  bloody  mucus  and 
pus  at  intervals  or  daily.  As  the  disease  progresses  the  vesical  inflammation 
becomes  more  intense,  the  urine  contains  blood  and  pus  in  increasing 
quantities,  and  calculi  are  found  which  produce  their  characteristic  symp- 
toms. The  ureters,  the  pelvis  of  the  kidneys,  the  kidneys,  the  rectum,  and 
occasional^  the  vagina  become  involved.  The  nutrition  is  greatly  impaired 
and  death  may  result  from  general  marasmus.  In  a  considerable  proportion 
of  the  cases  it  is  due  to  urgemia,  sepsis,  or  an  intercurrent  pneumonia. 
Perineal  and  urethral  abscess  formation  is  comm^on. 

Diagnosis. — The  urinary  symptoms  are  suggestive  and  the  direct 
diagnosis  may  be  made  bj^  finding  the  characteristic  ova  in  the  bloody 
urine  or  in  the  blood  and  mucus  discharged  from  the  rectum. 

Prognosis. — In  mild  infections  under  circumstances  in  which  rein- 
fection can  be  avoided,  the  symptoms  sometimes  disappear.  As  a  rule, 
the  prognosis  is  highly  unfavorable  both  as  to  mitigation  of  suffering  and 
as  to  recovery. 

Katsurada  in  1904  described  a  fluke,  closely  resembling  Schistosomum 
haematobium,  to  which  he  attributed  an  endemic  disease,  characterized  by 
enlargement  of  the  liver  and  spleen,  cachexia,  and  ascites,  and  to  which  he 
gave  the  name  S.  japonicum.  Three  months  later  the  same  parasite  was 
found  by  Dr.  John  Catto  and  named  by  Blanchard  Schistosoma  cattoi. 
The  ova  are  smaller  than  those  of  S.  haematobium,  brownish  in  color,  and 
not  provided  with  the  characteristic  terminal  spine.  This  parasite  infests 
the  blood-vessels  of  the  intestinal  canal  and  the  organs  related  to  it,  and 
the  ova  are  found  in  the  faeces. 

In  Porto  Rico  there  exists  a  rectal  form  of  bilharziasis  in  which 
the  ova  are  lateral-spined.  Sambon  has  considered  this  a  new  species 
and  has  called  it  S.  mansoni. 

C.   DISEASES   DUE   TO   CESTODES. 

Tapeworms  ;     Hydatid  Disease. 

i.   Intestinal  Cestodes — Tapeworms. 

Ce.stodes  are  flat  worms  without  mouth  or  intestine,  consisting  of  a 
scolex  and  proglottides,  which  develop  by  generation  in  alternate  hosts 
and  by  gemmation  with  elongated  tape-like  colonies.  They  combine, 
except  in  a  limited  number  of  species,  the  male  and  the  female  sexual 
organs  in  the  same  segment.  The  scolex  or  head  serves  as  the  means  of 
attachment  for  the  entire  worm  to  the  wall  of  the  intestine  and  is  for  that 
purpose  provided  with  suctorial  organs  and  clinging  organs  or  booklets. 
These  organs  of  attachment  are  differently  arranged  in  different  species. 
The  narrow  thread-like  part  immediately  posterior  to  the  scolex  is  known 
as  the  neck.  The  proglottides  or  segments  are  joined  to  the  scolex  longi- 
tudinally in  such  a  manner  that  the  youngest  proglottis  is  nearest  the  neck 
and  the  oldest  most  distant  from  it. 

The  number  of  segments  varies  in  different  species  from  a  few  to  several 
hundred.     They  are  quadrangular  and,  as  a  rule,  the  younger  ones  have 


DISEASES  DUE  TO   CESTODES, 


859 


their  long  diameter  transverse  to  the  long  axis  of  the  worm,  those  in  the 
middle  are  squarish,  and  the  most  distant  have  their  long  diameter  in  the 
long  axis  of  the  worm.  The  lateral  borders  usually  converge  toward  the 
anterior  extremit}^  in  such  a  manner  that  the  anterior  border  of  the  seg- 
ment is  shorter  than  the  posterior  border  of  the  next  younger  segment 
to  which  it  is  attached.  About  the  middle  of  one  margin  is  the  projection 
of  the  genital  pore  alternating  irregularly.  The  uterus  has  a  median  trunk 
with  lateral  branches,  which  may  be  seen  when  the 
segment  is  lightly  pressed  between  glass  plates. 

The  segments,  single  or  in  tape-like  sections 
of  several,  become  detached  from  the  posterior 
end  and  after  lingering  in  the  intestine  for  a  time 
are  evacuated  with  the  faeces,  or  work  their  way 
out  of  the  anus  and  are  sometimes  found  in  the 
clothing  of  the  host.  In  violent  vomiting  single 
or  several  united  segments  may  be  ejected  and 
segments  or  an  entire  worm  may  find  the  way 
through  abnormal  communications  into  contiguous 
organs,  as  the  bladder  or  the  peritoneal  cavity. 
The  length  of  tapeworms  depends  upon  the  size 
and  number  of  the  segments.  The  largest  species 
may  attain  a  length  of  8  to  10  metres. 

The  number  of  genera  is  about  eighty.  Cer- 
tain species  in  the  adult,  sexually  ripe  stage 
infest  the  small  intestine  of  man — the  definitive 
host;  the  corresponding  larval  forms  live  normally 
in  the  intramuscular  connective  tissue  and  viscera 
of  certain  animals  which  constitute  the  interme- 
diate host.  Exceptionally  man,  by  swallowing 
the  embryos — oncospheres — becomes  the  host  of 
the  larval  forms — Cysticercus  cellulosse;  Echino- 
coccus.    The  most  common  tapeworms  of  man  are : 

(a)  Taenia  Solium  {Armed  Tapeworm;  Pork- 
Tapeworm). — This  cestode  was  so  called  because 
it  was  supposed  to  exist  as  a  solitary  parasite  in 
the  intestine.  It  is  now  known  that  two  or  more 
tapeworms  ma}-  be  present  at  the  same  time. 

Average  length  3  metres;  head  globular, 
0.8-1.0  mm.  in  diameter  and  armed  with  a 
double  row  of  hooks;  suckers  hemispherical;  neck 
slender  and  o-lO  mm.  in  length;  proglottides  800-1000  in  number  when 
mature  and  ready  for  detachment,  10-12  mm.  in  length  by  5-6  mm.  in 
bi-eadth;  genital  pores  alternate;  uterus  consists  of  a  median  trunk  with 
7-10  lateral  branches  on  each  side,  some  of  which  again  branch;  eggs  oval 
with  very  delicate  shell;  embryonal  shell  thick,  globular,  of  a  pale  yellow- 
ish color  with  radial  stripes,  0.031-0.036  mm.  in  diameter;  the  embryo 
armed  with  six  hookiets.  This  parasite  when  fully  developed  is  found 
exclusively  in  the  small  intestine  of  man.  The  embryos  are  voided  with 
the  faeces  but  undergo  no  further  development  unless  taken  into  the  stom- 


FiG.  294. —  Tsenia  solium.  1, 
ovum;  2,  segment,  showing  uterus; 
3,  hook;  4,  head. 


860 


MEDICAL  DIAGNOSIS. 


ach  of  a  suitable  animal,  especially  the  hog  or  man  himself.  The  embryo 
shells  are  then  digested,  the  armed  embryos  are  set  free,  and,  finding  their 
way  to  various  parts  of  the  body,  develop  into  the  larvae  or  cysticerci. 

The  geographical  distribution  of  T.  solium  corresponds  in  general 
with  that  of  the  domestic  hog  and  the  customary  use  of  raw  or  insuffi- 
ciently cooked  pork.  It  is  relatively  common 
in  North  Germany,  rare  in  the  United  States, 
and  for  obvious  reasons  in  Mussulman  countries 
and  among  the  Jews. 

(b)  Taenia  Saginata  {T.  medio canellata; 
Unarmed  Tapeworm;  Beef  Tapeworm). — Length 
variable,  up  to  10  metres,  even  36  metres;  head 
cubical,  1.5-2  mm.  in  diameter  and  without 
booklets;  suckers  spherical  and  pigmented; 
neck  long  and  about  half  the  diameter  of  the 
scolex;  proglottides  average  in  number  1000; 
when  mature,  pumpkin-seed  shaped,  16-20  mm. 
in  length  by  4-7  mm.  in  breadth;  genital  pores 
irregularly  alternate ;  uterus  median  with  twenty 
to  thirty-five  lateral  branches  on  each  side,  also 
ramifying.  Eggs  globular,  shell  provided  with 
one  or  two  filaments.  Embryonal  shell  oval, 
thick,  transparent,  and  striated,  measuring  0.03— 
0.04  mm.  in  length  by  0.02-0.03  mm.  in  breadth. 
T.  saginata  in  its  adult  stage  is  found  only  in 
the  intestinal  canal  of  man.  The  ripe  segments 
and  ova  are  voided  in  the  faeces  and  swallowed 
by  cattle,  in  the  muscles  and  organs  of  which 
they  develop  into  Cysticercus  bovis.  T.  saginata 
is  the  most  common  tapeworm  of  man  and  is 
widely  distributed.  It  is  the  ordinary  tapeworm 
of  North  America,  is  very  common  in  Europe 
and  Africa,  and  has  been  known  in  the  East  for 
centuries.  The  Jews,  who  are  forbidden  to  eat 
pork,  especially  suffer  from  the  beef  tapeworm. 
The  eating  of  uncooked  beef  is  liable  to  be 
followed  by  this  form  of  parasite. 

Much  less  common  are: 

(c)  Taenia  Cucumerina  (T.  elliptica;  Dipy- 
lidium  canium). — A  small  tapeworm  found  in 
great    numbers  in    the    intestines    of    the    dog 

and  cat.  The  larvae  develop  in  the  lice  and  fleas  of  those  animals. 
This  parasite  is  sometimes  observed  in  little  children. 

(d)  Taenia  Nana  {Hymenolepis  nana). — A  small  parasite  having  the 
genital  pores  all  upon  one  side.  This  parasite  is  common  in  Italy.  Stiles 
states  that  H.  nana  is  the  most  common  tapeworm  in  children  in  the 
United  States.  It  is  supposed  to  have  cysticercus  stages  in  the  intestinal 
villi,  no  secondary  host  being  necessary.  There  are  marked  nervous 
symptoms  and  signs  of  profound  infection. 


Fig.  295. — Tsenia  saginata.  1, 
ovum;  2,  fully  developed  seg- 
ment showing  uterus;  3,    head. 


DISEASES  DUE  TO  CESTODES. 


861 


(e)  Taenia  Flavopunctata  (Hymenolepis  diminuta). — This  small  ces- 
tode  is  extremely  rare.  The  proglottides  show  posteriorly  a  yellow  area 
corresponding  to  the  male  sexual  organs;    hence  the  name. 

(f)  Taenia  Lata  (Dibothriocephalus  latus;  Bothriocephalus  latus). — The 
designation  of  this  cestode  indicates  the  lateral  pitting  of  the  head  and 
its  relatively  large  size.  Length  up  to  9  or  more  metres;  head  almond- 
shaped,  2-3  mm.  in  length  and  flattened,  a  deep  suctorial  groove  with  sharp 
edges  being  situated  at  each  side;  no  hooklets;  neck  very  thin;  pro- 
glottides numbering  3000-4500,  greater  in 
breadth  than  in  length ;  eggs  large  with 
brownish  shells,  deposited  in  the  intestines, 
voided  with  the  faeces,  and  hatched  in  water. 
The  intermediary  hosts  are  the  pike  and 
other  fish.  This  parasite  is  widely  encoun- 
tered in  the  Baltic  provinces  and  Switzerland 
and  is  the  common  tapeworm  in  Japan. 

Etiology. — The  eating  of  the  raw  or  insuf- 
ficiently cooked  flesh  of  animals  and  fish,  and 
uncleanly  habits,  constitute  predisposing  influ- 
ences of  great  moment.  Tapeworm,  owing  to 
systematic  food  inspection,  is  rapidly  becoming 
less  prevalent  in  well  organized  communities. 
The  parasites  may  be  encountered  at  any  pe- 
riod of  hfe.  They  are  common  in  children  and 
have  been  met  with  in  infants  at  the  breast. 

Symptoms. — Tapeworms  may  give  rise  to 
no  inconvenience.  They  are  rarely  danger- 
ous. Their  presence  may,  however,  occasion 
symptoms,  partly  gastro- intestinal,  partly 
nervous.  Among  the  former  are  a  ravenous 
appetite,  abdominal  uneasiness  and  distress, 
nausea,  and  diarrhoea;  among  the  latter, 
nervous  depression  and  hypochondria.  Con- 
vulsions, chorea,  vertiginous  attacks,  often 
attributed  to  the  parasite,  are  rarely  directly 
caused  by  it.  The  cessation  of  any  group  of 
symptoms  upon  its  removal  is  important. 
Autosuggestion  is  to  be  considered.  On  the 
other  hand  troublesome  symptoms  are  sometimes  undoubtedly  due  to 
intestinal  irritation  or  to  toxic  substances,  evolved  by  the  worm,  acting 
upon  the  nervous  system  and  the  blood — haemolysis.  The  Bothriocephalus 
may  be  the  cause  of  a  severe  anaemia  having  the  characters  of  pernicious 
anaemia,  which  sometimes  proves  fatal,  but  which  in  some  instances  has 
terminated  in  prompt  recovery  after  the  removal  of  the  worm. 

Diagnosis. — The  presence  of  the  segments  in  the  stoolS  or  in  the  gar- 
ments of  the  patient  is  positive.  The  ova  and  oncospheres  may  be  found 
in  great  numbers  upon  microscopic  examination  of  the  stools.  Tapeworm 
treatment  should  never  be  inaugurated  until  the  direct  diagnosis  has  been 
made  by  the  discovery  of  the  segments  or  ova  in  the  stools.     Various  sub- 


FiG    296 — Tffinia  lata      1,   ovum;   2, 
mature  segment,  3,  head. 


862  MEDICAL  DIAGNOSIS. 

stances  found  in  the  faeces,  such  as  shreds  of  mucus,  bits  of  aponeurosis  or 
tendon,  or  seeds  are  brought  to  the  physician  by  the  patient  who  suspects 
that  he  has  tapeworm.  The  differential  diagnosis  between  the  ova  may  be 
uncertain,  but  the  difference  between  T.  sohum  and  T.  saginata  is  at  once 
apparent  upon  examining  the  ripe  segments  between  glass  slides.  The 
rare  species  must  be  submitted  to  an  expert. 

The   prognosis   is   favorable.     There  are  several    efficient   tseniacides. 

ii.   Visceral  Cestodes. 

(a)  Cysticercus  Cellulosae. — Infection  of  human  beings  by  cysticerci 
takes  place  by  the  introduction  of  the  ripe  ova  (oncospheres)  of  T.  solium 
into  the  stomach.  This  occurs  by  drinking  contaminated  water,  eating 
salads  or  other  raw  vegetables  washed  with  such  water,  or  in  uncleanly 
persons  by  their  accidental  introduction  from  the  fingers.  Autoinfection 
doubtless  frequently  takes  place  in  this  manner  and  sometimes  from  the 
retropulsion  of  the  mature  segments  into  the  stomach  in  the  act  of  vomit- 
ing. The  development  of  Cysticercus  cellulosse  takes  from  two  to  three 
or  four  months.  Their  length  of  life  in  animals  is  unknown.  After  a  time 
they  die  and  become  calcified  or  undergo  caseation.  They  have  been  found 
in  almost  every  organ  in  the  human  body.  They  appear  in  subcutaneous 
tissues  and  in  the  muscles  as  ovoid  whitish  bodies,  on  the  surface  of  which 
a  spot  may  be  found  which  is  the  invaginated  head.  They  are  most  com- 
mon in  the  brain,  in  which  they  sometimes  attain  considerable  size.  They 
infest  next  in  the  order  of  frequency  the  eye,  muscles,  heart,  the  sub- 
cutaneous tissue,  the  lungs,  and  liver.  They  were  demonstrated  by  Von 
Graefe  in  the  vitreous  humor  and  many  cases  have  since  been  recorded. 
The  number  of  cysticerci  in  a  single  individual  varies  from  a  few  to 
several  thousand. 

Symptoms. — In  the  hog  the  cysticerci  are  often  present  in  enormous 
numbers  without  impairing  the  nutrition  or  giving  rise  to  noticeable 
symptoms.  In  America  they  are  extremely  rare  in  man.  When  present 
in  small  numbers  in  the  subcutaneous  tissues  or  the  muscles  they  cause 
little  or  no  trouble.  When  present  in  large  numbers  or  in  regions  where 
their  growth  is  unrestrained  by  pressure  they  may  cause  very  marked 
disturbances.  Their  general  distribution  causes  muscular  pain,  stiffness, 
tingling,  and  numbness;  in  the  silent  region  of  the  brain  they  may  cause  no 
symptoms,  but  elsewhere  they  have  the  same  effect  as  other  forms  of  tumor. 

Diagnosis. — Direct. — In  the  eye  a  positive  diagnosis  can  be  made  by 
ophthalmoscopic  examination.  Subcutaneous  nodules  may  be  excised 
and  examined.  The  sublingual  tissues  should  be  examined  in  a  sus- 
pected case.  The  cysticercus  of  the  ox  has  been  found  in  man  only 
in  a  few  instances. 

(b)  Echinococcus  Disease. — The  echinococci  are  the  larvse  of  T.  echino- 
coccus,  a  minute  cestode  measuring  2.5-6  mm.  in  length  and  0.06  mm.  in 
breadth,  having  a  scolex  armed  with  a  double  row  of  twenty-eight  to  fifty 
hooklets  on  the  rostellum  and  composed  of  three  or  four  segments,  of 
which  the  posterior  only  is  mature.  The  mature  segment  contains  about 
5000  ova.     This  parasite  lives  in  the  small  intestine  of  the  domestic  dog. 


DISEASES  DUE  TO  CESTODES. 


863 


The  larval  or  cysticercus  stage  is  passed  in  various  organs  of  numerous 
species  of  mammals,  especially  the  sheep,  ox,  and  hog.  Man  occasionallj^ 
acquires  echinococcus  by  ingesting  the  oncospheres  in  caressing  or  otherwise 
coming  into  too  close  contact  with  infected  dogs,  or  using  the  same  dishes. 
Structure  and  Development.  —  Echinococcus  or  bladder-worm 
consists  of  a  cyst  or  vesicle  filled  with  a  watery  fluid,  which  may  attain 
in  man  the  size  of  a  child's  head  but  in  cattle  does  not  often  exceed  the 
dimensions  of  an  orange  or  apple.  The  thin  wall  of  the  cyst  consists  of  two 
distinct  layers,  an  external,  laminated,  cuticular  membrane  or  capsule  and 


Fig.  297. — 1,  Taenia  echinococcus,    2,  mother  and   daughter  ey.'Sts   (from   Allen   J. 
Smith's  preparation);  3,  hooks. 

an  internal,  germinal,  or  parenchymatous  layer,  the  endo- 
cyst.  After  a  time  the  cyst  acquires  an  outer  or  accidental 
fibrous  investment.  The  development  in  cattle  is  often 
arrested  at  this  point  and  the  cysts  are  then  known  as 
acephalocysts  or  sterile  echinococcus  cysts.  In  other  cases 
in  domesticated  animals  brood  capsules  are  formed  within 
the  space,  upon  the  outer  surface  of  which  the  granular  or 
parenchj^matous  layer  is  found.  From  this  surface  arise 
little  buds  or  projections  which  develop  into  scolices  supplied 
with  four  sucking  discs  and  a  circle  of  booklets.  When 
transferred  to  the  intestine  of  the  dog  each  scolex  may  con- 
stitute the  head  of  a  mature  tapeworm.  This  form  is  termed  Echinococcus 
veterinorum  or  fertile  echinococcus  cyst.  In  man  the  mother  cyst  forms 
daughter  cysts  which  resemble  it  in  structure  and  organization  and  originate 
from  detached  portions  of  the  parenchymatous  layer.  These  daughter  cysts 
may  develop  outwardly  and  lie  between  the  outer  wall  of  the  mother  cyst  and 
the  adventitious  fibrous  capsule,  or  inwardly  and,  becoming  detached  from 
the  wall  of  the  mother  cyst,  float  free  within  the  latter.  Their  number  is 
variable.  The  daughter  cyst  may  remain  sterile  or  in  time  may  produce  brood 
capsules  or  granddaughter  cysts.  Finally  the  mother  cyst  may  undergo 
destruction  and  the  daughter  cysts,  surrounded  by  thick  capsules  of 
connective  tissue,  may  form  an  irregular  tumor  mass — multilocular 
echinococcus.  The  fluid  is  of  a  faint  yellowish  color,  neutral  or  faintl}^ 
acid  in  reaction,  non-albuminous,  and  of  a  specific  gravity  of  1.005-1.015. 


864  MEDICAL  DIAGNOSIS. 

It  contains  sugar,  inosite,  leucin,  tyrosin,  and  succinate  of  lime  and 
soda.     Scolices  and  booklets    may  be  found    in  tbe  fluid  of   tbe   cysts. 

Tbe  cbanges  wbich  tbe  cysts  undergo  are  as  follows:  (a)  Deatb, 
gradual  resorption  of  tbe  fluid  contents,  and  the  conversion  of  the  cyst  into 
a  granular,  partially  calcified  mass.  Such  masses  are  not  uncommon  in 
tbe  liver,  (b)  Rupture,  which  may  take  place  into  a  serous  sac,  a  hollow 
viscus  or  a  bronchus,  the  intestine  or  tbe  bladder,  into  tbe  bile  passages 
or  inferior  vena  cava,  or  externally.  These  accidents  are  all  unfavorable, 
though  recovery  may  follow  the  external  rupture  of  the  cyst,  (c)  Suppura- 
tion, which  may  occur  with  or  without  rupture  and  is  most  frequent  in 
hydatid  cysts  of  the  liver. 

The  geographical  distribution  of  echinococcus  disease  is  wide.  In 
Iceland  and  Australia  it  is  most  common.  In  European  countries  it  is  not 
rare.    It  is  extremely  infrequent  in  the  British  Isles  and  North  America. 

Symptoms. — The  condition  is  encountered  at  all  ages,  but  is  infre- 
quent in  children  and  old  persons.  The  period  of  greatest  liability  com- 
prises the  third  and  fourth  decades.  Women  are  more  frequently  affected 
than  men.  The  organs  most  commonly  involved  are  the  liver,  other 
abdominal  and  pelvic  organs,  brain,  and  circulatory  system.  In  a  majority 
of  the  cases  one  organ  only  is  affected.  The  primary  infection  may,  however, 
implicate  several  organs;  later,  infection  may  take  place,  or  in  consequence 
of  accidental  or  surgical  traumatism  daughter  cysts,  brood  capsules,  or 
scolices  may  find  their  way  into  a  serous  sac,  especially  the  peritoneum, 
and  colonize,  forming  new  tumors.  Hydatids  of  the  liver,  when  small 
and  deep-seated,  cause  neither  symptoms  nor  physical  signs.  When  large 
and  superficial  they  have  the  attributes  of  solid  or  cystic  tumors  in  general. 
Upon  the  anterior  surface  they  appear  as  circumscribed  round  or  oval 
tumors  of  firm  consistence  or  obscurely  fluctuating;  a  cyst  of  the  left  lobe 
may  displace  the  heart  upward  and  give  rise  to  extensive  dulness  in  the  left 
hypochondrium;  a  cyst  of  the  right  lobe  yields  dulness  extending  upward 
into  the  chest.  Hydatid  Fremitus. — When  the  cyst  is  superficially  situated, 
it  yields  in  some  instances,  upon  direct  finger  percussion  with  the  right  hand 
and  palpation  with  the  fingers  of  the  left,  a  peculiar  prolonged  vibratile 
tremor.  Very  large  cysts  are  attended  with  distressing  sensations  of  weight 
and  dragging,  sometimes  of  actual  pain.  When  suppuration  occurs  septic 
symptoms  arise.  Rupture  into  the  bile  passages  causes  a  suppurative 
cholangitis  with  deep  jaundice;  into  the  vena  cava  sudden  death  from  the 
action  of  the  daughter  cysts  as  plugs  in  arresting  the  circulation  at  the 
tricuspid  orifice  or  in  the  pulmonary  artery.  A  toxic  substance  in  the  fluid 
contents,  probably  a  leucomaine,  causes,  when  introduced  into  the  peri- 
toneal cavity,  a  general  peritonitis.  To  this  substance  has  been  attributed 
the  urticaria  which  frequently  accompanies  the  rupture  of  hydatid  cysts 
or  operation  upon  them. 

Diagnosis  of  Hydatids  of  the  Liver. — Direct. — Moderate-sized  cysts 
produce  no  symptoms  by  which  they  can  be  recognized.  A  large  circular 
or  oval  tumor  or,  in  the  case  of  multiple  cysts,  a  similar  large,  irregular 
mass,  unaccompanied  by  pain,  firm  and  elastic,  or  fluctuating,  and  espe- 
ciallj''  when  there  is  the  hydatid  tremor  connected  with  the  liver  and  not 
attended  by  derangement  of  the  health,  justifies  a  provisional  diagnosis  of 


DISEASES  DUE  TO  CESTODES.  865 

hydatid  cyst.  If,  upon  exploratory  puncture,  a  fluid  having  the  above 
characters  and  containing  hooklets  is  withdrawn  the  diagnosis  is  positive. 
If  there  is  a  history  of  acutely  developing  pulmonary  symptoms — rupture 
into  the  lung — and  hooklets  or  cysts  in  the  matter  coughed  up,  the  diag- 
nosis is  certain.    The  presence  of  hooklets  in  a  doubtful  fluid  is  diagnostic. 

Differential. — Abscess. — When  suppuration  occurs  the  condition 
is  actuafly  hepatic  abscess.  The  history  of  a  tumor  in  the  hepatic  region, 
unaccompanied  by  failure  of  health,  is  suggestive  of  hydatid  cyst;  of  dysen- 
tery or  traumatism  in  the  absence  of  previous  enlargement,  in  favor  of  pri- 
mary abscess.  Syphilis. — The  tumor  or  tumors  are  firm  and  non-fluctuating. 
The  anamnesis  is  important.  Cancer. — As  a  rule  the  course  of  the  disease 
is  very  different  from  that  of  carcinoma  hepatis;  but  there  are  cases  in 
which  the  multiple  tumor  formation  simulates  cancer  very  closely.  Large, 
single  tumors  and  fluctuation,  especially  the  hydatid  fremitus,  are  in  favor 
of  hydatids.  Dilatation  of  the  Gall-bladder. — Empyema  of  the  gall-bladder, 
in  the  absence  of  adhesions,  constitutes  a  pear-shaped  tumor  which  is  often 
movable  in  a  lateral  direction  more  freely  at  its  lower  than  its  upper  extrem- 
ity. Hydronephrosis. — The  discrimination  is  sometimes  beset  with  diffi- 
culties. In  this  condition  the  tumor  may  repeatedly  disappear  with  great 
diuresis.  If  a  hydatid  cyst  ruptures  into  the  bladder,  hooklets  may  be  found 
in  the  urine.  Pleural  Effusion  upon  the  Right  Side. — The  diagnostic  difficul- 
ties here  also  are  great.  Exploratory  puncture  is  necessary.  The  character 
of  the  fluid  is  distinctive. 

Diagnosis  of  Hydatids  of  the  Lungs  and  Pleura. — Lungs. — The  direct 
diagnosis  cannot  be  made  in  the  case  of  small  cysts  which  produce  only 
trifling  symptoms.  Larger  cysts  compress  the  pulmonary  tissue  and  lead 
to  inflammation  and  necrosis  with  ulceration  into  bronchi  and  the  dis- 
charge of  membrane,  daughter  cysts,  and  hooklets.  Hemorrhage  is  com- 
mon. Pleurce. — Hemorrhage  into  the  pleura  with  empyema  and  pleuro- 
pulmonary  fistula  occurs.  The  condition  simulates  ordinary  empyema  but 
the  anatomical  findings  in  the  sputa — membranes,  cysts,  or  hooklets — are 
diagnostic.  The  larvae  may  first  develop  in  the  pleura  and  reach  a  large 
volume,  simulating  effusion.  The  upper  line  of  dulness  is  irregular.  Inflam- 
mation may  ensue  with  perforation  of  the  chest  wall.  The  condition  is  a 
serious  one,  liable  to  be  followed  by  sepsis. 

Diagnosis  of  Echinococcus  of  the  Kidneys. — The  kidney  may  be  dilated 
and  simulate  hydronephrosis.  The  diagnosis  can  be  made  only  by  an  ex- 
ploratory puncture  and  examination  of  the  fluid. 

Diagnosis  of  Echinococcus  of  the  Brain. — The  symptoms  are  not  char- 
acteristic, being  those  of  tumor — persistent  headache  with  vertigo  and 
vomiting,  convulsions  of  Jacksonian  type,  and  optic  neuritis  with  atrophy. 
The  differential  diagnosis  cannot  be  made.  Echinococcus  cysts  in  the  liver 
or  elsewhere  would  justify  a  probable  diagnosis.  Cystic  disease  of  the 
choroid  plexus  is  to  be  considered. 

A  form  of  multilocular  echinococcus,  encountered  in  men  and  oxen  in 
Russia,  Bavaria,  Switzerland,  and  the  Austrian  Alps,  deserves  special 
consideration.  A  few  imported  cases  have  occurred  in  North  America. 
The  tumor  is  confined  to  the  liver  and  consists  of  dense  strands  of  connec- 
tive tissue  in  which  are  embedded  numerous  cysts  so  that  the  cut  section 
55 


866 


MEDICAL  DIAGNOSIS. 


has  a  honeycomb  appearance.     The  cysts  are  filled  with  a  transparent  or 
opaque   gelatinous   fluid   and   present   the   appearance   of   alveolar   colloid 
cancer.     There  is  a  tendency  to  disintegrating  ulceration.     The  spleen  is 
usually  enlarged.      Jaundice  is  common.      There  is  a  ten- 
dency to  hemorrhage  and   the  prognosis  is  unfavorable. 

D.  DISEASES  DUE  TO  NEMATODES. 

Nematodes  are  elongated  round  worms  of  a  filiform 
or  fusiform  shape,  provided  A'ith.  a  mouth  and  intestinal 
apparatus.  The  sexes  are  in  most  species  separate  and 
the  male  can  be  distinguished  from  the  female  by  its 
smaller  and  more  slender  form  and  spiral  or  incurvated 
posterior  extremity.  Fertilization  takes  place  within  the 
uterus,  and  the  ova,  according  to  the  species,  are  deposited 
before  or  during  segmentation  or  with  the  embryo  fully 
developed.  A  few  species  are  viviparous.  The  mode  of 
infection  of  the  host  differs  according  to  the  species  of  worm. 


i.  Ascariasis. 

Ascaris  Lumbricoides. — The  body  is  spindle-shaped 
and  of  a  reddish  or  graj-ish-yellow  color,  with  four  longi- 
tudinal bands  and  transverse  markings.  The  male  meas- 
ures 12-25  cm.  in  length  and  about  3  mm.  in  transverse 
diameter  at  its  thickest  part;  the  female  from  20-40  cm. 
by  5  mm.  The  ova  are  elhptical  with  a  thick  brownish- 
red  covering.  The}^  measure  0.05-0.07  mm.  in  length  by 
0.04-0.05  mm.  in  breadth.  They  are  deposited  before 
segmentation  and  are  sometimes  present  in  the  stools  in 
great  numbers.  Generation  takes  place  without  inter- 
mediate host.  This  nematode  worm  is  the  most  common 
parasite  of  man  and  is  distributed  over  the  entire  world. 
It  is  most  frequent  in  young  children,  but  occurs  at  all 
periods  of  life.  It  is  extremely  common  in  the  negro 
races.  As  a  rule  only  a  few  worms  are  present,  but  cases 
have  been  reported  in  which  hundreds  of  them  have  been 
harbored  by  one  individual. 

The  upper  portion  of  the  small  intestine  is  the 
normal  habitat  of  the  round  worm.  They  migrate,  how- 
ever, into  the  stomach  and  are  frequently  evacuated  by 
vomiting.  This  is  especially  common  in  febrile  diseases. 
They  sometimes  pass  through  the  oesophagus  into  the 
pharynx  and  creep  out  through  mouth  or  nostrils.  They  have  been  known 
to  penetrate  the  Eustachian  tube  and  appear  at  the  external  auditory  meatus. 
They  sometimes  occupy  the  biliary  and  pancreatic  ducts,  or  inflammatory 
adhesions  between  the  intestine  and  adjacent  parts— tforw  abscess.  Pass- 
ing from  the  pharynx  into  the  larynx  they  have  caused  fatal  asphyxia. 
In  other  cases  they  have  escaped  into  the  trachea  and,  penetrating  into  the 


Fig.  298. — Asca- 
ris lumbricoides.  1, 
ovum  (after  Braun) ; 
2,  female  worm. 


DISEASES  DUE  TO  NEMATODES. 


867 


bronchi,  have  been  the  occasion  of  gangrene  of  the  lung.  They  sometimes 
find  their  way  into  the  bladder  and  are  passed  with  the  urine.  These 
wanderings  are  the  cause  of  most  serious  and  often  unaccountable  symptoms, 
but  in  neurotic  persons  even  the  presence 
of  a  small  number  of  worms  within  the 
intestine  may  give  rise  to  nervous  phe- 
nomena— chiefly  hysterical — which  cease 
upon  their  expulsion.  In  other  cases 
irregular  fever  with  gastro-intestinal  symp- 
toms occurs.  These  symptoms  have  been 
regarded  as  reflex,  but  are  probably  due 
to  a  toxin.  The  presence  of  Ascaris 
lumbricoides  in  the  intestine  may  be 
demonstrated  by  finding  the  ova  upon 
microscopical  examination  of  the  faeces. 
Oxyuris  Vermicularis  (Thread  Worm; 
Seat  Worm). — One  of  the  most  common 
and  widely  distributed  of  human  para- 
sites. The  color  is  whitish  and  the 
females  may  be  seen  in  lively  movement 
in  the  recently  voided  faces  of  infected 
persons.  The  male  measures  3-5  mm.  in  length  and  the  female  is  10  mm, 
in  length  and  0.6  in  breadth.  The  ova  are  deposited  with  the  embryo  fully 
developed  and  are  very  rarely  found  in  the  faeces.  This  parasite  lives 
in  the  rectum  and  colon.  It  is  usually  present  in  enormous  numbers.  Its 
wanderings  are  chiefly  nocturnal  and  give  rise  to  troublesome  itching.  The 
localities  affected  are  the  sulcus  between  the  nates,  the  perineum,  and  the 
vulva.  As  the  result  of  scratching,  the  larvae  may  be  carried  to  the  nose 
and  mouth  and  the  patient  reinfects  himself,  or  he  may  infect  others  by 
the  hand  directly  or  indirectly.  The  primary  infection  takes  place  by 
means  of  water  or  fruits  or  vegetables  eaten  raw,  or  perhaps  through 
the  intervention  of  flies.  Direct  development  takes  place  without  an 
intermediate  host. 

Oxyuris  in  rare  instances  penetrates  the  wall  of  the  gut  and  causes  peri- 
rectal abscess.    Most  common  in  children,  it  may  be  encountered  at  any  age. 

The  symptoms  in  addition  to  local  irritation  and  itching  are  restless- 
ness, disturbed  sleep,  loss  of  appetite,  and  anaemia. 


Fig.  299. — 1,  dorsal  asi>ect  of  head  of 
Ascaris  lumbricoides;  2,  ventral  aspect  of 
head;  3,  tail  of  male;  4,  lateral  aspect  of  tail 
of  female;  5,  ventral  surface  of  tail  of 
female — After  Claus. 


ii.  Trichiniasis. 

The  disease  is  caused  by  the  embryos  of  Trichinella  spiralis,  which  pass 
from  the  intestines  and  are  distributed  widely  throughout  the  body,  but 
find  the  conditions  necessary  to  their  further  development  only  in  the 
fibres  of  the  transversely  striated  muscles,  in  which  they  develop  into 
encapsulated  larvae. 

Trichinella  Spiralis. — The  male  measures  1.4-1.6  mm.  in  length 
and  0.04  mm.  in  breadth;  the  female  3-4  mm.  in  length  and  0.06  mm.  in 
diameter.  This  parasite  in  the  adult  stage  inhabits  the  small  intestine  of 
man  and  various  mammals,  especially  the  hog.     The  larvae  are  0.8-1  mm. 


868 


MEDICAL  DIAGNOSIS. 


in  length  and  infest  the  striated  muscles,  in  which  they 
lie  coiled  spiralh'  in  ovoid  capsules  which  mostly  have 
their  longitudinal  axis  parallel  with  the  long  axis 
of   the   muscular   fibres. 

It  has  been  experimental!}''  demonstrated  that  the 
encysted  larvae,  shortl}^  after  their  introduction  into 
the  stomach,  are  freed  from  their  capsules  by  the 
action  of  the  gastric  juice  and  pass  into  the  upper  part 
of  the  small  intestine,  where  they  quickly  attain  their 
adult  form.  Copulation  takes  place  in  the  course  of 
two  or  three  days,  after  which  the  males  die  and  the 
females,  which  are  viviparous,  penetrate  the  intestinal 
mucosa  and  reach  the  lymph  spaces,  in  which  they 
deposit  their  young.  Carried  by  the  tymph  stream 
and  ultimately  b}^  the  blood  current  the  embryos  invade 
the  striated  muscles,  in  which  encapsulation  takes  place. 
On  the  ninth  or  tenth  clay  after  ingestion  of  the 
affected  flesh  the  first  embryos  have  reached  their 
destination.  Two  or  three  embrj^os  may  occupy  the 
same  capsule.  The  infested  muscular  fibres  undergo 
degeneration  and  lose  their  striation.  The  intra- 
muscular connective  tissue  undergoes  an  inflammatory 
hyperplasia  and  forms  the  cystic  capsule.  In  the 
course  of  several  months  the  capsular  walls,  at  first 
translucent,  undergo  calcification,  which,  beginning  at 
the  poles,  gradually  progresses  until  in  the  course  of 
time  the  enclosed  larvae  also  become  calcified.  In 
hogs  calcification  is  usually  long  delayed,  so  that  the 
capsule  may  elude  ordinary  examination. 

The  larvae  are  not  evenly  distributed  throughout 
the  muscular  system.  Favorable  locations  are  the 
intercostal  muscles,  the  muscles  of  the  diaphragm, 
abdomen,  larynx,  and  tongue.  In  their  encysted  state 
the  larvffi  sometimes  preserve  their  capacity  for  devel- 
opment for  many  years.  The  beginning  of  calcification 
marks  the  end  of  this  period.  Rats  appear  to  be  the 
normal  hosts  of  T.  spiraHs.  They  infect  themselves 
by  devouring  the  fiesh  of  their  own  kind  and  the  hog 
waste  in  abattoirs,  and  infect  other  animals,  as  pigs, 
dogs,  cats,  etc.,  by  which  they  are  sometimes  eaten. 
Pigs  are  also  infected  by  feeding  upon  the  offal  of 
trichinous  pigs.  Man  is  infected  by  eating  the  raw  or 
insufficiently  cooked  flesh  of  infected  hogs.  The  geo- 
graphical distribution  of  T.  spiraUs  is  much  more 
extensive  than  the  occurrence  of  trichiniasis  in  man. 
The  custom  of  eating  raw  or  only  partially  cooked 
pork  is  the  important  cause  of  trichiniasis.  Where 
this  custom  does  not  prevail  epidemics  of  trichiniasis  do  not  occur,  even 
though  there  are  great  numbers  of  infected  hogs.     North  Germany  espe- 


m 


Fig.  300.— Trichinella 
spiralis.  1,  larval  worm 
encapsulated  ;  2,  male  ; 
3,  female. 


DISEASES  DUE  TO  NEMATODES.  8G9 

cially  suffers  and  affords  many  examples  of  grave  epidemics.  In  South 
Germany,  France,  England,  and  the  United  States  the  disease  is  infrequent. 
Post-mortem  investigations  indicate  that  mild  sporadic  cases  are  more 
common  in  this  country  than  was  formerly  supposed  and  that  they  are 
frequently  overlooked. 

The  anatomical  lesions  consist  of  minute  local  wounds  of  the  intestine 
caused  by  the  boring  female  trichinellse  and  important  chiefly  in  proportion 
to  their  number;  of  the  lesions  in  the  muscles,  the  primitive  bundles  under- 
going granular  degeneration  with  local  myositis;  and  of  important  changes 
in  the  blood,  which  shows  a  marked  leucocytosis — 25,000-30,000.  The 
eosinophiles  are  enormously  increased,  comprising  20  per  cent,  or  more  of 
all  the  leucocytes.  Fatty  degeneration  of  the  liver  and  enlargement  of 
the  superficial  lymph-glands  have  been  described.  New  broods  of  embryos 
are  produced  from  time  to  time  and  adult  trichinse  are  found  post  mortem 
in  the  intestine  in  cases  fatal  at  the  end  of  four  or  five  weeks. 

Symptoms. — Sporadic  cases  occur,  but  the  disease  is  more  commonly 
endemic  and  local  epidemics  are  common.  The  last  can  almost  always  be 
directly  traced  to  the  pork  supply  and  not  rarely  have  followed  a  "  Fest " 
or  entertainment  in  which  uncooked  ham,  sausages,  or  similar  food  have 
been  largely  partaken  of.  Trichinous  flesh  may  be  eaten  without  causing 
trichiniasis.  This  occurs  when  the  cysts  have  been  thoroughly  acted  upon 
by  heat  in  cooking,  when  a  limited  number  of  embryos  have  been  ingested, 
and  when  active  purgation  has  promptly  occurred. 

(a)  Stage  of  Gastro-intestinal  Irritation. — A  few  days  after 
eating  trichinous  meat  loss  of  appetite,  abdominal  pain,  vomiting,  and 
diarrhoea  occur.  These  symptoms  are  of  varying  intensity,  sometimes  being 
absent  altogether,  sometimes  almost  choleraic.  These  symptoms  are 
often  attended  with  great  general  debility,  (b)  General  Infection. — 
The  invasion  of  the  muscles  gives  rise  in  man  to  a  more  or  less  intense 
myositis,  manifested  by  pain  upon  movement  and  pressure,  swelling  and 
tension  of  the  muscles,  and  oedema  of  the  overlying  skin.  The  muscles  of 
mastication  and  deglutition  are  especially  involved  and  the  predilection 
of  the  embryos  for  the  muscles  of  the  diaphragm  and  the  intercostal  muscles 
is  the  occasion  of  serious,  sometimes  fatal  dyspnoea.  The  onset  of  these 
symptoms,  which  follows  infection  in  about  ten  days  or  two  weeks,  is 
accompanied  by  fever  of  remittent  or  intermittent  type — 102°-104°  F. 
(39°-40°  C.) — and  local  oedemas,  especially  under  the  eyes.  Excessive 
sweating,  itching,  and  urticaria  occur.  Antemia,  rapid  wasting,  and  loss  of 
strength  are  common.  In  the  severer  cases  delirium,  tremor,  and  dry  tongue 
occur.     Albuminuria  is  common  and  polyuria  may  occur. 

Diagnosis. — Direct. — When  a  number  of  persons  fall  ill  at  the  same 
time  shortly  after  a  festival  or  who  are  customers  of  the  same  pork  butcher, 
suspicion  should  be  aroused.  The  finding  of  the  parasites  in  the  pork,  in 
the  stools  of  the  patients,  in  shreds  of  muscle  removed  for  the  purpose  under 
local  anicsthesia;  muscular  tenderness  upon  movement  or  pressure;  oedema 
under  the  eyes;  the  blood  count,  showing  high  leucocytosis  with  marked 
eosinophilia,  constitute  positive  diagnostic  criteria. 

Trichinellse  in  the  stools,  when  examined  with  a  low  power,  appear  as 
short,  silvery,  glistening  threads,  which  are  sometimes  still  in  movement. 


870 


MEDICAL  DIAGNOSIS. 


Differential. — Enteric  Fever. — Any  resemblance  that  may  occur  is 
superficial.     On  the  one  hand  we  have  a  definite  symptom-group  charac- 
terized by  the  gradual  rise  of  temperature,  relatively  slow  pulse  as  compared 
with  the  rise  of  temperature,  palpable  spleen,  and  rose  spots,  together  with 
a  positive   agglutination   test;    on   the   other  the  equally 
characteristic  symptom-complex  described  in  the  foregoing 
paragraph.       Rheumatic   Fever. — Pain  on   movement    and 
tenderness   are  suggestive.      But  the  joints  and  not  the 
muscles    are    involved    and    the    oedema   is   periarticular. 
Cholera. — The  urgency  of  the  intestinal  symptoms  and  the 
great  number  of  persons  simultaneously  affected  in  some 
of   the   epidemics   has   aroused   the   suspicion   of   cholera. 
Rice-water   discharges,  collapse,  and   the   rapid   course  of 
the  latter  disease  are  diagnostic  points  of  importance. 

Prognosis. — The  duration  and  severity  of  the  attack 
depends  upon  the  number  of  the  invading  embryos.  The 
symptoms  are  aggravated  by  the  access  of  fresh  groups. 
In  mild  cases  the  symptoms  are  slight  and  disappear  in  the 
course  of  two  or  three  weeks.  In  the  more  severe  cases  the 
active  symptonas  continue  for  several  weeks  and  convales- 
cence is  tardy.  The  death-rate  varies  from  1  or  2  to  20  or 
30  per  cent,  in  different  outbreaks.  Death  most  commonly 
occurs  in  the  fourth,  fifth,  or  sixth  week. 


iii.   Uncinariasis. 

Ankylostomiasis;  Hook=worm  Disease. — The  parasite 
of  this  disease  belongs  to  the  Strongylidse.  There  are  two 
species  parasitic  in  man,  distinguished  by  specific  ana- 
tomical differences,  especially  in  the  mouth,  and  by  differ- 
ences in  size — the  (a)  old-world  Ankylostoma  duodenale 
and  (b)  Necator  americanus.  The  general  characters  are 
similar.  The  body  is  cylindrical,  attenuated  anteriorly, 
and  of  a  reddish  color.     The  males  measure  8-10  mm.  in 

length  and  0.4-0.5  mm.  in 
breadth;  the  females  10-18 
mm.  in  length.  The  eggs 
are  elliptical,  thin -shelled, 
and  measure  0.05-0.06  mm. 
by  0.03-0.0-1  mm.  and  arc 
laid  in  a  state  of  segmen- 
tation. In  the  European 
species  the  mouth  is  supplied 
with  four  sharp,  hook-like  ventral  teeth,  projecting  backward,  and  with 
two  teeth  projecting  forward  on  the  dorsal  surface,  while  in  the 
base  of  the  oral  cavity  there  is  one  tooth  directed  forward.  The 
Cauda  bursa  of  the  male  has  one  small  dorsal  and  two  large  lateral 
alar  processes.     The  development  is  direct  without  an  intermediate  host. 


Fig.    301. — Ankylostoma  duodenale,  natural    size  below,  and 
much  magnified  male. — After  Schulthess. 


DISEASES  DUE  TO  NEMATODES. 


871 


The  adult  worm  infests  the  duodenum,  less  frequently  the  jejunum, 
and  sucks  blood  with  its  head  buried  in  the  mucosa,  changing  its  position 
from  time  to  time  so  that  minute  hemorrhages  continue.  The  number  of 
worms  varies  from  a  few  to  a  thousand  or  more.  The  duration  of  life  in 
the  bowel  is  unknown.  The  disease  is  essentially  chronic.  It  may  be  kept 
up  by  the  prolonged  life  of  the  parasite,  or  by  reinfection. 

This  parasite  is  the  cause  of  "  Egyptian  chlorosis, "  the  tunnel  disease 
of  St.  Gotthard,  miners'  and  brickmakers'  disease,  and  tropical  anaemia. 
It  is  widely  distributed  in  warm  countries,  but  occurs  in  all  parts  of  the  old 
world.  Since  the  Spanish-American  War  uncinariasis  has  attracted  much 
attention  and  Necator  americanus  (Stiles)  has  been  found  to  be  the  cause 
of  the  so-called  southern  anaemia.  It  is  endemic  in  Virginia,  North  and 
South  Carolina,  Georgia,  Florida,  Alabama,  and  Texas.  It  is  extremely 
prevalent  in  Porto  Rico;   less  so  in  Cuba  and  Brazil. 

The  larvae  live  in  water  and  moist  soil.  There  are  two  hypotheses 
as  to  the  mode  of  their  introduction:  first,  that  they  are  ingested  by  the 


Fig.  302. — Eggs  of  Uncinaria  duodenalis.     a,  unsegmented;  6,  with  four  segments  and  showing  nuclear 
spindles;  c  and  d,  later  stages  of  segmentation.     X  400. — Emerson. 

mouth  in  drinking  water,  upon  uncooked  vegetables,  from  the  soiled  hands 
of  men  who  work  and  children  who  play  in  moist  earth,  or  by  clay  eaters; 
and  second,  that  they  penetrate  the  skin  by  way  of  the  hair-follicles,  and 
are  transported  by  the  venous  blood  to  the  right  side  of  the  heart  and  the 
lungs,  whence  they  pass  by  way  of  the  bronchi  and  trachea  to  the  pharynx, 
and  are  then  swallowed.  This  extraordinary  observation  of  Looss  has  been 
confirmed  by  others,  and  Smith  of  Atlanta  produced  uncinariasis  in  man  by 
the  application  of  mud  containing  the  larvae  to  the  arm.  The  long  vexed 
question  of  the  relation  of  "  ground  itch  "  to  uncinariasis  is  thus  settled. 

Symptoms. — The  clinical  phenomena  are  due  to  the  constant,  pro- 
longed drain  of  blood  from  the  intestinal  mucosa  by  the  parasites  them- 
selves and  from  the  wounds  which  they  have  made,  bacterial  infection  at 
the  site  of  the  lesions,  chronic  local  inflammation  and  thickening  of  the 
bowel,  and  the  deleterious  action  of  toxins  produced. 

The  ova  are  frequently  found  in  the  stools,  especially  in  children,  in 
the  absence  of  symptoms.  From  this  fact  it  has  been  inferred  that  a 
large  number  of  the  parasites  are  necessary  to  cause  the  disease.  The 
anaemia  is  the  most  striking  condition.  Some  associated  pigmentation 
gives  the  skin  a  peculiar  dirty  appearance.  The  facies  has  been  regarded 
as  characteristic,  its  peculiarities  consisting  in  a  pallid,  waxy  color  with 
faint  pigmentation,  and  a  lustreless,  blank  expression  of  the  eyes.  When 
the  disease  is  marked  in  children,  nutrition  and  growth  are  seriously  inter- 


872  MEDICAL  DIAGNOSIS. 

fered  with.  Enlargement  of  the  liver  and  spleen,  with  oedema,  occurs  in 
advanced  cases,  and  the  symptoms  of  anaemia — breathlesnesss  and  palpita- 
tion upon  exertion,  pallor,  puffiness,  and  headache — are  common.  The  blood 
shows  corpuscular  and  haemoglobin  reduction,  infrequent  leucocytosis,  and 
a  moderate  eosinophilia.  In  old  cases  with  marked  anaemia,  which  has 
lasted  a  long  time,  the  eosinophile  count  is  low. 

Diagnosis. — Direct. — The  presence  in  fresh  faeces  of  ova  showing  seg- 
mentation, or  in  older  faeces  of  ova  containing  the  curled  embryos  within  or 
penetrating  the  thin  shell,  is  characteristic.  The  blotting-paper  test  may  be 
employed.  A  little  of  the  faeces  placed  on  white  blotting  paper  after  an  hour 
will  show  a  reddish  color  like  blood.     Eosinophilia  is  of  diagnostic  value. 

Differential. — Pernicious  Ancemia. — Many  of  the  cases  suggest  this 
condition.  The  presence  of  the  ova  in  the  stools,  the  locality  from  which 
the  patient  comes,  his  occupation,  the  facies,  the  blood  picture,  and  the 
therapeutic  test  with  thymol  are  all  to  be  considered. 

Prognosis. — The  outlook  under  thymol  treatment,  except  in  advanced 
cases  with  marked  anaemia,  is  fairly  favorable. 

iv.    Filariasis. 

Filariae  are  long,  slender  nematodes,  which  live  parasitically  in  the 
serous  cavities  and  subcutaneous  tissues  of  the  mammals  which  they  infest. 
The  males  are  usually  much  smaller  than  the  females,  having  the  tail 
sharply  bent  or  spiral  and  being  supplied  with  wing-like  appendages. 

Nineteen  genera  are  described,  of  which  the  following  are  classed  under 
the  general  term  Filaria  sanguinis  hominis: 

1.  Filaria  bancrofti. — The  male  is  colorless  and  measures  40  mm.  in 
length  by  0.1  mm.  in  breadth.  The  female  is  of  a  brownish  color  and  70- 
80  mm.  in  length,  0.2-0.3  mm.  in  diameter,  and  possessed  of  two  uteri 
which  occupy  the  greater  part  of  the  body.  The  embryos  are  contained 
in  an  elongated,  scarcely  perceptible  membrane  in  which  they  move  freely. 
Their  length  is  0.13-0.3  mm.,  their  breadth  0.007-0.011  mm.  By  way  of 
the  lymph  stream  they  reach  the  blood  and  are  distributed  to  all  parts  of 
the  body.  Their  appearance  in  the  peripheral  circulation  is  peculiar, 
showing  a  remarkable  periodicity.  During  the  day  there  are  very  few  if 
any  to  be  found;  but  towards  sunset  they  appear  and  steadily  increase  in 
number  until  midnight,  when  they  gradually  decrease  and  disappear  by 
the  middle  of  the  morning.  If  the  patients  sleep  during  the  day  and  remain 
awake  at  night  the  order  of  the  appearance  of  embryos  is  reversed,  namely, 
they  are  present  during  the  day  and  not  to  be  found  at  night.  The  further 
development  of  filariae  is  associated  with  the  mosquito,  which  constitutes 
the  intermediate  host. 

This  parasite  is  distributed  in  nearly  all  tropical  countries,  and  filariasis 
is  common  in  India,  China,  Japan,  the  Australasian  Islands,  Egypt,  The 
Sudan,  Zanzibar,  Madagascar,  and  the  Southern  United  States.  Sporadic 
cases  are  occasionally  encountered  in  the  Middle  States  and  elsewhere  in 
temperate  climates  in  the  course  of  routine  examinations  of  the  blood. 
Some  of  these  cases  are  imported,  but  there  are  instances  in  which  the 
source  of  the  infection  could  not  be  traced. 


DISEASES  DUE  TO  NEMATODES.  873 

Symptoms. — In  animals  and  during  a  long  period  of  latency  in  man, 
filarise  may  exist  in  the  blood  without  causing  any  inconvenience.  Their 
presence  becomes  known  only  upon  examination  of  the  blood.  After  a 
time  anaemia,  splenic  enlargement,  and  irregular  fever  of  moderate  intensity 
may  occur.  When  the  lymph-vessels  become  blocked  by  the  adult  worm 
or  the  ova,  characteristic  conditions  arise,  namely,  hsematochyluria,  lymph 
scrotum,  and  elephantiasis. 

H^MATOCHYLURiA. — The  urine  is  opaque,  milky  white,  or  blood- 
tinged.  On  standing  a  reddish  coagulum  sometimes  forms.  Microscopic- 
ally there  are  minute  globules  and  molecular  fat  and  erythrocytes  in 
varying  numbers.  The  quantity  of  urine  is  normal  or  it  may  be  increased. 
The   condition   is  intermittent,   and 

after  passing  chylous  urine  for  a  short     iP*->'55chmi'cO''.oti  ,  .    -      -- 

period  the  patient  commonly  passes 
for  weeks  or  even  months  urine  that 
is  normal.  The  general  health  is 
often  fair.  In  other  cases  there  is 
more  or  less  uneasiness  in  the  lumbar 
region,  anaemia,  and  vesical  irritation, 
with  difficulty  in  passing  the  blood- 
clots  which  form  in  the  bladder. 

Lymph  Scrotum. — Blocking  of 
the  lymph  channels  is  followed  by  a 
dilatation  of  the  lymph  plexuses  that 
is  sometimes  enormous.  When  the 
scrotum  is  involved  there  is  great 
thickening   of    the  tissues   and    the 

distended  lymph-vessels  are  plainly  . 

visible.  Upon  puncture  a  clear  or 
sometimes  a  turbid  fluid  exudes. 

A  form  of  elephantiasis  follows 
permanent  occlusion  of  the  lymph 
channels  of  the  lower  extremities. 
The  lymphatic  glands,  especially  in 
the  groin,  are  much  enlarged.  :^C(;"^  ' 

Diagnosis. — The  living  embryos 
in  the  recent  blood  are  readily  recog- 
nized. Their  presence  is  made  known  by  the  commotion  which  they  cause 
among  the  red  corpuscles,  and  the  worm  itself,  usually  in  active  movement, 
may  be  made  out  with  a  low  power.  Chylous  urine  may  occur  under  other 
circumstances  not  well  understood.  The  non-parasitic  form  is  very  rare. 
Withdrawal  of  fat  from  the  diet  is  usually  followed  by  disappearance  of 
the  chylous  appearance,  but  a  glass  or  two  of  milk  will  render  the  urine 
again  opaque. 

Most  cases  of  elephantiasis  in  temperate  climates  are  non-parasitic. 

Prognosis. — A  large  proportion  of  the  cases  remain  latent  for  an  indefi- 
nite period.  Many  of  the  cases  of  lymph  scrotum  and  elephantiasis  are 
progressive,  and  the  patient  succumbs  to  exhaustion  or  intercurrent  disease. 
The  removal  of  an  adult  worm  from  the  enlarged  inguinal  lymph-glands 


Fig.  303. — Microfilaria  nocturna. 


874 


MEDICAL  DIAGNOSIS. 


has  been  followed  by  the  disappearance  of  the  embryos  from  the  blood. 
If  two  or  more  were  present  this  result  would  not  occur. 

2.  Filaria  diurna.  —  This  parasite  closely  resembles  F.  bancrofti. 
It  appears  in  the  blood  during  the  day  only,  or  at  night  when  the  patient 
remains  awake.  Manson  found  the  larvae  in  the  blood  of  several  negroes 
from  Congo.  The  mangrove  fly  is  supposed  to  be  the  intermediate  host. 
F.  loa  is  the  adult  form. 

3.  Filaria  perstans. — The  larva  was  discovered  by  Manson  in  1S91. 
Manson  found  in  the  blood  of  Carib  Indians  sent  from  British  Guiana  two 
forms  of  larval  filarise  differing  in  type,  one  closely  resembling  those  of  F. 


Fig.  304.- 


Patient  aged  twenty-three  years,  affected    with  elephantiasis  arabum. 
aged  forty-seven  years.     {International  Clinics.) 


b.  Same  patient, 


perstans,  the  other  slightly  larger  and  likewise  without  a  sheath.  Daniels 
in  1898  found  the  adult  worm,  both  male  and  female.  The  female  is  70- 
80  mm.  in  length  by  0.12  mm.  in  breadth;  the  male  45  mm.  by  0.06  mm.; 
the  embryos  0.2  mm.  in  length  by  0.004  in  breadth  and  possess  no  sheath. 
The  adult  worms  inhabit  the  connective  tissue  of  the  mesentery  at  its 
spinal  attachment.  This  parasite  infests  the  tribes  who  dwell  in  dense 
swamps  and  deep  forests.  It  abounds  on  the  West  Coast  of  Africa,  in 
British  Guiana,  and  in  Porto  Rico.  It  may  be  observed  in  the  blood  both 
during  the  night  and  day.  It  is  thought  to  be  the  cause  of  a  pustular  disease 
of  the  skin  common  among  the  negroes  of  the  West  Coast  of  Africa.  The 
intermediarv  host  has  not  been  settled. 


DISEASES  DUE  TO  NEMATODES. 


875 


V.   Dracontiasis. 

Guinea-worm  Disease. 

Filaria  (Dracunculus)  medinensis   {Guinea-worm;    Medina  worm). — 
The  female  measures  50-80  cm.  in  length  and  0.5-2  mm.  in  diameter  and 
is  cylindrical  in  form  with  a  blunt 
anterior    extremity    and    a    pointed 
posterior  end  terminating  in  a  hook.  ff0^ 


Fig.    305.  —  Filaria  medinensis.     1,  head; 
2,  3,  4,  larvse;  5,  adult  worm. — After  Claus. 


-Trichocephalus  dispar.     1,  egg; 
2,  female;    3,   male. 


Only  the  female  has  been   known. 

Quite  recently,  however,  small  worms        Fig.  306.- 

about  4  cm.  in  length  were  found 

in  two  instances  attached  to  the  females  and  regarded   by  Charles,  who 

made  the  observation,  as  males.     The  uterus  contains  a  great  number  of 


876  MEDICAL  DIAGNOSIS. 

living  embryos,  which  may  reach  the  open  by  the  rupture  of  the  body  of 
the  adult  female.  They  develop  in  the  body  of  Cyclops.  The  male  and 
female  are  probably  ingested  by  the  mouth,  the  former  dying  and  the  latter, 
after  impregnation,  finding  its  way  to  the  subcutaneous  tissues,  in  which  it 
slowly  develops,  remaining  quiescent  during  a  period  of  eight  to  ten  months. 
It  feels  like  a  coil  of  string  under  the  skin.  As  the  embryos  develop  the 
adult  worm  slowly  makes  its  way  downward  to  the  leg  or  foot,  where  it 
forms  a  small  vesicle  or  abscess,  which  bursts,  leaving  an  ulcer  in  the  base 
of  which  its  head  appears.  The  uterus  ruptures  and  the  embryos  are  dis- 
charged in  a  whitish  fluid.  The  worm  may  now  leave  the  host  spontane- 
ously. Guinea-worms  are  usually  solitary,,  but  several  have  been  observed 
in  the  same  individual.  It  attacks  all  races  without  distinction.  It  has 
been  known  from  the  earliest  historical  periods.  It  is  especially  prevalent 
in  Africa  and  the  West  Indies,  but  imported  cases  are  occasionally  observed 
in  the  United  States. 

When  the  worm  first  becomes  palpable  there  is  sometimes  fever 
together  with  an  eosinophilia. 

Trichocephalus  dispar  {T.  trichiurvs;  Whip-worm). — This  parasite 
may  be  recognized  by  the  difference  between  its  filiform  anterior  extremity 
and  its  much  thicker  posterior  portion.  Its  length  is  40-50  mm.,  the  male 
being  slightly  shorter  than  the  female.  The  ova  are  lemon-shaped,  and 
have  a  thick  brownish  shell  at  the  ends  of  which  are  light  yellow  plugs  or 
buttons.  They  measure  0.05  mm.  in  their  long  diameter  and  0.02  mm.  in 
their  transverse  diameter.  This  is  a  common  and  widely  spread  parasite 
of  man  infesting  the  caecum  and  other  parts  of  the  intestine.  It  usually 
gives  rise  to  no  symptomS;  but  exceptionally  its  presence  in  great  numbers 
is  associated  with  anaemia  and  diarrhoea. 

A  number  of  less  important  nematode  worms  have  been  observed  in 
man,  but  the  infrequency  of  their  occurrence,  and  the  facts  that  they  do  not 
cause  definite  internal  diseases  and  that  their  life  history  is  mostly  unknown 
renders  any  extended  consideration  of  them  at  this  time  inappropriate. 


III. 
THE  DIAGNOSIS  OF  THE  CHRONIC  INTOXICATIONS. 

I.   ALCOHOLIC   INTOXICATION;    ALCOHOLISM. 

The  discussion  here  will  be  confined  to  a  brief  statement  of  the  effects 
of  alcohol  on  the  nervous  system.  As  is  well  known  this  poison  acts  most 
injuriously  upon  other  tissues  of  the  body  also,  but  these  effects  are  best 
discussed  under  other  and  appropriate  headings. 

The  ravages  of  alcohol  are  greater  in  modern  life  than  among  the 
ancients,  for  the  reason  that  strong  alcoholic  drinks  are  now  distilled  and 
marketed  at  a  low  price.  The  first  modern  writer  to  attempt  to  treat  this 
subject  adequately  was  Magnus  Huss,  who  made  his  observations  on  the 
Swedish  brandv  drinkers. 


ALCOHOLIC  INTOXICATION.  877 

Pathology. — Changes  are  found  in  the  coats  of  the  blood-vessels,  in 
the  brain  membranes,  and  in  the  neuroglia,  as  well  as  in  the  kidneys,  liver, 
stomach,  and  heart.  Bevan  Lewis  and  Berkley  described  with  minute 
care  the  changes  in  the  central  nervous  system.  According  to  Lewis  these 
changes  are  particularly  marked  in  the  blood-vessels  and  neuroglia,  and 
Berkley  found  microscopic  changes  in  the  neurons  of  the  brain.  Inflam- 
mation of  the  peripheral  nerves,  constituting  the  well-known  multiple 
neuritis,  is  often  seen  in  chronic  alcoholics. 

Symptoms. — Alcoholic  intoxication  is  either  acute  or  chronic. 

Acute  intoxication  requires  only  a  passing  notice.  In  the  first 
stage  there  is  exhilaration,  with  slight  confusion  of  ideas;  then  follows  a 
stage  in  which  memory  is  impaired,  self-consciousness  is  obscured,  and  the 
victim  may  be  violent  and  even  maniacal.  In  the  terminal  stage  a  condi- 
tion of  sleep,  or  even  of  stupor  and  coma,  supervenes;  the  pupils  are  slightly 
dilated,  the  face  congested  or  even  cyanosed,  the  breathing  normal  in  fre- 
quency, the  pulse  regular,  and  the  consciousness  usually  not  so  lost  but  that 
the  patient  can  be  roused  slightly  at  least.  After  some  hours  he  wakes 
with  a  sense  of  depression,  headache,  nausea,  and  a  dry  mouth  and  throat. 
Profound  intoxication  may  simulate  cerebral  hemorrhage,  uraemia,  diabetic 
coma,  and  opium  poisoning. 

Delirium  tremens  is  caused  by  protracted  acute  poisoning.  It  is  the 
result  of  a  disturbed  nutrition  of  the  brain-cells,  and  continues  even  after 
the  alcohol  is  withheld;  in  fact,  it  sometimes  does  not  occur  until  after  the 
patient  is  deprived  of  his  drink — the  delirium  potu  suspense.  This  latter 
form  is  seen  especially  in  hospital  practice — as  after  a  fractured  leg,  a 
surgical  operation,  or  even  in  acute  disease,  such  as  pneumonia.  The 
patient  may  seem  to  do  well  for  a  day  or  two,  when  delirium  suddenly 
develops. 

Delirium  tremens  is  a  psychosis  in  which  the  mental  faculties  are  in 
entire  confusion,  with  terrifying  hallucinations,  such  as  the  sight  of  snakes, 
bats,  and  other  repulsive  objects,  and  the  disturbing  sounds  of  voices; 
there  is  restlessness,  tremor,  incoherence,  muttering,  insomnia,  aversion 
to  food,  rapid  pulse,  and  great  physical  prostration.  The  so-called  typhoid 
state  may  develop,  with  irregular  fever  and  a  dry  brown  tongue,  and  the 
case  may  end  fatally.  The  prognosis  is  in  the  main  favorable,  except  in 
old,  broken-down  topers. 

Subacute  forms  of  delirium  occur,  in  which  the  patient  is  able  to  be 
about  and  to  continue  his  drinking.  He  is  in  a  dream-like,  confused  state, 
irritable,  irresponsible,  insomnious,  unable  to  attend  to  his  work,  eating 
little,  and  subject  to  violent  outbursts  in  which  he  may  even  commit  murder. 
Alcoholic  melancholia  is  also  seen  in  some  hard  drinkers,  and  occasionally 
leads  to  suicide.  It  occurs  especially  after  protracted  sprees.  The  affec- 
tion known  as  mania  a  potu,  often  confused  with  delirium  tremens,  is,  as 
its  name  implies,  a  state  of  furious  maniacal  excitement,  in  which  the 
inebriate  is  especially  dangerous. 

The  CHRONIC  INTOXICATION  from  alcohol  shows  itself  in  the  gradual 
deterioration,  mental,  moral,  and  phj^sical,  of  the  individual.  The  char- 
acter and  reliability  of  the  man  suffer;  he  is  unfit  for  business  or  society; 
subject  to  moral  lapses  of  various  kinds;   untruthful,  indifferent,  cruel,  and 


878  MEDICAL  DIAGNOSIS. 

sometimes  dangerous.  His  memory  and  his  mental  faculties  generally  are 
impaired.  He  has  a  bad  color,  injected  capillaries,  a  tremor  of  his  hands 
and  tongue,  and  is  a  poor  eater  and  sleeper.  There  is  always  a  chance  also 
that  he  has  a  bad  liver  and  bad  kidneys.  Optic  neuritis  and  atrophy  ma}- 
occur  in  chronic  cases. 

Neurasthenia  and  hysteria  are  among  the  conditions  seen  in  chronic 
alcoholics.  These  complications  are  seen  especially  in  persons  who  drink 
not  to  such  great  excess,  as  steadily — a  form  of  slow  chronic  poisoning. 
Chronic  alcoholic  insanity  occasionally  occurs  in  confirmed  inebriates. 
The  patient  has  a  form  of  paranoiac  deterioration.  In  addition  to  the 
mental  failure  already  noted,  he  begins  to  have  hallucinations  of  sight  and 
hearing,  somewhat  as  in  delirium  tremens.  He  sees  disgusting  objects  and 
hears  insulting  voices,  and  these  are  readily  excited  by  every  fresh  debauch. 
He  then  begins  to  form  delusions,  often  quite  well  systematized.  They 
are  of  the  persecutory  type:  he  has  enemies,  who  are  in  league  against  him, 
or  who  would  poison  him.  Sometimes  he  is  markedly  hypochondriacal, 
and  has  an  animal  or  some  unknown  disease  within  him;  but  his  com- 
monest delusion  is  the  delusion  of  marital  infidelity.  This  is  so  common 
as  to  be  held  typical  by  almost  universal  testimony;  and  whatever  its 
cause,  whether  due  to  failing  sexual  power  or  to  the  natural  aversion  of 
the  wife,  it  is  in  a  sense  pathognomonic.  In  time  these  persecutory  delu- 
sions may  give  way  to  delusions  of  an  expansive  type,  just  as  in  paranoia, 
but  by  that  time  the  chronic  inebriate  is  usually  passing  into  well-marked 
dementia,  and  his  case  is  hopeless.  Some  of  these  patients  under  the  influ- 
ence of  their  delusions  commit  crime.  The  terminal  stage  is  one  of  per- 
manent dementia.  In  France  nearly  14  per  cent,  of  the  insane  in  the 
asylums  are  alcoholics.^  In  America  the  percentage  may  be  not  so  high. 
Epilepsy  is  sometimes  a  result  of  alcoholism.  It  is  occasionally  seen  after 
prolonged  sprees  in  susceptible  individuals,  but  often  it  sets  in  later  in 
life  in  chronic  topers.  In  the  latter  case  it  is  usually  a  sign  of  beginning 
degradation  of  brain  tissue.  Alcoholic  general  paresis,  or  pseudoparesis,  is 
a  condition  which  closely  simulates  the  genuine  disease.  There  is  the 
expansive  psychosis,  with  tremor  and  speech  defects,  but  these  patients 
may  recover  rapidly  when  they  are  deprived  of  their  drink.  Dipsomania  is 
the  overpowering  impulse  to  drink  which  is  seen  in  a  class  of  excitable 
and  neurotic  persons,  and  which,  according  to  Spitzka,  is  allied  to  periodical 
mania.  Korsakoff's  psychosis  is  a  mental  disorder,  seen  especially  in  alco- 
holic multiple  neuritis,  in  which  there  is  mental  confusion  with  loss  of 
identity  of  time,  place,  and  person,  and  a  tendency  to  fabulation. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  alcoholic  intoxica- 
tion is,  as  a  rule,  easy.  The  history  in  most  cases  is  clear  and  condition 
unmistakable. 

Mistakes,  however,  occur  in  the  diagnosis  of  acute  drunkenness, 
especially  in  hospital  practice  when  the  history  is  unknown.  The  odor 
of  the  breath  is  entirely  unreliable,  for  the  drunken  man,  or  even  the  man 
who  has  only  been  drinking  moderately,  may  have  opium  poisoning,  or 
uraemia,  or  cerebral  hemorrhage,  or  a  fractured  skull.  In  opium  poison- 
ing there  are  contracted  pupils  and  slow  breathing,  and  the  coma  is  more 

1  Semaine  M^d.,  July  10,  1907. 


OPIUM  POISONING.  879 

profound,  as  a  rule,  than  in  drunkenness.  In  cerebral  hemorrhage  there  is 
usually  a  hemiplegia,  which  is  shown  by  the  diminished  resistance  to  pas- 
sive motion  on  the  paralyzed  side,  and  there  may  be  unequal  pupils  and 
deviation  of  the  head  and  eyes.  Injury  to  the  head,  or  fractured  skull,  is 
usually  detected  on  careful  examination.  Uraemia  is  indicated  by  the 
state  of  the  urine  and  the  subnormal  temperature,  but  the  latter  is  seen 
also  in  alcoholic  intoxication,  and  the  former  is  not  always  conclusive. 
Convulsions  are  rare  in  drunkenness,  but  not  unheard  of. 

Delirium  tremens  is  not  likely  to  be  mistaken,  but  when  it  breaks 
out  suddenly  in  a  surgical  case  or  in  pneumonia  it  may  be  confusing.  The 
tremor  and  peculiar  wandering  delirium,  with  frightful  hallucinations, 
are  significant.  Patients  with  delirium  tremens  should  always  be  care- 
fully examined  for  head  injuries,  fractured  ribs,  and  other  bodily  damage; 
also  for  pneumonia. 

The  other  forms  of  alcoholic  insanity  are  usually  recognized  with  ease 
from   the   history   and   the   character   of    the   symptoms   as   given   above. 

II.   OPIUM  POISONING;   MORPHINISM. 

The  use  of  opium  and  its  alkaloid,  morphia,  has  increased  greatly  in 
America,  until  it  is  now  one  of  the  recognized  evils  of  the  time.  The  drug 
is  taken  in  its  crude  form,  or  as  laudanum,  or  occasionally  as  paregoric, 
but  the  commonest  practice  is  to  use  morphia  by  the  hj^podermic 
syringe.  Accidental  poisoning  is  rare,  but  suicide  by  laudanum  or  morphia 
is  more  common. 

Pathology .^Opium  or  morphia,  when  taken  habitually,  is  a  slow 
and  insidious  poison  to  the  nerve  centres,  but  it  does  not  cause  such  marked 
organic  changes  in  the  tissues  as  does  alcohol.  In  old  habitues  there 
is  often  a  condition  of  malnutrition  or  cachexia,  shown  bj'  a  sallow 
complexion,  loss  of  weight,  and  gastro-intestinal  disorders;  but  some 
narcomaniacs  show  remarkably  little  physical  effect  from  the  drug. 

Symptoms. — The  effects  are  acute  and  chronic.  The  symptoms  of 
acute  poisoning,  after  an  initial  stage  of  excitement  or  dreaminess,  are 
somnolence,  passing  into  stupor  and  coma,  congestion  and  even  cyanosis 
of  the  face,  full  and  slow  pulse,  slow  respiration,  and  stronglj^  contracted 
pupils.  As  death  approaches  the  pupils  may  dilate  widely,  and  they  maj'- 
even  be  unequal;  the  respirations  are  not  only  slow  but  also  imperfect; 
the  surface  pallid  or  cyanosed,  and  covered  with  a  clammy  sweat;  and  the 
pulse  rapid.  Trismus  and  convulsions  are  rare  symptoms.  This  stage  of 
opium  poison  closely  resembles  apoplexy  and  uraemia,  and  a  positive 
diagnosis  cannot  always  be  made  unless  the  history  is  clear. 

The  chronic  effects  of  opium  poisoning  are  seen  in  the  habitual  users 
of  the  drug,  and  they  are  most  marked  in  the  nervous  system,  especially 
the  brain. 

Attempts  have  been  made  to  distinguish  the  various  forms  of  the 
opium  habit,  and  their  pathological  effects.  In  India  opium  is  eaten;  in 
China  it  is  smoked;  and  in  America  it  is  drunk  as  laudanum  or  used  as 
morphia  under  the  skin.  To  draw  distinctions  between  these  varieties  of 
the  same  vice  is,  however,  hardly  possible.     Opium,  in  whatever  way  it  is 


S80       ■  MEDICAL  DIAGNOSIS. 

taken  into  the  system,  acts  in  the  end  very  similarly,  especially  on  the  brain 
and  nerves.  When  taken  by  the  mouth  it  acts,  indeed,  more  directly  and 
injuriously  upon  the  digestive  system;  nevertheless  old  habitues  acquire 
a  wonderful  tolerance.  The  opium  habit  becomes  a  disease,  and  this  dis- 
ease presents  some  well-marked  symptoms.  An  abnormal  mental  state 
results  from  the  habitual  use  of  the  drug.  There  are  moral  perversions, 
enfeebled  will,  loss  of  power  of  attention,  and,  in  advanced  cases,  a  delir- 
ious delusional  psychosis.  In  these  chronic  cases  the  victim  is  often  insane 
and  irresponsible,  although  he  may  be  able  to  present  a  fairly  good  front 
and  to  conceal  his  disorder.  There  is  loss  of  memory,  loss  of  volition  and 
power  of  attention,  loss  of  initiative  and  energy,  diminished  muscular  power, 
often  with  trembling,  blunting  of  the  higher  moral  and  ethical  sense, 
insomnia,  nutritive  disturbances,  and,  finally,  illusions,  hallucinations,  and 
delusions.  The  tendency  of  the  morphinomaniac  to  lie  and  to  romance  is 
proverbial.  The  patient  lives  so  much  of  his  time  in  an  unreal  world  that 
he  loses  his  ability  to  distinguish  the  true  from  the  false.  He  becomes 
both  delusional  and  mendacious.  In  advanced  stages  the  patient  may 
be  violently  insane,  even  maniacal,  and  may  commit  acts  of  violence. 
Obscure  medicolegal  problems  arise  occasionally,  for  the  narcomaniac  is 
sometimes  also  a  kleptomaniac,  a  pyromaniac,  etc.^ 

The  physical  symptoms  vary  greatly;  in  fact,  they  can  hardly  be  said 
to  be  characteristic.  Among  them  are  anaemia,  rapid  exhaustion  and  lack 
of  endurance,  tremor,  itching  of  the  skin,  anorexia,  constipation,  wasting, 
blunting  of  the  special  senses,  and  contracted  pupils.  The  sexual  power  is 
weakened  and  finally  destroyed,  and  in  women  amenorrhoea  is  common. 
Children  born  of  mothers  addicted  to  morphia  have  a  low  vitality  and 
often  die  early. 

Diagnosis. — The  only  rule  is  to  detect  the  habit.  Obscure  mental 
changes,  such  as  those  mentioned  above,  may  exist  for  a  long  while  and  not 
excite  suspicion;  and  he  must  be  a  shrewd  diagnostician  who  can  detect 
the  morphia  taker  by  his  mental  symptoms  alone.  The  history,  therefore, 
is  all  important.  Spells  of  irritability  and  unrest  occur  when  the  victim  is 
deprived  of  his  drug,  and  are  followed  by  a  mysterious  calm  and  serenity 
when  he  has  taken  his  secret  dose.  But  such  signs  require  to  be  inter- 
preted with  great  caution.  Instances  are  known  of  judges  presiding  on 
the  bench,  and  clergymen  preaching  in  their  pulpits,  when  fully  under 
the  influence  of  their  accustomed  doses.  Diarrhoea,  faintness,  collapse,  are 
among  the  graver  ''abstinence  symptoms." 

The  morphia  fiend  may  also  take  cocaine,  and  is  occasionally  addicted 
to  alcohol,  with  bromide  or  chloral  as  a  help.  These  all-round  drug-takers 
sometimes  break  down  in  a  state  not  unlike  general  paresis — a  sort  of 
pseudoparesis — from  which  recovery  is  possible  if  they  are  pulled  up  in  time. 

A  state  of  neurasthenia  is  seen  in  some  morphia  takers,  especially  in 
women  who  take  small  doses  and  are  successful  in  concealing  the  habit. 
Hence  the  necessity  of  careful  inquiry.  The  morphia  taker  often  has 
sores  on  the  skin  from  the  use  of  the  needle. 

1  Wharton  and  Still^'a  Med.  Jurisprudence,  5th  ed.    Chapt.  on  "  Narcomania  "  by  Lloyd,  vol.  i,  p.  874. 


LEAD  POISONING.  881 

III.  COCAINE   POISONING;    COCAINISM. 

Erlenmeyer  was  the  first  to  describe  cocomania  as  a  distinct  disease. 
The  habit  has  prevailed  only  in  recent  years,  for  cocaine,  the  active 
principle  of  the  coca  plant,  was  only  discovered  by  Gardeke  in  1855. 

Symptoms. — The  physical  symptoms  are  loss  of  weight,  muscular 
weakness,  tremor,  anaesthesia,  and  disturbance  of  the  heart  and  circulation. 

The  mental  symptoms  are  marked.  No  other  narcotic  makes  such  a 
pleasing  impression  on  the  brain.  It  is  a  sense  of  well-being,  of  strength, 
and  of  entire  happiness.  But  the  duration  is  brief.  Later,  as  the  habit 
is  formed,  a  delusional  insanity  occurs,  with  hallucinations,  which  may 
appear  suddenly  and  develop  rapidly.  The  delusions  are  of  the  persecutory 
type,  such  as  fear  of  enemies,  suspicion  of  marital  infidelity,  and  dread  of 
burglars.  The  hallucinations  are  both  visual  and  auditory,  and  are  dis- 
turbing or  alarming,  such  as  the  sight  of  insects,  the  sound  of  insulting 
words,  etc.  One  of  the  most  characteristic  is  the  so-called  ''cocaine-bug:" 
the  patient  imagines  he  feels  a  hard  object  beneath  the  skin  of  his  fingers 
or  hand.  It  is  called  Magnan's  sign,  and  is  probably  due  to  anajsthesia  of 
the  sensory  nerve-endings. 

Cocaine  is  a  virulent  poison  to  the  nervous  system — much  worse 
and  much  more  rapid  in  its  effects  than  morphia.  Many  of  these  patients, 
in  fact,  are  also  addicted  to  morphia.  Their  career  is  short;  they  go  to 
pieces  quickly  and  suddenly;  and  for  some  time  before  the  final  collapse 
they  have  their  spells  of  depression,  in  which  there  is  acute  distress.  They 
are  also,  sometimes,  excitable  and  violent.  A  peculiarity  of  some  cases  is 
an  extreme  slowness  of  the  mental  processes,  and  prolixity  in  speech  and 
letter  writing.  The  habit  has  much  increased  lately,  especially  among  the 
lower  classes,  even  the  negroes  in  some  places  becoming  addicted. 

Diagnosis. — This  presents  no  difficulty,  as  a  rule,  for  the  secret  will 
out.  It  is  important  to  bear  in  mind  that  a  large  number,  probably  the 
majority,  of  cocomaniacs  also  use  morphia.  They  are  worse  physical 
wrecks,  as  a  rule,  than  the  pure  morphia  takers.  Kerr  says  that  the  bodily 
wasting  appears  quickly;  there  is  great  loss  of  the  sense  of  time;  and  in 
fatal  cases  stupor  and  coma,  with  convulsions,  occur.  Mosso  directs  atten- 
tion to  what  he  calls  tetanus  of  the  respiratory  muscles.  In  some  cases  there 
is  great  muscular  unsteadiness.  Insomnia  is  common,  as  in  all  drug  takers 
when  deprived  of  their  allowance.  While  individually  these  symptoms  are 
common  to  many  conditions,  it  is  the  grouping  of  them  that  characterizes 
the  chronic  poisoning  by  cocaine.  Delusions  and  hallucinations  are  rather 
more  common  than  in  chronic  opium  poisoning.  Some  of  these  patients 
are  covered  with  wounds  and  scars  from  the  hypodermic  needle. 

IV.  LEAD  POISONING;    PLUMBISM. 

Lead  is  widely  used  in  the  arts;  hence  lead  poisoning  in  its  various 
forms  is  not  uncommon.  The  persons  most  exposed  to  the  poison  are 
the  workmen  in  white  lead  factories,  painters,  and  smelters.  Plumbism 
occurs  also  in  type-founders,  file-makers,  shot-makers,  gilders,  bronzers, 
lace-makers,  glass-cutters,  plumbers,  and  in  other  artisans. 

56 


882  MEDICAL  DIAGNOSIS. 

Chronic  lead  poisoning  is  sometimes  unrecognized,  for  the  patient 
may  have  been  exposed  in  unsuspected  ways,  as  by  hair-dye,  food  stuffs, 
etc.,  drinking  water,  and  may  not  even  know  himself  the  nature  of  his 
ailment.  The  chromate  of  lead  has  been  used  by  bakers  to  give  color  to 
their  products,  as  reported  by  D.  D.  Stewart,  of  Philadelphia;  wines,  beer, 
and  cider  have  been  contaminated  by  lead  pipes  and  lead  vessels;  and 
sewing  thread  is  sometimes  weighted  with  lead,  so  that  poisoning  has 
occurred  in  a  seamstress  from  the  constant  biting  off  of  the  ends. 

Pathology. — Lead  affects  many  of  the  tissues.  In  the  nervous  system 
it  causes  a  peripheral  neiu-itis,  and  also  poisons  the  brain-cells,  but  the 
pathological  changes  in  the  brain,  according  to  Berkley,  are  not  as  yet 
clearly  demonstrated.  Optic  neuritis  is  seen  occasionally.  The  motor 
cells  in  the  anterior  horns  of  the  spinal  cord  are  sometimes  affected.  Con- 
tracted kidneys  and  arteriosclerosis  are  not  uncommon  in  chrome  lead 
poisoning.  Gastro-intestinal  irritation  and  inflammation  are  the  results 
of  the  ingestion  of  lead.  T.  Oliver  found  changes  in  the  liver,  such  as 
atrophy  of  the  hepatic  cells  and  increase  of  connective  tissue.  Lead  is 
found  in  the  muscles  and  in  other  tissues,  and  ma}^  even  be  detected 
in  the  urine  and  fseces  for  long  periods  after  its  introduction  into  the 
system  has  stopped. 

Symptoms. — These  are  acute  and  chronic.  Acute  lead  poisoning 
is  marked  hj  pain  in  the  stomach  and  bowel,  vomiting,  constipation  or 
diarrhoea,  the  stools  being  black  from  the  sulphuret;  cramps,  neuralgic 
pains,  paralysis,  and  anaesthesia  in  the  limbs;  and  finally  syncope  and 
collapse.  Convulsions  and  coma  occur  in  some  cases.  Chronic  lead 
POISONING  is  known  by  the  following  symptoms:  a  blue  line  on  the  gums, 
anaemia,  colic,  pain,  vomiting,  paralysis,  anaesthesia,  ataxia,  tremor, 
cramps,  convulsions,  encephalopathy,  neurasthenic  and  hysterical  symp- 
toms, optic  neuritis  or  atrophy,  contracted  kidneys,  and  the  so-called 
lead  gout. 

The  blue  line  at  the  gingival  border  is  very  commonly  seen,  but  it 
has  no  necessary  relationship  to  the  severity  of  the  other  s^^mptoms.  As  a 
diagnostic  sign,  however,  it  is  of  great  value.  Anaemia  is  said  to  be  common 
among  lead  miners,  and  it  can  occur  in  any  one  who  is  much  exposed. 

Colic  and  epigastric  and  precordial  pains  are  very  characteristic.  The 
familiar  term  "  colica  pictonum"  dates  from  the  seventeenth  century 
when  the  affection  prevailed  as  an  epidemic  in  Poitou  from  the  contam- 
ination of  wine  with  lead.  The  attacks  are  often  acute,  are  even  seen 
in  persons  onlj^  recently  exposed  to  lead,  and  may  or  may  not  be  asso- 
ciated with  wT-ist-drop.  The  coHc  centres  about  the  navel  and  is  often 
severe  and  usually  without  diarrhoea.  It  may  be  accompanied  with  vomit- 
ing. This  pain  and  distress  about  the  precordia  may  simulate  angina 
pectoris  or  pericarditis.  Myalgic  and  arthralgic  pains  are  also  observed, 
especially  about  the  knees  and  in  the  lumbar  muscles,  and  they  may 
simulate  gout. 

Paralvsis  is  often  seen.  The  commonest  form  is  the  familiar  irrist- 
droj),  caused  by  involvement  especially,  but  not  exclusively,  of  the  inter- 
osseous branch  of  the  musculospiral  nerve.  The  supinator  longus  muscle 
and  the  extensor  of  the  metacarpal  bone  of  the  thumb,  for  some  unknown 


LEAD  POISONING.  883 

reason,  always  escape,  and  as  a  rule  there  is  no  anaesthesia.  The  paralysis 
is  of  the  peripheral  or  flaccid  type,  with  muscular  atrophy  and  reactions 
of  degeneration.  The  hand  falls  at  the  wrist  and  is  almost  powerless,  for 
not  only  are  the  extensors  paralyzed,  but  the  flexors  act  at  such  disad- 
vantage that  they  can  only  be  partially  brought  into  use,  as  can  readily 
be  shown  by  asking  the  patient  to  grasp  the  observer's  hand,  when  the 
grip  will  be  found  weak;  but  if  the  hand  is  passively  extended  the  grip  is 
much  improved.  This  wrist-drop  is  always  bilateral.  In  some  cases  the 
paralysis  is  not  confined  to  the  extensors  of  the  hand:  the  muscles  of 
the  upper  arms  are  occasionally  involved,  and  the  deltoids  seem  especially 
prone  to  suffer.  Again,  the  paralysis  may  be  even  more  wide-spread, 
involving  the  legs,  and  presenting  the  form  of  a  more  or  less  generalized 
peripheral  neuritis,  with  abolished  deep  reflexes. 

A  true  progressive  muscular  atrophy  and  a  pseudotabes,  due  to  lead, 
are  occasionally  seen. 

Tremor  and  cramps  are  not  common  in  lead  poisoning;  the  former 
resembles  other  forms  of  metallic  tremor — it  is  at  first  fine,  gradually 
increases  in  amplitude,  and  is  worse  on  voluntary  movement  and  during 
emotion.  Anaesthesia  likewise  is  rare  in  uncomplicated  cases.  This  is 
true  especially  of  the  cases  of  wrist-drop.  Slight  hypsesthesia  or  retarda- 
tion may  occasionally  be  seen.  In  the  rare  pseudotabes  various  modes  of 
anaesthesia  are  noted,  especially  deep  anaesthesia,  such  as  alteration  in  the 
muscular  sense,  pressure  sense,  and  sense  of  position.  But  there  is  a  form 
of  hysterical  anaesthesia  which  is  not  so  rare,  as  has  blen  pointed  out  by 
the  French.  It  may  be  of  the  segmental  type  and  is  sometimes  influenced 
by  suggestion. 

Under  the  head  of  encephalopathy  are  included  a  group  of  symptoms 
sometimes  seen  in  lead  poisoning.  These  comprise  headache,  confusion, 
delirium,  convulsions,  and  coma.  The  attack  may  come  on  suddenly,  and 
is  seen  even  in  persons  not  long  exposed,  but  it  is  probably  more  common 
in  the  victims  of  chronic  poisoning.  There  is  sometimes  an  initial  head- 
ache, with  restlessness  and  insomnia,  or  the  attack  begins  abruptly  with 
a  fit.  The  delirium  persists  for  some  hours  or  even  days,  and  is  accom- 
panied with  hallucinations  of  sight  and  hearing.  The  convulsions  may 
recur,  the  delirium  persisting  between  them.  An  isolated  attack,  without 
delirium  before  or  after  it,  may  also  occur.  If  the  convulsions  recur  fre- 
quently, the  patient  may  pass  into  an  epileptic  status,  with  fever,  coma, 
stertorous  breathing,  rapid  pulse,  and  failing  vitality,  and  die.  If  these 
attacks  occur  often  there  is  risk  of  permanent  damage  to  the  brain,  as  is 
shown  by  recurring  epilepsy,  maniacal  seizures,  melancholia,  and  dementia. 
It  must  not  be  forgotten  that  a  type  of  so-called  hystero-epilepsy,  totally 
different  from  the  preceding,  sometimes  occurs  in  lead  poisoning;  it  is 
purely  hysterical,  and  is  to  be  known  by  the  hysterical  stigmata.  Changes 
in  the  optic  nerves  occur  in  lead  poisoning.  Atrophy  is  observed,  and  it  may 
follow  a  neuritis.  The  association  of  kidney  disease  with  chronic  plumbism 
must  not  be  overlooked,  and  hence  the  possibility  of  albuminuric  retinitis. 

Neurasthenic  and  hysterical  symptoms  may  complicate  lead  poison- 
ing. Among  the  symptoms  are  anaesthesia,  including  hemianaesthesia  and 
segmental   anaesthesia,   tremor,   hysterical   paralysis,   and   hysterical   con- 


884  MEDICAL  DIAGNOSIS. 

vulsions.  The  association  of  gout  with  plumbism  is  insisted  on  by  many- 
English  physicians.  They  point  to  the  contracted  kidneys,  arteriosclerosis, 
arthralgia,  and  in  some  cases  arthritic  changes  and  deposits,  as  evidences 
of  this  "lead-gout."  Bright's  disease  is  a  not  uncommon  complication 
of  chronic  lead  poisoning. 

Diagnosis. — When  the  history  is  clear  the  diagnosis  is  easy;  but 
when  the  history  of  exposure  to  lead  is  wanting,  the  case  may  be  most 
obscure.  The  blue  line  on  the  gums  is  of  the  greatest  value,  but  it  is  not 
always  present.  The  precordial  pain  in  lead  poisoning  may  simulate 
angina  pectoris,  but  the  history  and  the  blue  line  are  usually  determina- 
tive. The  wrist-drop  due  to  lead  is  always  bilateral,  although  it  may 
be  worse  on  one  side;  and  the  supinator  longus  and  the  extensor  of  the 
metacarpal  bone  of  the  thumb  escape;  thus  the  case  differs  from  one  of 
trauma  of  the  musculospiral  nerve,  which  is  usually  unilateral,  and  involves 
more  muscles.  Other  forms  of  paralysis  are  rare  in  lead  poisoning,  but 
the  history  and  the  blue  line  are  usually  clear.  The  pseudotabes  due  to 
lead  is  distinguished  from  locomotor  ataxia  by  the  presence  of  muscular 
atrophy  and  the  reactions  of  degeneration,  and  the  absence  of  fulgurant 
pains,  Argyl-Robertson  pupils,  and  other  true  tabetic  symptoms.  Lead 
encephalopathy  closely  simulates  uraemia,  also  idiopathic  epilepsy.  If 
the  history  is  obscure  the  difficulty  may  be  great.  The  blue  line  would 
be  important,  and  there  may  be  an  absence  of  urinary  symptoms.  If  the 
history  is  clear  there  need  be  no  great  difficulty  in  the  diagnosis  of 
epilepsy,  of  ursemfa,  or  of  encephalopathy. 

The  stigmata  of  hysteria  can  usually  be  recognized  with  a  little  care. 
Hemianesthesia  and  segmental  anaesthesia  are  not  caused  by  lead  alone; 
they  are  hysterical. 

V.  ARSENICAL  POISONING. 

Chronic  poisoning  by  arsenic  is  much  less  common  now  than  some 
years  ago,  partly  because  of  more  widely  disseminated  knowledge  con- 
cerning the  dangers  of  the  use  of  this  metal  and  its  salts  in  the  arts  and 
partly  because  of  the  enactment  of  laws  hmiting  the  amount  of  arsenic 
in  wall-papers  and  dress  goods.  This  form  of  intoxication  is  at  present 
occasionally  encountered  in  persons  engaged  in  certain  occupations,  as  the 
manufacture  of  wall-papers  and  other  papers,  playing  cards,  book  covers, 
and  artificial  flowers.  Those  who  handle,  and  more  particularly  those  who 
wear,  articles  of  apparel,  such  as  stockings,  gloves,  and  certain  dress  fabrics, 
dyed  with  arsenical  pigments  in  excess,  or  furs  cured  by  arsenic,  are  exposed 
to  a  theoretical  danger  which  is,  however,  trifling  as  compared  with  that 
of  a  generation  ago.  Not  only  the  greens,  as  popularly  supposed,  but  dyes 
of  various  colors  often  contain  arsenic  in  dangerous  amounts.  The  danger 
of  acute  or  chronic  poisoning  as  the  result  of  the  introduction  of  arsenic 
into  articles  of  food  as  a  preservative  is  no  longer  to  be  considered. 

It  is  a  remarkable  fact  that  a  large  proportion  of  cases  of  chronic 
arsenical  poisoning  at  the  present  time  are  caused  by  the  use  of  this  metal 
for  therapeutic  purposes.  This  untoward  occurrence  may  be  due  to  exces- 
sive doses,  an  improper  prolongation  of  the  treatment  by  proper  doses, 


ARSENICAL  POISONING.  885 

or  to  an  unusual  degree  of  susceptibility  on  the  part  of  certain  individuals 
to  some  of  the  toxic  effects  of  arsenic.  Patients  and,  in  particular,  those 
subject  to  diseases  of  the  skin  frequently  continue  the  use  of  prescriptions 
containing  arsenic  without  regularly  reporting  to  the  physician.  It  is 
important  that  medical  men  should  protect  themselves  and  their  patients 
by  emphasizing  the  risks  attendant  upon  such  a  course.  The  growing 
use  of  less  toxic  arsenical  preparations,  as  atoxyl  and  sodium  cacodylate, 
will  diminish  this  danger. 

Arsenic  eating,  as  practiced  in  Styria  and  elsewhere  for  the  purpose 
of  stimulating  the  powers  of  endurance  and  the  sexual  capacity  or  improv- 
ing the  complexion,  has  in  many  cases  resulted  in  chronic  poisoning.  The 
presence  of  arsenic  in  beer,  derived  from  the  sulphuric  acid  used  in  the 
manufacture  of  the  glucose  employed  in  brewmg,  recently  attracted  much 
attention  in  England  as  a  source  of  danger.  The  use  of  Paris  green  and 
other  arsenical  preparations  as  insecticides  is  attended  with  little  risk  in 
itself.  The  chief  danger  lies  in  having  such  substances  about  under  con- 
ditions in  which  they  may  give  rise  to  accidental  or  intentional  poisoning. 
Miners  and  smelters  of  ores  containing  arsenic  are  much  exposed  to  the 
danger  of  chronic  poisoning.  Acute  arsenical  poisoning  is  rarely  acci- 
dental, but  by  no  means  uncommon  in  suicidal  or  homicidal  cases. 

Pathology. — In  the  acute  form  gastro-enteritis,  nephritis,  and  fatty 
changes  in  the  muscles  and  viscera,  especially  the  liver,  constitute  the  chief 
lesions;  in  the  chronic  form  anaemia,  pigmentation  of  the  skin^  and  lesions 
of  the  nervous  system,  particularly  of  the  peripheral  nerves,  are  common. 

Symptoms. — The  chief  clinical  manifestations  of  chronic  arsenical 
poisoning  relate  to  the  skin  and  the  peripheral  nervous  system.  The 
general  health  may  not  be  at  first  greatly  impaired.  As  a  rule,  however, 
anaemia,  emaciation,  loss  of  strength,  cardiac  asthenia,  and  vasomotor 
derangements  are  present  in  varying  degree. 

The  Skin. — Hyperidrosis,  glossiness,  local  ulceration,  herpes,  and 
erythromelalgia  are  occasionally  observed.  Pigmentation  is  very  common 
and  often  marked.  It  varies  from  a  faint  brownish-yellow  to  a  deep  brown, 
and  is  sometimes  distributed  over  the  greater  part  of  the  surface;  some- 
times collected  in  circumscribed  areas  and  frequently  diffuse,  with  patches 
of  deeper  coloring  upon  exposed  parts,  in  the  folds  about  the  joints,  and 
in  regions  normally  pigmented,  as  the  nipples  and  pudenda,  especially  in 
those  of  dark  complexion.  Small  dense  collections  of  pigment  may  form 
and  present  the  appearance  of  pigmented  moles.  Patches  of  pigmentation 
are  occasionally  observed  upon  the  mucous  membranes.  As  a  rule,  to 
which  there  are  exceptions,  the  skin,  after  the  exposure  to  arsenic  ceases, 
gradually  resumes  its  normal  appearance.  Keratosis  is  less  common. 
It  is  usually  confined  to  the  palms  and  soles  and  occurs  in  circumscribed 
patches.  Epitheliomatous  degeneration  may  occur.  Less  common  are 
erythema,  which  is  sometimes  symmetrical,  polymorphous  lesions,  fur- 
uncles, acne,  depraved  nutrition  of  the  nails,  and  alopecia.  Puffiness  of 
the  eyelids  is  a  common  and  early  symptom. 

The  Nervous  System. — The  principal  symptoms  are  those  of  a 
peripheral  neuritis,  which  involves  the  lower  extremities  much  more  com- 
monly than  the  upper,  and  when  both  are  affected  the  lower  to  a  greater 


886  MEDICAL  DIAGNOSIS. 

degree.  Motor  derangements,  varying  from  a  slight  palsy  to  actual  paraly- 
sis, may  appear  in  a  few  hours,  or  not  for  several  days  after  a  single  toxic 
dose,  when  the  acute  gastro-intestinal  and  depressive  symptoms  have 
wholly  subsided.  In  some  instances  palsy  has  appeared  several  weeks 
after  a  single  poisonous  dose,  recovery  having  in  the  intervening  period 
been  apparently  complete.  In  chronic  poisoning  the  paralysis  develops 
gradually  after  a  variable  period,  the  length  of  which  is  determined  by 
individual  peculiarities  and  the  degree  of  intoxication.  Deeangements  of 
SENSATION  consist  of  parajsthesias  of  various  kinds,  and  pain.  The  latter 
is  frequently  severe  and  associated  with  tenderness  along  the  nerve-trunks. 
Anaesthesia,  hyperaesthesia,  polyaesthesia,  and  other  derangements  of  sen- 
sation occur.  The  nervous  symptoms,  both  motor  and  sensory,  do  not 
often  extend  above  the  knees  or  elbows,  and  the  thighs  and  arms,  together 
with  the  trunk,  remain  uninvolved.  The  sphincters  escape.  In  severe 
cases  the  muscles  of  the  legs  and  feet  and  arms  and  hands  undergo  atrophy; 
the  knee-jerks  are  lost.  Reactions  of  degeneration  are  present  and  con- 
tractures occur.  There  are  cases  in  which  the  resemblance  to  tabes  is 
very  striking.  Mental  symptoms  occur  in  severe  and  prolonged  cases. 
They  comprise  loss  of  memory,  mental  weakness,  hallucinations  of  sight 
and  hearing,  and  may  gradually  assume  the  form  of  a  terminal  dementia. 

Diagnosis. — Direct. — This  rests  upon  the  association  of  the  fore- 
going symptoms,  especially  those  relating  to  the  skin  and  nervous  system, 
and  a  histor}^  or  knowledge  of  exposure  to,  or  the  ingestion  of,  arsenic. 
The  disappearance  of  the  symptoms  upon  the  removal  of  arsenic  would 
render  the  diagnosis  positive.  When  any  of  the  above  symptoms  arises 
in  a  patient  who  is  under  treatment  b}'  arsenic  for  chronic  skin  disease, 
angemia,  chorea,  habit-spasm,  or  Hodgkin's  disease,  or  in  any  person  who 
is  employed  in  arts  or  manufactures  in  which  arsenic  is  freely  used,  or 
who  lives  under  conditions  involving  exposure  to  arsenic,  who  habitu- 
ally eats  it  for  any  purpose,  or  who  has  a  history  of  acute  poisoning  by 
arsenic,  a  provisional  diagnosis. of  chronic  arsenical  poisoning  is  justified 
but  should  be  at  once  tested  by  the  complete  withdrawal  of  the  patient 
from  exposure  to  the  action  of  arsenic  in  any  manner  whatever. 

Differential. — Peripheral  neuritis  due  to  other  causes,  as  lead, 
alcohol,  and  the  infections.  Lead  palsy  may  be  recognized  by  the  absence 
of  pain,  the  more  common  and  severe  implication  of  the  upper  extremi- 
ties, bilateral  wrist-drop  without  involvement  of  the  supinator  longus  or 
the  flexors,  the  blue  line  on  the  gums,  colic  and  constipation,  and  a  known 
historv  of  exposure  to  lead.  Alcoholic  neuritis  may  be  recognized  by 
pain,  a  history  of  alcoholic  excesses,  other  signs  of  alcoholism,  as  the  facies, 
the  condition  of  the  mind,  or  visceral  lesions,  as  for  example  fatty  liver  or 
cirrhosis.  Post-infectious  neuritis  usually  shows  a  clear  history  of  some 
foregoing  acute  or  chronic  infectious  disease,  as  enteric. fever,  diphtheria, 
or  pulmonary  tuberculosis.  Tabes  dorsalis  may  be  distinguished  from 
the  rare  cases  of  arsenical  poisoning  which  somewhat  resemble  it,  by 
the  gradual  onset,  the  commonly  prolonged  and  progressive  course,  the 
ocular  phenomena,  the  various  "  crises,"  a  history  of  syphilis  in  nearly 
every  case,  the  lightning  pains,  and  the  absence  of  the  cutaneous  lesions 
produced  by  arsenic. 


POISONING  BY  MERCURY.  887 

In  any  doubtful  case  it  may  be  necessary  to  examine  the  urine  for 
the  presence  of  arsenic,  though  it  must  be  borne  in  mind  that  arsenic  is 
not  always  present  in  the  urine  when  it  is  known  to  have  been  ingested, 
and  that  when  present  it  disappears  within  two  or  three  weeks  after  its 
administration  has  been  discontinued.  For  this  pm-pose  it  is  best  for  the 
practitioner  to  secure  the  services  of  a  competent  chemist. 

VI.  POISONING  BY  MERCURY. 

As  in  the  case  of  arsenic,  chronic  poisoning  by  mercury  is  far  less 
common  than  formerly,  because  the  employment  of  this  metal  in  the  arts 
is  now  much  restricted  and  far  greater  care  is  exercised  in  its  use  in  medicine. 

Etiology. — As  an  occupation  disease  chronic  mercurial  poisoning 
occasionally  occurs  in  those  emplo3^ed  in  making  certain  dyes,  the  use  of 
amalgams,  the  preparation  of  fulminate,  the  manufacture  of  fireworks, 
among  taxidermists,  and  in  those  engaged  in  the  making  of  felts  for  hats 
and  other  purposes  (Edsall).  Especially  hazardous  are  occupations  such 
as  the  mining  and  smelting  of  mercurial  ores.  The  manufacture  of  scien- 
tific instruments  depending  upon  the  physical  properties  of  mercury,  as 
thermometers,. barometers,  and  manometers,  involves  prolonged  exposure 
to  the  risk  of  a  slow  intoxication.  The  number  of  persons  engaged  in  these 
various  occupations  is  comparatively  limited,  but  for  this  very  reason  a 
knowledge  of  the  effects  caused  by  mercury,  while  of  relatively  slight 
importance  to  the  general  practitioner,  is  of  especial  interest  to  the  h3^gienist 
because  they  are  preventable,  and  to  the  diagnostician  because  they  are 
rare.  It  is  of  diagnostic  importance  that  not  only  those  actually  engaged 
in  occupations  concerned  with  mercury  are  liable  to  this  metallic  intoxi- 
cation, but  also  others  who  breathe  an  atmosphere  containing  volatilized 
or  dust-borne  mercury,  or  drink  water  in  the  neighborhood  of  mines. 

Pathology. — Chronic  gastro-enteritis,  anaemia,  emaciation,  and  fatty 
degeneration  of  the  viscera  are  encountered.  Neuritis  is  very  rare.  Its 
occurrence  has  been  questioned. 

Mode  of  Access. — Chiefly  by  inhalation,  since  mercury  volatilizes  at 
ordinary  temperatures;  to  a  subsidiary  extent  through  the  skin.  In 
medicinal  mercurialization  most  commonly  by  ingestion;  less  frequent!}'- 
MMnunction.  Fortunately  ptyalism,  mercurial  stomatitis  (which  see),  is  a 
danger  signal  and  usually  leads  to  the  immediate  discontinuance  of  the  drug. 

Symptoms. — Ptyalism  does  not,  however,  alwa3^s  occur  in  chronic 
mercurial  poisoning.  In  a  small  proportion  of  the  cases  it  is  an  early  and 
persistent  condition.  Early  symptoms  are  headache,  disturbed  and  unre- 
freshing  sleep,  and  mental  and  ph^^sical  depression,  especially  in  the  early 
hours  of  the  day.  x4nsemia  is  common.  The  association  of  tremor  and  a 
curious  emotional  condition  suggestive  of  hysteria  dominate  the  symptom- 
complex.  Tremor  is  usually  at  first  absent  when  the  patient  is  at  rest, 
but  shows  itself  at  once  upon  voluntary  movement  and  is  greatly  aggra- 
vated by  emotional  excitement.  It  chiefly  involves  the  hands  and  lips, 
but  may,  in  severe  cases,  affect  all  the  extremities  to  such  an  extent  as  to 
interfere  seriously  with  the  ordinary  movements  of  everyday  life.  In  the 
early  cases  the  tremor  is  fine,  but  later  it  increases  in  amplitude  and  becomes 


888  MEDICAL  DIAGNOSIS. 

coarse  and  rapid.  When  it  affects  the  muscles  of  articulation,  speech  is 
much  deranged  and  this,  with  the  tremor  of  the  lips  and  tongue,  may 
suggest  disseminated  sclerosis.  Attacks  of  vertigo  occasionally  occur.  In 
grave  cases  muscular  weakness,  choreiform  movements,  and  various  palsies, 
together  with  anaesthesia  and  other  disturbances  of  sensation,  are  encount- 
ered. These  motor  and  sensory  phenomena  are,  as  a  rule,  irregularly 
distributed,  incomplete,  and  transitory.  Epileptiform  convulsions,  paroxys- 
mal tonic  spasm  involving  chiefly  the  flexors  of  the  forearm,  and  clonic 
spasms  also  paroxysmal  and  affecting  all  the  muscles  of  the  body  but  with- 
out loss  of  consciousness,  have  been  described.  The  emotional  derange- 
ments assume  a  form  highly  suggestive  of  hysteria.  But  the  conclusion 
that  groups  of  previously  healthy  individuals  collected  in  one  locality 
from  various  sources  and  developing  emotional  symptoms  along  with  the 
other  phenomena  and  the  tremor,  after  prolonged  exposure  to  mercurial 
poisoning,  should  be  hysterical  is  unwarranted.  This  group  of  symptoms 
includes  sensations  of  weakness,  powerlessness,  and  fright,  which,  in  rare 
instances,  gradually  increase  to  actual  obsessions  of  fear  and  doubt  which 
render  the  life  of  the  patient  one  of  abject  wretchedness  and  have  in  some 
instances  amounted  to  a  form  of  dementia. 

Diagnosis. — Direct. — The  fact  of  habitual  exposure  to  mercury, 
either  in  occupation,  therapeutically,  or  under  other  circumstances  men- 
tioned under  the  subtitle  etiology,  together  with  the  character  of  the  tremor 
and  the  emotional  disturbances,  render  a  positive  diagnosis  a  comparatively 
easy  matter.    If  necessary  a  chemical  examination  of  the  urine  may  be  made. 

Differential. — The  following  conditions  are  to  be  considered: 
Hysteria. — The  presence  of  the  stigmata  of  this  condition  (see  article  on 
Hysteria)  and  of  the  visual  phenomena,  the  intermittent  and  paroxysmal 
character  of  the  symptoms  in  many  cases  of  hysteria,  and  the  absence  of 
the  peculiar  tremor  of  mercurial  intoxication,  are  significant.  Dissemi- 
nated Sclerosis. — The  finer  tremor,  absence  of  emotional  or  hysterical 
phenomena,  the  staccato  speech,  nystagmus,  occasional  focal  phenomena, 
and  the  persistent  and  progressive  character  of  the  symptoms,  are  impor- 
tant in  the  differential  diagnosis.  Paralysis  Agitans. — The  passive  tremor, 
unemotional  mental  condition,  peculiar  mask-like  facies,  persistent  muscu- 
lar rigidity  and  festination  of  this  condition  are  in  strong  contrast  with 
the  symptom-complex  of  mercurial  intoxication.  Paresis. — The  tremor 
is  suggestive,  but  the  differentiation  may  be  made  without  difficulty.  The 
emotional  states  are  wholly  different.  In  paresis  delusions  of  grandeur 
and  perversions  of  the  moral  sense  occur.  There  are  apoplectiform  seizures, 
epileptiform  convulsions,  remarkable  remissions  of  all  symptoms,  occa- 
sional focal  phenomena,  and  progressive  mental  and  physical  deteriora- 
tion. Alcoholism. — The  two  conditions  are  frequently  associated.  The 
anamnesis,  the  slight  degree  of  influence  of  emotional  states  upon  the 
tremor,  and  the  facies,  dilated  venules,  circulatory  and  visceral  conditions 
attendant  upon  chronic  alcoholism,  are  important.  Plumbism. — The  history 
of  exposure  to  lead,  constipation,  colic,  the  gingival  line,  and  the  wrist-drop 
are  characteristic. 

Prognosis. — In  the  early  cases  the  outlook  is  favorable.  Even  after 
prolonged    and   well-characterized   symptoms   recovery   may   take   place. 


PHOSPHORUS  POISONING.  889 

In  such  cases,  however,  tremor  may  persist.  Persistent  palsy,  headache, 
progressive  anaemia,  and  the  cachectic  state  are  unfavorable  as  regards 
prognosis.  Change  of  occupation  and  complete  freedom  from  exposure 
are  essential  to  recovery.  If  such  requirements  cannot  be  met  the 
prognosis  is  uncertain  or  unfavorable. 

VII.  PHOSPHORUS   POISONING. 

Etiology. — Acute  poisoning  by  phosphorus  is  rare  and  usually  results 
from  the  swallowing  of  match-heads  with  suicidal  intent.  Chronic  poison- 
ing is  likewise  rare  and  occurs  as  an  industrial  disease  in  localities  in  which 
matches  are  manufactured. 

Pathology. — Acute  Phosphorus  Poisoning. — The  coagulability  of 
the  blood  is  reduced;  there  are  diffuse  hemorrhages  into  the  skin  and 
viscera  and  from  mucous  surfaces;  jaundice;  fatty  degeneration  of  the 
muscles  and  parenchymatous  organs,  especially  of  the  liver,  which  also 
rapidly  undergoes  enlargement  and  changes  to  a  bright  saffron  color. 
Leucin,  tyrosin,  cystin,  sarcolactic  acid,  peptones,  and  sugar  are  found  in 
the  urine  and  blood.  Acid  intoxication  occurs,  as  a  result  of  which  the 
urinary  ammonia  is  greatly  increased  and  the  urea  decreased.  In  its 
derangement  of  metabolic  processes  phosphorus  acts  like  a  ferment. 

Chronic  Phosphorus  Poisoning. — In  man  the  chief  pathological 
change  consists  of  necrosis  of  the  inferior  maxilla  with  suppuration  and 
the  formation  of  sequestra.  Exceptionally  the  upper  jaw  bones  are  affected. 
This  process  is  accompanied  by  destructive  ulceration  of  the  soft  parts 
with  more  or  less  abundant  pus  formation. 

Symptoms. — Acute  poisoning  presents  a  close  clinical  resemblance  to 
acute  yellow  atrophy.  Early  symptoms  are  vomiting  and  diarrhoea, 
which  presently  subside,  to  return  in  the  course  of  forty-eight  or  seventy 
hours,  and  are  then  accompanied  by  intense  jaundice,  epigastric  distress, 
and  diffuse  pains  in  the  muscles.  At  this  time  petechias,  submucous  hemor- 
rhages, and  blood  in  the  vomitus  and  stools  appear.  When,  as  is  not  rarely 
the  case,  match-heads  have  been  taken  to  produce  abortion,  this  accident 
frequently  occurs.  There  is  profound  asthenia,  with  maniacal  excitement 
which  rapidly  passes  into  stupor  and  coma  and  is  followed  by  death.  The 
vomited  matters  may  be  phosphorescent. 

The  necrosis  of  the  jaw,  which  constitutes  the  chief  morbid  condition 
in  the  chronic  form,  commonly  begins  about  a  single  tooth,  with  caries 
and  abscess  formation.  The  process  involves  the  tooth  and  surrounding 
alveolar  process  and  rapidly  extends  to  the  neighboring  teeth  and  contigu- 
ous structures.  The  pus  is  often  abundant  and  very  foul.  It  burrows  in 
various  directions  and  may  form  sinuses  which  discharge  in  the  neck.  One 
or  several  sequestra  may  form.  Rapid  anaemia  and  general  sepsis  may 
occur,  and  in  neglected  cases  amyloid  disease,  tuberculous  infection,  and 
basal  meningitis  have  been  observed. 

Diagnosis. — Both  in  acute  and  chronic  phosphorus  poisoning,  the 
diagnosis  depends  largely  upon  the  anamnesis.  In  the  former  suicidal 
intention,  or  rarely  the  eating  of  match-heads  by  young  children;  in  the 
latter  the  exposure  to  phosphorus,  which  is  volatile  at  ordinary  temper- 


890  MEDICAL  DIAGNOSIS. 

atureS;  as  an  occupation  risk,  are  of  great  diagnostic  significance.  The 
main  points  of  discrimination  from  acute  yellow  atrophy  of  the  liver  con- 
sist in  the  period  of  relief  which  occurs  in  the  interval  between  the  early 
gastro-intestinal  symptoms  in  phosphorus  poisoning  and  the  graver  phe- 
nomena, the  enlargement  of  the  liver,  the  occasional  absence  of  leucin  and 
tyrosin  or  their  relatively  smaller  amount,  and  the  less  intense  nervous 
symptoms.  There  are,  however,  cases  in  which,  in  the  absence  of  a  clear 
history,  the  differential  diagnosis  is  attended  with  difficulty.  As  to  chronic 
poisoning,  there  are  no  conditions  characterized  by  similar  persistent 
and  extending  necrotic  processes  in  the  jaw.  Actinomycosis  may  be 
recognized   by  the  presence  of  the  ray  fungus  in  the  pus. 

Prognosis. — The  mortality  in  acute  poisoning  is  about  50  per  cent. 
The  fatal  issue  occurs  in  less  than  a  week.  In  the  chronic  form  recovery 
frequently  follows  early  operation.  In  neglected  or  very  severe  cases,  even 
extensive  resection  may  fail  to  arrest  the  advance  of  the  necrotic  process. 

VIII.  ACUTE  AND  CHRONIC  POISONING  BY  ILLUMI- 
NATING GAS. 

Etiology. — A  number  of  gases  enter  in  varying  proportion  into  the 
composition  of  illuminating  gas,  but  carbon  monoxide  constitutes  the 
chief  toxic  agent.  Water  gas  is  especially  active  as  a  poison,  because  of 
the  relatively  large  amount  of  carbon  monoxide  which  it  contains. 

Acute  poisoning  commonly  occurs  as  the  result  of  the  escape  of  gas 
by  way  of  an  unlighted  burner  into  sleeping-rooms.  This  has  resulted 
accidentally  from  a  gust  of  wind,  from  leaving  the  gas  turned  on,  from 
ignorance,  or  with  suicidal  intent.  This  method  of  suicide  has  become  ver}^ 
common  and  when,  as  is  usually  the  case,  the  access  of  air  is  carefully 
guarded  against  and  rubber  hose,  is  used  it  is  a  very  certain  one.  Acute 
.  poisoning  may  occur,  however,  in  those  employed  in  gas  works,  and  I 
have  seen  a  case  in  which  it  resulted  from  the  escape  of  gas  from  a  street 
main.  Chronic  poisoning  is  probably  rare  and  is  likely  to  arise  among 
those  employed  in  gas  works  or  those  dwelling  in  houses  into  which  slow 
but  continuous  leakage  occurs  from  pipes  or  fixtures.  Toxic  symptoms 
may  arise  upon  breathing  an  atmosphere  containing  0.02  per  cent,  of 
carbon  monoxide;  0.05  is  highly  dangerous,  and  above  this  the  air  speedily 
becomes  irrespirable. 

Pathology. — The  toxic  action  is  chiefly  upon  the  red  blood-corpuscles, 
the  oxyhsemogiobin  being  converted  into  carbon  monoxide  haemoglobin, 
and  the  function  of  the  affected  corpuscles  as  carriers  of  oxygen  and  carbon 
dioxide  destroyed.  The  blood  is  cherry-red  in  color.  There  are  areas  of 
bluish-red  discoloration  upon  the  neck,  chest,  and  elsewhere,  visceral 
hypersemia,  and  local  hemorrhages.  In  the  chronic  cases  fatty  degenera- 
tion of  the  heart,  anaemia,  and  enlargement  of  the  spleen  have  been  noted. 

Symptoms. — The  clinical  phenomena  depend  upon  the  proportion  of 
gas  in  the  atmosphere  and  the  duration  of  exposure.  Progressively  they 
are  as  follows:  malaise,  sensations  of  throbbing,  especially  in  the  head, 
headache,  vertigo,  muscular  weakness,  nausea,  vomiting,  drowsiness,  lose 


POISONING  BY  ILLUMINATING  GAS.  891 

of  consciousness,  and  relaxation  of  the  sphincters.  Muscular  twitchings 
and  general  convulsions  occur.  In  the  comatose  state  there  are  rapid 
respiration,  a  rapid  and  full  pulse,  and  cyanosis.  The  blood  is  cherry-red 
in  color  and  there  is  leucocytosis,  high  in  proportion  to  the  gravity  of  the 
case.  When  recovery  takes  place,  sequels  relating  to  the  respiratory  tract, 
bronchitis,  and  bronchopneumonia  are  common.  Lobar  pneumonia  is 
rare.  Cardiac  derangements  of  a  functional  kind  also  occur.  To  these,  in 
many  cases,  are  added  gastric  irritability  and  epigastric  pain  and  tender- 
ness, symptoms  of  a  subacute  gastritis.  Icterus  has  been  observed  and 
glycosuria  is  common.  Local  oedema  and  various  inflammatory  and 
necrotic  cutaneous  lesions  occur.  Nervous  symptoms  are  common  and 
important.  They  comprise  various  neuralgias  and  forms  of  neuritis, 
tremors  and  choreiform  movements,  and  neurasthenic  manifestations, 
among  which  fatigue  symptoms  are  very  marked.  Amaurosis,  nystagmus, 
and  ocular  palsies  may  occur.  Persistent  headache,  dulness  of  hearing,  and 
tinnitus  have  been  noted.  Psychical  derangements  vaiy  from  confusional 
states  with  hallucinations  to  dementia.  The  foregoing  sequels  may  develop 
directly  after  exposure,  or  they  may  come  on  after  several  days  or  even 
some  weeks  of  apparent  recovery  and  undergo  gradual  intensification. 
In  the  suicidal  cases  the  antecedent  condition  of  the  patient  is  to  be  con- 
sidered in  estimating  the  actual  relation  between  the  carbon  monoxide 
poisoning  and  the  mental  state  at  a  more  or  less  remote  period  after 
recovery  from  such  poisoning.  The  symptoms  of  chronic  poisoning  are 
those  of  the  milder  forms  of  acute  poisoning  continued  through  an  indefi- 
nite period,  namely,  headache,  vertigo,  nausea,  occasional  vomiting, 
muscular  weakness,  fatigue  symptoms,  and  inability  to  perform  the  ordi- 
nary physical  and  mental  duties  of  life.  A  slow  pulse,  anaemia,  and  absence 
of  the  deep  reflexes  have  been  observed. 

Diagnosis. — Direct. — This  rests  upon  the  history  of  the  case,  which  is 
usually  very  clear,  and  the  demonstration  of  carbon  monoxide  in  the  blood. 

The  most  satisfactory  tests  are:  (a)  Hoppe-Seyler's  sodium  hydrate 
test:  A  solution  of  specific  gravity  of  L30  is  added  to  the  blood;  if  carbon 
monoxide  is  present  the  clot  formed  is  of  bright  red  color,  while  with  nor- 
mal blood  the  color  of  the  mass  is  greenish-brown,  (b)  Katagama's  ammo- 
nium sulphide  and  acetic  acid  test:  To  10  c.c.  of  blood  diluted  with  water 
are  added,  first,  0.2  c.c.  of  ammonium  sulphide  solution,  and  then  0.2  c.c. 
of  36  per  cent,  acetic  acid.  Blood  containing  carbon  monoxide  gives  a 
bright  red  precipitate;  normal  blood  a  green  precipitate,  (c)  The  Kunkel- 
Welzer  test  consists  in  the  addition  to  the  undiluted  blood  of  an  equal 
volume  of  20  per  cent,  potassium  ferrocyanide  and  a  small  quantity  of  36 
per  cent,  acetic  acid.  Carbon  monoxide  blood  yields  a  bright  red  reaction, 
while  the  color  of  normal  blood  changes  to  a  deep  brown.  The  spectro- 
scopic test  may  be  employed. 

In  a  comatose  patient  of  obscure  or  uncertain  antecedents  a  positive 
result  may  be  of  great  importance,  (a)  in  the  immediate  diagnosis,  (b)  in 
determining  the  character  of  later  morbid  conditions,  and  (c)  from  a 
medicolegal  point  of  view . 

Differential. — Alcoholic  Coma. — The  anamnesis  is  most  impor- 
tant.   The  fact  is,  however,  to  be  borne  in  mind  that  a  drunken  man  may 


892  MEDICAL  DIAGNOSIS. 

blow  out  the  gas,  turn  the  burner  off  and  on  again,  or  conclude  to  end 
his  life  by  gas  poisoning.  The  history  of  a  spree  and  the  odor  of  alcohol 
have,  therefore,  no  positive  value  in  the  differentiation  of  these  two  condi- 
tions. Of  greater  moment  are  the  appearance  of  the  blood,  the  above-named 
tests,  cyanosis,  and  the  cutaneous  hypersemia.  Uramic  Coma. — Urinary 
suppression,  the  presence  of  albumin,  and  casts,  dropsy,  and  cardiovas- 
cular lesions  are  of  importance,  particularly  when  associated  with  negative 
results  upon  testing  for  carbon  monoxide  in  the  blood. 

The  diagnosis  of  chronic  poisoning  by  illuminating  gas  is  not  readily 
made.  When  all  the  occupants  of  a  dwelling  habitually  awake  with  nausea^ 
headache,  and  vertigo  and  these  symptoms  steadily  increase,  and  there  is 
associated  muscular  and  mental  weakness  and  depression,  it  would  become 
necessary  to  carefully  test  the  gas-pipes  and  fixtures.  Under  such  circum- 
stances the  gas  present  in  the  atmosphere  might  produce  toxic  symptoms, 
though  insufficient  to  give  positive  reactions  either  in  the  air  or  in  the  blood 
of  patients.  If  certain  members  of  the  household,  upon  removal  to  a  differ- 
ent locality,  were  gradually  to  recover  their  health,  while  those  remain- 
ing continued  ill,  chronic  gas  poisoning  would  become  a  sound  provisional 
diagnosis  and  the  point  of  departure  for  further  systematic  investigation. 


IV. 

THE  DIAGNOSIS  OF  FOOD   POISONING. 

Certain  articles  that  are  always  injurious  are,  sometimes  through 
ignorance  or  by  accident,  used  as  foods.  Examples  of  these  are  poisonous 
mushrooms,  which  contain  muscarine,  and  some  species  of  fish.  The  poison 
present  in  such  substances  is  said  to  be  endogenous.  Entirely  different  are 
the  poisons  which  are  occasionally  present  in  foods  otherwise  normal. 
These  consist  of,  (a)  poisonous  metals,  (b)  animal  parasites,  (c)  fungi,  and 
(d)  bacteria.    These  poisons  are  exogenous. 

(a)  Poisonous  Metals. — This  subject  is  considered  under  the  appropri- 
ate headings  (see  pp.  881,  884,  and  887,  etc.).  The  contamination  of  water 
in  the  neighborhood  of  mines — lead,  mercury;  of  beer  by  arsenic  (out- 
break in  Manchester  in  1900) ;  of  wine  (lead  shot  used  in  washing  bottles) ; 
the  presence  of  chrome  yellow  as  a  coloring  matter  in  cakes;  and  the  possi- 
bility that  canned  vegetables  and  other  foods  may  become  poisonous  by 
slow  chemical  changes  of  the  lead  in  the  solder  or  the  tin,  are  to  be  con- 
sidered. Under  all  these  conditions  the  poisoning  is  chronic,  the  symptoms 
are  slowly  progressive,  and  a  number  of  persons  are  affected,  very  often 
within  the  boundaries  of  a  limited  district,  (b)  Animal  Parasites.— Cer- 
tain meats  are  occasionally  rendered  poisonous  by  the  presence  of  trichina 
or  cysticercus  (q.v.).  (c)  Fungi. — The  grains  used  for  food  may  be  infected 
with  the  ergot  fungus,  spurred  rye — Claviceps  purpurea — and  become 
the  cause  of  outbreaks  of  epidemic  disease — ergotismus.  (d)  Bacteria. — 
Vegetable  micro-organisms  constitute  the  chief  factor  in  poisonous  foods. 
Meats  obtained  from  diseased  animals  may  give  rise  to  actual  infections. 


FOOD  POISONING.  893 

Poods  contaminated  with  specific  infectious  organisms,  for  example,  B. 
typhosus,  may  cause  circumscribed  outbreaks  of  enteric  fever.  Finally 
foods  infected  with  saprophytic  bacteria,  which  evolve  poisonous  products 
in  the  substance  of  the  food  itself,  may  become  highly  poisonous — ptomaine 
■poisoning — a  term  which  in  popular  parlance  is  used  interchangeably 
with  "food  poisoning." 

I.  Fish  Poisoning — Icthyismus  ;  Ichthyotoxismus. — The  toxic  sub- 
stances may  be  endogenous,  as  in  species  of  Tetrodon  and  Diodon,  found  in 
Japan  and  the  East  Indies.  The  nature  of  the  poison  is  unknown.  It  is 
located  in  the  testicles  and  ovaries.  In  its  effects  it  resembles  curare.  The 
symptoms  are  vertigo,  vomiting,  dyspnoea,  cyanosis,  muscular  relaxation, 
and  dilatation  of  the  pupils.  Death  results  very  rapidly.  This  is  the  fugu 
poisoning  of  Japan.  In  certain  species  of  sturgeon,  pike,  and  barb  a  poison- 
ous substance  is  developed  during  the  spawning  season.  The  intoxication 
is  grave  and  often  fatal,  the  symptoms  being  those  of  an  acute  gastro- 
enteritis. Exogenous  poisons  are  more  common.  If  diseased  fish  is  eaten 
raw,  the  specific  infection  may  be  communicated,  or  wholesome  and  edible 
feh  may,  if  not  properly  cared  for,  speedily  develop  toxic  substances 
-associated  with  putrefactive  changes.  These  substances,  in  some  instances, 
resist  boiling,  so  that  the  infected  flesh  is  also  injurious  after  cooking.  The 
intensely  poisonous  ptomaines  are  present  during  the  early  days  of  putre- 
faction, even  before  changes  recognizable  by  the  taste  or  smell  have 
occurred,  while  those  of  a  later  period  are  less  toxic.  The  symptoms  do 
not  usually  appear  until  after  a  period  of  eight  to  twenty-four  hours. 
There  are  two  groups  of  cases.  In  one  the  clinical  phenomena  relate  chiefly 
1)0  the  nervous  system.  These  are  collapse  symptoms,  with  subnormal 
temperature,  abdominal  pain,  dry  mouth,  inability  to  swallow,  dull  pain 
in  the  belly,  dyspnoea,  and  nervous  symptoms,  as  vertigo,  dilatation  of  the 
pupils,  and  diplopia.  In  another  group  the  clinical  manifestations  are 
those  of  an  acute  gastro-enteritis,  uncontrollable  vomiting,  griping  pains, 
diarrhoea,  and  profound  cardiac  asthenia.  Beri-beri  and  leprosy  have 
been  ascribed  to  the  habitual  eating  of  certain  kinds  of  fish. 

Shell-fish. — Poisoning  by  mussels  is  not  uncommon  in  Europe  and 
'Great  Britain.  Brieger,  in  1885,  isolated  a  ptomaine — mytilotoxin — which 
proved  to  be  highly  poisonous.  It  resists  the  temperature  at  which  the 
mussels  are  cooked,  and  in  this  respect  mussel  poisoning  is  analogous  to 
poisoning  by  mushrooms.  The  poison  is  not  regarded  as  endogenous  but 
as  the  result  of  changes  caused  by  bacteria  present  in  polluted  waters. 
The  symptoms  are  variable,  sometimes  not  occurring  until  after  the  lapse 
of  several  hours  and  being  choleraic  in  character;  in  other  cases  not  show- 
ing themselves  for  a  few  days  and  indicating  an  action  of  the  poison  upon 
the  nervous  system.  They  consist  of  a  general  urticarious  eruption, 
associated  with  asthma-like  attacks  of  dyspnoea.  Recovery  takes  place 
in  the  course  of  several  days.  In  other  cases  the  symptoms  come  on 
rapidly  and  resemble  those  produced  by  curara.  Death  has  occurred 
with    great   rapidity. 

Oysters  which  have  begun  to  decompose,  and  those  obtained  from 
beds  in  waters  defiled  by  sewage,  frequently  cause  poisoning,  with  gastro- 
intestinal symptoms.     Intense  and  fatal  poisoning  from  this  cause  is  very 


894  MEDICAL  DIAGNOSIS. 

infrequent.  Much  more  important  is  the  occasional  conveyance  of  specific 
infections,  especially  that  of  enteric  fever,  and  the  causation  of  epidemics 
by  the  eating  of  oysters  and  other  shell-fish  from  sewage-polluted  water. 

Lobsters  and  crabs,  when  not  fresh,  frequently  cause  symptoms  of 
poisoning  similar  to  those  produced  by  other  fish  and  shell-fish  under  like 
circumstances.  All  kinds  of  canned  fish  may,  under  certain  conditions,  as 
decomposition,  or  infection  previous  to  canning,  or  injury  to  the  cans, 
develop  poisonous  qualities. 

IL  Meat  Poisoning — Sausage  Poisoning. — As  in  the  case  of  fish 
poisoning,  the  great  majority  of  the  cases  are  due  to  bacterial  infection, 
either  specific,  as  in  the  case  of  animals  infected  at  the  time  of  slaughter, 
or  accidental,  from  contact  with  various  articles  that  are  unclean,  or  from 
improper  care  in  other  respects.  In  the  former  case  the  organisms  are 
those  comprised  in  the  'paratyphoid  and  paracolon  groups;  in  the  latter 
they  are  saprophytes,  as  Proteus  vulgaris  and  B.  botulinus,  or  members  of 
the  colon  group.  Clinically  the  cases  may  be  referred  to  two  categories: 
first,  those  in  which  the  symptoms  chiefly  relate  to  the  nervous  system, 
and  second,  those  in  which  they  are  gastro-intestinal.  Botulismus — allan- 
tiasis— sausage  poisoning,  a  specific  intoxication  caused  by  B.  botulinus, 
comes  on  twenty-four  or  thirty-six  hours  after  eating  the  food.  The 
sj^mptoms  comprise,  on  the  one  hand,  gastro-intestinal  derangements,  as 
epigastric  distress,  nausea,  vomiting,  sometimes  diarrhoea,  sometimes  con- 
stipation, dryness  of  the  mouth  and  throat,  choking  attacks,  and  stomatitis, 
with  tough,  adherent  secretion;  on  the  other,  nervous  disorders,  as  dim- 
ness of  vision,  mydriasis,  diplopia,  strangling  sensations,  aphonia  and  pro- 
found muscular  weakness.  The  pulse  and  temperature  remain  normal. 
Recovery  is  slow.  In  fatal  cases  maniacal  delirium,  passing  into  coma, 
constitutes  a  terminal  event. 

III.  Poisoning  by  Milk  and  Milk  Products.  —  Milk  is  especially 
exposed  to  bacterial  infection,  and  constitutes  a  favorable  culture  medium. 
For  these  reasons  as  a  raw  food  it  is  an  abundant  cause  of  intoxications 
and  infections.  Boiled  milk,  properly  protected  until  used,  is  safe.  Path- 
ogenic bacteria  may  reach  milk  directly  from  a  diseased  animal,  as  in 
tuberculosis,  or  by  way  of  water  polluted  with  excreted  matter,  as  in  enteric 
fever,  or  from  cases  of  diphtheria  or  scarlet  fever  in  various  ways.  The 
gastro-intestinal  diseases  of  infants  in  hot  weather  are  due  to  the  bacterial 
infection  of  milk.  Acute  intoxications,  in  contradistinction  to  the  specific 
infections,  are  common,  and  not  only  milk  itself,  but  also  articles  made 
from  it,  such  as  ice-cream,  custards,  and  cream  puffs,  may  give  rise  to 
serious  poisoning.  Vaughan  isolated  from  cheese  a  poisonous  ptomaine,- 
w^hich  has  been  found  in  milk,  but  among  the  milk  poisons  it  is  not  "the 
one  most  frequently  present,  nor  is  it  the  most  active  one."  Of  the  many 
different  bacteria  for  which  milk  forms  a  culture  medium,  each  has  its 
special  toxin.  The  bacteria  which  have  been  especially  studied  belong 
to  the  B.  enteritidis  group.  These  organisms  do  not  cause  any  apparent 
change  in  the  milk,  which  presents  an  alkaline  or  amphoteric  reaction, 
and  is  not  curdled. 

Cheese  frequently  develops  highly  poisonous  qualities.  The  acci- 
dental introduction  of  various  toxin-producing  bacteria  and  their  devel- 


FOOD  POISONING.  895 

opment  are  very  common.  The  toxins  are  probably  different,  but  have 
not  yet  been  fully  studied.  Tyrotoxicon  was  the  first  to  be  isolated.  The 
symptoms  of  cheese  poisoning  are  those  of  acute  gastro-intestinal  irritation. 

Diagnosis. — Food  poisoning  may  be  recognized  by  the  history  of  the 
case  in  respect  to  the  eating  of  certain  articles  of  food,  and  the  character 
of  the  symptoms,  which  are  usually  urgent  and  are  nervous,  or  gastro- 
intestinal, or  both.  In  most  instances  it  occurs  in  circumscribed  epidemics, 
and  all  the  victims  are  seized  at  about  the  same  time,  which  varies  accord- 
ing to  the  nature  of  the  intoxication  from  a  brief  period  to  two  or  three 
days.  In  a  suspected  case  the  careful  investigation  of  the  antecedent 
facts,  and  the  character  of  the  symptoms,  are  sufficient  for  a  provisional 
diagnosis,  which  may  be  confirmed  by  bacteriological  studies,  including 
agglutination  tests. 

IV.  Grain  and  Vegetable  Poisoning — Ergotismus. — The  cause  is  a 
parasitic  fungus — Claviceps  purpurea — which  grows  in  the  flowers  of  several 
grains,  especially  rye,  and  is  known  as  ergot.  This  substance  contains  a 
number  of  toxic  substances,  among  which  the  more  important  are  sphace- 
linic  acid,  regarded  as  the  cause  of  the  trophic  or  gangrenous  form,  and 
cornutin,  the  cause  of  the  nervous  or  convulsive  form  of  the  disease.  Ergo- 
tismus does  not  occur  in  this  country,  but  is  frequently  epidemic  in  cer- 
tain parts  of  Europe.  It  is  due  to  prolonged  ingestion  of  the  poison  and  is 
essentially  a  chronic  intoxication,  though  the  onset  may  be  marked  by 
acute  symptoms.  In  the  gangrenous  form,  distant  parts  of  the  body  in 
which  the  circulation  is  feeble,  as  the  toes,  fingers,  ears,  and  the  tip  of  the 
nose,  suffer,  and  the  tissue  necrosis  is  preceded  by  tingling,  anaesthesia, 
muscular  spasms,  and  signs  of  local  congestion.  In  the  nervous  form, 
the  chief  symptoms  are  weakness,  headache,  cramps  in  the  muscles,  and 
contractures.  There  may  be  moderate  fever  with  mania,  and,  in  the 
severer  cases,  melancholia  and  dementia  occur.  There  are  tabetic  S5^mp- 
toms,  and  at  the  autopsy  sclerosis  of  the  posterior  columns  has  been 
observed. 

Lathyrismus;  Lupinosis;  Vetch  Poisoning. — Chick-pea  poisoning 
occurs  in  extended  outbreaks  in  Austria,  Italy,  Northern  Africa,  and  India 
as  the  result  of  the  admixture  of  the  powdered  seeds  of  Lathyrus  sativus 
with  flour  from  wheat  and  other  cereals  in  the  making  of  bread.  The 
symptoms  are  pain  in  the  lumbar  region,  girdle  sensations,  spastic  paralj^sis 
of  the  lower  extremities,  which  may  increase  to  complete  paraplegia, 
tremor,  and  fever. 

Pellagra;  Maidismus. — An  affection  caused  by  the  continued  eating 
of  food  prepared  from  fermented  or  diseased  Indian  corn.  It  has  pre- 
vailed in  extensive  epidemics  in  the  south  of  p]urope,  especially  in  Italy. 
The  actual  cause  has  not  as  yet  been  demonstrated,  but  is  probabh^  a 
specific  toxin  evolved  by  the  growth  of  bacteria.  Early  symptoms  are 
debihty,  sleeplessness,  pains  in  the  spine,  and  gastro-intestinal  derange- 
ments. The  skin  becomes  rough  and  dr}^;  then  follows  desquamation, 
with  crusts  and  abscess  formation.  In  the  graver  forms  there  are  serious 
nervous  symptoms — spasms,  paralysis  of  the  lower  extremities  proceed- 
ing to  paraplegia,  and,  after  repeated  attacks,  a  terminal  cachexia. 
Melancholia   and   mania  occur. 


896  MEDICAL  DIAGNOSIS. 

Potatoes. — Local  outbreaks  of  acute  poisoning  traced  to  eating 
potatoes  that  have  sprouted  have  recently  been  recorded.  The  toxic 
principle  is  solanin — present  in  considerable  amounts  as  the  result  of  the 
growth  of  the  Bacterium  solaniferum  colorabile  and  B.  solaniferum  non- 
colorabile.  The  symptoms  are  those  of  an  acute  gastro-intestinal  catarrh, 
with  headache,  jaundice,  and  great  prostration. 

Examination  of  Food  in  Cases  of  Suspected  Food  Poisoning. — As  much 
of  the  food  as  can  be  obtained  should  be  preserved  for  examination.  The 
quantity  is  usually  small.  The  investigation  should  be  conducted  without 
unnecessary  delay.  Meanwhile,  perishable  articles  should  be  kept  on  ice 
without  the  addition  of  chemical  preservatives.  The  bacteriological 
examination  should  precede  the  chemical  unless  there  are  clear  indications 
of  poisoning  by  definite  substances,  as  arsenic,  lead,  etc. 

The  methods  comprise  animal  experimentation  by  feeding,  the  injec- 
tion of  sterile  water  in  which  the  material  has  been  macerated,  further 
injections  of  such  macerations  after  filtration  through  a  Berkshire  or 
Pasteur  filter,  and  the  determination,  when  necessary,  of  the  presence  of  a 
heat-resisting  toxin  by  injecting  the  macerations  after  boiling.  Culture  and 
agglutination  methods  are  necessary. 


V. 

THE   DIAGNOSIS   OF   AUTOINTOXICATIONS. 

The  term  autointoxication  is  used  to  designate  the  intoxications  of 
endogenous  metabolic  origin.  It  has  been  used  vaguely  for  a  long  time  to 
suggest  hypothetical  conditions  rather  than  demonstrable  facts.  Quite 
recently,  under  the  application  of  scientific  methods,  the  subject  has  been 
to  some  extent  cleared  up. 

I.  Qastro=intestinaI  Autointoxication. — There  appears  to  be  no  proof 
that  intoxication  takes  place  from  the  resorption  of  digestive  juices,  or 
of  the  products  of  normal  digestion,  or  of  the  abnormal  products  of  diges- 
tion, except  in  the  case  of  the  acetone  bodies.  Nor  has  it  been  demon- 
strated that,  in  the  normal  action  of  bacteria  upon  the  contents  of  the 
alimentary  canal,  toxic  substances  are  produced.  Even  in  the  case  of 
intestinal  putrefaction,  which,  to  some  extent,  is  a  normal  process,  an 
increased  amount  does  not  necessarily  mean  an  intoxication.  Intestinal 
putrefaction  is  largely  dependent  upon  the  diet;  an  excess  of  protein  affords 
an  abundant  medium  for  bacterial  growth,  yet  there  is  no  constant  ratio 
between  the  protein  intake  and  the  output  of  aromatic  substances.  An 
increase  of  these  bodies,  especially  indican  in  the  urine,  actually  indicates 
increased  bacterial  activity,  whereas  it  is  constantly  assumed  to  be  the 
sign  of  an  intoxication.  Intestinal  putrefaction  is  to  be  distinguished 
from  tissue  putrefaction,  which  is  the  cause  of  an  excess  of  aromatic  bodies 
in  the  urine.  The  aromatic  bodies  are  not  in  themselves  toxic.  It  has 
been  assumed  that  other  substances  of  a  poisonous  character  are  produced 
by  putrefaction,  and  that  these,  Hke  the  amount  of  putrefaction,  may  be 


AUTOINTOXICATIONS.  897 

approximately  estimated  by  the  aromatic  substances.  In  point  of  fact  the 
aromatic  substances  in  the  urine  afford  no  indication  of  the  presence  or 
amount  of  any  hypothetical  poison  and  bear  no  constant  relation  to  the 
symptoms  in  any  particular  case. 

Tetany. — The  extremely  rare  and  fatal  tetany  in  adults,  occurring  in 
the  dilatation  of  stomach,  has  been  attributed  to  poisons  produced  by 
the  decomposition  of  food. 

Gastro-intestinal  Attacks  Associated  with  Cutaneous  Symptoms. — The 
seizures  are  acute  and  recur  periodically.  They  consist  of  epigastric  pain, 
vomiting,  diarrhoea,  and  various  skin  eruptions,  most  commonly  urticaria 
and  erythema.     Desquamation  may  occur. 

Acute  Paroxysmal  Gastro-enteritis. — The  attack  occurs  suddenly  in  the 
absence  of  errors  in  diet,  particularly  in  the  absence  of  food  poisoning. 
The  symptoms  are  vomiting,  often  uncontrollable;  severe  abdominal  pain; 
diarrhoea,  frequently  profuse;  and  tympanites;  together  with  marked  ner- 
vous phenomena,  as  vertigo,  spasms,  shock,  and  in  grave  cases  general 
convulsions  and  coma. 

Intestinal  Obstruction. — This  condition,  either  partial  or  complete,  is 
very  commonly  attended  by  symptoms  of  autointoxication,  namely,  head- 
ache, fever,  sleeplessness,  and  albuminuria,  with  increase  in  the  aromatic  sub- 
stances in  the  urine;  all  of  which  subside  when  the  obstruction  is  relieved. 

Constipation. — Many  symptoms  are  attributed  to  this  condition,  but 
there  are  few  that  are  constant  and  none  that  is  characteristic.  A  furred 
tongue,  poor  appetite,  headache,  lassitude,  and  mental  depression  may 
occur  in  habitual  constipation,  but  these  symptoms  are  common  in  those 
who  have  a  regular  daily  action  of  the  bowels.  There  are  those  who  are 
miserable  if  the  daily  morning  movement  is  missed,  while  others  are 
uncomfortable  if  by  drugs  or  injections  their  bowels  are  moved  more 
frequently  than  once  in  the  course  of  some  days.  Coprcemia,  a  hypothetical 
intestinal  autointoxication  from  constipation,  lacks  the  support  of  accu- 
rate clinical  observation  and  objective  chemical  investigation.  The  work  of 
Horace  Fletcher  has  shown  that  constipation  amounting  to  the  evacuation 
of  small  masses  of  dry  faeces  at  intervals  of  several  days  is  not  incompatible 
with  excellent  health.  The  secondary  mechanical  effect  of  the  accumulation 
of  fecal  matter  in  the  intestines  is  considered  under  its  appropriate  heading. 

Gastric  Neurasthenic  and  Other  Conditions  Vaguely  Described  as  Ner- 
vous Dyspepsia. — This  group  of  nervous  affections  is  sometimes  attrib- 
uted, upon  wholly  insufficient  evidence,  to  autointoxication,  and  the  same 
statement  may  be  made  in  regard  to  a  number  of  nervous  diseases,  as 
migraine,  neuritis,  and  epilepsy,  and  some  of  the  psychoses,  as  melancholia 
and  forms  of  dementia. 

I'he  Ancemias. — The  theory  of  Sir  Andrew  Clark  in  regard  to  fecal 
poisoning  as  the  cause  of  chlorosis  rests  upon  an  insufficient  basis  of  fact 
and  is  no  longer  accepted.  That  pernicious  anaemia  is  probably  due  to 
an  autointoxication  of  intestinal  origin  finds  support  in  the  following  facts, 
namely:  that  a  persistent  haemolysis  is  the  essential  pathological  process  in 
the  disease;  that  the  haemolytic  process  is  active  in  the  portal  system;  and 
that  there  are,  in  many  of  the  cases,  atrophic  changes  in  the  gastro-intes- 
tinal mucosa.^  The  nature  of  the  toxic  agent  has  not  been  demonstrated, 
57 


898  MEDICAL  DIAGNOSIS. 

II.  The  Retention  Intoxications. — Biliary  intoxication  is  due  to  the 
biliary  salts  and  the  pigments.  The  toxic  influence  is  exerted  upon  the 
cells  of  the  parenchymatous  organs,  the  muscles,  and  the  blood.  Many 
persons  suffer  from  marked  jaundice  for  considerable  periods  of  time  with- 
out manifesting  evidences  of  intoxication.  Hepatic  coma  cannot,  in  the 
strict  sense,  be  ascribed  to  cholaemia,  since  it  occurs  in  cirrhosis  of  the 
liver,  in  which  jaundice  is  a  subordinate  symptom  or  absent  altogether. 
It  is  probably  due  to  derangement  of  the  hepatic  functions  in  metabolism. 

III.  Autointoxication  from  Extensive  Abolition  of  the  Function  of 
the  Skin. — Extensive  superficial  burns  are  followed  by  rapidly  oncoming 
collapse,  associated  with  acute  degenerative  changes  in  the  cells  of  the 
parenchymatous  organs  and  muscles,  and  haemolysis — evidences  of  the 
action  of  toxic  agents,  the  nature  of  which  is  unknown. 

IV.  Acidosis. — Under  this  term  are  grouped  the  derangements  of 
metabolism  which  result  from  an  excess  of  acids  in  catabolism — an  acid 
intoxication.  The  principal  sources  are:  (a)  the  acids  of  carbohydrate 
fermentation  in  the  alimentary  canal;  (b)  the  sulphuric  and  phosphoric 
acids  derived  from  the  catabolism  of  common  protein  and  nuclein  respec- 
tively; (c)  lactic  acid;  (d)  the  members  of  the  acetone  group,  diacetic  and 
/?-oxybutyric  acids  derived  from  the  fats  (A.  E.  Taylor).  This  form  of 
autointoxication  is  encountered  in  diabetes,  starvation,  phosphorus  poison- 
ing, toxaemia  of  pregnancy,  cyclic  vomiting  of  children,  in  severe  febrile 
infections,  after  prolonged  chloroform  anaesthesia,  in  the  cachexia  of 
carcinoma,  and  many  other  diseases.  The  condition  may  be  caused  by  the 
withdrawal  of  fixed  alkalies  or  the  toxic  action  of  salts  of  the  acid  com- 
pounds. James  Ewing  has  shown  "that  the  chemistry  and  pathological 
anatomy  of  these  diseases  lends  support  to  the  view  that  there  are  two 
distinct  classes  of  acidosis  following  two  experimental  prototypes. 

"Type  I. — Hydrochloric  Acid  Poisoning. — Clinical  forms:  diabetes; 
starvation.  Chemistry:  acetone  compounds.  Pathological  anatomy: 
no   lesions. 

"Type  II. — Extirpation  of  the  Liver  or  Eck  Fistula. — Clinical  forms: 
phosphorus  poisoning;  toxaemia  of  pregnancy;  cyclic  vomiting;  chloro- 
form poisoning.  Chemistry:  lactic  acid  prominent;  ammonia  in  excess 
of  any  acetone  compounds  present.  Pathological  anatomy:  extensive 
fatty  degeneration"  (Ewing). 

Notwithstanding  the  fact  that  considerable  quantities  of  acids  may 
be  present  in  the  blood  in  combination,  an  acid  reaction  of  the  blood-serum 
does  not  occur.    It  could  only  be  a  terminal  phenomenon. 

V.  Gout  in  the  present  state  of  knowledge  may  be  regarded  as  an  auto- 
intoxication dependent  upon  derangements  of  the  purin  metabolism; 
VI.  glycosuria  and  diabetes,  as  autointoxications  arising  in  consequence 
of  faults  in  the  carbohvdrate  metabolism. 


HEAT-STROKE.  899 


VI. 
THE    DIAGNOSIS   OF  HEAT-STROKE   AND   ELECTRIC    STROKE. 

HEAT-STROKE. 

Heat-stroke  is  commonly  seen  in  laboring  men,  and  is  also  not  unusual 
in  armies.  In  the  United  States  Army,  from  1868  to  1893,  there  were  not 
less  than  1250  cases,  with  47  deaths. 

Pathology. — Congestion  of  the  brain  and  membranes,  as  well  as  of 
the  lungs,  is  common.  According  to  Gihon'  loss  of  coagulabihty  of  the 
blood  is  the  one  great  lesion  in  coup  de  soleil.  Rigor  mortis  and  putre- 
factive changes  occur  early.  The  post-mortem  appearances  are  mostly 
negative,  but  there  is  rigid  contraction  of  the  left  ventricle  of  the  heart, 
while  the  right  side  and  the  great  vessels  contain  partly  coagulated  dark 
blood.  Meningitis  is  one  of  the  sequels  of  sun-stroke.  The  vitochemical 
changes  in  the  blood,  muscles,  and  nerve-centres  are  not  fully  understood. 

Symptoms. — Two  forms  are  recognized:  simple  heat  exhaustion, 
and  heat-stroke  proper. 

In  heat  exhaustion  the  patient  usually  collapses,  and  may  even  fall  in 
a  partial  or  complete  syncope.  The  surface  of  the  skin  is  cool,  the  pulse 
rapid  and  feeble,  and  the  temperature  may  even  be  subnormal — as  low  as 
95°  or  96°.  In  the  worst  cases  there  is  sometimes  mental  confusion,  and 
dehrium  has  been  occasionally  reported.  The  prognosis  in  these  cases  is 
usually  good,  if  the  patient's  general  health  is  sound. 

In  heat-stroke  proper  the  chief  symptoms  are  as  follows:  headache, 
oppression  in  the  epigastrium,  sometimes  nausea  and  vomiting,  a  sense 
of  weakness,  vertigo,  dimness  of  vision,  and  unconsciousness,  with  fever 
and  rapid  pulse.  Coplin,  among  the  sugar  refiners  of  Philadelphia,  also 
describes  a  "cramp"  in  the  epigastrium,  and  sometimes  in  the  back 
and  the  calves  of  the  legs,  as  among  the  premonitory  symptoms.  Of  the 
various  symptoms  the  only  one  that  can  be  called  pathognomonic  is  the 
exceedingly  high  temperature.  Richards,  in  the  Rhode  Island  Hospital, 
observed  temperatures  ranging  as  high  as  110°,  and  Packard,  in  31  cases 
in  the  Pennsylvania  Hospital,  saw  the  temperatures  range  up  to  110°, 
111°,  and  even  112°.  These  are  extreme  cases,  usually  with  contracted 
pupils  and  profound  unconsciousness,  and  many  of  these  patients  die. 
Death  sometimes  occurs  so  quickly  that  a  special  or  apoplectic  type  is  recog- 
nized, and  if  dyspnoea  is  prominent,  the  type  is  called  asphyxial.  Most 
authors  are  in  accord  about  the  contracted  pupils,  but  an  exceptional 
case  of  dilated  pupils  has  been  noted,  and  as  death  approaches  the  pupils 
may  dilate.  Convulsions  are  not  common.  Great  oppression  of  breathing 
is  sometimes  experienced,  with  a  sense  of  constriction  of  the  chest.  Pirrie, 
in  his  cases  in  Central  India,  observed  priapism  and  seminal  emission  just 
before  the  seizure.  Alcoholism  is  an  active  promoter  of  heat-stroke.  Most 
cases  occur  in  persons  who  have  been  over-exerting  themselves. 

1  "Heat-stroke,"  in  XX.  Cent.  Pract.,  vol.  iii.,  p.  253.  This  article  by  Gihon  is  a  useful  review  of 
the  whole  subject,  botli  historical  and  clinical. 


900  MEDICAL  DIAGNOSIS. 

Diagnosis. — Heat-stroke  must  be  distinguished  from  cerebral  hemor- 
rhage, uraemia,  alcohoHc  intoxication,  and  opium  poisoning;  but  from  all 
these  conditions  it  differs  in  its  history  and  its  high  temperature.  The 
history  alone  is  so  clear  and  suggestive  in  most  cases  that  a  mistake  is 
hardly  possible.  In  uraemia  a  subnormal  temperature  is  common,  and 
the  condition  of  the  urine  is  characteristic;  if  the  temperature  rises,  as  it 
does  in  some  cases,  especially  towards  the  end,  it  does  not  mount  as  high 
as  in  sun-stroke.  The  contracted  pupils  in  heat-stroke  may  suggest  opium 
poisoning,  but  in  the  latter  there  is  slow  respiration,  and  in  the  former 
high  temperature.  In  mere  alcohohc  intoxication  we  do  not  see  pyrexia, 
much  less  hyperpyrexia,  nor  contracted  and  immobile  pupils.  In  fact, 
in  all  comatose  conditions,  as  in  those  just  named,  and  in  diabetic  coma, 
we  do  not  see  high  fever,  nor  is  there  the  history  of  exposure  to  heat.  Injury 
to  the  head  can  usually  be  excluded  by  the  history  and  by  careful  physical 
examination.  In  cerebral  hemorrhage  there  is  usually  hemiplegia,  which 
can  be  recognized  as  a  rule  by  the  difference  in  resistance  on  the  two  sides. 
The  temperature  often  rises  as  death  approaches.  The  attempt  to  distin- 
guish sun-stroke  from  heat-stroke  is  not  called  for. 

ELECTRIC  STROKE. 

Under  this  heading  are  included  both  lightning  stroke  and  shocks 
from  dynamos.  The  vast  extension  of  the  use  of  electricity  in  recent  years 
has  made  these  accidents  not  uncommon,  and  the  use  of  the  current  as  an 
agent  for  executing  criminals  in  the  State  of  New  York  has  furnished  rare 
opportunities  for  the  systematic  study  of  the  subject. 

Pathology. — Some  of  the  lesions  are  purely  surgical,  such  as  the  burns 
which  are  caused  by  immediate  contact  with  a  "live"  wire.  It  is  impossible 
to  state  in  scientific  terms  what  is  the  exact  pathology  of  electric  shock, 
especially  in  cases  of  sudden  death.  The  results  of  examinations  are  often 
negative.  Van  Gieson,  in  autopsies  on  the  bodies  of  criminals,  found  fluid 
blood,  but  no  recognizable  changes  in  the  tissues  or  organs. 

Symptoms. — Macdonald  and  Ward  have  recorded  the  effects  as  noted 
in  the  execution  of  four  criminals  at  Sing  Sing,  N.  Y.^  With  a  current  of 
1785  volts,  passed  through  wet  sponge  electrodes  from  the  forehead  to  the 
calf  of  one  leg,  the  heart  continued  to  beat  after  the  first  contact  of  27 
seconds,  and  a  noisy  respiration  was  re-established  after  an  interval  of  more 
than  one  minute.  After  a  second  contact  of  26|  seconds  respiration  and 
the  heart  action  had  ceased  permanently.  It  seems  that  the  action  of  the 
heart  is  not  permanently  arrested  as  quickly  as  is  respiration.  With  a 
stronger  voltage,  as  in  a  lightning  stroke,  it  is  possible  that  the  respiration 
and  the  heart  are  arrested  instantaneously. 

E.  A.  Spitzka,  whose  observations  are  based  upon  thirty-one  electro- 
cutions, finds  that  "the  death  is  undoubtedly  painless  and  instantaneous. 
The  vital  mechanisms  of  life,  circulation  and  respiration,  cease  with  the 
first  contact.  Consciousness  is  blotted  out  instantly  and  the  prolonged 
apphcation  of  the  current  as  it  is  usually  practised  by  Mr,  E.  F.  Davis, 

1  Medico-Legal  Journal,  vol.  ix.    Also  XX.  Cent.  Pract.,  vol.  iii.  pp.  403-411. 


PREGNANCY.  901 

the  State  electrician  of  New  York,  ensures  the  permanent  derangement  of 
the  vital  functions  so  that  there  could  be  no  recovery  of  these.  Occasion- 
ally, the  drying  of  the  sponges  through  undue  generation  of  heat  causes 
desquamation  or  superficial  blistering  of  the  skin  at  the  site  of  the  elec- 
trodes, but  not  often.  Post-mortem  discoloration,  or  lividity,  often  appears 
during  the  first  contact.  The  pupils  of  the  eyes  dilate  instantly  and  remain 
dilated  in  death." 

Diagnosis. — This  must  depend  largely,  if  not  entirely,  upon  the  history. 
Burns  on  the  surface  of  the  body,  as  already  said,  are  common  from  con- 
tact with  a  "  live"  wire,  but  in  the  case  of  lightning  stroke,  while  not  unseen, 
they  do  not  appear  to  be  so  extensive  or  so  common. 

The  after-effects  in  non-fatal  cases  usually  consist  in  states  of  neu- 
rasthenia and  traumatic  hysteria.  Organic  palsies,  or  permanent  lesions 
of  any  kind,  seem  to  be  rare  sequels. 


VII. 
THE   DIAGNOSIS    OF   PREGNANCY. 

Under  ordinary  circumstances  the  question  as  to  the  existence  of 
pregnancy,  as  it  presents  itself  to  the  general  practitioner  or  to  the  specialist 
in  midwifery  or  in  gynaecology,  presents  no  difficulty.  As  a  rule,  the  patient 
has  already  made  the  diagnosis  for  herself.  As  it  occurs,  however,  to  the 
medical  diagnostician,  it  frequently  assumes  a  high  degree  of  importance 
and  involves  responsibility  of  the  gravest  kind.  This  is  especially  the 
case  in  illegitimacy  in  young  girls,  who  very  often  stoutly  deny  exposure 
to  the  possibility  of  such  a  condition  until  the  approach  of  actual  labor. 
On  the  other  hand,  married  women  long  childless  sometimes  positively 
assert  that  their  hopes  are  about  to  be  realized,  and  enumerate  in  detail 
and  with  precision  the  signs  of  the  condition  even  to  the  motion  of  the 
child,  under  circumstances  in  which  the  occurrence  of  such  an  event  is 
impossible— pseudocyesis.  There  are  obvious  reasons  why  the  opinion  of 
the  medical  man  is  often  first  sought. 

Early  Gestation. — Symptoms. — Amenorrhoea  in  a  healthy  woman 
previously  regular  is  a  symptom  of  primary  importance,  and  usually  the 
first  to  arouse  a  suspicion  on  the  part  of  the  woman  as  to  her  condition. 
Cessation  of  the  menses,  under  these  circumstances,  is  physiological  and 
unattended  by  the  signs  of  the  grave  chronic  diseases,  as  nephritis,  tuber- 
culosis, and  the  cachexias,  in  which  it  is  pathological.  Abrupt  cessation 
at  a  later  period  of  life  may  also  be  physiological  and  mark  the  occurrence 
of  the  grand  climacteric.  The  occasional  occurrence  of  this  physiological 
event  at  an  unusually  early  period  of  life  is  to  be  borne  in  mind.  On  the 
other  hand,  the  recurrence  of  a  menstrual  flow  for  two  or  three  months, 
or  in  extremely  rare  instances  throughout  pregnancy,  must  be  considered 
in  a  doubtful  case.  Nausea  is  next  in  importance.  It  begins,  as  a  rule, 
from  two  to  four  weeks  after  amenorrhoea  and  may  or  may  not  be  associated 
with  vomiting.     It  is  troublesome  and  distressing  at  the  hour  of  rising, 


902  MEDICAL  DIAGNOSIS. 

but  the  gravida  may  be  annoyed  by  waves  of  nausea  from  time  to  time 
during  the  day.  Cravings  for  unusual  articles  of  food,  and  hysterical 
manifestations,  may  accompany  the  nausea.  Constipation  is  common. 
Further  subjective  manifestations  are  irritability  of  the  bladder,  increased 
flow  of  saliva,  and  sensations  of  fulness  and  tingling  in  the  breasts. 

Signs. — Certain  signs  usually  show  themselves  during  the  first  two 
months,  and  have  a  diagnostic  value.  Those  relating  to  the  breasts  com- 
prise general  enlargement,  a  nodular  fulness  in  the  glandular  area,  slight 
prominence  of  the  nipple,  pigmentation  of  the  areola,  and  enlargement 
of  the  sebaceous  glands  surrounding  it.  Pressure  of  the  contents  of  the 
ducts  outward  toward  the  nipple  reveals  the  presence  of  a  yellowish  watery 
fluid — colostrum.  In  multigravida  a  persistent  secretion  may  follow  lacta- 
tion and  simulate  colostrum.  Signs  apparent  upon  examination  of  the 
abdomen  are  pigmentation  of  the  linea  alba,  flattening  of  the  hypogastrium, 
and  retraction  of  the  umbihcus.  In  fair  women  pigmentation  may  not 
occur,  and  in  fat  women  flattening  and  retraction  are  not  marked. 

Pelvic  signs  are  more  distinctive.  Of  these  the  more  important  are  a 
violaceous  coloring  of  the  cervical  portion  of  the  uterus,  thinning  and  com- 
pressibility of  the  junction  of  the  cervix  with  the  body, — Hegar's  sign, — 
lateral  expansion  of  the  fundus  in  anteflexion,  and  pulsation  of  the  uterine 
arteries.  The  body  of  the  uterus  presents  a  peculiar  softness.  The 
presence  in  the  os  of  a  plug  of  tenacious  mucus  is,  in  connection  with 
the  foregoing  changes,  very  suggestive. 

Advanced  Pregnancy. — A  tendency  to  constipation  persists  and 
waves  of  nausea  occur.  Striation  of  the  breasts,  abdominal  walls,  and 
upper  parts  of  the  thighs  becomes  conspicuous.  There  are  elevation  of 
the  fundus  uteri  and  protrusion  of  the  navel.  Recurrent  rhythmical  con- 
tractions of  the  uterus  after  the  completion  of  the  third  month,  unattended 
with  pain — Braxton  Hicks's  sign — are  highly  suggestive  of  pregnancy. 
Finally,  the  rise  and  fall  of  the  foetus  in  ballottement,  the  movements  of 
its  limbs,  and  the  sounds  of  its  heart  are  positive  and  conclusive  signs. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  presence  of  the 
above  symptoms  and  signs  and  becomes  probable  in  proportion  to  the 
number  of  them  in  association  at  the  time  of  the  examination.  It  assumes 
greater  certainty  as  pregnancy  advances,  and  demonstrable  signs,  which 
offer  more  positive  indications,  become  associated  with  the  symptoms. 

Differential  Diagnosis. — The  Distinction  between  Normal  Pregnancy 
and  Conditions  which  Simulate  it. — As  to  special  symptoms,  the  amenor- 
rhcBa  of  pregnancy  may  usually  be  distinguished  from  pathological  amen- 
orrhcea  by  the  anamnesis.  The  absence  of  a  history  of  disease,  such  as 
malaria,  nephritis,  an  acute  or  chronic  infection,  is  important.  But  the 
fact  that  women  subject  to  such  diseases  may  become  pregnant  is  not 
to  be  overlooked.  Amenorrhoea  due  to  local  pathological  conditions — 
heematometra,  pyometra,  and  hydrometra — is  attended  by  uterine  colic, 
and  the  enlargement  of  the  organ  does  not  present  the  softening  of  the 
pregnant  uterus.  On  the  contrary,  it  offers  a  tense,  fluctuating  tumor. 
The  amenorrhoea  of  acquired  atresia  may  be  readily  recognized  by  the 
history  and  local  conditions.  The  amenorrhoea  of  the  menopause  is  rarely 
abrupt,  mostly  partial  and  progressive,  and  frequently  accompanied  by 


PREGNANCY.  903 

hysterical  manifestations.  Accumulations  of  omental  fat  or  abdominal- 
wall  fat  are  common.  Moreover,  the  uterus  is  not  enlarged  or  softened, 
and  the  other  local  signs  of  pregnancy  recognizable  upon  vaginal  examina- 
tion are  wholly  absent. 

Intra-abdominal  tumors  arising  from  the  level  of  the  pelvis  are  to  be 
distinguished  from  the  gravid  uterus  by  their  consistency,  as  in  the  case 
of  fibromyomata,  where  the  enlargement  is  tense,  nodular,  and  of  slow 
growth.  The  impairment  of  the  patient's  health,  and  the  attacks  of  pelveo- 
peritonitis  occurring  with  more  or  less  regularity,  together  with  the  metror- 
rhagia, are  conclusively  opposed  to  the  diagnosis  of  pregnancy.  Tumors 
of  the  adnexa,  and  pelvic  exudates,  reveal  their  character  both  by  the 
local  symptoms  and  by  the  situation  in  the  pelvis  of  the  swellings  to  which 
they  give  rise. 

Subjective  manifestations  of  pregnancy  which  simulate  functional 
disturbances  arising  in  disease,  such  as  nausea  and  albuminuria,  are  to  be 
weighed  relative  to  their  association  with  other  symptoms  and  with  the 
signs  of  pregnancy.  The  presence  or  absence  of  casts,  the  amount  of  urine 
excreted,  and  the  history  of  the  case  render  it  possible  to  differentiate  the 
albuminuria  of  pregnancy  from  that  occurring  in  nephritis. 

Abnormal  Pregnancy  and  Simulative  Conditions. — Abnormal  preg- 
nancy comprises,  first,  the  development  of  the  ovum  in  abnormal  situa- 
tions; second,  pregnancy  following  the  fertilization  of  the  ovum  in  loco 
but  pursuing  an  abnormal  course. 

As  to  the  points  of  difference  in  the  diagnosis  of  tubal  gestation  and 
cornual  pregnancy  from  pelvic  tumors  simulating  either  of  these  condi- 
tions, the  irregular  uterine  bleeding,  the  pain,  the  collapse  occurring  with 
rupture  or  tubal  abortion,  and  the  symptoms  of  internal  bleeding,  together 
with  the  localization  of  a  mass  outside  the  uterus — all  in  the  presence  of 
symptoms  of  early  pregnancy — are  suggestive. 

Certain  symptoms,  which  by  their  occurrence  characterize  the  course 
of  pregnancy  as  abnormal,  may  give  rise  to  confusion.  The  continuance 
of  menstruation,  for  instance,  may  obscure  the  diagnosis.  The  syncope 
which  occurs  in  pregnancy  may  likewise  require  the  observation  of  associ- 
ated symptoms  to  explain  its  presence.  The  oedema  of  pregnancy  shows 
itself  in  the  presence  of  signs  which  distinguish  it  from  the  oedema  of  cardiac 
disease  and  the  anasarca  of  nephritis;  it  is  usually  progressive  without 
symptoms  of  nephritis,  is  not  accompanied  by  pallor  or  waxiness  of  the 
skin,  and  is  evidently  connected  with  the  pressure  of  the  uterus. 

Finally,  hydramnios  may  suggest  the  presence  of  a  tumor  within  the 
abdomen  originating  from  some  condition  other  than  pregnancy.  Hydram- 
nios, however,  may  be  diagnosticated  by  the  presence  of  fluctuation,  the 
rapid  increase  in  the  size  of  the  tumor,  the  location  of  the  latter  within 
the  abdomen,  and  the  associated  symptoms  and  signs  of  pregnancy. 


904  MEDICAL  DIAGNOSIS. 


VIII. 
THE    DIAGNOSIS    OF    CONSTITUTIONAL    DISEASES. 

I.  GOUT. 

Podagra. 

Definition. — A  disease  of  disordered  metabolism,  due  to  the  presence 
in  the  blood  of  uric  acid  in  abnormal  amounts,  and  characterized  clinically 
by  attacks  of  acute  arthritis  involving  one  or  several  joints  and  recurring 
at  irregular  intervals,  the  deposition  of  sodium  biurate  in  and  around  the 
joints,  and  irregular  constitutional  symptoms. 

Etiology. — It  is  necessary  to  consider  the  gouty  constitution  and  the 
attack.  An  individual  may  present  marked  evidences  of  the  gouty  diathesis 
and  never  experience  an  attack;  or  there  may,  fortunately,  be  long  intervals 
between  the  attacks,  during  which  the  health  is  excellent.  As  the  disease 
advances  the  attacks  become  more  frequent  and  the  general  health  is 
progressively  impaired. 

Predisposing  Influences.  —  Heredity.  —  The  gouty  constitution  is 
inherited  more  frequently  than  it  is  acquired.  Transmission  appears  to 
be  more  common  in  the  male  line,  but  in  this  connection  the  different 
mode  of  life  of  the  sexes  is  to  be  considered.  In  hereditary  cases  the  attack 
may  occur  in  childhood.  It  is  not  common  before  thirty,  but  in  a  majority 
of  the  cases  the  first  attack  occurs  in  early  middle  life.  Alcoholic  excesses, 
and  especially  the  habitual  free  use  of  alcoholic  beverages — regular  drink- 
ing— is  an  important  causative  factor.  Malt  liquors  tend  to  cause  gout 
more  than  wines,  and  these  more  than  distilled  spirits.  Excesses  in  food 
are  more  important  still.  Eating  too  much,  without  active  exercise,  is  a 
predisposing  cause  of  the  highest  importance.  Gouty  persons  are  often 
hard  workers,  with  excellent  appetites  and  good  gastric  digestion.  More- 
over, rich  viands  and  fine  wines  are  associated  in  the  pleasures  of  the  table. 
But  gout  is  not  restricted  to  the  rich;  exhausting  toil,  poor  food,  and  excesses 
in  beer  may  cause  it — "poor  man's  gout."  Chronic  lead  poisoning  plays 
an  important  part  in  the  etiology  of  this  disease.  Sedentary  Habits. — Lack 
of  fresh  air  and  sunshine,  with  prolonged  mental  effort,  predisposes  to  the 
attack.  Sydenham's  "  Whenever  I  return  to  my  studies  my  gout  returns 
to  me"  is  well  known. 

Exciting  Causes. — When  the  attack  is  due,  it  may  be  brought  on 
by  apparently  trifling  causes — an  unusually  hearty  meal,  a  glass  of  cham- 
pagne, sudden  chilling,  worry,  or  sudden  depressing  emotion,  or  mental 
shock.    It  may  also  be  precipitated  by  a  slight  injury  or  accident. 

Pathology. — The  nature  of  gout,  beyond  that  it  is  due  to  faultj^ 
metabolism  with  overproduction  and  deficient  elimination  of  uric  acid,  is 
unknown.  The  hypotheses  regarding  the  actual  part  played  by  uric  acid, 
which  is  now  regarded  as  one  of  the  purin  bodies  derived  from  the  nuclein 
resulting  from  nuclear  disintegration,  in  causing  gout  are  very  numerous. 
None  of  them,  however,  arises  to  the  dignity  of  a  theory. 


GOUT.  905 

Symptoms. — Gout  may  be  acute,  chronic,  and  irregular. 

1.  Acute  Gout. — The  attack  is  commonly  preceded  by  prodromes, 
which  consist  of  fleeting  pains  in  the  small  joints  of  the  hands  or  feet, 
restlessness,  irritability,  and  dyspepsia  with  acid  eructations.  In  some 
cases  there  is  an  erythematous  angina,  broncliitis,  or  asthmatic  symptoms. 
The  elimination  of  uric  acid  has  been  found  to  be  diminished  before  and 
during  the  early  part  of  the  attack.  In  many  instances  there  are  no  pre- 
monitory symptoms.  The  attack  begins,  as  a  rule,  in  the  early  morning 
hours.  There  is  agonizing  pain  in  the  metatarsophalangeal  joint  of  the 
great  toe,  more  frequently  the  right,  or  the  tarsometatarsal  joints,  especially 
at  the  outer  border  of  the  foot.  There  is  intra-  and  periarticular  effusion; 
the  skin  is  hot,  red,  tense,  and  glistening.  Tenderness  is  extreme  and  the 
patient  cannot  endure  the  slightest  pressure  upon  the  affected  part.  There 
is  moderate  fever,  the  temperature  rising  to  102°-103°  F.  (39°-39.5°  C.) 
and  falling  to  normal  toward  the  end  of  the  attack  by  lysis.  The  intensity 
of  the  symptoms  somewhat  abates  in  the  morning,  but  the  foot  remains 
swollen,  red,  and  painful,  and  during  the  night  the  patient's  sufferings  are 
again  intensified.  Other  joints,  and  particularly  the  great  toe  of  the  oppo- 
site foot,  may  become  affected.  The  nocturnal  exacerbations  gradually 
subside  and,  in  the  course  of  a  few  days  or  a  week,  the  acute  symptoms 
disappear  with  itching  and  desquamation,  but  the  affected  joint  remains 
tender  and  swollen,  often  requiring  the  use  of  a  loose  shoe  and  crutches 
for  another  week  or  more.  SupjDuration  in  the  affected  joints  does  not 
occur.  Transient  albuminuria  or  glycosuria  may  occur.  There  is  a  moder- 
ate leucocytosis  during  the  acute  S3^mptoms.  Physical  and  mental  depres- 
sion persist  for  a  period,  but  after  a  time  the  patient  regains  his  former 
health.  Recurrences  follow  at  intervals  varj'ing  from  a  few  months  to  a 
year  or  more.  In  the  later  attacks  not  only  the  joints  of  the  feet,  but  also 
the  knees,  wrists,  and  fingers  may  be  involved. 

Retrocedent  or  Suppressed  Gout;  Visceral  Gout. — These  terms  are 
used  to  designate  groups  of  symptoms,  usually  grave,  indicative  of  disease 
of  internal  organs,  which  sometimes  arise  coincidently  with  a  sudden  sub- 
sidence of  the  local  manifestations  of  the  attack.  The  principal  gi-oups 
are,  (a)  gastro-intestinal — pain,  vomiting,  purging,  and  collapse,  so  severe 
in  some  instances  as  to  prove  fatal;  (b)  cardiac — dyspnoea,  precordial 
pain  and  distress,  arrhythmia,  and  tachycardia;  and  (c)  delirium,  stupor, 
coma,  or  apoplectiform  attacks.  These  symptoms  are  in  many  of  the 
cases  uraemic. 

Chronic  Gout. — The  attacks  become  more  frequent  and  prolonged, 
and  many  joints  are  affected.  In  debilitated  persons  and  those  suffering 
from  chronic  lead  poisoning,  the  attacks  of  arthritis  may  not  occur — atypi- 
cal gout.  Deposits  of  sodium  biurate — tophi — occur  in  the  cartilages  and 
ligamentous  structures  of  the  joints,  which,  in  the  course  of  time,  become 
enlarged  and  deformed.  The  feet  are  first  and  most  markedly  affected, 
then  the  hands  to  a  less  extent,  and  in  some  cases  tophaceous  deposits 
form  about  the  knees  and  elbows  or  in  the  line  of  the  tendons.  The  cartilage 
of  the  ear  frequently  contains  tophi  which  appear  as  yellowish-white 
nodules  at  the  edge  of  the  helix.  Less  frequently  similar  deposits  take 
place  in  the  cartilages  of  the  nose,  eyelids,  and  larynx.     The  skin  covering 


906  MEDICAL  DIAGNOSIS. 

the  tophi  frequently  undergoes  slow  necrotic  change,  with  ulceration 
exposing  the  felted  chalk-stones.  As  the  disease  advances  the  patients 
become  sallow  and  dyspeptic;  the  signs  of  arteriosclerosis  develop;  there 
are  cardiac  hypertrophy,  increased  arterial  tension,  increased  urine  with 
low  specific  gravity,  slight  albuminuria  which  may  be  intermittent,  and 
hyaline  casts.  Muscular  cramps,  especial!}^  affecting  the  calves  of  the  legs 
and  starting  in  the  predormitium,  are  common.  Attacks  of  arthritis, 
implicating  one  or  several  joints,  characterized  by  pain,  redness,  and  swell- 
ing, occur  with  or  without  fever.  Croupous  pneumonia  and  apoplexy  are 
common  terminal  events,  but  death  often  results  from  uraemia  or  from  an 
acute  inflammation  of  one  of  the  great  serous  sacs. 

Irregular  Gout. — In  addition  to  the  attacks  of  arthritis  and  the 
chalk-stones,  there  are  diverse  morbid  conditions  to  which  gouty  subjects 
and  members  of  gouty  families  are  alike  especially  liable,  and  which  are 
commonly  regarded  as  irregular  manifestations  of  gout.  Among  the  more 
important  of  these  are  cutaneous  eruptions,  and  especially  eczema;  period- 
ical gastro-intestinal  catarrh — so-called  bilious  attacks;  pulmonary  affec- 
tions, especially  bronchitis  and  emphysema;  cardiovascular  lesions, 
myocardial  degenerations,  arteriosclerosis,  and  aneurism  and  nervous 
affections,  among  which  migraine,  headache,  sciatica,  and  other  neuralgias 
are  the  more  common.  Burning  sensations  and  itching  of  the  feet  at  night 
are  very  common  and  annoying  symptoms.  Among  affections  of  the  eye, 
scleritis,  iritis,  cataract,  glaucoma,  and  hemorrhagic  retinitis  have  been 
attributed  to  gout.  It  is  the  custom  to  regard  gout  as  the  cause  of  the 
recession  of  the  gums  so  common  in  advancing  life. 

The  urinary  conditions  are  more  especially  gouty  because  they  are 
based  upon  anatomical  lesions  of  the  kidneys.  Chronic  interstitial  neph- 
ritis, without  characteristic  changes,  is  not  uncommon  in  gouty  subjects. 
More  common  are  conditions  believed  to  be  distinctive,  namely,  a  deposit  of 
urates  in  the  intertubular  tissue,  mostly  in  the  papillae;  less  frequently  the 
deposits  occupy  both  the  tissue  and  the  tubules,  and  there  are  also  minute 
foci  of  necrosis  in  the  cortex  and  medulla,  in  which  are  deposited  crystals 
of  sodium  urate.  The  clinical  manifestations  of  gouty  deposits  are  the 
same  as  those  of  this  form  of  chronic  nephritis  occurring  in  non-gouty 
persons:  increased  output  of  urine,  albuminuria  (usually  slight),  low 
specific  gravity,  hyaline  casts,  increased  arterial  tension,  accentuated 
aortic  second  sound,  and  uraemic  symptoms.  Prior  to  the  development 
of  renal  changes  the  urine  is  often  very  acid  and  high-colored  and  may, 
upon  standing,  deposit  crystals  of  uric  acid.  In  chronic  gout  the 
uric  acid  is  diminished,  as  a  rule,  with  occasional  excess.  Intermittent 
glycosuria,  traces  of  albumin,  and  tube  casts  may  occur.  Oxaluria  is 
common.  Renal  calculi  are  not  infrequent.  The  association  of  vesical 
calculi  and  gout  is  often  observed.  I  have  several  times  seen  purulent 
urethritis  follow  an  attack  of  gout. 

Diagnosis.- — The  direct  diagnosis  of  acute  gout  is  usually  a  simple 
matter.  Recurrent  attacks  of  arthritis,  beginning  in  or  limited  to  the 
great  toe,  with  a  hereditary  history  of  gout  and  a  personal  history  of  over- 
indulgence in  food  and  drink,  are  of  positive  diagnostic  value.  When 
other  joints  are  implicated  and  there  is  fever,  and  a  satisfactory  family 


GOUT.  907 

and  personal  history  cannot  be  obtained,  there  may  be  a  question  as  to 
the  differential  diagnosis  between  acute  gout  and  rheumatic  fever.  The 
following  facts  are  in  favor  of  the  diagnosis  of  gout:  the  occupation  and 
habits  of  the  patient;  the  involvement  of  a  limited  number  of  larger  joints; 
the  persistence  of  the  arthritis  in  the  affected  joint  in  contrast  to  the  migra- 
tory character  of  rheumatic  arthritis;  the  appearance  of  the  inflamed 
joints,  which  are  commonly  tense,  deeply  red  or  violaceous,  and  shiny; 
the  suddenness  of  onset;  and  the  condition  of  the  urine,  which  shows  a  low 
uric  acid  output  in  the  beginning  of  the  attack,  with  marked  increase 
toward  its  close. 

The  Diagnosis  of  Chronic  Gout.  —  The  history,  the  presence  of 
tophi,  and  the  deformities  are  characteristic.  A  tophus  in  the  neighbor- 
hood of  a  joint  is  easily  recognized.  Tophi  upon  the  ears  appear  earlier 
and  are  positively  diagnostic.  Other  things  at  the  ear  margin  may  be 
mistaken  for  them:  the  helical  apex,  called  from  the  English  sculptor  and 
poet  Woolner's  tip;  small  sebaceous  tumors;  and  fibroid  nodules.  The 
last  are  very  rare.  In  the  felted  material  from  an  open  tophus  the  needle- 
shaped  crystals  of  sodium  biurate  are  characteristic.  Garrod's  uric  acid 
thread  test  may  be  tried.  In  a  watch  glass,  15  c.c.  of  blood-serum,  which 
may  be  obtained  by  blistering,  are  treated  with  0.25  of  acetic  acid.  A  fine 
thread  immersed  in  it  may  show  in  a  few  hours  crystals  of  uric  acid.  The 
result  is  often  negative  in  cases  in  which  there  is  no  question  as  to  the 
clinical  diagnosis.  An  excess  of  uric  acid  in  the  circulating  blood  occurs 
also  in  leukaemia  and  chlorosis. 

The  differential  diagnosis  between  chronic  gout  and  arthritis 
deformans  demands  some  words  of  consideration.  This  necessity  arises 
more  from  the  misleading  influence  of  the  term  ''rheumatic  gout"  than 
from  any  real  resemblance  between  the  diseases.  In  the  rare  cases  in  which 
the  deformities  of  chronic  gout  arise  insidiously,  in  the  absence  of  acute 
attacks,  the  following  points  are  important:  Arthritis  deformans  is  com- 
mon in  women  and  among  the  poor  and  poorly  nourished;  spontaneous 
pain  in  the  affected  joints  is  less  common  and  less  urgent;  the  deformities, 
especially  those  of  the  hands,  are  more  uniform  and  symmetrical;  and 
tophaceous  deposits  form  no  part  of  the  pathology  of  the  disease. 

The  diagnosis  of  irregular  gout  is  based  upon  the  family  and 
personal  history  of  the  patient,  and  the  general  experience  of  clinicians 
that  gouty  individuals  more  frequently  manifest  these  particular  derange- 
ments of  health  than  others.  The  diagnosis  of  visceral  gout  depends, 
likewise,  upon  the  anamnesis  and  the  fact  that  the  onset  of  the  symptoms, 
indicating  disease  of  a  particular  organ,  corresponds  in  time  to  the  sub- 
sidence or  disappearance  of  the  familiar  symptoms  of  the  acute  attack  of 
gout.  The  diagnosis  of  irregular,  retrocedent,  and  visceral  gout  should  be 
made  with  some  reserve  and  only  in  the  case  of  a  distinct  hereditary 
predisposition,  or  of  an  individual  who  has  had  acute  attacks,  or  who  shows 
tophi  or  characteristic  deformities,  and  in  whom,  in  the  absence  of  such 
signs,  other  etiological  factors  can  be  excluded. 


908  MEDICAL  DIAGNOSIS. 

II.   ARTHRITIS  DEFORIViANS. 

Definition. — A  chronic  disease  of  the  joints,  of  undetermined  causa- 
tion, characterized  anatomically  by  lesions  of  the  synovial  membrane 
with  hypertrophy  of  its  fringes,  atrophic  changes  in  the  cartilages  and 
bones,  irregular  hypertrophy  of  the  bones,  and  wasting  in  the  periarticular 
structures;   and  clinically  by  characteristic  deformities. 

Etiology. — Predisposing  Influences. — The  synonyms  rheumatic  gout 
and  rheumatoid  arthritis  indicate  the  prevalent  belief  that  arthritis  deformans 
has  some  relationship  to  those  affections — a  belief  that  finds  little  support 
in  fact.  In  less  than  one-third  of  the  cases  the  family  history  shows  a 
tendency  to  joint  disease — gout  or  rheumatism.  Arthritis  deformans  in 
successive  generations  is  unusual.  Two  or  more  cases  have  been  noted 
in  a  family.  Children  are  sometimes  affected;  young  girls  frequently; 
the  greater  number  of  cases  begin  in  early  adult  and  middle  life.  Women 
are  affected  more  frequently  than  men.  The  disease  very  often  first  shows 
itself  about  the  time  of  the  menopause,  and  is  more  common  among  women 
who  suffer  from  diseases  of  the  reproductive  organs.  Habitual  exposure 
to  cold  and  damp,  hardship  and  privation,  sudden  mental  shock,  and  de- 
pressing emotions,  appear  to  bear  a  causal  relation  to  the  disease. 

Exciting  Cause. — There  are  two  theories:  first,  that  the  joint 
affection  is  secondary  to  some  disease  of  the  nervous  system;  second, 
that  it  is  a  chronic  infection.  The  latter  is  now  generally  accepted.  A 
variety  of  micro-organisms  have  been  found  in  the  lesions,  but  none 
that  is  uniformly  present.  The  fact  that,  in  a  considerable  proportion 
of  the  cases,  there  is  a  history  of  gonorrhoea,  does  not,  in  view  of 
the  wide  prevalence  of  that  disease,  indicate  a  causal  relation  on  the 
part  of  the  gonococcus. 

Morbid  Anatomy. — All  the  tissues  which  enter  into  the  structures 
of  the  affected  joints  are  involved  in  the  morbid  process,  but  in  which  of 
them  the  process  starts  cannot  be  affirmed  with  certainty.  It  is  probable, 
however,  that  the  cartilages  are  first  affected.  The  lesions  consist  of 
fibrillation  and  atrophy  of  the  cartilages;  in  the  bones,  eburnation,  abra- 
sion, and  osteophyte  formation;  in  the  synovial  membranes,  thickening 
and  hypertrophy  of  the  fringes  and  atrophy  of  the  periarticular  tissues. 
Osteophytes  developing  at  the  margins  of  the  bones  may  interfere  with 
movement.  Bony  ankylosis  is  rare  in  the  joints  of  the  extremities,  but 
common  in  the  spine,  which  sometimes  becomes  rigid  and  immovable. 
A  late  condition  is  contracture,  with  fixation  of  the  joints  in  flexion.  On 
the  other  hand,  the  muscles  are  atrophied  and  the  ligaments  relaxed,  so 
that  subluxation  is  common,  especially  in  the  knees  and  fingers.  The 
hands  are  greatly  deformed  and  the  fingers,  under  the  influence  of  gravity, 
show  deflection  to  the  ulnar  side.  Some  of  the  joints  are  the  seat  of  an 
effusion.  Neuritis  occasionally  occurs.  The  most  striking  feature  of  the 
arthropathy  is  its  symmetry.  The  changes  in  the  cartilages  and  bones 
are  well  shown  in  radiographs. 

Clinical  Varieties. — Heberden's  nodes;  the  progressive  polyarticular 
form;  the  monarticular  form;  the  vertebral  form;  and  arthritis  deformans 
in  children. 


ARTHRITIS  DEFORMANS.  909 

(a)  Heberden's  Nodes. — "Tumors  attaining  to  the  size  of  a  pea, 
which  are  sometimes  developed  near  the  third  joints  of  the  fingers.  They 
have  certainly  nothing  in  common  with  arthritis  (gout),  since  they  are 
met  with  in  many  persons  to  whom  that  disease  is  unknown.  They  remain 
throughout  life,  are  devoid  of  all  pain,  and  show  no  tendency  to  ulceration. 
The  deformity  is  more  conspicuous  than  the  inconvenience  they  cause, 
though  the  movement  of  the  fingers  is  somewhat  impeded  by  them."  They 
occur  much  more  commonly  in  women  than  in  men,  and  about  middle 
life.  The  nodules  may  become  tender  and  red.  Tophi  do  not  appear. 
The  larger  joints  are  not  involved.    They  are  not  influenced  by  treatment. 

(b)  The  Progressive  Polyarticular  Form. — The  acute  variety 
in  the  initial  attack  bears  a  close  resemblance  to  rheumatic  fever,  for  which 
it  is  very  often  mistaken.  It  occurs  frequently  in  young  women  among 
the  working  classes,  and  especially  in  mill  girls.  It  is  common  after  child- 
bearing  and  during  lactation.  It  begins  in  some  of  the  cases  at  the  meno- 
pause. The  joints  become  swollen,  tender,  and  painful  upon  movement; 
there  is  fever  and  the  patients  become  anaemic  and  weak,  and  rapidly  lose 
flesh.  The  attack  passes  over,  leaving  the  affected  joints  slightly  deformed. 
From  time  to  time  similar  attacks  recur,  each  leaving,  as  it  subsides,  some 
increase  of  deformity  and  further  impairment  of  health,  until  at  length 
the  patient  becomes  completely  broken  down  and  crippled.  The  small 
joints  of  the  hands  and  feet  first  and  chiefly  suffer,  but  the  ankles,  knees, 
wrists,  elbows,  shoulders,  and  spine  frequently  become  involved.  Chronic 
Form. — This  variety  is  most  common.  Acute  attacks  may  occur.  Only 
one  or  two  joints  may  be  at  first  affected;  usually  the  hands  are  first  in- 
volved, then  the  knees  or  feet.  Gradually  new  joints  suffer  until,  in  the 
severe  cases,  scarcely  an  articulation  escapes.  As  the  disease  progresses 
the  joints  are  symmetrically  involved.  The  earliest  symptoms  are  pain 
on  movement  and  slight  swelling,  which  may  be  intra-  or  periarticular. 
The  pain  varies  greatly  in  intensity.  There  are  cases  in  which  a  high  degree 
of  deformity  gradually  comes  to  pass,  without  pain;  others  in  which  there 
is  pain  only  at  the  time  of  outbreaks  of  the  arthritis,  or  at  night;  and  a 
few  in  which  pain  is  intense  and  persistent. 

The  deformities  are  progressive.  The  joints  are  enlarged  in  part  by 
the  outgrowth  of  osteophytes,  in  part  by  thickening  of  the  capsular  hga- 
ments,  and  in  part  by  subluxation.  While  they  remain  movable,  crepita- 
tion may  be  felt.  The  periarticular  tissues,  and  especially  the  muscles, 
undergo  atrophy,  and  at  length  the  function  of  the  joints  is  wholly  lost. 
Osteophytes,  adhesions,  and  infiltration  of  the  tissues  prevent  movement, 
and  the  joints  become  fixed,  usually  in  strong  flexion,  so  that  in  extreme 
cases  the  patient  lies  completely  helpless,  unable  to  move  any  part  of  the 
body  except  the  eyes.  Trophic  changes,  atrophy  of  the  muscles,  glossj^ 
skin,  pigmentation,  and  onychia  occur,  and  numbness  and  tingling  are 
common.  In  many  of  the  severe  cases  the  joints  of  the  hands  and  wrists 
suffer  to  a  less  extent,  and  the  ability  to  sew  or  write  is  in  part  retained. 
A  considerable  proportion  of  the  cripples  caused  by  this  form  of  arthritis 
deformans  maintain  fair  general  health  and  a  cheerful  disposition. 

(c)  The  Monarticular  Form. — This  form  is  usuallj^  seen  in  elderly 
persons.    The  knee,  hip,  and  shoulder  are  commonly  involved.    They  very 


910  MEDICAL  DIAGNOSIS. 

often  follow  traumatism.  In  other  cases  they  develop  insidiously.  Expos- 
ure to  damp  cold  appears  to  exert  a  predisposing  influence,  and  aged  fisher- 
men, oystermen,  and  hunters  often  suffer.  The  joint  lesions  are  the  same 
as  in  the  polyarticular  forms;  the  muscles  rapidly  waste,  adhesions  limit 
the  movements  of  the  parts,  and  motion  is  extremely  painful. 

(d)  The  Vertebral  Form. — Two  varieties  are  recognized.  In  one, 
the  spine  alone  is  involved.  The  disease  begins  with  obscure  meningeal 
symptoms,  with  evidences  of  compression  of  nerve-roots,  pain,  anaesthesia, 
loss  of  function,  and  wasting  of  spinal  muscles,  atrophy  of  the  disks,  and 
progressive  ankylosis  of  the  vertebrae  (Von  Bechterew).  In  the  second 
variety,  the  hips  and  shoulders  are  also  ankylosed — spondylosis  rhizomelic 
— (Strumpell-Marie).  Spondyhtis  deformans  is  more  common  in  males 
than  in  females.  It  may  result  from  spinal  injury.  The  early  manifesta- 
tions are  sometimes  confined  to  the  cervical  or  to  the  lumbar  region.  In 
other  cases  the  entire  spine  gradually  becomes  rigid  and  immobile.  There 
may  be  marked  kyphosis,  with  a  rigid  and  immobile  thorax  and  with 
diaphragmatic  breathing. 

(e)  Arthritis  Deformans  in  Children. — The  disease  occurs  in 
early  childhood.  Girls  are  more  commonly  affected  than  boys.  The 
disease  may  present  the  same  features  as  in  adult  life.  In  some  cases 
direct  inheritance  has  been  noted.  Cold,  privation,  and  unsanitary  sur- 
roundings are  predisposing  influences.  The  onset  may  be  acute,  with  the 
symptoms  of  infection,  fever,  profuse  sweating,  enlargement  of  the  spleen 
and  superficial  lymph-glands — Still's  disease.  One  or.  two  joints  may  be 
at  first  affected,  and  others  later.  There  is  loss  of  function  together  with 
muscular  atrophy.     The  prognosis  is  more  favorable  than  in  adult  life. 

Diagnosis.  —  The  direct  diagnosis  depends  upon  the  subacute 
exacerbations  of  the  joint  affection,  the  fact  that  after  each  outbreak  the 
deformity  is  increased,  the  remarkable  symmetry  of  the  lesions,  the  per- 
sistence of  the  process  in  the  affected  joints,  the  relaxations  of  the  ligaments, 
the  atrophy  of  the  muscles,  and  the  progressive  character  of  the  disease. 
The  initial  attack  often  presents  a  remarkable  resemblance  to  subacute 
rheumatic  fever. 

Differential  Diagnosis. — From  rheumatic  fever  the  diagnosis  may 
be  made  by  the  permanence  of  the  arthritis  in  particular  joints,  the  persis- 
tence of  the  lesions,  the  extreme  infrequency  of  endo-  or  pericarditis,  and  the 
incurability  of  the  affection;  and  from  gout  by  the  history,  the  fact  that 
gout  is  mostly  a  disease  of  men  and  middle  life,  and  the  absence  of  tophi. 
The  monarticular  forms  are  usually  regarded  as  cases  of  chronic  rheumatism. 

III.  THE  RHEUMATOID  AFFECTIONS. 

Most  of  the  cases  of  so-called  chronic  rheumatism  are  forms  of  ar- 
thritis deformans,  especially  those  in  which  a  single  joint  is  involved.  A 
majority  of  the  cases  of  so-called  muscular  rheumatism  are  purely  myalgic. 
Nevertheless,  out  of  deference  to  an  almost  universal  custom,  chronic 
rheumatism  and  muscular  rheumatism  are  permitted  to  retain  their  noso- 
logical position.  It  is  important  to  note  the  entire  absence  of  etiological 
and  clinical  relationship  to  rheumatic  fever. 


RHEUMATOID  AFFECTIONS.  911 

A.  Chronic  Rheumatism. 

Definition. — A  chronic  joint  affection  of  elderly  persons,  character- 
ized anatomically  by  synovial  inflammation,  capsular  thickening,  and 
wasting  of  the  periarticular  tissues  and  the  related  muscles,  and  clinically 
by  stiffness,  pain,  and  impairment  of  motion. 

Etiology. — Predisposing  influences  are  advanced  age,  occupations 
which  expose  the  individual  to  cold  and  damp — as  in  the  case  of  washer- 
women, ditch-diggers,  and  fishermen — poverty,  and  hardship.  The  exciting 
cause  is  sometimes  an  injury,  which  may  be  slight.  In  many  cases  the 
disease  develops  insidiously. 

Morbid  Anatomy. — The  synovial  inflammation  is  unattended  by 
effusion.  There  is  thickening  of  the  ligaments,  especially  of  the  capsular 
ligament  and  the  sheaths  of  the  tendons.  Erosion  of  the  cartilages  may 
be  found.  There  is  marked  atrophy  of  the  muscles  related  to  the  affected 
joint.  Subluxation  and  other  deformities  are  usually  not  marked  until 
late  in  the  course  of  the  disease. 

Symptoms. — Pain,  which  is  more  marked  in  the  morning  and  when 
the  weather  changes;  tenderness,  which  subsides  after  gentle  massage; 
stiffness,  which  is  usually  relieved  to  some  extent  by  exercise,  are  the  chief 
symptoms.  Swelling  is  commonly  present,  but  not  redness.  A  single 
joint  is  often  affected,  as  a  knee,  hip,  or  shoulder;  in  many  cases  several 
joints  are  involved,  more  commonly  the  large  than  the  small  joints.  Anky- 
losis and  more  or  less  deformity  may  gradually  come  to  pass.  The  subjects 
are  often  broken  down  and  anaemic.  The  prognosis  as  regards  cure  is  not 
hopeful. 

B.  Myalgia. 

Muscular  Rheumatism. 

Definition. — An  affection  of  the  voluntary  muscles  and  their  fibrous 
structures,  of  undetermined  pathology,  characterized  by  pain  upon  move- 
ment and  pressure.  The  disease  is  local  and  is  designated  by  various 
names,  as  lumbago,  torticollis,  pleurodynia,  according  to  the  parts  involved. 

Etiology. — Predisposing  Influences. — The  rheumatic  and  gouty 
habit  of  body,  laborious  occupations,  and  those  involving  exposure  to 
cold  and  damp  are  important  factors.  Men  suffer  more  frequently  than 
women.    It  is  an  affection  of  middle  and  late  life. 

Exciting  Causes. — The  attacks  follow  cold  and  exposure,  especially 
when  heated.  A  draught  of  air  may  bring  it  on.  Overuse  of  a  group  of 
muscles  is  a  frequent  cause.  The  muscular  pains  and  soreness  after  a  first 
horseback  ride  are  myalgic. 

Whether  the  pain  and  tenderness  arise  from  some  nutritional  dis- 
turbance of  the  muscle  substance  acting  upon  the  sensory  nei'ves  of  the 
muscles,  or  these  symptoms  are  due  to  a  neuralgia  of  such  nerves,  has  not 
been  positively  settled.  Myalgia  is  usually  acute;  it  may  be  subacute 
and  is  sometimes  chronic. 

Symptoms. — The  disease  is  local.  Constitutional  derangements  are 
rare  and  due  to  pre-existing  or  accidental  conditions.     They  consist  of 


912 


MEDICAL  DIAGNOSIS. 


loss  of  appetite,  languor,  and  slight  rise  of  temperature.  Pain  is  the  chief 
symptom.  It  is  rarely  constant,  but  is  acute,  even  agonizing,  when  the 
affected  muscles  are  contracted.  It  is  sharp  and  cramp-like  upon  move- 
ment, but  dull  and  sore,  or  absent  altogether,  when  the  muscles  are  in 
repose.  Firm  pressure  causes  soreness,  as  may  be  seen  in  lumbago — a 
sign  of  diagnostic  value. 

According  to  the  seat  of  the  affection  the  following  principal  varieties 
are  described:  Lumbago. — The  erector  muscles  of  the  spine  and  their 
attachments  are  affected.  There  is  pain  upon  rising  and  turning.  The 
patient    can    lean    over    to    lace    his    shoes,    but    cannot    straighten    his 

back  without  pain.  There  is  marked 
tenderness  upon  firm  pressure  over 
the  affected  muscles  and  their  attach- 
ments. The  attack  is  of  sudden  onset 
and  often  completely  disabling.  Tor- 
ticollis— Wry-neck. — The  sternoclei- 
domastoid and  adjacent  muscles  are 
affected.  In  some  instances  the  pos- 
I  terior  cervical  muscles  are  also  involved. 

I  \  This    form    is    very    common.      Young 

f  persons    frequently   suffer.      The    head 

[  is   held  rigidly  and  cannot  be  rotated 

r  from    side    to    side.      Pleurodynia. — 

I  The  intercostal  muscles    and,  in   some 

«i^  rMIMi  cases,   other  chest   muscles  are   painful 

4  ,^  "^^^^B  &^d    tender    upon    pressure.      The    left 

•^  ^  side   is    more    commonly   affected   than 

the  right.  A  deep  breath,  coughing, 
sneezing,  even  laughter  may  cause  the 
patient  to  cry  out  with  pain.  It  is 
to  be  distinguished  from  pleurisy  by 
the  absence  of  friction  rales  and 
from  intercostal  neuralgia  by  the 
absence  of  painful  points  along  the 
course  of  the  nerves,  and  the  fact 
that  in  the  latter  affection  the  pain  is  more  paroxysmal.  The  epi- 
gastric pain  often  seen  in  measles  is  myalgic.  Other  forms  are 
cephalodynia,  in  which  the  muscles  of  the  scalp  are  involved;  dorso- 
clynia,  scapulodynia,  and  so  on. 


Fig.    307. 


-Acute    rheumatic    torticollis. - 
Rotch. 


IV.  DIABETES. 

Diabetes  mellitus  and  diabetes  insipidus  have  little  in  common  except 
a  persistent  increase  in  the  amount  of  urine  secreted.  Glycosuria,  a  sympto- 
matic condition  characterized  by  the  transient  presence  of  sugar  in  the 
urine,  corresponds  to  polyuria,  a  symptomatic  condition  in  which  the 
urinary  output  is  greatly  increased  for  a  short  time.  These  conditions 
are  to  be  distinguished  from  diabetes  mellitus  and  diabetes  insipidus, 
which  are  substantive  diseases. 


DIABETES.  913 

A.  Diabetes  Mellitus. 

Definition. — A  chronic  nutritional  disease  due  to  diminished  capacity 
for  the  combustion  of  carbohydrates,  and  characterized  by  the  persistent 
excretion  of  grape-sugar  in  the  urine  when  moderate  amounts  of  carbo- 
hydrates are  ingested,  or  even  none  at  all  in  certain  cases.  Polyuria, 
polydipsia,  polyphagia,  and  emaciation  are  prominent  but  not  constant 
S3'mptoms. 

Etiology. — Predisposing  Influences. — Diabetes  mellitus  prevails 
in  every  part  of  the  world,  but  more  extensively  in  some  countries  than  in 
others.  Southern  Italy  and  India  suffer  to  an  especial  degree.  The  disease 
is  about  as  prevalent  in  the  United  States  as  in  Europe  and  appears  to  be 
increasing  upon  both  sides  of  the  Atlantic.  In  all  countries  it  is  more 
common  among  those  living  in  affluence  than  among  the  poor.  The 
Semitic  race  manifests  an  especial  predisposition  to  the  disease.  This 
racial  peculiarity  has  been  noted  by  competent  observers  in  various 
countries.  In  the  United  States  the  negroes  suffer  to  a  less  extent  than  the 
whites.  The  predisposition  is  very  commonly  inherited.  The  remarkable 
prevalence  of  diabetes  among  the  Hebrews  is  in  many  of  the  cases  due  to  this 
tendency.  Not  only  is  the  disease  observed  in  successive  generations  in  the 
direct,  but  also  in  collateral,  lines,  and  it  occasionally  occurs  at  an  early  age 
in  two  or  more  children  of  the  same  family.  The  descendants  of  gouty  or 
obese  persons  show  an  especial  liability  to  diabetes.  R.  Schmitz  first 
directed  attention  to  the  possibility  of  the  transmission  of  the  disease 
from  one  person  to  another.  A  long  and  intimate  association,  as  in  the 
case  of  a  wife  taking  care  of  a  husband  suffering  from  the  disease,  has,  in 
rare  instances,  been  followed  by  the  development  of  the  same  symptoms. 
Previous  good  health  on  the  part  of  the  second  individual,  with  absence  of 
hereditary  predisposition,  has  been  established  in  those  cases.  They  are 
extremely  rare  and  the  transmissibility  of  the  disease  appears  highly 
improbable.  Diabetes  mellitus  is  more  common  in  men  than  in  women, 
the  ratio,  according  to  available  statistics,  being  about  three  to  two.  The 
disease  mav  occur  at  any  period  of  life.  Infants  at  the  breast  are  sometimes 
affected,  but  such  cases  are  extremely  rare;  they  also  run  a  rapid  and  fatal 
course.  Hereditary  influences  are  usually  in  evidence,  and  several  of  the 
children  in  one  family  may  be  afTected.  But  diabetes  mellitus  is  essentially 
an  affection  of  adult  life.  A  majority  of  the  cases  come  under  observation 
between  the  third  and  the  sixth  decades.  The  disease  is  often  discovered 
upon  routine  medical  examination  for  hfe  insurance  or  other  purposes, 
and  has  already  existed  in  many  cases  for  a  considerable  time.  Diabetes 
is  much  more  common  among  persons  living  in  afHuence  than  among  the 
poor.  Those  who  live  luxurious,  aimless,  and  idle  lives  are  peculiarly  hable 
to  the  disease.  The  wear  and  tear  of  a  strenuous  intellectual  hfe,  especially 
when  coupled  with  great  anxiety  and  mental  excitement,  contribute  a 
predisposing  influence  of  great  importance.  Absorbing  application  to 
business,  excesses  at  table,  and  a  sedentary  life  are  important  factors  in 
producing  the  disease.  Those  Avho  dwell  in  cities  suffer  in  greater  propor- 
tion than  countrymen.  It  is,  however,  to  be  noted  in  this  connection  that 
the  disease  is  less  apt  to  be  recognized  in  the  latter  class.    Neurotic  persons 

58 


914  MEDICAL  DIAGNOSIS. 

are  more  commonly  affected  than  those  of  a  phlegmatic  temperament,  a 
fact  to  be  considered  in  the  matter  of  the  great  relative  frequency  of  the 
disease  among  the  Jews.  Gout,  syphihs,  and  malaria  have  been  regarded 
as  predisposing  influences.  It  was  at  one  time  thought  that  the  children 
of  phthisical  parents  were  especially  liable  to  diabetes.  The  disease  fre- 
quently develops  during  the  course  of  chronic  nervous  affections;  still  more 
frequently  forms  of  nervous  disease,  particularly  neuralgia,  neuritis,  and 
neurasthenia,  are  dependent  upon  the  diabetes,  and  arise  as  intercurrent 
affections  during  its  course.  Diabetes  occurs  among  the  insane,  but  not, 
according  to  the  statistics  of  large  institutions,  in  greater  proportion  than 
in  general  hospitals.  Obesity  is  frequently  associated  with  diabetes.  In 
a  majority  of  such  cases  the  obesity  precedes  the  diabetes  often  by  a  period 
of  years.  Under  these  circumstances  the  disease  commonly  runs  a  favor- 
able course,  the  glycosuria  diminishing,  even  disappearing  under  a  moder- 
ately strict  regimen,  and  reappearing  when  the  rules  are  neglected.  ]\Iuch 
less  favorable  are  the  cases  in  which  obesity  and  diabetes  are  simultaneously 
developed  in  early  life.  The  form  that  develops  consecutively  to  obesity  has 
been  designated  "lipogenous  diabetes."  Von  Noorden,  who  believes  that 
in  the  obese  cases  the  burning  up  of  sugar  is  interfered  with,  and  not  its  con- 
version into  fat,  proposes  for  this  form  the  term  "  diabetogenous  obesity." 

Exciting  Causes. — Psychical. — Mental  shock,  intense  nervous  strain, 
worry,  and  violent  depressing  emotions  are  frequently  followed  by  diabetes. 
Physical. — Disease  or  injury  of  the  brain  or  spinal  cord,  an  irritative  lesion 
of  the  diabetic  centre,  and  epilepsy  may  also  give  rise  to  the  disease.  The 
infectious  febrile  diseases,  especially  enteric  fever,  influenza,  diphtheria, 
rheumatic  fever,  and  syphilis,  appear  in  some  instances  to  have  been  the 
starting  point  of  diabetes,  the  symptoms  of  which  have  shown  themselves 
either  during  or  directly  after  the  attack.  Under  all  these  circumstances 
the  causal  importance  of  the  particular  event  or  condition  depends  upon  the 
known  absence  of  glycosuria  prior  to  its  occurrence.  In  the  vast  majority 
of  cases  diabetes  mellitus  develops  insidiously,  Avithout  discoverable  cause. 

Pancreatic  Diabetes. — It  has  long  been  kno^Mi  that  diabetes  and  disease 
of  the  pancreas  are  occasionally  associated,  and  Lancereaux  described, 
in  1877,  a  special  form  of  diabetes  under  the  name  diabete  pancreatique. 
The  discoveries  of  Minkowski  and  von  Mering,  in  1899,  aroused  intense 
interest  in  this  subject.  The  facts  are,  first,  that  experimental  extirpation 
of  the  pancreas  is  followed  by  glycosuria;  second,  that  if  a  portion  of  the 
gland  is  allowed  to  remain,  glycosuria  does  not  occur;  third,  that  in  a 
considerable  proportion  of  the  cases  of  diabetes,  lesions  of  the  pancreas 
have  been  found — sclerosis,  chronic  interstitial  inflammation,  hyaline 
degeneration  of  the  islands  of  Langerhans;  fourth,  that  the  glycosuria  is 
secondar}^  to  the  lesions  of  the  pancreas.  The  theory  of  an  internal  secre- 
tion containing  a  glycolytic  body  necessary  to  the  proper  combustion  of 
glucose  in  the  muscles  supplies  the  key  to  the  above  facts.  Pancreatic 
disease  causes  diabetes  bj^  arresting  the  formation  of  the  internal  secretion 
of  the  organ. 

Carbohydrate  Metabolism. — In  health  the  carboliydrates  of  the  food 
are  stored  in  the  liver  and  muscles  in  the  form  of  glycogen.  This  substance 
is  also  formed  from  the  proteids  of  the  food,  and  under  certain  conditions 


DIABETES.  915 

glucose  is  formed  from  the  proteids  of  the  tissues  of  the  body.  The  glycogen 
is  again  converted  into  glucose  and  given  up  gradually  to  the  blood,  in 
which  it  circulates  in  a  0.1  to  0.2  per  cent,  solution,  to  be  distributed  to  the 
muscles,  where  it  undergoes  combustion,  with  the  production  of  heat  and 
energy.  According  to  the  investigations  of  the  younger  Cohnheim  this 
is  brought  about  by  the  action  of  the  glycolytic  bodies,  one  derived  from 
the  muscles,  the  other  from  the  pancreas. 

Whenever  the  glucose  in  the  blood  is  in  excess  of  0.2  per  cent,  glycosuria 
results.  This  may  occur  in  the  absence  or  in  the  excess  of  the  glycolytic 
body;  by  the  sudden  ingestion  of  an  excess  of  carbohydrates — more 
than  180  to  250  grammes,  fasting — alimentary  glycosuria;  and  by  derange- 
ments of  circulatory  disturbances  or  instability  of  the  glycogen-storing 
mechanism. 

Symptoms. — In  a  large  proportion  of  the  cases  the  onset  is  insidious 
and  not  attended  by  symptoms  which  attract  the  attention  of  the  patient. 
In  some  instances,  in  physicians  and  others  who  have  examined  their  urine 
at  intervals,  the  disease  has  been  preceded  by  an  intermittent  glycosuria, 
which,  after  a  period  of  months  or  years,  has  become  persistent.  There 
are  other  cases  in  which,  under  treatment,  glycosuria  has  disappeared,  to 
recur  when  the  strict  regimen  has  been  relaxed.  The  existence  of  the 
disease  is  usually  recognized  by  the  occurrence  of  conspicuous  symptoms, 
as  polyuria,  polydipsia,  polyphagia,  emaciation,  or  pudendal  pruritus,  or 
by  the  discovery  of  sugar  in  the  urine  upon  examination  as  a  matter  of 
routine  or  for  life  insurance. 

In  rare  instances  it  follows  an  injury,  profound  depressing  emotion, 
or  a  chill.  There  are  cases  in  which  thirst  is  not  inordinate  and  the  amount 
of  urine  not  excessive.  The  tongue  in  established  cases  is  usually  red,  dry, 
and  denuded  of  epithelium;  the  saliva  scanty;  and  the  gums  swollen  and 
spongy.  There  are  constipation  and  lumbar  pain.  The  skin  is  dry  and 
harsh  and  perspiration  is  scanty  or  absent  altogether.  In  women  prui'itus 
vulvae  is  a  common  and  distressing  symptom,  and  general  pruritus  is  of 
frequent  occurrence  in  both  sexes.  The  pulse-frequency  is  high  and  there 
is  increased  arterial  tension.  The  temperature  is  commonly  slightly  sub- 
normal. Emaciation  is  common  and  rapid  in  young  subjects,  but  older 
persons  may  preserve  their  weight  for  long  periods. 

The  Urine. — Under  a  rigorous  regimen  the  quantity  may  not  be 
greatly  increased,  and  it  may  be  reduced  to  normal  during  an  intercurrent 
febrile  disease.  It  is,  however,  commonly  increased  to  three  or  four  litres 
in  cases  of  moderate  severity,  and  maj^  reach  as  much  as  twenty  litres  in 
twenty-four  hours  in  grave  cases.  The  specific  gravity  i-anges  from  1.030 
to  1.045,  but  in  exceptional  cases  may  be  low,  1.015  to  1.020,  a  fact  to  be 
borne  in  mind  in  the  diagnosis.  It  is  pale  in  color,  with  a  faint  greenish 
tinge,  and  has  a  mawkish,  sweetish  odor,  and  is  said  to  have  a  sweetish 
taste.  Sugar  is  present  in  amounts  varying  from  1.5  to  5  or  even  10  per 
cent.  The  total  quantity  excreted  in  twenty-four  hours  ranges  from  300 
to  750  grammes  or  more. 

Tests  for  Glucose. — The  most  satisfactory  tests  for  clinical  purposes 
are  Fehling's,  Trommer's,  the  bismuth  test,  the  fermentation  test,  and 
polariscopy.     If  close  results  are  desired  the  chemical  tests  may  be  con- 


916 


MEDICAL  DIAGNOSIS. 


trolled  by  fermentation  or  the  polariscope.  The  urea  and  calcium  salts  are 
increased,  the  uric  acid  does  not  show  important  changes,  and  the  phos- 
phates may  be  much  increased. 

Phosphatic  Diabetes.— This  term  has  been  applied  to  cases  in  which 
there  is  an  excessive  excretion  of  phosphates,  with  symptoms  similar  to 
those  of  diabetes  mellitus  but  with  inconstant  glycosuria. 

Acetone  and  diacetic  acid  are  often  present.  The  presence  of  these 
substances  in  the  urine  is  conclusive  evidence  that  /3-oxybutyric  acid,  of 


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Fig.  308. — Chronic  diabetes  mellitus;  male,  age  44.  Chart  showing  daily  variations  in  the  intake  of 
fluid,  the  amount  of  urine,  the  quantity  of  sugar  and  urea,  the  specific  gravity,  and  body  weight. — Jefifer- 
son  Hospital. 

which  they  are  derivatives,  is  being  produced  within  the  organism.  There 
are  three  stages  in  the  excretion  of  the  acetone  bodies:  (a)  acetone  alone 
in  the  urine — this  substance  is  exhaled  with  the  expired  air;  (b)  diacetic 
acid  is  also  present  in  the  urine;  and  (c)  /3-oxybutyric  acid  is  present  in  the 
urine  in  addition  to  acetone  and  diacetic  acid.  Much  of  the  acetone  fails 
of  excretion  by  the  urine,  since,  being  highly  volatile,  it  passes  off  by  the 
respirator}^  surfaces  and  lends  its  characteristic  odor  to  the  atmosphere 
about  the  patient.  The  presence  in  the  urine  of  these  bodies  is  of  the  highest 
clinical  importance,  since  ;3-oxybutyric  acid  is  the  cause  of  diabetic  coma. 
Glycogen  has  been  found  in  the  urine.  Albumin  is  common,  especially 
in  the  advanced  stages  of  the  disease.    Pneumaturia. — Gas  in  rare  instances 


DIABETES. 


917 


of  diabetes  passes  from  the  urethra  Avith  a  bubbhng  sound.  Its  presence 
is  the  result  of  fermentative  processes  in  the  urine  within  the  bladder.  An 
associated  cystitis  is  common. 

The  Blood. —  Hypergly- 
csemia  is  constant.  An  increase 
in  the  cellular  elements — poly- 
cythaemia  ■ —  may  occur,  the 
erythrocytes  reaching  6,000,- 
000  or  7,000,000  per  cubic 
millimetre.  In  coma  there  is 
leucocytosis,  and  /3-oxybutyric 
acid  is  present.  Lipwmia.  — 
Large  quantities  of  fat  are 
often  present  in  the  blood. 
The  plasma  presents  a  milky 
appearance,  and  if  the  blood 
is  allowed  to  stand  in  a  glass 
a  thick  creamy  layer  forms  at 
the  top,  the  nature  of  which 
is  apparent  upon  testing  with 
ether,  osmic  acid,  and  other 
substances  which  possess  char- 
acteristic reactions  with  fats. 
A  similar  fatty  layer  is  obtained 
by  centrifugalization.  The  fat 
particles  may  be  readily  seen 
upon  microscopical  examina- 
tion of  the  fresh  blood.  The 
fat  is  identical  with  that  of  the 
chyle  and  is  therefore  probably 
derived  directly  from  the  food. 
The  methylene  blue  reaction 
—  Williamson,  Bremer  —  is  of 
diagnostic  value. 

Complications. — The  dia- 
betic has  less  power  of  resist- 
ance against  pathogenic  influ- 
ences than  others,  and  suffers 
in  a  remarkable  manner  from 
complications.  Among  these 
the  following  are  especially 
important:  Skin.  —  Local  in- 
flammations, and  in  particular 
boils  and  carbuncles,  are 
common.  These  lesions  have 
their  origin  in  cracks  or  fis- 
sures of  the  skin  by  way  of 
which  infection  occurs.  Wounds  and  injuries  heal  slowly  and  granula- 
tion tissue  has   an   especial   tendency  to   slough.     Gangrene  is   common 


INTAKE- 

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Fig.  309. — Acute  diabetes  mellitus;  male,  age  27.  Chart 
.showing  daily  variations  in  the  intake  of  fluid,  tlie  amount 
of  urine,  the  quantity  of  .sugar  and  urea,  the  specific 
gravity,  and  the  body  weight. — Jefferson  Hospital. 


918  MEDICAL  DIAGNOSIS. 

and  is  due  to  arteriosclerosis.  In  rare  instances  perforating  ulcer  of  the 
foot  has  been  observed.  I  have  recently  seen  symmetrical  perforating  ulcer 
of  the  ball  of  the  foot  in  a  woman  aged  52.  Eczema  maj^  occur.  Pruritus 
is  common,  and  pruritus  vulvae  is  an  early  and  harassing  complication.  A 
balanitis  may  occur  in  men.  Bronzing  of  the  skin — diahete  bronze — is  a 
rare  cutaneous  manifestation  associated  with  hsemochromatosis.  The 
skin  is  usually  dry  and  harsh,  but  profuse  sweating  may  occur  in  terminal 
conditions.  Xanthoma  and  purpura  occur  as  in  other  chronic  affections, 
but  have  no  direct  etiological  relation  with  diabetes.  The  Lungs. — 
Pulmonary  affections  are  common  terminal  events.  Croupous  pneumonia 
ind  bronchopneumonia  occur  as  acute  complications.  Gangrene  may 
supervene  and  pulmonary  abscess  has  been  observed.  Pulmonary  tuber- 
culosis of  the  bronchopneumonic  type  is  common.  It  runs,  as  a  rule,  a 
rapid  course.  The  Kidneys. — The  signs  of  nephritis,  albuminuria,  and 
casts  very  often  occur  in  the  later  stages  of  diabetes  mellitus.  (Edema  of 
the  feet  and  legs  may  occur,  but  the  polyuria  prevents  general  anasarca. 
Dropsy  may  precede  coma.    Cystitis  may  occur.    The  Sexual  Organs. — 

Amenorrhoea  may  come  on  early,  or  the  men- 
strual function  may  continue  more  or  less 
regularly  to  an  advanced  stage  of  the  dis- 
ease. Impotence  is  common  and  often  an 
early  symptom.  Conception  is  not  unusual, 
but  is  often  followed  by  abortion.  Pregnancy 
is  followed  by  an  aggravation  of  the  diabetic 
symptoms.  The  Nervous  System. — Diabetic 
Fig.  310.— Diab.  u.  gaugrene.  coma  is  the  most  important  of  the  complica- 
tions on  the  part  of  the  nervous  system.  This 
affection  "represents  the  culmination  of  the  specific  diabetic  intoxica- 
tion" (Von  Noorden).  It  is  often  preceded  by  gastric  symptoms,  as  loss 
of  appetite,  nausea,  vomiting,  epigastric  tenderness,  and  constipation, 
which  extend  over  days  or  weeks  and  are  followed  by  mental  dulness, 
drowsiness,  and  fatigue  symptoms.  The  dulness  increases  and  the  patient, 
though  capable  of  being  roused,  quickly  falls  back  into  stupor,  like  a  drunken 
man.  The  respiration  becomes  full  and  deep,  without  being  much  increased 
in  frequency.  The  pulse  is  quickened,  but  remains  strong  and  full.  Cyanosis 
is  not  constant.  Finalh^  drowsiness  gives  way  to  coma,  and  in  the  course 
of  twenty  to  thirty-six  hours  death  terminates  the  scene.  In  another 
group  of  cases  coma  suddenly  supervenes  in  persons  who,  if  not  well  and 
strong,  are  in  their  usual  health.  This  fatal  complication  often  follows 
some  unusual  bodily  or  mental  effort.  Again,  coma  diabeticum  may  follow 
an  acute  infectious  or  septic  process,  or  alcoholic  intoxication,  or  ether 
or  chloroform  narcosis  induced  for  surgical  purposes.  The  diagnosis  may 
be  obscure  when  the  diabetic  becomes  comatose  in  consequence  of  apoplexy 
or  ursemia. 

jMinor  forms  of  diabetic  intoxication  may  explain  the  numbness  and 
tingling,  which  are  common  symptoms,  and  the  neuralgias,  which  some- 
times affect  the  upper  or  lower  extremities,  sometimes  a  single  nerve- 
trunk,  as  the  third  or  the  sciatic.  Herpes  zoster  is  encountered  in  diabetes, 
but  not  more  frequently  than  in  the  non-diabetic. 


DIABETES.  919 

Tabetic  symptoms,  lightning  pains,  loss  of  knee-jerks,  and  extensor 
palsies,  manifested  by  a  steppage  gait,  are  mostly  the  manifestations  of  a 
peripheral  neuritis,  though  changes  in  the  posterior  columns  have  been 
described.     Paraplegic  symptoms  are  due  to  neuritis. 

The  Organs  of  Special  Sense. — Cataract,  almost  always  double, 
is  a  late  development  and  occurs  in  cases  in  which  the  glycosuria  is  of 
high  grade.  It  develops  with  great  rapidity  in  young  diabetics,  but  more 
slowly  in  the  elderly,  in  which  it  cannot  be  differentiated  from  the  senile 
form.  Retinitis,  due  to  associated  renal  disease,  or  the  ordinary  hemor- 
rhagic form,  may  occur,  and  optic  neuritis  followed  by  atrophy.  Sudden 
amaurosis  without  ophthalmoscopic  changes  may  come  on  in  the  early 
stages  of  diabetes.  Changes  in  the  organs  of  hearing,  smell,  and  taste  are  not 
common.     Otitis  media  may  occur  and  be  followed  by  mastoid  disease. 

Diagnosis. — Direct  Diagnosis. — The  presence  of  grape-sugar  in  the 
urine,  continuing  for  weeks,  months,  or  years,  even  upon  a  diet  containing 
carbohydrates  in  moderate  amounts,  is  the  fundamental  diagnostic  criterion. 
Of  secondary  importance  in  the  diagnosis  because  they  are  not  constant 
are  inordinate  thirst,  excessive  appetite,  the  excretion  of  abnormally  large 
quantities  of  urine,  and  loss  of  weight.  Very  often  all  these  symptoms  are 
present  and  give  rise  to  a  characteristic  clinical  picture.  The  occasional 
temporary  absence  of  sugar  under  a  diet  which  does  not  contain  carbo- 
hydrates, or  during  an  acute  illness,  does  not  constitute  an  objection  to 
this  diagnosis,  since  such  a  diet  cannot  be  indefinitely  continued,  and 
sugar  reappears  in  the  urine  when  carbohydrates  are  added,  and  also 
reappears  upon  convalescence  from  an  intercurrent  febrile  disease. 

In  the  examination  of  the  urine  for  sugar  the  total  quantity  for  twenty- 
four  hours  is  collected,  that  of  the  day  and  of  the  night  separately.  Both 
the  percentage  and  the  total  quantity  of  sugar  are  ascertained.  The  pres- 
ence or  absence  of  acetone  and  oxybut^^ric  acid  is  also  noted  and  tests  for 
albumin  are  made.    The  specific  gravity  and  reaction  are  recorded. 

The  quantitative  estimation  of  the  ammonia  is  of  great  importance, 
since  it  permits  conclusions  in  regard  to  the  approximate  amount  of  oxy- 
butyric  acid  which  is  excreted  at  the  same  time.  When  more  than  2  grammes 
of  ammonia  are  excreted  in  twenty-four  hours,  there  is  danger  of  coma. 

It  is  to  be  remembered  that  the  glycuronates,  which  sometimes  precede 
the  excretion  of  sugar  and  are  frequently  associated  with  sugar  in  the 
urine,  reduce  alkaline  copper  solutions  but  do  not  ferment,  and  that  the 
homogentisic  acid  of  alkaptonuria  reacts  to  the  copper  tests  but  not  to 
Nylander's  bismuth  test,  nor  to  fermentation.  The  fermentation  test  is 
the  most  reliable  single  test,  but  must,  in  doubtful  cases,  be  controlled  by 
other  tests,  since  the  yeast  sometimes  contains  sugar. 

Differential  Diagnosis.  —  N on-diabetic  Glycosuria.  (a)  Transient 
Glycosuria. — In  rare  instances  this  condition  follows  concussion  of  the 
brain,  cerebral  apoplexy,  severe  neuralgias,  and  profound  depressing 
emotion.  The  sugar  is  present  usually  for  a  few  hours,  in  some  instances 
for  a  few  days,  and  shows  no  tendency  to  recur. 

Under  this  heading  must  also  be  grouped  the  acvite  forms  of  glycosuria, 
lasting  but  a  few  hours,  which  accompany  poisoning  by  morphine,  amyl 
nitrite,  carbonic  oxide,  chloralamide,  and  nitrobenzole;   the  rare  glycosuria 


920  MEDICAL  DIAGNOSIS. 

noted  in  biliary  coliC;  and  that  observed  in  hydrocyanic  poisoning.  Phlorid- 
zin  Poisoning;  Renal  Glycosuria. — The  sugar  is  present  so  long  as  the  admin- 
istration of  phloridzin  is  continued,  alike  when  carbohydrates  have  been 
ingested,  or  the  animal  is  fed  upon  a  proteid  diet  or  is  fasting. 

(b)  Intermittent  Glycosuria. — This  condition  occasionally  occurs  in 
gouty  persons  and  in  the  non-gouty  as  the  precursor  of  diabetes.  The 
assimilation  limit  for  carbohydrates  may  be  determined  by  the  administra- 
tion of  100  grammes  of  glucose  in  solution,  two  hours  after  a  breakfast  of 
a  roll  and  butter  with  coffee,  during  a  period  in  which  glycosuria  is  absent. 
This  amount  of  sugar  should  not,  in  a  healthy  person,  cause  glycosuria. 
The  excretion  of  sugar  indicates  a  fault  in  the  storage  or  metabolism  of 
the  carbohydrates.  Many  cases  of  diabetes  mellitus  begin  as  intermittent 
glycosuria. 

(c)  Alimentary  Glycosuria. — The  limit  of  assimilation  for  glucose  in 
the  healthy  subject  varies  from  120  to  200  grammes  in  a  single  dose.  If 
this  be  exceeded  glycosuria  occurs,  but  only  a  portion  of  the  quantity 
ingested  appears  in  the  urine,  the  remainder  being  stored  as  glycogen  in 
the  liver  and  muscles  for  future  use.  The  limit  for  cane  sugar  is  about  the 
same,  that  for  milk  sugar  rhuch  lower,  and  for  maltose  in  many  individuals 
very  low.  It  is  stated  by  Von  Noorden  that  in  some  persons  half  a  litre 
of  beer  is  sufficient  to  give  rise  to  sugar  in  the  urine  and  that  this  fact 
should  be  known  to  avoid  the  danger  of  mistaking  a  harmless  symptom 
for  a  serious  disease. 

(d)  Malingering. — Persons  have  been  known  to  feign  diabetes  by 
dissolving  sugar  in  the  urine.  The  specific  gravity  is  high  and  the  reactions 
those  of  cane  sugar;  but  verj^  well-informed  patients  may  use  glucose  for 
this  purpose.    The  fraud  is,  however,  easy  of  detection. 

(e)  Glycosuria  in  Pregnancy  and  the  Lying-in  State.- — Sugar  occurs 
under  two  circumstances:  First,  the  pregnant  woman  may  have  been 
diabetic  before  conception  or  may  have  become  so  during  pregnancy.  The 
reactions  are  those  of  grape-sugar  and  the  significance  is  unfavorable; 
secondly,  milk  sugar  may  be  resorbecl  from  the  breasts  and  excreted  by 
the  kidneys.  This  occurs  when  there  is  a  hypersecretion  of  milk  or,  for 
some  reason,  such  as  fissure  of  the  nipple  or  the  removal  of  the  child,  there 
is  an  interruption  of  its  withdrawal.  The  reactions  are  those  of  lactose 
and  the  prognosis  is  favorable,  the  sugar  disappearing  as  the  secretion  of 
milk  is  arrested.     The  condition  is  not  glycosuria  but  puerperal  lactosuria. 

Prognosis. — The  dangers  of  diabetes  consist  in  lowered  nutrition, 
diminished  powers  of  resistance  to  intercurrent  diseases,  inflammatory 
and  chronic  degenerative  processes,  and,  in  the  severe  cases,  an  abnormal 
production  of  acids. 

Favorable  prognostic  indications  are  onset  or  recognition  of  the 
disease  at  an  advanced  period  of  life,  absence  of  emaciation,  the  gouty 
habit  of  body,  the  occurrence  in  the  patient's  family  of  other  cases  running 
a  mild  course,  slight  glycosuria,  and  tolerance  for  moderate  amounts  of 
carbohydrates.  The  prognosis  is  unfavorable  when  the  disease  begins  at 
an  early  age  and  when  other  cases  of  severe  type  have  occurred  in  the 
patient's  family.  Rapid  emaciation,  grave  intercurrent  affections  or  com- 
plications, intense  glycosuria,  and   intolerance   for  carbohydrates   are  of 


DIABETES.  921 

ominous  prognosis.  The  patient's  circumstances  and  ability  to  avail  him- 
self of  favorable  personal  influences,  such  as  the  avoidance  of  overwork 
and  worry,  are  very  important.  Finally,  the  excretion  of  ammonia  in 
large  amounts  and  the  presence  of  the  acetone  bodies  in  the  urine  are  of 
immediate  gravity,  because  they  are  the  common  heralds  of  coma. 

B.  Diabetes  Insipidus. 

Definition. — A  chronic  disease  characterized  by  great  thirst  and  the 
habitual  discharge  of  excessive  quantities  of  urine  of  low  specific  gravity. 

This  affection  is  a  primary  or  idiopathic  disease  and  is  to  be  differen- 
tiated from  the  transient  or  persistent  hypersecretion  of  urine,  which  is 
symptomatic  of  certain  forms  of  chronic  Bright's  disease  and  some  affec- 
tions of  the  nervous  system. 

Etiology. — -Predisposing  Influences. — Heredity  exerts  an  impor- 
tant influence.  Cases  have  been  known  to  occur  in  four  generations.  The 
disease  is  sometimes  congenital.  There  is  very  often  a  history  of  chronic 
disease  on  the  part  of  the  parents  of  the  patient.  Diabetes,  ?'enal  affections, 
pulmonary  phthisis,  gout,  and  rheumatism  have  been  noted.  Diabetes 
insipidus  most  commonly  develops  in  early  life.  It  is  relatively  frequent 
in  young  children  and  rarely  begins  after  thirty.  It  is  more  common  in 
males  than  in  females. 

Exciting  Cause. — The  actual  cause  is  unknown.  The  disease  usually 
develops  insidiousl}^  without  assignable  cause.  It  has  in  some  instances 
been  attributed  to  excessive  quantities  of  water  or  beer,  and  has  followed 
an  acute  infectious  disease,  especially  influenza.  In  young  children  malnu- 
trition arising  from  neglect,  insufficient  food,  and  constitutional  taint 
have  been  assigned  as  a  cause;  in  older  persons  acquired  syphilis,  alcohol- 
ism, worry,  anxiety,  and  prolonged  exposure  to  cold. 

Symptoms. — The  two  symptoms  which  are  characteristic  are  an 
excessive  quantity  of  urine  without  sugar,  and  intense  thirst. 

The  Urine. — The  quantity  voided  is  enormous.  It  often  reaches 
twenty  or  thirty  pints  in  twenty-four  hours.  Fifty-six  pints  have  been 
noted.  It  may  even  at  times  exceed  the  fluid  ingested,  the  difference 
being  made  up  of  fluid  withdrawn  from  the  tissues  of  the  body  and  the 
food.  It  is  pale  in  color  and  limpid,  the  specific  gravity  varying  between 
1.001  and  1.007.  The  reaction  is  faintl}^  acid  or  neutral.  The  total  urinary 
solids  are  increased  by  one-fourth  or  one-third.  Inosite — muscle  sugar — 
is  occasionally  present  in  small  amounts.  Albumin  is  usually  absent  until 
late  and  grape-sugar  is  occasionally  present  toward  the  close,  when  the  symp- 
toms of  diabetes  mellitus  sometimes  occur.  Thirst. — This  symptom  is 
proportionate  to  the  quantity  of  urine.  As  much  as  fifty  pints  of  fluid 
have  been  consumed  by  a  patient  in  the  course  of  a  day.  There  is  usually 
a  remarkable  thirst  for  alcoholic  beverages.  Bulimia. — The  appetite  is 
usually  enormous  and  the  digestion  well  performed.  These  conditions 
fail,  however,  in  the  terminal  dyscrasia,  when  there  may  be  complete 
anorexia,  flatulence,  and  unmanageable  diarrhoea.  The  patients  are  often 
well  nourished  and  healthy-looking  for  years,  the  main  troubles  being 
unquenchable   thirst   and   frequent   micturition.      Emaciation  is   an   early 


922  MEDICAL  DIAGNOSIS. 

symptom  and  becomes,  toward  the  last,  extreme.  The  sahva  is  scanty, 
the  mouth  dry,  perspiration  sHght,  and  the  skin  dry  and  harsh. 

Diagnosis. — Direct. — Extreme  thirst,  excessive  habitual  secretion 
of  non-saccharine  urine  of  low  specific  gravit}^,  and  emaciation  justify  the 
diagnosis  of  diabetes  insipidus. 

Differential. — The  distinction  between  the  idiopathic  disease  and 
S5^mptomatic  polyuria  is  extremely  important.  The  following  forms  of 
the  latter  are  to  be  considered:  Diabetes  Mellitus. — Persistent  glycosuria 
and  high  specific  gravity  are  important.  If  sugar  appears  in  diabetes  insip- 
idus it  is  usually  in  faint  traces  and  transitory.  To  this  statement  an  excep- 
tion must  be  made  in  regard  to  the  cases  in  which  diabetes  mellitus  consti- 
tutes a  terminal  condition.  Diseases  of  the  Nervous  System.. — Polyuria  is  a 
conspicuous  symptom  in  certain  cases  of  brain  tumor,  lesions  of  the  medulla, 
and  intracranial  hemorrhage.  It  occurs  also  with  some  frequency  in  cere- 
bral syphilis  and  has  been  observed  in  lesions  of  the  cord.  Hysterical 
Polyuria. — Copious,  limpid  urine  of  low  specific  gravit}^  may  simulate 
diabetes  insipidus.  The  condition  is  transitory  and  the  characteristic 
features  of  hysteria  render  the  diagnosis  a  simple  matter.  Contracted 
Kidney. — There  is  frequently  a  large  amount  of  urine  of  low  specific  gravity. 
Albumin  is  at  times  absent.  It  is,  however,  much  more  commonly  present 
in  association  with  granular  and  hyaline  casts.  The  signs  of  arteriosclerosis 
and  cardiac  hypertrophy  are  important.  Polyuria  in  Abdominal  Diseases. — 
This  symptom  is  sometimes  prominent  in  tuberculous  peritonitis,  aneurism 
of  the  abdominal  aorta  or  iliac  arteries,  tumors  of  various  kinds,  and  espe- 
cially malignant  new  growths.  Hydronephrosis. — The  periodical  discharge 
of  large  quantities  of  urine  in  connection  with  the  subsidence  of  fluctuating 
abdominal  tumor,  which  slowly  reforms  during  the  intervals,  is  of  positive 
diagnostic  significance.  Intercurrent  Polyuria  in  Enteric  Fever. — I  have 
reported  a  case  of  excessive  urinary  discharge,  reaching  a  maximum  of 
six  litres  in  twenty-four  hours,  with  slight  increase  of  total  urinary  solids, 
occurring  during  the  course  of  an  otherwise  mild  attack  of  enteric  fever, 
with  disappearance  of  the  polyuria  upon  convalescence.  Other  similar 
cases  have  been  observed.  Malingering. — Water  may  be  added  to  the 
urine,  but  the  absence  of  thirst,  bulimia,  and  emaciation  would  lead  to  a 
suspicion  of  fraud  which  may  be  readily  exposed  upon  investigation. 

Prognosis. — The  course  of  diabetes  insipidus  is  extremely  variable. 
It  may  be  acute  and  rapid,  or  continue  for  many  years  with  but  slight 
deterioration  of  the  general  health.  Recovery  may  occur  and  spontaneous 
cures  have  been  noted.  Death  commonly  results  from  some  intercurrent 
affection. 

V.   NUTRITIONAL  DISEASES. 
A.  Scurvy. 

Scorbutus. 

Definition. — A  nutritional  disease,  due  mainly  to  improper  food, 
and  characterized  by  ansemia,  great  debiHty,  swollen  and  ulcerated  gums, 
and  subcutaneous,  submucous,  and  subperiosteal  hemorrhages. 


SCURVY.  .  923 

Etiology. — Predisposing  Influences. — Scurvy  is  a  disease  of  unsan- 
itary conditions  and  has  occurred  in  all  parts  of  the  world  in  which  such 
conditions  prevail.  It  has  been  known  from  the  earliest  historical  periods 
a,nd  has  been  the  scourge  of  armies  in  the  field,  soldiers  and  sailors  on  long 
voyages,  and  the  peoples  of  beleaguered  cities.  This  disease  may  occur 
in  any  climate,  but  is  more  common  in  northern  climates  and  cold  countries. 
It  is  more  frequent  in  cold  weather  than  in  warm,  in  rigorous  winters  than 
in  mild,  and  in  periods  of  famine.  Among  adults  males  suffer  more  fre- 
quently than  females,  and  more  severely.  In  besieged  cities  where  the 
conditions  affecting  the  sexes  have  been  very  similar,  the  proportion  of  men 
affected  has  exceeded  that  of  women.  It  is  most  common  in  adult  life,  but 
affects  children  and  the  aged.  A  special  form  is  known  as  infantile  scurvy. 
Malaria,  syphilis,  dysentery,  alcoholism,  defective  teeth,  and  gastro-intes- 
tinal  disorders  constitute  predisposing  influences  of  recognized  importance. 
Anxiety,  prolonged  fear,  nervous  depression,  and  nostalgia  play  an  impor- 
tant part  in  the  predisposition  to  the  disease,  but  are  incapable  of  causing  it. 

P.'^THOGENESis. — There  are  four  hypotheses  as  to  the  essential  cause 
of  the  disease: 

1.  That  it  is  due  to  the  absence  in  the  food  of  certain  substances 
present  in  fresh  vegetables.  The  nature  of  these  substances  has  not  been 
positively  determined.  They  have  been  thought  to  be  various  organic 
salts  present  in  fruits  and  vegetables;  or  the  potassium  salts  (Garrod). 
According  to  Ralfe  the  lacking  substances  are  the  malates,  citrates,  and 
lactates,  from  which  are  derived  the  carbonates  upon  which  the  alkalinity 
of  the  blood  depends.  This  view  appears  to  be  disproved  by  the  fact  that 
scurvy  does  not  prevail  among  the  Esquimaux,  who  live  exclusively  upon 
animal  foods  and  fats  which  are  often  tainted,  and  that  of  Nansen  and 
other  Arctic  explorers  who,  living  for  months  upon  a  similar  diet  in  most 
unhygienic  surroundings,  escaped  the  disease. 

2.  That  it  is  due  to  toxic  substances  of  unknown  character,  products 
of  decomposition,  in  the  food. 

3.  That  it  is  essentially  a  toxaemia,  resulting  from  the  absorption  of 
poisonous  substances  from  the  gastro-intestinal  tract,  produced  by 
microorganisms  in  the  intestinal  contents. 

4.  That  it  is  an  infection  depending  upon  an  unknown  specific  micro- 
organism, for  which  depressing  influences,  unsanitary  conditions,  and 
improper  food  prepare  the  soil. 

It  is  to  be  noted  that  prolonged  insufficiency  of  food — starvation — on 
the  one  hand  does  not  necessarily  result  in  scurvy,  and  that,  upon  the 
other,  the  disease  may  occur  with  an  abundant  diet  of  improper  and 
monotonous  food. 

Symptoms. — Scurvy  occurs  as  an  epidemic,  endemic,  and  sporadic 
disease.  Sporadic  cases  are  often  encountered  in  prisons,  almshouses, 
hospitals,  and  other  similar  institutions,  and  occasionally  among  well-to-do 
persons  in  private  life,  who,  as  a  matter  of  fancy,  or  for  some  other  reason, 
have  lived  for  a  long  period  upon  a  restricted  and  unvaried  diet.  In  the 
United  States,  where  scurvy  is  at  present  a  rare  disease,  these  sporadic 
cases  are  often  unrecognized.  The  disease  is  insidious  in  its  development. 
It  may  be  subacute  or  chronic.     In  very  rare  cases  the  onset  is  abrupt. 


924  MEDICAL  DIAGNOSIS. 

The  course  in  ordinary  cases  is  progressive  and  attended  by  fluctuations 
in  the  intensity  of  the  symptoms.  The  earh^  manifestations  consist  of 
weakness,  pallor,  and  loss  of  weight.  The  gums  become  swollen,  spongy, 
and  ulcerated.  Sometimes  they  show  the  continuous  oozing  of  blood. 
The  teeth  are  loosened  and  frequentlj^  fall  out.  The  tongue  is  enlarged, 
red,  and  frequently  heavily  coated.  Submucous  hemorrhages  in  the  mouth 
occur  and  the  breath  is  disgustingly  fetid.  The  skin  becomes  dry  and 
harsh  and  petechise  appear  in  and  around  the  hair-follicles,  at  first  upon 
the  legs  and  later  upon  the  arms  and  trunk.  Subperiosteal  extravasations 
upon  the  legs  often  give  rise  to  painful  nodes,  which  sometimes  break 
down  and  form  deep  ulcerations.  Subcutaneous  hemorrhages  occur  at 
points  of  injury  or  pressure,  and  brawny  indurations  occur  in  the  subcu- 
taneous tissues,  with  discoloration  of  the  overlying  skin.  Epistaxis  is 
common  and  free  bleeding  from  other  mucous  surfaces  takes  place  in  the 
graver  cases.  Hemorrhagic  infarcts  in  the  lungs  and  spleen  with  character- 
istic symptoms  may  be  noted.  Feeble  action  of  the  heart  with  arrhythmia 
and  palpitation  are  frequent  and  there  is  often  a  basic  sj^stolic  murmur. 
There  is  anorexia  and  inability  to  masticate  food  owing  to  the  condition 
of  the  gums.  Constipation  is  the  rule.  Arthritis  has  been  noted.  The 
urine  is  albuminous.  Urea  is  diminished.  The  other  constituents  show 
inconstant  changes.  Mental  depression  and  languor  are  common.  Delirium 
and  coma  occur  as  terminal  events.  Subconjunctival  and  intra-ocular 
hemorrhages  are  of  common  occurrence  and  hemeralopia  and  nyctalopia 
are  occasional  symptoms.  Fever  is  not  usual,  but  pyrexia  of  irregular 
type  may  occur  in  the  presence  of  complications,  such  as  pleurisy,  peri- 
carditis, or  abscess  formation. 

Complications  and  Sequels. — Abscesses,  inflammation  of  the  serous 
sacs  with  hemorrhagic  effusion,  croupous  pneumonia  and  bronchopneu- 
monia, pulmonary  gangrene,  and  pulmonary  oedema  as  terminal  events 
constitute  the  most  serious  complications.  Gastro-intestinal  complications 
are  common.  Ankjdosis  of  joints  that  have  been  inflamed,  particularly 
the  elbow,  knee,  and  ankle,  may  cause  permanent  deformity, 

Diagnosis. — The  dikect  diagnosis  in  the  epidemic  and  endemic 
disease  is  unattended  with  difficulty.  The  surroundings  and  circumstances 
of  the  patient,  the  condition  of  the  gums,  the  petechias  and  ecchymoses, 
the  languor  and  anaemia,  the  nodes  due  to  subperiosteal  bleeding,  and  the 
results  of  dietetic  and  hygienic  treatment  establish  the  nature  of  the  disease. 

Differential  DiAGNOSis.-^The  diagnosis  in  sporadic  cases  may 
be  difficult,  especially  in  persons  living  in  affluence  in  whom  errors  of  diet 
and  unhygienic  surroundings  are  unsuspected.  The  foregoing  diagnostic 
criteria  are  important.  The  lesions  of  the  gums  are  absent  in  early  infancy 
prior  to  dentition,  and  in  aged  persons  who  have  lost  their  teeth.  Peri- 
carditis and  pleural  effusion  of  scorbutic  origin  may,  in  the  absence  of  the 
lesions  of  the  gums  and  subcutaneous  hemorrhages,  give  rise  to  serious 
diagnostic  difficult3\  The  anamnesis,  the  evidences  of  deep-seated  hemor- 
rhages, and  the  results  of  treatment  are  important.  Puryura. — The  various 
forms  of  purpura  differ  from  scurvy  in  their  causal  relations,  the  absence 
of  the  peculiar  lesions  of  the  gums,  and  the  absence  of  the  deeper-seated 
hemorrhages. 


INFANTILE  SCURVY.  925 

Therapeutic  Diagnosis. — An  abundance  of  fresh  vegetables  and 
meat,  such  as  constitutes  an  ordinary  wholesome  mixed  diet,  is  visually 
followed  by  a  remarkable  disappearance  of  the  symptoms,  even  in  cases 
of  great  severity.  The  articles  of  diet  which  have  the  reputation  of  being 
especially  valuable  comprise  potatoes,  lettuce,  cabbage,  spinach,  and 
fresh  fruits  and  fruit  juices,  as  lemon  and  lime  juice.  From  the  time  that 
the  regulations  of  the  Board  of  Trade  have  required  that  a  sufficient  quantity 
of  such  articles  be  included  in  ships'  supplies,  the  occurrence  of  scurvy 
among  sailors  has  become  a  rare  event. 

Prognosis. — The  cases  are  apt  to  recover  unless  the  causal  conditions 
persist  or  they  are  far  advanced  when  treatment  is  begun.  This  disease 
is  now  infrequent  and  the  mortality  low.  Death  results  from  progressive 
inanition,  sudden  syncope,  large  serous  effusions,  pneumonia,  pulmonary 
cedema,  meningeal  hemorrhage,  or  sepsis. 

B.  Infantile  Scurvy. 

Barlow's  Disease. 

Definition. — A  nutritional  disease  of  young  infants,  due  to  improper 
food  and  characterized  by  subperiosteal  hemorrhages,  particularly  in  the 
lower  extremities,  a  form  of  pseudoparalysis,  and  a  cachectic  condition. 
Our  knowledge  of  this  disease,  which  was  formerly  confounded  with  rickets 
and  infantile  syphilis,  is  of  comparatively  recent  origin  (1881-83). 

Etiology.  —  Predisposing  Influences.  —  Infantile  scurvy  is  more 
common  among  the  well-to-do  than  among  the  poor,  a  condition  to  be 
explained,  first,  by  the  fact  that  the  children  of  the  former  are  more  com- 
monly fed  upon  artificial  foods,  and  second,  that  among  the  latter  the 
child  has  at  an  early  age  a  more  varied  diet,  into  which  enter  to  some 
extent  articles  of  ordinary  table  food  quite  unknown  to  children  of  the 
same  period  among  the  affluent.  Scurvy  begins  most  commonly  between 
the  sixth  and  eighteenth  months.  It  is  rare  earlier,  but  has  been  observed 
as  late  as  the  fifth  year.  Rheumatism,  syphilis,  and  rickets  have  been 
supposed  to  bear  a  causal  relation  to  infantile  scurvy.  Of  these  the  first 
two  have  nothing  to  do  with  the  disease  in  question  and  the  last,  though 
sometimes  associated  with  it,  is  wholly  different  in  its  etiology,  pathology, 
and  symptomatology,  and  when  present  in  the  same  individual  persists 
when  the  scorbutic  symptoms  have  disappeared. 

The  Immediate  Cause. — Improper  diet  is  the  cause  of  this  disease. 
The  various  commercial  foods,  including  condensed  milk  (especially  when 
prepared  with  water),  sterilized  milk,  and  other  artificial  foods  (particularly 
when  administered  in  unvarying  monotonj^),  are  found  to  have  consti- 
tuted the  diet  in  almost  every  case  for  a  considerable  period  prior  to  the 
manifestation  of  the  symptoms. 

Symptoms.  —  The  disease  shows  itself  as  an  insidiously  developing 
cachexia.  The  child  is  fretful  and  peevish.  It  lies  quiet  when  undisturbed, 
with  its  thighs  and  legs  strongly  flexed,  but  screams  when  any  attemjit 
is  made  to  extend  them.  Obscure  swellings  due  to  subpei-iosteal  hemor- 
rhages mav  be  observed  on  both  lower  extremities  but  i\\e\  are  not  svm- 


926  MEDICAL  DIAGNOSIS. 

metrical.  These  ill-defined,  tumor-like  prominences  occupy  the  lower 
ends  of  the  femurs,  the  tibiae,  and  less  frequently  the  bones  of  the  forearms. 
They  are  most  marked  just  above  the  epiphyseal  junction  and  extend 
along  the  shafts  of  the  bones.  Similar  swellings  may  sometimes  be  found, 
upon  the  scapulae.  The  overlying  tissues  are  boggy  and  slightly  cedema- 
tous  and  the  skin  is  somewhat  tense.  As  the  disease  progresses  the  whole 
limb  becomes  thickened.  Presently  the  limbs  assume  a  different  position, 
being  no  longer  drawn  up,  but  everted  and  motionless — 'pseudoparalysis. 
The  joints  are  not  involved.  Separation  of  the  epiphyses  and  fracture 
may  occur  in  severe  cases,  these  lesions  being  manifest  by  crepitus  and 
further  deformity.  Barlow  described  a  remarkable  depression  of  the 
sternum  and  costal  cartilages.  Proptosis  of  the  eyeballs,  more  marked 
upon  one  side  than  the  other,  with  oedema  and  slight  discoloration  of  the 
eyelids,  may  occur  in  advanced  cases.  Petechiae  occur,  but  are  much  less 
conspicuous  than  in  the  scurvy  of  adults,  but  hemorrhages  from  the  mucous 
surfaces  are  common.  Anaemia — 3,000,000  to  2,000,000  or  lower — is 
proportionate  to  the  severity  of  the  case.  The  white  corpuscles  show 
no  constant  changes.  The  color  of  the  skin  is  pallid  and  earthy; 
emaciation  is  not  a  marked  feature;  asthenia  is  extreme.  The  tempera- 
ture may  be  normal  or  slightly  subnormal,  with  occasional  transient 
rises  to  102°  or  more,  these  usually  accompanying  the  signs  of  fresh 
subperiosteal  hemorrhages.  If  the  teeth  have  appeared  the  gums  may 
be  swollen  and  spongy. 

Diagnosis. — Direct. — It  is  a  matter  of  surprise  that  the  true  character 
of  infantile  scurvy  is  so  often  overlooked.  Few  diseases  of  infants  present 
a  more  characteristic  symptom-complex  or  a  more  obvious  etiology.  The 
attitude,  the  behavior  of  the  child  upon  being  handled,  the  anaemia,  the 
elongated,  subperiosteal  nodes  and  thickening  of  the  limbs,  the  immobile, 
forced  flexion  of  the  limbs  in  the  early,  and  the  pseudoparalysis  in  the 
later,  course  of  the  af?"ection  are  diagnostic.  Proptosis  and  oedema  of  the 
eyeballs  are  significant. 

Differential. — Rickets. — The  gastro-intestinal  symptoms  are  more 
prominent  than  in  scurvy.  The  rachitic  rosary  and  the  lesions  of  the  bones 
are  characteristic.  The  boggy  swellings,  protrusion  of  the  eyeballs,  pe- 
techiae, and  spongy  gums  when  the  teeth  are  present  do  not  occur  in  rickets. 
The  two  diseases  may,  however,  be  associated.  The  forms  of  purpura 
resemble  scurvy  only  in  the  presence  of  petechial  and  other  hemorrhages, 
but  the  distribution  of  these  lesions  and  the  absence  of  all  else  character- 
istic of  the  latter  disease  render  the  diagnosis  an  easy  matter.  Infantile 
Paralysis. — The  pseudoparalysis  may  suggest  this  affection,  but  the  history 
of  the  case,  the  sudden  onset,  the  absence  of  pain,  tenderness,  and  the 
localized  swellings  are  diagnostic.  Syphilitic  Pseudoparalysis;  Parrofs 
Disease. — Sudden  loss  of  motion  in  the  lower  or  upper  limbs,  or  both, 
with  great  pain  on  passive  movement,  and  crepitus  due  to  a  separation  of 
the  epiphyses  may  present  a  superficial  resemblance  to  infantile  scurvy. 
This  resemblance  ceases  upon  a  proper  consideration  of  the  anamnesis 
and  the  lesions.  The  diagnostic  criteria  of  congenital  syphilis  are  usually 
unmistakable.  In  any  doubtful  case  an  etiological  diagnosis  based  upon 
the  nature  of  the  diet  will  be  helpful. 


RICKETS.  927 

Prognosis. — The  outlook  is  favorable  in  cases  early  recognized.  Com- 
plete recovery,  with  the  disappearance  of  the  lesions,  often  takes  place 
in  the  course  of  two  to  four  weeks  after  the  institution  of  a  proper  diet. 
More  advanced  cases  recover  more  slowly. 

C.  Rickets. 

Rhachitis. 

Definition. — A  disease  of  infants  due  to  improper  diet  and  character- 
ized by  impaired  nutrition  of  the  tissues  of  the  body  and  specific  alterations 
of  the  skeleton. 

Etiology. — Predisposing  Influences. — All  those  conditions  which 
involve  neglect  of  hygiene,  and  especially  of  alimentary  hygiene,  favor 
the  development  of  rickets.  The  geographical  distribution  of  this  disease 
is  wide.  It  abounds  in  great  cities  and  crowded  industrial  centres.  It  is 
more  common  in  Europe  than  America.  In  this  country  it  is  especially 
prevalent  among  the  children  of  recent  immigrants.  The  great  frequency 
of  rickets  among  the  children  in  the  Italian  and  negro  colonies  of  American 
cities  is  due  not  to  racial  but  to  social  conditions.  Rickets  affects  male 
and  female  children  to  the  same  extent  and  degree.  If  we  except  the 
rare  condition  known  as  fetal  rickets  —  achondroplasia,  chondrodystro- 
phia  foetalis — and  the  late  form  described  by  Jenner- — the  osteomalacia  of 
puberty — rickets  is  a  disease  of  the  first  two  years  of  life,  a  period  corre- 
sponding to  the  first  dentition.  It  rarely  begins  before  the  sixth  month 
or  after  the  third  year.  Rickets  is  especially  a  disease  of  poverty  and  all 
that  poverty  entails — want  of  sunlight  and  want  of  fresh  air,  neglect, 
j51th,  and  insufficient  and  improper  food.  Rickets,  like  scurvy,  occasionall)^ 
occurs  as  a  sporadic  disease  in  the  families  of  the  well-to-do.  Rickets  has 
been  looked  upon  as  a  manifestation  of  congenital  syphilis,  but  this  view 
has  been  abandoned  alike  upon  etiological  and  pathological  grounds.  A 
syphilitic  child  is  not  rhachitic,  though  it  may  acquire  rickets,  and  the 
two  conditions  frequently  coexist.  There  is  no  evidence  that  rickets  is 
hereditary.  The  endemic  and  epidemic  prevalence  of  the  disease,  under 
certain  social  conditions,  is  neither  evidence  of  its  hereditarj'-  nature  nor 
of  its  contagiousness,  as  has  been  assumed. 

The  Cause. — An  improper  diet  is  the  essential  cause  of  the  disease. 
Prolonged  lactation  and  suckling  the  child  after  pregnancy  has  occurred 
bring  the  rnilk  of  the  nursing  mother  within  the  category  of  improper 
food.  Cow's  milk,  foods  rich  in  starches,  condensed  milk,  and  the  various 
commercial  infant's  foods  are  responsible  for  a  large  proportion  of  the  cases. 
Deficiency  in  fat  and  proteids,  and  failure  in  the  assimilation  of  the  lime 
salts,  constitute  the  chief  alimentary  defects. 

The  Pathogenesis. — The  following  are  the  chief  h3'potheses:  (1) 
Rickets  is  a  manifestation  of  congenital  syphilis  (Parrot) ,  (2)  a  trophic 
disease  of  the  bones,  resulting  from  nervous  derangements;  (3)  an  infec- 
tion; (4)  a  disease  of  nutrition  due  to  faulty  alimentary  hygiene.  Of 
these,  the  last,  in  various  modified  forms,  is  the  view  now  generally 
maintained. 


928  MEDICAL  DIAGNOSIS. 

Symptoms. — Rickets  is  a  chronic  disease  of  insidious  onset,  beginning 
during  the  first  dentition  and  usually  before  the  child  begins  to  walk.  It 
is  preceded  by  digestive  disorders  of  varying  degree,  and  impaired  nutrition, 
but  not  necessarily  by  emaciation.  The  child  is  often  pallid,  plump,  and 
soft.  Slight  fever,  irritability,  and  poor  sleep  are  suggestive  symptoms. 
He  is  feeble  and  unsteady  on  his  feet  and  disinclined  to  walk.  There  is 
diffuse  tenderness  of  the  tissues  and  unwillingness  to  be  handled  or  touched. 
Free  sweating,  especially  about  the  head  and  neck,  is  common.  The  weak- 
ness of  the  muscles,  and  especially  in  the  legs,  is  suggestive  of  partial 
paralysis — pseudoparalysis  of  rickets.  The  skeletal  changes  appear  early 
in  the  course  of  the  disease  and  are  characteristic.  They  consist  of:  1.  The 
"rhachitic  rosary,"  composed  of  nodular  enlargements  of  the  ribs  at 
their  juncture  with  the  cartilages  on  both  sides.  These  enlargements 
may  be  readily  felt  upon  palpation  and  in  thin  children  may  be  recognized 
upon  inspection.     They  appear  early  and  gradually  increase  in  size  until 


Fig.  311. — Rickets.     Showing  the  epiphyseal  enlargements,  the  rosary,  the  distended  belly,  and  the  de- 
formities as  a  whole. — Pennsylvania  Hospital. 

some  time  in  the  second  year,  after  which  they  gradually  disappear.  2. 
Changes  in  the  Thorax. — Shallow  furrows,  corresponding  to  the  junc- 
tion of  the  cartilages  with  the  ribs,  pass  obhquely  downward  and  outward. 
A  similar  transverse  depression  extends  from  the  level  of  the  ensiform 
cartilage  toward  the  infra-axillary  space — Harrison's  groove.  The  sternum 
projects,  particularly  in  its  lower  half,  giving  rise  to  the  prominent  deform- 
ity known  as  chicken-  or  fig  eon-breast.  These  changes  in  the  contour  of 
the  chest  are  not  peculiar  to  rickets  and  may  occur  in  any  condition  habitu- 
ally interfering  with  inspiration  in  early  life.  3.  Changes  in  the  Head. — 
As  a  rule  the  head  appears  large,  the  frontal  and  parietal  eminences  are 
exaggerated,  and  the  fontanelles  remain  open  for  a  long  time.  The  fore- 
head is  prominent,  the  top  of  the  skull  flattened,  and,  in  some  cases,  the 
head  viewed  from  above  appears  square — caput  quadratum.  Craniofahes. — 
There  are  circumscribed  areas,  mostly  in  the  occipital,  parietal,  and  squa- 
mous portions  of  the  temporal  bones,  in  which,  in  consequence  of  decalcifica- 
tion, the  skull  may  yield  to  the  pressure  of  the  finger,  giving  rise  to  "  parch- 
ment crackling."  This  condition  has  been  observed  also  in  syphilis.  A 
systolic  murmur  may  frequently  be  heard  over  the  anterior  fontanelle  or 
in   the   temporal   region.     This   auscultatory   phenomenon   is   sometimes 


RICKETS. 


929 


heard  in  healthy  children.  The  bones  of  the  face  also  show  changes,  espe- 
cially in  the  maxilla;,  which  are  small  and  angular.  The  normal  course  of 
dentition  is  deranged  and  retarded.  The  first  teeth  may  not  appear  until 
some  time  in  the  second  year  and  undergo  caries  at  the  time  of  their  eru  ,- 
tion.  The  cephalic  changes  of  rickets  are  very  often  first  in  the  point  of 
time.  4.  Changes  in  the  Pelvis.  —  The  changes  in  the  pelvis  are 
of  especial  importance  in  female  children, 
since  they  lead  to  deformities  with  narrow- 
ing, which  interfere  with  natural  labor  and 
frequently  render  it  impossible.  5.  Changes 
IN  the  Extremities. — The  scapula?  are  not 
usually  affected.  The  clavicles  are  often 
thickened  at  the  sternal  ends  and  at  the  point 
of  insertion  of  the  sternocleido  muscles; 
their  curves  are  exaggerated  and  they  are 
shortened.  The  rhachitic  deformities  are 
most  conspicuous  in  the  long  bones.  They 
consist  of  enlargements  in  the  region  of  the 
junction  of  the  shaft  and  epiphysis,  and 
curvatures,  which  in  the  lower  extremities 
cause  a  corresponding  diminution  in  the 
height  of  the  individual.  The  enlargements 
in  the  upper  extremities  are  most  marked 
at  the  distal  ends  of  the  radius  and  ulna. 
To  a  less  degree  the  lower  end  of  the 
humerus  may  be  affected.  The  Rhachitic 
Hand. — Koplik  has  described  a  deformity 
of  the  hands  which  occurs  in  rickets,  con- 
sisting in  thickening  and  bowing  of  the  pha- 
langes of  the  fingers,  associated  with  laxity 
of  the  ligamentous  structures  of  the  phalan- 
geal joints.  The  changes  give  rise  to  a  some- 
what characteristic  appearance  of  elongation 
of  the  fingers  and  plumpness  of  the  whole 
hand.  They  have  been  observed  in  connec- 
tion with  the  ordinary  lesions  and  deformities 
of  well-marked  rickets.  In  cases  attended 
by  pains  in  the  bones  ''the  rhachitic  hand" 
may  suggest  syphilis,  but  the  association  of 
the  lesions  of  infantile  syphilis  renders  the 

differential  diagnosis  easy.  In  the  lower  extremities  the  lower  end  of  the 
tibia,  of  the  fibula,  and  of  the  femur  show  progressive  enlargements  propor- 
tionate to  the  severity  of  the  case.  If  the  child  walks,  the  femurs  are  curved 
forward  and  the  bones  of  the  legs  forward  and  outward.  Exceptionally 
the  curves  may  cause  the  deformity  known  as  knock-knee.  These  abnormal 
curvatures  are  due  to  the  muscular  traction  and  the  weight  of  the  body 
upon  the  decalcified  and  softened  bone. 

The  liver  is  enlarged;    the  spleen  enlarged  and  palpable.     There  is 
usually  more  or  less  flatulent  distention.     These  conditions  combine  to 
59 


Fig.   312. — The  skeleton  of  the  body 
shown  in  Fig.  311. 


930  MEDICAL  DIAGNOSIS. 

render  the  belly  large  and  protuberant,  a  condition  made  more  conspicu- 
ous by  the  relatively  small  size  of  the  thorax. 

The  urine  shows  no  constant  changes.  There  is  slight  ansemia;  the 
X.  ^moglobin  is  decreased;  leucocytosis  may  or  may  not  be  present.  The 
neivous  symptoms  increase  with  the  severity  of  the  other  symptoms. 
Convulsions  are  common.  Tetany  and  laryngismus  stridulus  are  occa- 
sional intercurrent  affections.  The  growth  of  the  child  is  greatly  retarded 
and  many  dwarfs  are  rhachitic. 

Diagnosis. — Direct. — Many  cases  are  so  slight  as  to  escape  recogni- 
tion. Weakness,  fretfulness,  pallor,  diffuse  soreness,  profuse  sweating  of 
the  head  during  sleep,  an  open  fontanelle,  and  irregular  evening  fever 
justify  a  provisional  diagnosis,  especially  when  defects  of  hygiene  and 
diet  exist.  When  to  these  symptoms  are  added  the  skeletal  changes  above 
described,  especially  those  which  first  appear,  namely,  the  rosary  and 
craniotabes,  it  becomes  positive. 

Prognosis. — The  slighter  forms  are  amenable  to  treatment  and  recovery 
takes  place  without  deformity.  The  graver  cases  recover  more  slowly  and 
with  lasting  skeletal  changes.  The  disease  is  essentially  chronic,  and,  though 
not  in  itself  fatal,  renders  the  patient  peculiarly  liable  to  intercurrent 
affections,  while  it  at  the  same  time  diminishes  the  powers  of  resistance. 

D.  Obesity. 

Definition. — An  excessive  development  of  fat. 

The  condition  is  not  always  pathological.  It  is  better  to  be  fat  and 
enjoy  a  normal  amount  of  health  and  vigor  than  to  reduce  the  fat  by  an 
unwise  and  rigorous  regimen  and  depleting  drugs,  and  become  an  invalid. 

Etiology. — Predisposing  Influences. — The  hereditary  tendency  to 
obesity  may  be  demonstrated  in  about  fifty  per  cent,  of  the  cases.  This 
tendency  may  be  manifest  in  childhood,  in  women  after  the  first  pregnancy, 
or  not  until  middle  life.  It  is  more  common  in  women  than  in  men.  Not 
alone  in  the  hereditary  cases,  but  also  in  those  in  which  the  tendency  is 
acquired,  is  the  condition  more  common  in  the  female.  There  is  a  manifest 
relation  between  sexual  inactivity  and  the  tendency  to  corpulence.  In 
males  the  tendency  to  accumulate  excessive  fat  frequently  begins  in  the 
fifth  decade  of  life;  in  females  at  puberty,  during  the  period  of  child- 
bearing,  and  at  the  grand  climacteric.  The  distribution  of  fat  varies  at 
different  periods  of  life.  In  infancy  and  childhood  the  undue  accumulation 
is  chiefly  subcutaneous;  in  middle  life  it  is  visceral  as  well  as  subcutaneous, 
while  in  the  aged  the  subcutaneous  fat  may  disappear  and  that  in  the 
omentum,  mesentery,  pericardium,  mediastinum,  and  around  the  kidneys 
persist.  Persons  of  phlegmatic  temperament,  given  to  repose  and  the 
pleasures  of  the  table,  are  more  disposed  to  obesity  than  those  who  are 
sanguine,  active,  and  self-denying. 

The  Actual  Causes. — In  general,  obesity  is  due  to  the  ingestion  of 
excessive  and  improper  food  and  an  indolent  and  inactive  life,  but  to  this 
statement  there  are  many  exceptions.  There  are  fat  persons  who  are 
small  eaters  and  exercise  constant  care  in  the  selection  of  their  diet,  and 
among  the  obese  are  to  be  found  men  of  superior  intelligence  and  energy. 


OBESITY.  931 

Fats,  starches,  and  sugars  taken  in  excess  cause  obesity.  The  habitual 
ingestion  of  large  quantities  of  fluids  and  the  abuse  of  alcohol  are  important 
etiological  factors. 

Symptoms. — Oertel  describes  a  plethoric  and  an  anaemic  form.  The 
first  is  more  common  in  men  who  are  high  livers  and  consume  much  beer. 
The  face  is  flushed,  the  subcutaneous  and  visceral  fat  are  increased,  but 
the  muscular  power  is  preserved  for  a  long  time.  The  second  is  especially 
encountered  in  chlorotic  girls  and  anaemic  women.  The  face  is  pallid,  the 
skin  white,  the  subcutaneous  fat  especially  abundant,  and  the  muscular 
power  feeble.  The  ankles  are  often  slightly  cedematous.  The  hands  and 
feet  long  remain  free  from  disfiguring  fat.  Both  types  are  too  familiar  to 
require  detailed  description. 

Diagnosis. — Direct. — The  recognition  of  obesity  is  a  matter  of  little 
difficulty.  The  contour  of  the  body  and  the  disproportion  between  the 
height  and  weight  of  the  individual  are  diagnostic.  More  difficulty  arises 
in  determining  the  line  at  which  normal  corpulence  proper  to  the  age, 
habits,  and  hereditary  peculiarities  of  the  individual  ends,  and  obesity 
with  its  inconveniences  and  dangers  begins.  This  can  only  be  done  by  a 
careful  study  of  individual  cases. 

Differential.  —  (Edema.  —  The  irregular,  doughy  masses  of  sub- 
cutaneous fat,  with  the  sharp  folds  of  the  skin  and  general  distribution 
which  characterize  obesity,  are  in  sharp  contrast  to  the  smooth,  tense, 
glistening  skin  of  anasarca,  with  its  tendency  to  accumulate  in  the  depend- 
ent tissues,  where  there  is  characteristic  pitting  upon  pressure.  Myxccdema. 
— The  dense  subcutaneous  infiltration,  symmetrical  and  of  moderate 
extent,  not  pitting  upon  pressure,  the  implication  of  the  hands,  the  pads, 
the  mental  state,  and  the  prompt  reaction  to  thyroid  medication  render  the 
diagnosis  clear.  Emphysema  of  the  S^ibcutaneous  Tissues. — This  rare  con- 
dition may  suggest  obesity,  but  the  history  of  the  case,  the  circumscription 
of  the  sweUing,  and  crackling  upon  palpation  are  characteristic. 

Prognosis. — The  outlook,  varying  with  the  causes,  degree,  symptoms, 
complications,  and  the  disposition  of  the  patient,  ranges  from  favorable 
to  positively  ominous.  It  is  less  favorable  in  the  hereditary  than  in  the 
acquired  form,  in  the  anaemic  than  in  the  plethoric,  and  in  the  cases  in 
which  feeble  action  of  the  heart,  arteriosclerosis,  gout,  albuminuria,  or 
diabetes  is  present.  Obese  persons  bear  intercurrent  febrile  infections 
badly  and  usually  make  a  tardy  and  unsatisfactory  convalescence  because 
of  the  slow  regeneration  of  red  blood-corpuscles  and  enfeebled  recupera- 
tive powers. 

Adiposis  Tuberosa  Simplex. — Under  this  term  Anders  has  described 
a  rare  condition  encountered  in  obese  persons,  characterized  by  the  presence 
of  circumscribed  masses  of  fat  in  the  subcutaneous  tissues,  particularly 
in  the  extremities  and  abdomen,  and  forming  distinct,  moderately  dense, 
slightly  movable,  somewhat  flattened  tumors  varying  in  size  from  a  bean 
to  a  hen's  egg  and  in  number  from  six  to  twenty-four  or  more.  These 
masses  are  not  elevated  above  the  surface  and  show  no  tendency  to  fuse 
together.  They  are  sensitive  to  palpation  and  are  sometimes,  but  not 
always,  the  seat  of  pain  of  variable  intensity.  The  overlying  skin  is  not 
adherent.    Their  etiology  is  not  clear,  but  their  relationship  to  corpulency 


932  MEDICAL  DIAGNOSIS. 

is  manifest  from  the  fact  that  they  disappear  as  that  condition  is  reduced 
under  treatment.  Adiposis  tuberosa  simplex  is  to  be  distinguished  from; 
(1)  Adiposis  dolorosa — Dercu77i's  disease — which  is  not  amenable  to  treat- 
ment, and  in  which  definite  changes  in  the  thyroid  gland  and  the  pituitary 
body,  together  with  extensive  interstitial  neuritis  and  degeneration  of  the 
columns  of  Goll,  have  been  found  post  mortem.  (2)  Lipomata. — Fatty 
tumors  which  are  painless,  soft  and  doughy,  globular  in  shape,  often  lobu- 
lated,  usually  distinctly  elevated  above  the  surface,  and  which  occur 
independently  of  general  obesity  and  remain  uninfluenced  by  treatment. 
(3)  Adenolipomatosis,  in  which  fatty  accumulations  develop  in  relation 
with  the  lymph-nodes  of  the  neck,  axillae,  or  groins.  These  fat  masses 
are  symmetrical  in  distribution  and  occur  in  various  chronic  constitutional 
diseases,  and  only  rarely  are  associated  with  general  obesity.  In  fact, 
they  may  persist  when,  in  consequence  of  the  progress  of  the  associated 
malady,  emaciation  has  occurred  or  cachexia  developed. 

Adiposis  Dolorosa. — Definition. — Dercum  first  called  attention  to 
"  a  disorder  characterized  by  irregular,  symmetrical  deposits  of  fatty 
masses  in  various  portions  of  the  body,  preceded  by  or  attended  with  pain." 

The  disease  occurs  chiefly  but  not  exclusively  in  women  at  middle 
life.  Neuralgic  pains  precede  and  accompany  the  disorder.  Irregular 
hyperaesthesia  and  parsesthesia  occur.  Fatty  masses,  sometimes  of  enor- 
mous size,  lumpy,  soft,  and  pendulous,  form  at  various  points  of  the  body, 
in  association  with  a  general  great  increase  of  the  subcutaneous  fat.  The 
face,  hands,  and  feet  are  not  affected.  Atrophy  of  the  thyroid  body  has 
been  noted  in  some  of  the  cases,  and  the  administration  of  thyroid  extract 
has  been  followed  by  relief  of  the  neuralgia  and  diminution  of  "the  fat. 
Lesions  of  the  pituitary  body  with  interstitial  neuritis  and  degeneration 
of  the  columns  of  Goll  have  also  been  found  post  mortem.  The  essential 
nature  of  the  trouble  is  unknown.  This  disease  differs  from  other  forms 
of  obesity  in  its  unknown  etiology,  the  distribution  of  the  fat  in  masses, 
and  the  presence  of  marked  nervous  symptoms,  especially  pain. 

VI.   AMYLOID  DISEASE. 

Lardaceous  Disease;   Waxy  or  Bacony  Infdtration;  Amyloidosis. 

Definition.  —  A  secondary  affection  in  suppuration  and  syphilis, 
characterized  by  the  formation  and  deposition  of  amyloid  material  or 
lardacein  in  the  walls  of  the  arteries  and  the  viscera. 

Pathologically,  lardaceous  disease  is  regarded  as  a  degenerative  change 
involving  certain  elements  in  the  blood  and  an  infiltration  in  the  tissues 
of  the  organs.  The  process  is  general  or  constitutional.  It  affects  no  par- 
ticular organ  locally,  but  many  organs  and  tissues  at  the  same  time,  though 
not  to  the  same  degree.  The  organs  commonly  affected  are,  in  the  order 
of  frequency,  the  kidney,  the  spleen,  the  liver,  the  intestines,  the  adrenals, 
and  the  lymph-glands.  The  pancreas,  thyroids,  testis,  oesophagus,  and 
endocardium  are  less  frequently  involved.  The  amyloid  material  is 
deposited  at  first  in  the  arterioles,  and  in  certain  anatomical  structures  or 
regions,  as  the  intermediate  or  hepatic  artery  zone  of  the  liver  lobule,  the 


AMYLOID  DISEASE.  933 

Malpighian  tufts  and  the  cortex  generally  in  the  kidney,  the  Malpighian 
bodies  in  the  spleen,  and  the  arterioles  in  the  mucous  membranes.  In 
many  of  the  cases  the  material  is  distributed  throughout  the  whole  of  the 
organ,  with  the  result  that  the  solid  viscera  are  increased  in  bulk,  sometimes 
to  an  enormous  extent.  This  increase  is  sometimes,  especially  in  the  kidney, 
followed  by  contraction. 

Etiology. — Suppuration,  chronic  or  recent,  with  or  without  discharge, 
is  present  in  the  great  majority  of  the  cases.  Pulmonary  tubercvdosis 
and  disease  of  bone  are  the  most  frequent  causes  of  suppuration  antecedent 
to  amyloid  disease.  Tuberculosis  without  suppuration  does  not  appear 
to  be  a  factor.  On  the  other  hand,  suppuration,  in  the  absence  of  tuber- 
culosis or  other  specific  constitutional  infection,  is  a  very  common  ante- 
cedent. Syphilis  without  purulent  lesions  must  be  recognized  as  a  cause. 
Malaria  is  a  possible  cause,  but  its  agency  is  still  in  question.  As  a  rule, 
the  suppuration  has  been  prolonged,  but  there  are  exceptions  to  this  rule. 
The  amyloid  process  develops  during  the  suppurative  process,  but  may 
not  cause  recognizable  clinical  manifestations  until  after  suppuration 
has  continued  for  years,  or  not  until  after  it  has  ceased.  Males  are  more 
liable  than  females,  not  because  of  any  differences  incident  to  sex,  but 
because  they  are  more  exposed  to  injuries  and  diseases  attended  by  purulent 
lesions,  and  to  syphilis.  The  predisposition  associated  with  age  is  shown 
by  the  rarity  of  amyloid  disease  before  ten  and  after  fifty.  It  is  most 
common  between  twenty  and  forty. 

Symptoms.  —  There  are  general  manifestations  of  amyloid  disease 
irrespective  of  the  visceral  changes.  The  suppurative  primary  diseases 
have  almost  always  produced  changes  that  are  characteristic,  or  at  least 
suggestive.  These  are  manifest  in  the  signs  of  advanced  phthisis,  the 
deformities  of  old  empyema  or  bone  disease,  especially  those  forms  which 
involve  the  spine  and  joints.  Since  such  processes  are  attended  with  wast- 
ing, the  pinched  features,  emaciated  frame,  and  shrunken  extremities  are 
highly  suggestive,  especially  as  they  are  associated  with  a  prominent  or 
enormously  distended  abdomen  due  to  the  overgrown  size  of  the  amyloid 
viscera.  A  muddy  pallor  of  the  skin,  dropsical  effusions  in  the  dependent 
parts,  diarrhoea,  polyuria,  thirst,  albuminuria,  and  great  weakness  complete 
the  picture.     The  onset  is  insidious. 

It  is  customary  to  describe  the  clinical  manifestations  of  amyloid 
disease  in  the  organs  in  connection  with  the  various  diseases  of  each;  it 
seems,  however,  more  appropriate  and  more  useful  for  the  purposes  of  the 
diagnostician  to  consider  them  here. 

1.  Amyloid  Kidney.  —  The  process  is  associated  with  wide-spread 
am5doid  degeneration  in  other  viscera  due  to  suppurative  diseases  or  syphi- 
lis. It  has  been  attributed  also  in  some  instances  to  leuksemia,  chronic 
lead  intoxication,  and  gout.  It  is  frequently  associated  with  the  chronic 
form  of  parenchymatous  nephritis.  The  kidney  is  usually  much  increased 
in  size;  in  exceptional  cases  it  does  not  exceed  the  normal  kidney  in  this 
respect.  The  surface  is  smooth  and  the  stellate  veins  are  conspicuous. 
The  organ  is  firm.  Upon  section  the  cortex  is  thickened,  the  glomeruli  dis- 
tinct, and  the  pyramids  of  a  deep  red  color.  The  iodine  test  shows  a  deep 
mahogany  color  most  marked  in  the  Malpighian  tufts  and  straight  vessels. 


934  MEDICAL  DIAGNOSIS. 

Symptoms. — There  are  urinary  features  of  importance.  The  quantity 
is  increased,  the  color  pale  and  transparent,  the  specific  gravity  low.  Albu- 
min is,  as  a  rule,  abundant;  exceptionally  there  is  a  mere  trace  or  it  may 
be  absent.  Hyaline,  fatty,  and  granular  tube-casts  are  present,  and  occa- 
sionally the  amyloid  color-reaction  may  be  obtained.  Dropsy  is  usually 
present,  but  there  are  cases  in  which  it  does  not  occur.  Diarrhoea  is  com- 
mon. Increased  arterial  tension,  cardiac  hypertrophy,  retinal  lesions, 
and  uraemia  do  not  occur  except  in  cases  of  amyloid  degeneration  affecting 
the  small  granular  kidney. 

Diagnosis. — The  renal  symptoms  alone  have  little  diagnostic  value. 
Their  development  in  connection  with  prolonged  suppuration  or  syphilis, 
and  in  association  with  an  enlarged  liver  and  spleen,  and  persistent  diar- 
rhoea, is  highly  suggestive. 

2.  Amyloid  Liver. — The  etiological  relations  of  this  condition  are  the 
same.  It  constitutes  an  important  visceral  manifestation  of  amyloid  disease. 
The  organ  is  large  and  may  attain  an  enormous  size.  It  is  firm,  dense,  and 
resistant.  Upon  section  the  surface  is  pale  and  presents  at  the  edges  a  slightly 
translucent  appearance.  It  responds  to  the  iodine  test  by  the  development 
of  a  mahogany-brown  color  in  the  affected  areas.  The  capsule  is  smooth  and 
the  borders  of  the  enlarged  organ  are  rounded  and  blunt.  Exceptionally  the 
margins  are  sharp  and  well-defined.    The  enlargement  is  commonly  uniform. 

Symptoms. — There  are  no  characteristic  hej^atic  features.  Jaundice 
does  not  occur.  The  stools  are  sometimes  light  but  not  clay-colored. 
There  are  no  signs  of  portal  obstruction.    The  spleen  is  often  enlarged. 

Diagnosis. — The  history  taken  in  connection  with  progressive  enlarge- 
ment of  the  liver  which,  upon  palpation,  yields  the  above  signs,  together 
with  enlarged  spleen,  polyuria  with  or  wdthout  albumin,  and  diarrhoea, 
constitutes  positive  evidence  of  the  presence  of  amyloid  disease. 

3.  Amyloid  Spleen. — The  organ  is  not  usually  greatly  enlarged  but 
can  be  readily  recognized  upon  palpation.  Its  edges  are  thick  and  rounded 
and  its  consistence  dense.  Upon  section  the  lardaceous  infiltration  is  seen 
to  affect  especially  the  Malpighian  bodies,  which  are  prominent  and  glisten- 
ing, giving  rise  to  the  appearance  described  as  "sago  spleen."  In  some 
cases  the  intervening  tissue  is  more  or  less  diffusely  affected. 

There  are  no  special  symptoms. 

Diagnosis. — A  history  of  suppuration  or  syphilis,  a  cachectic  state, 
emaciation,  prominent  abdomen  clue  to  coincident  enlargement  of  the 
liver,  urinary  changes,  and  diarrhoea  when  present  justify  the  assumption 
that  an  enlarged  spleen  is  amyloid. 

4.  Amyloid  Disease  of  the  Intestines. — The  blood-vessels  of  the  entire 
digestive  tract  may  be  affected.  More  commonly  the  small  intestine, 
especially  the  ileum,  or  the  colon  is  the  seat  of  the  disease. 

Symptoms. — When  slight  in  intensity  or  of  limited  extent  the  disease 
presents  no  features  by  which  it  can  be  recognized  clinically.  The  one 
symptom  of  advanced  or  extensive  amyloid  degeneration  in  the  intestines 
is  persistent  diarrhoea.  The  stools  are  variable  in  consistency  and  number. 
They  are  usually  thin  and  liquid  but  without  distinctive  characters.  Espe- 
cially are  they  not  bloody.  They  are  not  attended  by  colic  or  tenesmus 
and  the  abdomen  is  not  sensitive  to  pressure. 


GASTRITIS.  935 

Diagnosis. — The  recognition  of  the  disease  is  difficult  and  uncertain, 
since  diarrhoea  without  pain  and  tenderness  and  equally  intractable  may 
occur  in  various  other  intestinal  diseases.  The  association  of  this  symptom 
with  the  above-described  clinical  manifestations  in  a  person  suffering, 
or  who  has  suffered,  from  prolonged  suppuration,  or  who  has  syphilis, 
renders  it  in  the  highest  degree  probable  that  there  is  amyloid  disease  of 
the  gut. 

Prognosis  in  Amyloid  Disease. — The  outlook  is  doubly  unfavorable. 
The  antecedent  disease  is  a  frequent,  the  amyloid  disease  a  common, 
cause  of  death.  The  highest  mortality  among  the  visceral  forms  relates 
to  the  kidneys,  the  next  to  the  intestines.  Extensive  lardaceous  degen- 
eration of  the  liver  and  spleen  may  occur  without  special  symptoms  of 
importance,  and  without  great  impairment  of  health  in  addition  to 
that  caused  by  the  primary  disease. 


IX. 

THE    DIAGNOSIS    OF    THE    DISEASES    OF    THE 
DIGESTIVE    SYSTEM. 

(diseases  of  the   mouth,  tongue,  gums,  salivary  glands,   pharynx, 

TONSILS,    and    OSSOPHAGUS    ARE    CONSIDERED    IN    PART    III.) 

I.  DISEASES  OF  THE  STOMACH, 
i.  Acute  Gastritis. 

The  following  forms  are  recognized:  toxic,  phlegmonous,  diphtheritic, 
parasitic,  and  dietetic. 

1.  Toxic  Gastritis. — An  intense  form  of  inflammation  produced  by 
various  irritant  and  corrosive  poisons.  It  varies  in  degree  according  to 
the  nature,  concentration,  and  quantity  of  the  poison,  and  the  length  of 
time  it  has  remained  in  contact  with  the  gastric  mucosa. 

Symptoms. — Sudden  pain,  nausea,  retching,  and  vomiting  occur. 
The  vomitus  in  severe  cases  consists  of  blood-stained  food  remnants, 
mucus,  shreds  of  mucous  membrane,  and  the  poison  itself.  Thirst  and 
dysphagia  are  distressing.  Later  there  is  usually  diarrhoea.  Collapse 
comes  on  rapidly;  the  temperature,  at  first  subnormal,  rises  later;  and 
jaundice  is  not  uncommon.  Epigastric  and  abdominal  tenderness  may  be 
followed  by  the  signs  of  general  peritonitis.  Death  occurs  from  the  intoxi- 
cation, or  from  exhaustion,  convulsions,  or  suffocation.  When  recovery 
takes  place,  ulceration  with  stenoses  or  chronic  gastritis  supervene.  The 
direct  diagnosis  depends  upon  the  anamnesis,  the  evidences  of  the  corrod- 
ing poison  upon  the  lips,  mouth,  and  pharynx,-  the  odor  of  the  breath  in 
certain  cases,  the  presence  of  the  vial  or  package  which  contained  the 
poison,  the  analysis  of  the  vomitus,  the  analysis  of  the  urine,  and  the  fore- 
going associated  symptoms.     The  prognosis  is,  in  the  main,  unfavorable. 


936  MEDICAL  DIAGNOSIS. 

It  depends,  however,  upon  the  nature  of  the  poison,  its  amount,  the  time 
elapsing  before  its  removal  or  the  administration  of  antidotes,  the  direct 
damage  to  the  stomach  itself,  the  intensity  of  the  collapse,  and  the 
occurrence  of  peritonitis. 

2.  Phleg-monous  Gastritis. — Acute  diffuse  or  circumscribed  suppura- 
tive inflammation  of  the  gastric  submucosa. 

Etiology. — This  is  a  verj^  rare  affection.  The  cases  are  primary,  in 
which  alcohoUsm  appears  to  be  a  predisposing  influence,  and  trauma, 
faulty  diet,  and  various  irritant  poisons  the  exciting  causes;  and  secondary, 
in  which  the  various  general  febrile  infections,  sepsis,  and  peptic  or  car- 
cinomatous ulceration  constitute  the  primary  disease.  Streptococcus 
infection  is  most  common.  The  colon  bacillus  may  be  present.  Cases 
have  been  reported  at  evers^  period  of  life  between  ten  and  ninety.  Phleg- 
monous gastritis  is  four  times  as  common  in  males  as  in  females. 

Symptoms. — In  the  circumscribed  variety  the  symptoms  are  obscure. 
Pain  may  be  absent.  There  may  be  a  circumscribed  tumor  in  the  epigas- 
trium, and  vomiting  of  pus  and  blood.  In  the  diffuse  form  the  onset  is 
sudden,  -^ith  a  rigor,  severe  prostration,  and  a  rise  of  temperature  to  104°- 
105°  F.  (40°-40.5°  C).  Gastric  symptoms  speedily  supervene.  They 
consist  of  the  urgent  and  continuous  vomiting  of  pus,  mucus,  and  bile, 
epigastric  pain  and  tenderness,  and,  in  rare  instances,  the  signs  of  a 
fluctuating  tumor.  In  the  course  of  a  brief  period  general  abdominal 
tenderness,  meteorism,   and  other  signs  of  peritonitis   usually  appear. 

The  diagnosis  has  rarely  been  made  intra  vitam.  The  occurrence  of 
the  above  sj^mptoms  in  the  course  of  a  severe  general  infection  or  sepsis 
would  be  suggestive.  The  differential  diagnosis  concerns  perigastritis 
following  peptic  ulcer,  circumscribed  peritonitis,  acute  pancreatitis,  chole- 
cystitis, and  toxic  gastritis.  The  prognosis  is  in  the  highest  degree  unfavor- 
able.    Of  the  reported  cases  95  per  cent,  have  terminated  fatally. 

3.  Diphtheritic  Gastritis. — Pseudomembranous  inflammation  of  the 
gastric  mucosa  occurs  as  a  true  diphtheria  of  the  stomach  in  cases  of  inva- 
sion by  the  Klebs-Loffler  bacillus  in  diphtheria  of  the  cesophagus,  throat, 
or  upper  respiratory  passages,  but  it  is  a  very  rare  complication.  More 
commonly  it  occurs  as  a  complication  of  other  infectious  diseases,  as  enteric 
fever,  pneumonia,  the  exanthemata,  and  sepsis.  In  children  tuberculosis 
is  often  the  primary  infectious  disease.  A  condition  closely  resembling 
diphtheritic  gastritis  may  be  produced  by  corrosive  poisons.  The  char- 
acteristic lesion  is  the  presence  of  the  pseudomembrane,  which  may  be 
diffuse,  patchy,  or  arranged  in  irregular  streaks-  extending  from  the  cardia 
to  the  pylorus.  The  superficial  layer  is  formed  by  a  coagulation  necrosis. 
The  bacteriological  findings  vary.  Streptococci,  tubercle  bacilli,  and  Klebs- 
Loffler  bacilli  have  been  more  commonly  isolated.  The  symptoms  are  not 
characteristic.  Vomited  membrane  may  have  been  dislodged  from  the 
upper  air-passages,  or  the  pharynx  or  oesophagus.  The  diagnosis,  with  a 
very  few  exceptions,  has  not  been  made  during  life. 

4.  Parasitic  Gastritis. — Inflammation  of  the  stomach  as  the  result  of 
infection  by  various  pathogenic  organisms  by  way  of  the  blood  and  lymph 
stream — infectious  gastritis — is  of  common  occurrence.  This  form  occurs 
in  various  septic  conditions,  enteric  fever,  pneumonia,  and  the  exanthemata. 


GASTRITIS.  937 

The  presence  of  moulds  and  yeasts  in  lesions  of  the  gastric  mucosa  renders 
it  probable  that,  under  certain  circumstances,  those  agencies  may  cause 
or  aggravate  such  conditions  as  inflammation,  erosion,  and  ulceration. 
Among  the  growths  obtained  by  lavage  or  observed  post  mortem  are  mucor 
mycelia,  forms  of  leptothrix,  thread  fungi,  Oidium  lactis  and  albicans, 
favus,  and  Penicillium  glaucum.  The  symptoms  are  not  characteristic 
and  their  dependence  upon  the  presence  of  fungi  is  uncertain.  The  subject 
is  of  anatomical  rather  than  of  clinical  importance. 

5.  Dietetic  gastritis  is  of  common  occurrence  and  great  clinical 
importance. 

Etiology. — Individual  and  family  predisposition  are  common.  Gouty 
subjects  are  peculiarly  liable  to  subacute  and  acute  gastritis. 

The  exciting  causes  comprise  excesses  at  table,  highly  seasoned  foods, 
unwholesome,  indigestible,  or  tainted  articles  of  food,  large  amounts  of 
unduly  cold  or  hot  fluid,  and  alcohol. 

Symptoms. — Habitual  sensations  of  weight  and  gastric  distress  char- 
acterize the  subacute  forms.  The  more  acute  variety  is  associated  with 
colicky  pain,  distention,  fulness,  and  vomiting,  which  are  often  relieved  by 
removing  the  offending  material.  In  very  acute  cases  the  inflammation 
persists  with  the  pain,  colic,  and  hypersecretion  of  mucus  and  gastric  fluid. 
Under  such  circumstances  vomiting  does  not  always  afford  relief.  Bile 
frequently  appears  in  the  vomited  matter.  The  early  vomitus  may  contain 
undigested  food,  hydrochloric,  lactic,  and  butyric  acids,  and  have  a  butyric 
odor;  the  subsequent  vomitings  consist  principally  of  water  and  mucus 
and  are  of  a  light  green  color.  Diarrhoea  may  occur.  Only  in  very  severe 
cases  is  there  fever.  The  tongue  is  coated,  the  pulse  and  general  condition 
are  usually  good.  Improvement  commonly  takes  place  in  a  few  hours; 
occasionally  an  attack  lasts  two  or  three  days.  Slight  fulness  in  the  epigas- 
trium and  tenderness  on  pressure  over  the  stomach  are  common  in  severe 
cases.  Two  or  three  days  of  persistent  vomiting  may  be  followed  by 
retraction  of  the  abdomen. 

Diagnosis. — Direct. — Epigastric  pain,  nausea,  and  vomiting,  follow- 
ing or  referable  to  some  indiscretion  of  the  diet,  justify  a  diagnosis  of  simple 
acute  gastritis,  particularly  in  the  absence  of  fever  or  marked  general 
symptoms.  Fever,  rapid  pulse,  and  prostration,  with  persistent  vomiting, 
should  arouse  the  suspicion  of  an  acute  infection,  cholecystitis,  or  intes- 
tinal or  pyloric  obstruction. 

Differential. — If  associated  with  fever  at  the  onset,  acute  gastritis 
must  be  differentiated  from,  (a)  various  infections,  as  scarlet  fever,  menin- 
gitis. In  acute  gastritis  the  constitutional  symptoms  are  less  severe, 
there  is  absence  of  local  or  other  phenomena  peculiar  to  the  specific  infec- 
tions, less  intense  pyrexia,  and,  as  a  rule,  early  improvement,  (b)  Mild 
or  Abortive  Enteric  Fever. — Acute  gastritis  has  a  more  rapid  onset,  an  abrupt 
rise  of  temperature  rather  than  the  step-like  rise,  and  rose  spots,  bronchitis, 
enlarged  spleen,  and  diarrhoea  do  not  occur,  (c)  Severe  pain  may  suggest 
gall-stone  colic,  but  the  pain  is  usually  less  severe;  the  vomiting  and  pain 
of  gastritis  are  more  continuous;  chilliness  or  a  chill  does  not  occur;  and 
the  general  symptoms  are  less  pronounced.  Marked  icterus  is  absent, 
though  the  possibility  of  an  associated  duodenitis  with  catarrhal  jaundice 


938  MEDICAL  DIAGNOSIS. 

is  to  be  borne  in  mind,  (d)  Gastric  Crises  of  Locomotor  Ataxia. — The 
Argyll-Robertson  pupil,  ataxia,  and  loss  of  knee-jerks  are  distinctive.  If 
associated  with  persistent  vomiting,  acute  gastritis  must  be  differentiated 
from,  (e)  pyloric  obstruction  and  intestinal  obstruction.  In  both  of  these 
conditions  the  local  signs  are  apt  to  be  marked,  serious  general  symptoms 
are  present,  and  the  history  of  the  condition  is  different. 

ii.   Chronic  Gastritis. 

Chronic  Gastric  Catarrh. 

Definition.— Chronic  inflammation  of  the  gastric  mucosa,  giving  rise 
to  mucus  in  excess  and  alterations  in  the  gastric  juice,  associated  with 
marked  disturbance  of  the  digestion  and  weakening  of  the  muscular  coat. 

Etiology. — In  many  families  there  is  a  predisposition  to  chronic 
gastritis — chronic  dyspepsia.  Many  constitutional  diseases  act  as  pre- 
disposing factors.  Careless  habits  of  eating  and  drinking,  and  the  persistent 
use  of  gastric  irritants  are  the  chief  causes.  Chronic  congestion  of  the 
stomach,  the  result  of  heart  disease  or  hepatic  cirrhosis,  commonly  ends 
in  chronic  gastritis,  and  most  of  the  local  gastric  diseases,  as  cancer  and 
ulcer,  bring  about  the  same  condition. 

Symptoms. — Headache,  drowsiness,  dizziness,  inaptitude  for  work, 
and  sallow  complexion  are  common  general  symptoms.  A  coated  tongue, 
bad  taste  in  the  mouth,  aphthous  stomatitis,  chronic  pharyngitis  are  usually 
present.  A  variable  and  capricious  appetite,  occasional  repugnance  for 
food,  burning  sensations  in  the  oesophagus  and  at  the  cardiac  end  of  the 
stomach — heart-burn — are  early  symptoms.  Distress  and  weight  in  the 
stomach,  oppression,  distention,  and  actual  pain  (more  particularly  after 
meals),  belching  of  gas,  and  eructations  of  bitter  fluid  soon  occur  if  the 
condition  persists.  Nausea  may  be  an  early  symptom.  Vomiting  usually 
appears  late  and  occurs  soon  after  eating  or  in  the  morning  before  food. 
That  which  occurs  after  a  meal  contains  mucus  in  excess.  Undigested 
food,  indicating  retention,  fermentation  of  the  carbohydrates,  diminished 
amount  of  free  H CI  and  ferments  (or  none  at  all),  and  traces  of  lactic  and 
butyric  acids  are  characteristic  of  delayed  vomiting  in  rare  cases.  The 
vomitus  has  a  sour  odor.  That  occurring  early  in  the  day  is  composed  of 
small  amounts  of  thick  mucus. 

The  Ewald  test-breakfast  may  be  below  the  normal  amount,  or,  where 
dilatation  has  occurred,  it  may  be  in  excess.  At  times  it  is  brought  up  with 
difficulty  owing  to  the  thick  grayish  mucus.  The  toast  or  bread  may 
have  passed  out  of  the  stomach  completely,  or  it  may  remain  in  vary- 
ing amounts  mixed  with  mucus  and  poorly  minced.  Early  in  the  disease 
the  free  HCl  may  be  normal  in  amount  or  even  slightly  increased;  later  it 
is  diminished  or  absent.  Lactic  acid  is  not  usually  present.  Both  peptic 
digestion  and  the  milk-curdling  reaction  for  rennin  may  be  absent.  Further 
proof  of  muscular  weakness  and  excess  of  mucus  follows  the  washing  of 
the  stomach  after  the  removal  of  the  test-meal.  The  water  used  must 
often  be  removed  by  suction  or  siphonage  instead  of  gushing  back  as  is 
the  case  when  poured  into  a  normal  stomach.     It  contains  numerous  mucus 


DILATATION  OF  THE  STOMACH.  939 

flakes,  which  accumulate  in  a  stringy  mass  on  the  surface.  Inflation  often 
shows  dilatation  at  the  lower  border,  reaching  the  level  of  the  umbilicus. 

Differential  Diagnosis. — 1.  Ulcer  of  the  Stomach. — In  chronic  gastritis 
the  pain  is  less  intense  and  more  continuous,  less  aggravated  after  food, 
and  more  diffuse.  The  decline  in  general  health  is  less  marked  and  rapid, 
and  there  is  absence  of  haematemesis  or  blood  in  the  stools.  A  coated 
tongue  is  common  in  chronic  gastritis,  while  a  clean  red  tongue  is  usually 
present  in  the  hyperacid  conditions  in  which  ulcer  occurs.  There  is  no  point 
of  extreme  local  tenderness  in  chronic  gastritis  and  no  evidence  of  obstruc- 
tion and  muscular  hypertrophy  such  as  are  sometimes  demonstrable  in 
chronic  ulcer. 

The  results  of  gastric  analysis  in  chronic  gastritis  and  peptic  ulcer  are 
in  strong  contrast  (see  Gastric  Ulcer).  The  chemical  and  physical  condi- 
tions of  the  vomitus  are,  however,  much  modified  when  gastritis  and  ulcer 
are  associated,  as  not  rarely  happens. 

2.  Cancer  of  the  Stomach. — The  differential  diagnosis  in  the  absence  of 
tumor  is  at  times  almost  impossible.  The  loss  of  flesh  and  strength  in 
chronic  gastritis  is  rarely  so  rapid  as  in  cancer.  A  protracted  course  is  in 
favor  of  gastritis.  Pain  and  vomiting  are  less  marked,  less  persistent,  and 
more  amenable  to  treatment  in  chronic  gastritis  than  in  carcinoma  ventriculi. 
For  differences  in  the  results  of  gastric  analysis  see  Cancer  of  the  Stomach. 

3.  Pernicious  Ancemia  with  Gastric  Symptoms. — The  gastric  condition  is 
usually  a  chronic  anacid  gastritis.  The  differentiation  rests  upon  the  compar- 
atively rapid  and  extreme  deterioration  of  health  and  the  blood  examination. 

4.  Gastric  Neuroses. — The  conditions  are  frequentl)^  associated.  The 
irregular  dietetic  .  habits  and  despondency  characteristic  of  neurasthenia 
often  cause  chronic  gastritis.  Chronic  gastritis  is  more  amenable  to  die- 
tetic treatment.  Articles  of  food,  such  as  tea,  coffee,  alcohol,  and  hot 
stimulating  drinks,  which  aggravate  the  symptoms  of  gastritis  often  allay 
the  subjective  symptoms  of  a  neurosis.  Regulation  and  restriction  of  the 
diet  is  usually  beneficial  in  gastritis;  not  so,  as  a  rule,  in  the  neuroses. 
Fermentation  and  consequent  flatulence  and  belching  are  more  pronounced 
in  gastritis;  the  flatulence  of  the  neuroses  is  largely  due  to  air  swallowed 
or  worked  into  the  stomach.  Anaemia  is  more  marked  in  chronic  gastritis 
than  in  the  gastric  neuroses. 

The  analysis  of  the  stomach  contents  in  chronic  gastritis  shows  mucus 
in  excess,  lack  of  free  acid,  and  fermentative  changes;  in  the  neuroses  a 
normal  or  excessive  acidity  without  mucus. 

Prognosis. — Cases  of  chronic  gastritis  seen  early  and  systematically 
treated  get  well.  Advanced  cases  are  comfortable  only  on  a  non-irritating 
diet  and  require  continuous  therapeutic  management. 

iii.  Dilatation  of  the  Stomach. 

Gastrectasis. 

Enlargement  of  the  stomach,  usually  attended  with  weakening  and 
thinning  of  the  various  coats,  and  supersecretion.  Acute  and  chronic 
dilatations  are  recognized. 


940  MEDICAL  DIAGNOSIS. 

Acute  Dilatation. — The  etiology  is  not  well  understood.  The  condi- 
tion is  that  of  paralytic  distention  of  the  organ.  Among  the  assigned  causes 
are  local  and  general  debilitating  conditions,  trauma,  general  anaesthesia 
and  other  forms  of  narcotism,  and  dietetic  errors,  especially  excesses  in  beer. 
Post-mortem  findings  point  to  acute  dilatation  as  a  terminal  condition  in 
acute  illness,  especially  pneumonia  and  cardiac  disease. 

Symptoms. — Sudden  collapse  symptoms,  the  vomiting  of  enormous 
amounts  of  fluid,  moderate  pain,  and  pressure  symptoms  from  distention, 
as  dyspnoea  and  cardiac  oppression,  constitute  the  symptom-complex. 
The  fluid  reaccumulates  as  fast  as  vomited,  the  pylorus  remaining  in  a 
condition  of  spasmodic  closure. 

Physical  Signs. — The  physical  signs  of  enormous  distention  of  the 
stomach  are  present.  The  enlargement  is  often  such  that  its  true  outline 
is  lost.  Peristalsis  is  not  observed.  The  removal  of  large  amounts  of  fluid, 
as  much  as  eight  or  nine  pints,  by  the  stomach-tube  and  subsidence  of  the 
distention  are,  as  a  rule,  followed  by  only  transient  relief  of  symptoms. 
This  fluid  is  dark  brown  or  clear  and  contains  traces  of  blood  and  bile. 
Its  odor  is  foul  but  not  fecal.  HCl  is  present  in  diminished  but  variable 
amounts,  and  there  are  in  some  cases  traces  of  lactic  acid.  Constipation, 
oliguria,  and  torturing  thirst  not  easily  allayed  aie  among  the  symptoms. 

Diagnosis. — Direct. — Acute  symptoms  of  collapse  and  oppression, 
epigastric  pain,  profuse  vomiting  of  dark  or  clear  fluid,  marked  distention 
of  the  stomach  (the  signs  indicating  fluid  rather  than  gas),  and  the  rapid 
reaccumulation  of  fluid  after  removal  are  the  diagnostic  criteria.  The 
condition  is  not  always  recognized  during  life. 

Differential. — Acute  Obstruction  of  the  Pylorus  and  Upper  Duo- 
denum.— Active  peristalsis,  moderate  distention,  and  a  relatively  small 
accumulation  of  fluid,  not  immediately  returning  after  withdrawal  by 
vomiting  or  the  tube,  point  to  pyloric  obstruction. 

Acute  Obstruction  of  the  Duodenum  below  the  Entrance  of  the  Bile  and 
Pancreatic  Ducts  or  of  the  Intestine  Still  Lower  Down. — The  presence  of 
considerable  quantities  of  bile  and  pancreatic  fluid  in  the  vomitus  or 
material  removed  would  be  significant.  A  fecal  odor  in  the  vomitus  would 
suggest  obstruction  lower  down. 

Prognosis. — The  condition  is  almost  always  fatal. 

Chronic  Dilatation. — Etiology. — There  may  be  a  family  tendency. 
General  and  gastric  debilitating  conditions  constitute  predisposing  influ- 
ences. Habitual  overdistention  from  excesses  in  eating  or  drinking  may 
induce  dilatation  without  pyloric  obstruction  being  present.  The 
majority  of  cases  arise  from  obstruction  at  the  pylorus,  from  cancer, 
ulcer  with  cicatricial  contraction,  adhesions  to  the  gall-bladder,  kink'ng 
of  •  the  duodenum,  or  stretching  of  the  gastric  walls  already  weakened 
by  chronic  gastritis. 

Symptoms. — The  condition  may  exist  for  an  indefinite  period  without 
symptoms.  In  cases  occurring  independently  of  cancer  or  ulcer  the  loss 
of  weight  and  strength  is  less  rapid  and  anaemia  and  cachexia  may  not  be 
present.  Thirst,  constipation,  headache,  torpor,  and  dizziness  are  common 
symptoms.  Persistent  dyspepsia,  flatulency,  belching,  eructations,  nausea, 
and  eventually  recurrent  vomiting  of  large  amounts  of  fermented  undi- 


DILATATION  OF  THE  STOMACH.  941 

gested  food  characterize  the  course  of  the  affection.  The  dyspeptic  symp- 
toms resemble  those  of  chronic  gastritis,  and  comprise  pain  and  weight 
immediately  or  shortly  after  eating,  or  hyperacidity  four  or  five  hours 
after  the  meal.  Retention  vomiting  is  common.  Pain,  in  the  absence  of 
hyperacidity,  is  not  usual  except  in  carcinoma  or  ulcer. 

Physical  Signs. — Thinning  of  the  abdominal  wall  is  usually  present 
with  the  general  wasting.  The  skin  is  often  dry  and  harsh.  Inspection. — 
The  abdomen  may  show  general  fulness,  or  the  epigastrium,  hypochon- 
dria, or  supra-umbilical  region  may  be  especially  prominent.  The  stomach 
may  be  distinctly  outlined,  its  greater  curvature  sometimes  reaching  nto 
the  pelvis.  Displacement  of  the  pylorus  and  lesser  curvature  may 
outline  the  whole  stomach  as  a  dilated  sac  lying  in  great  part  below 
the  umbilicus.  Peristalsis  from  left  to  right  is  easily  distinguished.  In 
obstructive  cases  it  ends  in  the  hypertrophied  pylorus  or  tumor  mass. 
On  palpation  "  clapotage "  or  splashing  of  fluid  is  readily  obtained  when 
the  dilatation  reaches  the  umbilicus.  The  cushiony  condition  of  the  air- 
distended  stomach  is  readily  felt.  Percussion  yields  tympany.  In  the 
erect  posture  the  lower  limit  of  the  stomach  can  be  determined  by  the 
dulness  of  the  contained  fluid.    Auscultation  reveals  nothing  important. 

Inflation  with  air  through  the  tube  or  by  COg  shows  distention  reach- 
ing to  the  umbilicus  or  below  it.  The  whole  stomach  can  often  be  outHned. 
Usually,  however,  the  outline  obtained  does  not  include  the  lesser  curva- 
ture. Auscultation. — The  cask-like  tympany  produced  in  the  distended 
stomach  by  quickly  compressing  or  relaxing  the  bulb  of  the  tube,  or  by 
percussing  with  the  finger,  is  readily  heard  with  the  stethoscope  and  can 
be  followed  over  the  whole  stomach,  being  lost  on  passing  the  stetho- 
scope's bell  away  from  the  immediate  area  of  the  stomach.  Inflation  with 
water  has  no  practical  value. 

Large  bismuth  meals  are  of  service  in  photographing  the  outline  of  the 
stomach  by  the  Rontgen  rays.  Both  recumbent  and  erect  positions  must 
be  employed.  Transillumination  can  at  best  only  give  us  the  lower  border 
of  the  stomach. 

The  vomitus  is  variable.  That  of  dilatation  consequent  upon  chronic 
gastritis  shows  mucus,  usually  absence  of  free  HCl,  marked  fermentation; 
that  associated  with  cancer  frequently  has  an  odor  of  putrefaction  in 
addition  to  that  of  fermentation;  the  vomitus  in  which  much  free  HCl  is 
present  is  rarely  foul,  the  HCl  acting  as  an  antiseptic.  The  amount  may 
be  enormous. 

The  test-meal  removed  in  an  hour  may  come  away  with  several  hun- 
dred c.c.  additional  fluid.  Much  mucus  is  present  in  chronic  gastritis. 
The  toast  is  poorly  minced  and  almost  wholly  returned.  Free  HCl  may  be 
present  in  excess,  even  in  very  advanced  cases,  or  may  be  absent,  as  in  cases 
of  cancer  or  gastritis.  Lactic  acid  may  be  persistently  present  in  cancer. 
It  tends,  however,  to  disappear  under  systematic  lavage.  The  weakness 
of  the  gastric  muscle  is  shown  by  the  necessity  of  using  suction  and 
siphonago  to  remove  the  contents  of  the  stomach. 

Diagnosis. — Direct. — Persistent  dyspepsia,  flatulence,  eructations,  and 
vomiting  of  large  amounts  of  long-retained  fermented  food  remains  are 
suggestive.     Distention,  the  outlining  of  an  enlarged  displaced  stomach, 


942  MEDICAL  DIAGNOSIS. 

visible  peristalsis,  and  an  abnormally  large  amount  of  gastric  contents  after 
a  test-meal  are  conclusive.  Inspection  alone  may  make  the  diagnosis. 
A  pyloric  tumor  with  its  associated  signs  suggests  gastrectasis. 

Differential. — The  anamnesis  distinguishes  dilatation  of  the  stomach 
from  cystic  conditions  of  the  mesentery,  gall-bladder,  and  ovary,  and  from 
chronic  dilatations  of  the  colon.  The  last  is  not  associated  with  "retention 
vomiting; "  it  shows  the  intestinal  outlines  and  peristalsis  from  right  to  left, 
and  can  be  reduced  by  passage  of  the  rectal  tube.  The  use  of  the  stomach- 
tube  is  of  great  diagnostic  importance. 

Prognosis. — Dilatation  of  the  stomach,  when  recent  and  unattended 
by  obstruction  at  the  pylorus,  and  not  excessive,  may  permanently  subside. 
Many  cases  require  systematic  lavage.  Operative  measures  are  required 
for  the  relief  of  marked  dilatation  with  pyloric  obstruction. 

iv.  Gastric  Ulcer. 

Definition. — Ulceration  of  the  gastric  mucosa  in  any  part  of  its  extent, 
due  to  nutritional  disturbance  in  a  circumscribed  region  and  the  action  of 
the  gastric  juice.  The  necrotic  areas  may  occur  in  the  lower  end  of  the 
oesophagus  and  in  the  duodenum  as  low  as  the  papilla  of  Vater.  They 
involve  the  various  coats  of  the  stomach  and  sometimes  perforate.  They 
are  usually  round  or  oval,  with  clean-cut  edges  in  the  acute  and  irregular 
indurated  borders  :'n  the  chronic  cases. 

Etiology. — Anaemia  and  chlorosis  predispose  to  the  affection.  The 
disease  is  more  common  in  the  working  classes.  Heredity  has  some  influ- 
ence. Hyperacidity  of  the  gastric  juice  is  usually  present.  Trauma  or 
large  superficial  burns  may  be  direct  causes.     Septic  cases  occur. 

Symptoms. — General  symptoms  are  often  absent.  Loss  of  weight  and 
strength,  and  progressive  anaemia,  often  of  extreme  degree,  are  common. 
Constipation  is  usual.  Simple  dyspepsia,  distress  and  fulness  after  eating, 
flatulence,  and  belching  are  common  symptoms.  In  such  cases  there  is 
often  normal  acidity.  In  the  more  severe  cases  the  dyspepsia  is  more 
intense;  nausea  and  vomiting  occurring  three  or  four  hours  after  eating, 
or  severe  agonizing  pain  on  taking  food  and  lasting  two  or  three  hours  or 
more,  or  not  beginning  until  the  height  of  gastric  acidity  is  reached,  two  or 
three  hours  after  the  meal,  are  frequent  symptoms.  At  times  the  pain 
is  gnawing  in  character,  more  marked  when  the  stomach  is  empty,  and 
relieved  by  food.  Cases  of  this  type  usually  show  a  high  degree  of  acidity. 
The  pain  is  referred  to  the  epigastrium,  often  radiating  to  the  back  and 
sides.  Vomiting  may  give  relief.  Hemorrhage  is  common  and  may  be  the 
first  symptom.  The  blood  may  be  passed  either  by  the  mouth  or  bowel. 
Concealed  hemorrhage  may  occur  with  characteristic  symptoms.  Recur- 
rent hemorrhage  may  end  fatally,  I  have  seen  a  single  profuse  hemorrhage 
followed  by  death  in  a  man  in  apparent  health.  Small  continued  hemor- 
rhages may  only  be  recognized  by  blood  tests.  The  testing  for  occult 
blood  in  the  stools  is  most  important  in  such  cases. 

The  symptoms  may  continue  for  years.  Perforation  of  the  stomach 
and  peritonitis  may  be  the  first  clear  indications  of  an  ulcer.  The  local 
symptoms  in  old  cases  with  pyloric  obstruction  are  those  of  gastrectasis. 


GASTRIC  ULCER.  943 

flatulence,  dyspepsia,  nausea,  and  retention  vomiting.  In  early  cases,  in 
the  absence  of  obstruction  there  may  be  nothing  to  indicate  disease  of  the 
stomach.  In  others  tenderness  in  the  epigastrium,  mostly  acutely  localized, 
may  be  the  onh"  symptom.  During  the  inactive  stage  of  an  ulcer  near  the 
pylorus  or  in  the  duodenum  temporary  signs  of  pyloric  obstruction  may 
develop.  These  are  probably  due  to  spasmodic  closure  of  the  pylorus  and 
the  infiltration  of  the  neighboring  tissue.  Fulness  of  the  epigastrium,  the 
outline  of  the  enlarged  stomach,  and  visible  peristalsis  may  be  evident. 
The  thickened  and  hypertrophied  pylorus  can  sometimes  be  felt  during 
contraction.  Tenderness  over  the  pylorus  is  often  marked.  In  chronic 
cases  the  physical  signs  indicate  tumor  formation  due  to  scarring  or  pucker- 
ing of  the  ulcerated  area,  thickening  and  muscular  hypertrophy,  and 
hour-glass  contraction.    These  are  often  much  more  manifest  upon  inflation. 

Gastric  Analysis. — The  vomitus  or  gastric  contents  from  the  fasting 
stomach,  usually  thin,  watery,  and  light  green  in  color,  frequently  contain 
large  amounts  of  free  HCl.  The  gastric  contents  removed  after  the  ordi- 
nary test-meals  are  usually  in  excess  of  the  normal  and  generally  contain 
some  mucus  and  a  small  amount  of  well-mixed  food  residue.  They  show 
a  high  total  acidity,  a  high  degree  of  free  HCl,  pepsin  and  rennin,  no  lactic 
or  butyric  acid.  Traces  of  blood  by  chemical  tests  are  common.  Under  the 
microscope  small  round  cells  and  pus-cells  can  be  demonstrated  in  most 
cases  when  the  ulceration  is  active.  The  red  blood-cells  are,  as  a  rule, 
disintegrated  by  the  high  acidity.  In  the  older  cases,  the  same  high  per- 
centage of  free  HCl  and  hypersecretion  is  found,  together  with  mucus  from 
the  coexisting  chronic  gastritis.  The  vomitus  in  cases  with  obstruction  is 
sometimes  of  enormous  quantity,  containing  free  HCl  and  mucus.  It  is 
acid  in  odor  but  rarely  foul.  The  high  total  acidity  and  free  HCl  are 
occasionally  absent  in  well-marked  cases  of  gastric  ulcer. 

Diagnosis. — Direct. — The  diagnosis  rests  upon  persistent  dyspepsia, 
anaemia  with  loss  of  weight  and  strength,  marked  circumscribed  tender- 
ness in  the  epigastrium,  a  high  degree  of  gastric  acidity,  and  occult  blood 
in  the  faeces,  gastric  contents,  or  vomitus.  In  marked  cases  intense 
pain  after  eating,  vomiting,  nausea,  the  sudden  appearance  of  haematem- 
esis  or  tarry  stools,  with  rapidly  developing  weakness  and  anaemia  occur. 
In  long-standing  cases  the  symptoms  and  signs  of  pyloric  obstruction  or 
gastric  malformation  are  significant. 

Differential. — 1.  Chronic  Gastritis. — In  ulcer  the  high  degree  of 
acidity  of  the  gastric  juice,  the  presence  of  occult  blood  in  the  gastric 
contents  and  faeces,  the  more  marked  tenderness  or  local  pain  are  distinc- 
tive. A  well-defined  haematemesis  or  the  passage  of  blood  per  rectum  is 
conclusive.  2.  Gastric  Superacidity. — Loss  of  weight  is  common  to  both; 
anaemia  is  more  common  in  ulcer.  Localized  pain  is  more  marked  in  ulcer; 
nausea  and  vomiting,  pain  after  eating,  haematemesis,  tarry  stools,  occult 
blood  in  the  faeces  or  gastric  contents  are  not  symptoms  of  superacidity. 
Relief  of  pain  on  taking  food  is  suggestive  of  simple  hj'peracidity,  in  which 
signs  of  obstruction  and  marked  retention  do  not,  as  a  rule,  occur.  3. 
Carcinoma  of  the  Stomach. — Sudden  onset  with  haematemesis,  hemorrhage 
from  the  bowels,  and  perforation  are  suggestive  of  ulcer.  The  history  of 
many  years'   duration  is  against  cancer.     Cachexia  develops  rapidly  in 


944  MEDICAL  DIAGNOSIS. 

cancer,  is  unusual  in  ulcer.  Haematemesis  or  hemorrhage  from  the  bowels 
is  common  in  ulcer,  as  is  hyperacidity  of  the  gastric  juice,  while  the  pres- 
ence of  lactic  and  butyric  acids  is  unusual.  Absent  or  diminished  free  HCl 
is  common  in  cancer,  the  presence  of  lactic  and  butyric  acids  frequent. 

The  signs  of  a  tumor  are,  as  a  rule,  present  early  in  cancer,  but  late 
if  at  all,  and  associated  with  scar  formation,  in  ulcer.  Pyloric  obstruction 
is  an  early  condition  in  cancer. 

V.  Cancer  of  the  Stomach. 

Carcinoma  Ventricidi. 

Definition. — Cancerous  infiltration  of  the  stomach  walls,  occurring 
most  frequently  toward  the  pylorus  and  about  the  lesser  curvature. 

Etiology. — The  predisposition  has  been  thought  to  be  hereditary.  A 
chronic  gastric  ulcer  not  infrequently  becomes  the  seat  of  a  carcinoma. 
Middle  and  advanced  life  is  the  time  of  common  occurrence,  but  there  is 
no  "age  of  cancer."  Irritation  of  the  stomach  by  improper  diet,  injury, 
or  pressure  from  without  have  all  been  considered  as  exciting  causes. 

Symptoms. — Rapid  anaemia,  loss  of  strength  and  weight,  and  early 
developing  cachexia  in  a  middle-aged  person  are  suggestive.  Persistent 
distress  in  the  stomach  after  eating  or  even  when  the  stomach  is  empty, 
often  amounting  to  intense  pain,  is  an  early  symptom.  Nausea  and  ano- 
rexia soon  follow.  Vomiting  may  be  an  early  symptom.  If  there  is  marked 
obstruction  at  the  pylorus  with  consequent  dilatation,  the  vomitus  may 
be  of  large  volume  and  foul  odor.  The  vomiting  of  altered  blood  ("  coffee- 
ground  vomit")  and  passage  of  small  amounts  of  blood  in  the  stools  occur. 
Constipation  is   often  present. 

Physical  Signs. — Inspection  may  show  nothing,  especially  in  early 
cases.  Metastasis  may  be  seen  in  the  supraclavicular  fossa  or  beneath  the 
skin  of  the  abdomen.  Fulness  of  the  epigastrium  and  left  hypochondrium, 
visible  outline  of  the  stomach,  displaced  and  distended  visible  peristalsis 
(usually  from  left  to  right),  and  distinct  contracting  tumor  may  be  observed. 
Inflation  will  often  produce  peristalsis  and  bring  a  tumor  mass,  not  other- 
wise recognizable,  into  evidence.  Inflation  will  often  show  the  abnormal 
size  and  position  of  the  stomach.  Palpation  also  may  reveal  nothing  at 
first,  especially  if  the  tumor  is  posterior  or  adherent.  Careful  and  repeated 
palpation,  aided  by  "dipping"  and  slapping  the  abdomen,  may  reveal  the 
presence  of  a  new  growth.  Inflation  aids  palpation  at  times  by  bringing 
the  tumor  into  the  field  of  examination.  The  movements  of  the  tumor, 
with  respiration,  with  movements  of  the  body,  with  the  aortic  pulsation, 
and  from  the  muscular  contraction,  should  be  noted. 

Gastric  Analysis. — Vomitus  or  a  test-meal  containing  traces  of  blood 
and  showing  no  free  hydrochloric  acid  and  a  lowered  total  acidity  must 
be  regarded  as  suspicious  in  all  cases.  Lactic  acid  is  usually  to  be  found 
in  the  vomitus  after  a  mixed  meal  if  there  is  any  degree  of  stagnation,  and 
in  the  test-meals  given  in  late  cases.  Alter  a  few  days'  lavage  it  diminishes 
and  may  disappear.  Butyric  acid  will  be  found  in  the  vomitus  under  the 
same  conditions  as  lactic  acid.     Pepsin  and  rennin  are  usually  to  be  found. 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS.  945 

Pieces  of  cancer  tissue  should  be  looked  for.  Oppler-Boas  bacilli  are 
found  more  frequently  in  the  vomitus  of  cancer  than  in  any  other  condi- 
tion. They  disappear  quickly  under  lavage.  Pus-cells,  sarcinae,  yeast 
cells,  and  many  bacteria  may  be  seen.  Free  HCl  is  not  alwaj^s  absent, 
and  may  even  be  present  in  excess.  With  obstruction  at  the  pylorus 
the  amount  of  material  obtained  after  a  test-meal  will  be  excessive. 

Diagnosis. — Direct. — Persistent  dyspepsia,  pain,  loss  of  weight  and 
strength,  anaemia,  a  tumor  in  the  gastric  area,  signs  of  displacement  and 
dilatation  of  the  stomach,  absence  of  free  HCl,  presence  of  lactic  acid,  and 
Oppler-Boas  bacilli  in  the  test-meal  or  vomitus,  an  excessive  amount  of 
vomitus,  and  gastric  contents  with  evidences  of  stagnation  are  the  main 
points  in  the  diagnosis. 

Differential. — Chronic  Gastritis  (see  Chronic  Gastritis).  Pernicious 
Ancemia. — Gastric  symptoms  with  absence  of  free  HCl  often  occur,  but 
this  condition  may  be  distinguished  by  the  blood  examination.  The  anaemia 
of  cancer  rarely  falls  as  low  as  in  pernicious  anaemia.  The  color  index  is 
low  in  cancer.  There  may  be  a  slight  leucocytosis,  and  the  presence  of 
megaloblasts  is  rarely  noted.  In  general  the  blood  picture  is  that  of  a 
secondary  anaemia.  Haematemesis,  tarry  stools,  the  reaction  for  occult 
blood  in  the  faeces  and  gastric  contents  are  indicative  of  a  gastric 
lesion.  Severe  Secondary  Ancemia  with  Gastric  Symptoms. — The  presence 
of  lactic  acid  in  the  test-meal,  the  absence  of  free  HCl,  the  presence 
of  a  tumor,  and  occult  or  gross  blood  in  the  gastric  contents  and  faeces 
point  to  cancer. 

Prognosis. — Unless  an  early  diagnosis  makes  a  total  extirpation  of 
the  tumor  possible  the  course  is  steadily  downward.  Gastro-enterostomy 
may  be  of  service.  Temporary  improvement  usually  follows  the  institu- 
tion of  lavage  in  cases  that  have  marked  obstruction  at  the  pylorus. 

vi.  Hypertrophic  Stenosis  of  the  Pylorus. 

Definition. — Obstruction  of  the  pylorus  from  hypertrophy  of  the 
musculature  and  the  submucous  tissue. 

Etiology. — Most  of  the  reported  cases  are  in  infants  and  are  congenital; 
even  those  reported  in  adults  are  considered  to  be  late  developing  cases. 
The  same  conditions  that  induce  pyloric  spasm,  namely,  nervous  and  direct 
irritation,  are  possible  exciting  causes. 

Symptoms. — The  symptoms  and  physical  signs  are  those  of  obstruc- 
tion at  the  pylorus. 

Diagnosis. — Direct. — Symptoms  of  obstruction  at  the  pylorus,  visible 
peristalsis,  and  palpable  pyloric  tumor  occurring  in  infants  are  diagnostic 
of  the  condition.  In  adults  the  condition  can  hardly  be  distinguished 
from  simple  pyloric  spasm. 

Differential. — There  is  no  other  condition  which  can  be  confused 
with  hypertrophic  stenosis  in  infants  except  pyloric  spasm.  Relief  follow- 
ing general  and  dietetic  treatment  would  justify  the  diagnosis  of  the  latter 
affection.  True  hypertrophic  stenosis  in  adults  cannot  always  be  distin- 
guished from  other  forms  of  pyloric  tumor  or  obstruction.  It  may  be 
differentiated  from  spasm  of  the  pylorus  by  the  fact  that  the  latter  is  not 
60 


94G  MEDICAL  DIAGNOSIS. 

followed  by  permanent  lesions,  as  tumor  or  dilatation.  Its  occurrence  in 
early  infancy  is  against  its  being  confounded  with  either  cancer  or  ulcer. 
In  adult  cases  the  absence  of  anaemia  and  wasting,  cachexia,  hemorrhage, 
and  occult  blood  are  of  diagnostic  value. 

vii.  Tuberculosis  of  the  Stomach. 

Tuberculous  ulceration  of  the  stomach  is  discussed  under  Tuberculosis. 

viii.  The  Gastric  Neuroses. 

The  gastric  neuroses,  nervous  disorders  of  the  stomach,  "nervous 
dyspepsia, "  include  a  host  of  conditions  many  of  which  are  explained  and 
described  by  their  names.  With  a  few  exceptions,  which  comprise  the 
nervous  disorders  of  secretion,  they  are  characterized  by  the  predominance 
of  symptoms  over  physical  signs.  Disorders  of  sensation,  secretion,  and  of 
the  motor  function  are  recognized. 

1.  Disorders  of  Sensation. — (a)  Gastric  Hyperaesthesia. — A  condi- 
tion of  oversensitiveness  of  the  gastric  mucous  membrane.  Etiology. — 
The  general  nervous  state  is  the  predisposing  influence.  Any  article  of 
food  may  be  the  exciting  cause.  Overacidity  of  the  gastric  juice  in  an 
empty  stomach  is  a  frequent  cause.  Symptoms. — Neurasthenia  or  hyster- 
ical symptoms  are  common;  wasting  or  anaemia  is  infrequent.  Gastric 
distress,  gnawing  sensations,  burning  in  the  stomach  immediately  or  shortly 
after  taking  food  or  when  the  stomach  is  empty  are  the  main  features. 
The  sensation  seems  to  be  that  of  feeling  the  stomach  doing  its  work. 
Stimulants  or  condiments  often  relieve  the  symptoms.  There  is  often 
tenderness  over  the  stomach.  The  gastric  contents  after  a  test-meal  usually 
yield  normal  results.  Diagnosis. — Direct. — Hysterical  or  neurasthenic 
manifestations,  gastric  symptoms  occurring  before  there  has  been  time  for 
acid  to  accumulate  or  for  fermentation  to  begin,  negative  physical  exami- 
nation and  negative  results  of  the  gastric  analysis  are  suggestive.  Differ- 
ential.— Gastric  Hyperacidity. — The  gastric  analysis  sometimes  shows  slight 
hyperacidity;  as  a  rule,  the  analysis  serves  to  distinguish  simple  hyper- 
aesthesia from  hyperacidity.  The  symptoms  in  hyperacidity  develop  later — 
three  to  four  hours  after  a  meai.  Chronic  Gastritis. — The  sensory  S3^mp- 
toms  in  some  forms  of  chronic  gastritis  are  practically  the  same  but  they 
are  definitely  related  to  certain  articles  of  diet.  The  gastric  analysis  of 
chronic  gastritis  shows  distinct  differences  (see  Chronic  Gastritis).  Gastric 
Ulcer. — Hyperaesthesia  rarely  produces  anaemia  or  wasting.  There  is  no 
vomiting,  no  haematemesis  or  tarry  stools,  no  signs  of  pyloric  obstruction, 
no  occult  blood  in  faeces  or  gastric  contents,  and  usually  no  hyperacidity 
of  the  gastric  juice.  Gastric  Cancer. — Absence  of  anaemia  and  cachexia, 
absence  of  vomiting,  hemorrhages,  gross  and  occult,  absence  of  a  tumor  or 
signs  of  dilatation  and  obstruction,  a  normal  condition  of  the  gastric  juice 
favor  the  diagnosis  of  hyperaesthesia. 

Prognosis. — Recovery  depends  upon  the  course  of  the  general  ner- 
vous condit'on.  Persistence  of  the  symptoms  may  reduce  the  patient  to 
an  extreme  degree. 


GASTRIC  NEUROSES.  947 

Anorexia  nervosa  is  considered  in  the  sections  on  hysteria  and  neuras- 
thenia. Excessive  hunger,  bulimia,  absence  of  the  sense  of  repletion — 
acoria — are  often  merely  symptoms  of  hyperacidity.  They  may  occur, 
however,  with  a  normal  condition  of  the  gastric  juice. 

(b)  Qastralgia;  Gastrodynia. — Severe  paroxysmal  pain  in  the  stom- 
ach, often  pciiodic,  not  referable  to  ulcer,  cancer,  or  organic  nervous  disease 
(gastric  crises  of  tabes) .  This  is  often  symptomatic  of  excessive  acid  secre- 
tion. Etiology. — The  predisposing  influence  is  always  neurotic.  An 
exciting  cause  cannot  always  be  found,  the  gastralgic  attacks  occurring 
more  or  less  independently  of  food  ingestion.  Symptoms. — There  are  almost 
always  general  nervous  symptoms.  Acute  grinding  pain  in  the  epigastrium 
and  gastric  region,  which  radiates  to  the  back,  is  the  main  feature.  Vomit- 
ing is  unusual.  Pressure  may  or  may  not  relieve  the  pain.  Tenderness  on 
deep  pressure  is  the  rule.  Diagnosis. — Acute  periodic  painful  attacks 
with  no  evidence  of  gastritis,  ulcer,  hyperacidity,  or  of  locomotor  ataxia. 
Marked  general  nervous  symptoms  are  suggestive.  The  differential  diag- 
nosis concerns  cancer,  peptic  ulcer,  the  gastric  crisis  of  tabes,  and  biliary 
colic.  Cancer  and  Ulcer. — The  nervous  symptoms  and  the  general  condi- 
tion of  the  patient  in  gastralgia  are  important  diagnostic  points,  since  many 
cases  of  gastralgia  show  absence  or  even  excess  of  HCl  in  the  gastric  juice. 
Negative  occult  blood-tests  of  the  faeces  and  gastric  material,  absence  of 
anaemia  and  cachexia,  of  tumor  mass  and  physical  signs  are  in  favor  of 
gastralgia  Gastric  Crisis  of  Tabes. — Absence  of  the  knee-jerk  and  other 
tabetic  phenomena  are  conclusive.  Gall-stone  Colic. — The  distinction  is 
sometimes  extremely  difficult,  since  the  pain  of  gall-stone  colic  may  be 
referred  to  the  epigastrium,  subsequent  jaundice  may  not  occur,  and  the 
calculus  may  be  masked  in  the  faeces  or  not  passed  from  the  duct.  Prog- 
nosis.— The  prognosis  in  gastralgia  is  usually  favorable.  It  depends  upon 
the  course  of  the  general  nervous  condition. 

2.  Disorders  of  Secretion. — Three  main  varieties  are  recognized: 
supersecretion,  hyperacidity  of  the  gastric  juice,  and  hypoacidity  and 
anacidity. 

Either  hyper-  or  hypoacidity  may  be  associated  with  supersecretion; 
hyperacidity  and  supersecretion  is  the  more  frequent  combination. 

(a)  Supersecretion  ;  Gastrosuccorrhoea. — A  condition  in  which  excess  of 
gastric  juice  is  secreted  continuously, — Teichmann's  disease, — or  period- 
ically,— Rosshach's  disease;  nervous  gastroxynsis, — usually  in  association 
with  a  certain  degree  of  dilatation  of  the  stomach  from  a  general  relaxation 
of  its  muscular  tone.  Etiology. — General  neurasthenia  is  the  main  pre- 
disposing cause.  Stimulants  and  tobacco  are  occasionally  exciting  causes. 
Symptoms. — Neurasthenic  symptoms  are  almost  always  present.  In  the 
per'odic  form  there  occurs  suddenly  the  accumulation  of  large  amounts  of 
fluid,  associated  usually  with  gnawing  distress  or  even  pain,  eructations 
or  vomiting  of  a  clear  watery  fluid  ensue  and  may  persist  for  several  days. 
The  secretion  is  enormous  and  independent  of  food,  the  symptoms  often 
occurring  in  the  early  morning.  If  hyperacidity  is  present  the  irritation 
of  oesophagus  and  pharynx  may  occasion  great  distress.  The  continuous 
form  ends  frequenth^  in  dilatation  of  the  stomach  from  the  persistent 
pyloric  spasm  so  often  present  and  the  weight  of  the  accumulating  fluid 


948  MEDICAL  DIAGNOSIS. 

upon  the  relaxed  muscles.  Physical  Signs. — Dipping  palpation  may 
give  clapotage.  Percussion  in  the  erect  position  may  show  a  level  of  fluid 
in  a  position  lower  than  normal.  The  stomach-tube,  passed  in  the  morning 
or  at  other  times  when  the  stomach  is  presumably  empty,  may  bring  away 
as  much  as  200  to  300  c.c.  of  fluid,  often  highly  acid  from  free  HCl.  Infla- 
tion shows  a  moderate  degree  of  dilatation.  Spasm  of  the  pylorus  and 
peristalsis  may  be  seen  and  felt.  The  test-meal  may  be  returned  after  an 
hour  with  an  accumulation  of  several  hundred  c.c.  of  a  high  or  normal 
degree  of  total  acidity  and  with  a  large  or  normal  amount  of  free  HCl. 
Mucus  is  not  in  excess;  lactic  acid  is  not  present.  In  late  cases  of  continu- 
ous supersecretion  the  condition  is  practically  that  of  dilatation.  Diag- 
nosis.— Direct. — The  continuous  or  periodical  presence  in  the  stomach  of 
an  excess  of  fluid  having  the  above  characters  and  its  accumulation  inde- 
pendently of  the  stimulation  of  food  are  the  main  characteristics  of  the 
condition.  Differential: — Acute  Gastritis. — Acute  gastritis  usually  has  a 
distinct  and  recognizable  etiology.  The  fluid  vomited  is  smaller  in  quantity, 
usually  anacid,  and  contains  mucus.  Acute  Dilatation. — In  acute  dilata- 
tion the  general  symptoms  are  marked  from  the  outset.  The  condition 
is  much  more  serious,  and  neither  vomiting  nor  lavage  has  much  effect 
upon  the  course  of  the  attack.  Chronic  Dilatation. — Supersecretion  often 
ends  in  dilatation.  Simple  supersecretion  in  its  early  stages,  however, 
has  a  different  history.  Retention  vomiting  and  the  physical  signs  of 
marked  dilatation  do  not  occur.  Prognosis. — This  depends  upon  the 
nervous  state;  as  a  rule  it  is  good. 

(b)  Hyperacidity;  Hyperchlorhydria. — Excess  of  free  HCl  in  the  gastric, 
juice.  Etiology. — Hysteria  and  general  neurasthenia  predispose  to  the 
condition.  Irregular  habits  of  eating,  stimulants,  tobacco,  and  an 
excess  of  proteid  nourishment  are  common  exciting  causes.  Symptoms. — 
The  general  nervous  symptoms  of  the  underlying  condition  are  present. 
Headache,  hunger,  and  constipation  are  common.  Gastric  hyperesthesia 
is  frequently  present.  Supersecretion  often  coexists.  Gnawing  distress, 
burning,  or  severe  pain  developing  two  to  four  hours  after  eating, 
relieved  in  turn  by  eating  proteid  food,  are  local  symptoms.  When 
vomiting  occurs  the  symptoms  are  usually  relieved.  The  tongue  is  com- 
monly clean,  red,  and  moist,  and  there  is  epigastric  tenderness.  The  test- 
meal  is  usually  expelled  vigorously  and  in  excessive  quantity,  as  some 
degree  of  supersecretion  is  almost  always  present.  The  digestion  of  the 
starch  is  retarded.  The  total  aciditj^,  instead  of  a  normal  40,  may  reach 
120  or  150.  Free  HCl  may  be  as  high  as  90  to  110.  If  the  condition  has 
been  persistent  mucus  may  be  present.  Lactic  acid  is  absent.  Many  round 
epithelial  cells  showing  mitosis  may  at  times  be  seen  under  the  micro- 
scope. The  vomitus  on  account  of  its  high  HCl  percentage  does  not  readily 
ferment.  Bacteria  are  not  present  in  any  large  numbers.  Meat  digestion 
can  be  shown  to  be  rapid.  Diagnosis. — Direct. — Distress  two  to  four 
hours  after  eating,  relieved  by  taking  food,  a  high  degree  of  free  acid  in  the 
vomitus,  and  the  results  of  the  chemical  examination  of  the  gastric  contents 
constitute  the  basis  of  a  direct  diagnosis.  Differential. — Ulcer. — Hyper- 
acidity of  the  gastric  juice  is  common  in  ulcer.  Pain  immediately  after 
eating  is  usual  in  ulcer,  and  vomiting  is  more  common.     Local  tenderness 


GASTRIC  NEUROSES.  949 

or  pain,  a  history  of  haematemesis  or  tarry  stool,  loss  of  weight,  anaemia, 
occult  blood  in  gastric  contents  and  fseces  are  important.  The  two  con- 
ditions often  coexist,  the  ulcer  being  unrecognized.  Laboratory  methods 
are  imperatively  required  in  doubtful  cases.  Cancer,  with  normally  acid  or 
hyperacid  gastric  juice.  The  general  symptoms,  as  loss  of  weight,  cachexia, 
anaemia,  the  persistence  of  local  symptoms,  as  vomiting  and  pain,  are  dis- 
tinctive of  cancer,  while  occult  blood  in  the  faeces  or  gastric  contents,  or  gross 
hemorrhages  are  against  the  diagnosis  of  simple  hyperacidity.  The  diag- 
nosis may,  in  rare  cases,  be  impossible  until  a  palpable  tumor  is  detected 
or  a  dense  shadow  appears  in  the  skiagram.  Prognosis. — The  condition 
may  last  for  years.     Relief  under  appropriate  treatment  is  the  rule. 

(c)  Hypoacidity  ;  Anacidity  ;  Hypochlorhydria. — Conditions  of  the  gas- 
tric juice  in  which  the  free  HCl  is  of  low  value,  or  lacking.  Etiology. — 
Hysteria  and  depressed  nervous  states  are  predisposing  causes  or  even  the 
exciting  cause.  It  is  to  be  remembered  that  the  Ewald  test-meal  may  fail 
to  provoke  much  secretion.  Low  HCl  in  organic  disease  occurs  as  follows: 
in  subacute  and  chronic  gastritis,  early  carcinoma,  dilatation  of  the  stom- 
ach, and  various  chronic  diseases  of  the  abdominal  viscera.  Symptoms. — 
Symptoms  are  frequently  absent.  Fermentation,  flatulence,  a  feeling  of 
dulness,  or  other  manifestations  of  indigestion  occur.  Diarrhoea,  anaemia, 
and  pallor  are  more  common  than  in  the  other  secretory  disorders.  Local 
signs  are  absent.  A  coated  tongue  is  usual.  Inflation  reveals  nothing. 
The  test-meal  is  brought  away  either  as  normal  amount,  or  thick  and  pasty 
from  lack  of  fluid.  Starch  digestion  has  progressed.  There  is  persistently 
a  low  degree  of  free  HCl,  and  the  total  acidity  is  also  low,  or  there  may  be 
no  reaction  for  either  acidity  or  free  acid.  Lactic  acid  is  absent.  Mucus 
is  not  in  excess.  Pepsin  and  rennin  are  present.  When  the  gastric  secre- 
tion is  completely  absent,  as  occurs  in  rare  instances,  the  condition  is 
designated  "achylia  gastrica. " 

Diagnosis. — Direct. — Persistent  absence  of  free  HCl,  or  its  presence 
in  an  abnormally  low  percentage  half  an  hour  or  one  and  a  half  hours  after 
the  test-meal,  is  suggestive.  General  nervous  symptoms  and  the  absence 
of  localizing  gastric  phenomena  are  important.  Differential. — Chronic 
Gastritis. — The  relation  of  symptoms  to  food  is  more  marked  in  gastritis. 
Dyspeptic  symptoms  are  more  marked,  vomiting  and  nausea  more  pro- 
nounced in  gastritis,  and  mucus  in  excess  is  common.  Nervous  symptoms 
are  not  especially  prominent  in  gastritis.  Cancer. — In  cancer  constitu- 
tional symptoms  are  more  marked.  Pain,  vomiting,  nausea,  occult  and 
gross  hemorrhages,  anaemia,  wasting,  physical  signs  of  tumor  and  dilata- 
tion may  be  present.  The  test-meal  may  show  no  distinguishing  feature. 
The  presence  of  lactic  acid  and  blood  is  in  favor  of  cancer.  The  Anacidity 
Seen  in  Pernicious  Ancemia. — The  blood  picture  is  the  only  means  of 
differentiation ;    the  gastric  conditions  are  undistinguishable. 

Prognosis. — The  condition  often  persists  unrelieved.  Occasionally 
the  secretion  of  free  HCl  may  be  restored. 

3.  Disorders  of  the  Motor  Functions. — With  one  or  two  exceptions 
disorders  of  the  motor  functions  of  the  stomach  are  the  expression  of 
hysteria  or  are  cultivated  habits.  They  are  usually  not  associated  with 
gastric  distress  and  show  no  physical  signs  or  changes  in  the  gastric  juice. 


950  MEDICAL  DIAGNOSIS. 

Some  of  them,  as  rumination,  peristaltic  unrest,  gurgling,  and  singultus, 
need  no  special  description  here.  Nervous  vomiting,  relaxation  of  the  car- 
diac orifice  is  unattended  by  nausea  or  symptoms  of  irritation.  The  ease 
with  which  the  gastric  contents  are  regurgitated  and  the  absence  of  the 
signs  of  fermentation,  hyperacidity,  etc.,  are  of  diagnostic  importance. 

Spasm  of  the  cardiac  orifice  may  be  differentiated  from  oesophageal 
stricture  by  the  use  of  oesophageal  sounds  and  bougies.  The  regurgitation 
of  unaltered  food,  without  the  chemical  reaction  of  gastric  juice,  is 
characteristic   of  stricture  or  diverticula  of  the  oesophagus. 

Spasm  of  the  pylorus  is  frequently  associated  with  hyperacidity.  Gas- 
tric distention,  flatulence,  belching,  colick}'-  pain,  are  common  associated 
symptoms.  In  thin  subjects  the  contracted  pylorus  can  be  seen  and  felt. 
Visible  peristalsis  may  occur.  The  diagnosis  from  organic  disease  may  be 
difficult.  The  good  general  condition  of  the  patient,  the  absence  of  severe 
local  signs,  a  normal  or  excessive  acidity  of  the  gastric  juice  are  in  favor 
of  a  neurosis 

Relaxation  of  the  pylorus  occasionally  occurs,  the  stomach  emptying 
itseK  almost  at  once.  The  condition  is  usually  discovered  accidentally 
during  attempts  at  removing  a  test-meal. 

Gastric  Atony. — Atony  of  the  gastric  muscles  is  usually  part  of  general 
muscular  relaxation  seen  in  nervous  and  exhausted  states.  It  is  practi- 
cally a  condition  of  moderate  dilatation  without  pyloric  obstruction. 
The  coexistence  of  neurotic  symptoms  or  other  disease  is  important  in 
its  recognition. 

The  prognosis  of  the  motor  neuroses  of  the  stomach  depends  upon  the 
underlying  nervous  condition  and  is  usually  good. 

ix.  Qastroptosis. 

Definition. — A  prolapse  of  the  stomach  from  its  natural  position,  due 
to  stretching  of  its  ligamentous  attachments,  usually  associated  with 
ptosis  of  other  organs,  especially  the  kidneys,  liver,  and  large  intestine. 

Etiology. — The  predisposing  influences  are  neurasthenic  states  with 
weakened  and  relaxed  musculature.  Possibly  the  bad  carriage  and 
slouching  forward  of  many  neurasthenics  who  always  require  "straight- 
ening up"  may  be  an  exciting  cause.  Repeated  pregnancies,  recurring 
ascites,  stretching,  relaxing,  and  diastasis  of  the  abdominal  muscles  are 
frequent  causes. 

Symptoms. — Cases  in  which  the  neurotic  element  is  absent  may  show 
no  symptoms,  even  with  the  stomach  far  out  of  place.  As  the  stomach 
drags  downward,  however,  kinking  at  the  duodenum  is  likely  to  occur, 
since  duodenal  ptosis  does  not  follow  to  any  marked  degree,  and  symp- 
toms of  mild  obstruction  may  develop.  In  the  markedly  neurotic,  gastrop- 
tosis  once  estabhshed  seems  to  give  rise  to  or  keep  in  continuance  many 
general  symptoms,  such  as  faintness,  weakness,  continued  exhaustion, 
headache,  depression,  dragging  pain  in  the  back  and  abdomen,  loss  of 
weight  and  strength,  sallowness,  and  sHght  anaemia.  Flatulence  from 
slight  obstructive  kinking  at  the  duodenum,  various  forms  of  nervous 
dyspepsia,  constipation,  colicky  abdominal  pain  are  common  symptoms. 


GASTROPTOSIS.  951 

Persistence  of  the  ptosis  and  obstruction,  eventually  causing  chronic  gas- 
tritis and  distinct  dilatation  as  well,  will  give  rise  to  the  symptoms  char- 
acteristic of  these  conditions.  Symptoms  due  to  ptosis  of  the  liver,  kidneys, 
and  transverse  colon  are  usually  coexistent. 

Physical  Signs. — Marked  relaxation  and  thinning  of  the  abdominal 
walls  may  be  evident.  If  the  patient  lifts  his  head  and  shoulders  from  the 
couch,  "diastasis  recti"  can  often  be  easily  made  out.  Peristalsis  of  the 
stomach  or  intestine  is  readily  seen  between  the  two  flat  band-like  recti 
muscles.  If  much  flatulence  is  present  the  stomach  can  be  seen  outlined 
and  occupying  the  umbilical  region  or  even  reaching  into  the  pelvis,  the 
lesser  curvature  falling  as  low  as  the  umbilicus.  Palpation  shows  whether 
or  not  other  organs,  as  the  hver,  kidneys,  or  spleen,  are  displaced,  and  on 
"dipping"  whether  or  not  clapotage  is  present.  Palpable  peristalsis  is  not 
as  evident  as  in  true  obstructions,  though  the  pylorus  in  contraction  can 
frequently  be  made  out.  The  relaxation  and  thinning  of  the  abdominal  walls 
is  also  readily  appreciated  by  the  touch.  xA.uscultatory  percussion  yields 
gastric  tympany  practically  normal  in  outline  but  completely  displaced 
downward.  Inflation  gives  characteristic  results.  The  stomach  is  entirely 
displaced  downward;  the  cardiac  portion  stretched  downward;  the  lesser 
curvature  clearly  outlined  about  the  umbilicus  in  more  or  less  natural  rela- 
tionship to  the  greater.  The  stomach  may  show  but  little  or  no  evidence 
of  dilatation.  The  test-meal  may  show  normal  acidity  of  the  gastric  juice 
and  normal  amount  of  free  HCl  or  hyperacid,  hypoacid,  or  anacid  juice. 
There  is  usually  some  degree  of  retention  and  evidence  of  poor  action  of 
the  gastric  muscles,  the  bread  or  material  used  not  being  well  minced  or 
digested.  Mucus  may  or  not  be  present.  The  passage  of  food  from  the  stom- 
ach, and  absorption  are  delayed,  as  can  be  demonstrated  by  the  potassium 
iodide  test. 

The  X-ray  examination  is  an  important  aid  in  the  diagnosis  of 
gastroptosis. 

Diagnosis. — Direct. — Gastric  and  neurasthenic  symptoms,  displace- 
ment of  liver  and  kidneys,  relaxed  abdominal  walls,  presence  of  the  stom- 
ach in  an  abnormal^  low  area,  the  organ  remaining  more  or  less  normal 
in  size  and  shape,  the  lesser  curvature  in  the  usual  relation  to  the  greater, 
are  characteristic  of  the  condition. 

Differential. — Dilatation  of  the  Stomach. — Gastrectasis  and  gastrop- 
tosis often  coexist.  Symptoms  such  as  nausea,  copious  vomiting,  thirst, 
and  wasting  are  significant  of  dilatation.  So  also  are  visible  and  palpable 
peristalsis  and  the  signs  of  hypertrophied  musculature.  In  dilatation  the 
enlargement  principally  displaces  the  greater  curvature  downward,  the 
lesser  curvature  remaining  more  or  less  fixed  except  in  the  case  of  movable 
tumor  involving  the  pyloric  extremity.  The  gastric  contents  removed 
in  cases  of  dilatation  are  usualh' excessive,  300-600  c.c,  whereas  in  gastrop- 
tosis there  may  be  but  a  few  c.c.  more  than  normal. 

Prognosis. — A  markedly  prolapsed  stomach  probably  never  returns 
to  its  former  position.  Untreated  cases  usually  terminate  in  dilatation  or 
become  complicated  with  chronic  gastritis.  In  many  cases  a  surgical 
procedure  is  necessary  to  maintain  the  stomach  in  a  position  to  properly 
empty  itself. 


952  MEDICAL  DIAGNOSIS. 

II.    DISEASES  OF  THE  INTESTINES. 
i.  Enteritis. 

Inflammation  of  the  intestines.  Any  part  or  the  whole  of  the  gut  may 
be  involved.  There  are  important  clinical  and  pathological  distinctions 
between  inflammation  of  the  large  and  of  the  small  intestine. 

Catarrhal  Enteritis.- — Definition. — A  disordered  condition  of  the  small 
intestine  associated  with  increased  secretion  and  frequent  watery  or  soft- 
ened stools.  Abdominal  pain,  mucous  stools,  and  evidences  of  disordered 
intestinal   digestion  occur.     Acute  and  chronic  forms  are  described. 

Etiology. — Predisposing  Influences. — Certain  individuals  are  espe- 
cially liable  to  catarrh  of  the  bowels  as  a  result  of  either  dietetic  or  climatic 
conditions.  In  women  and  children  intestinal  catarrh  occurs  very  readily. 
Habitual  dietetic  errors  and  chronic  disease  predispose  to  the  develop- 
ment of  catarrhal  enteritis.  Exciting  Cause. — Frequent  attacks  of  acute 
enteritis  may  lead  to  a  chronic  catarrhal  condition.  Unwholesome  food, 
toxic  food  products,  certain  poisons,  as  arsenic  and  mercury,  nervous 
irritability,  gastric  disorders,  particularly  hyperacidity,  intestinal  affections, 
tubercular  ulceration,  enteric  fever,  excessive  use  of  purgatives,  and  sud- 
den changes  from  a  warm  to  a  cold  temperature  are  exciting  causes.  Vari- 
ations in  the  composition  of  the  intestinal  juices,  arising  independently 
or  due  to  lack  of  proper  stimulus  on  the  part  of  the  gastric  juice,  may  play 
an  important  part. 

Symptoms.  —  General  symptoms,  such  as  depression,  exhaustion, 
thirst,  anorexia,  nausea,  are  common  to  acute  and  chronic  enteritis. 
Wasting  occurs  very  rapidly  in  the  former,  and  may  be  accompanied 
by  fever. 

Abdominal  colic  is  more  common  in  acute  than  in  chronic  enteritis. 
It  is  apt  to  occur  shortly  after  eating  and  is  usually  referred  to  the  mid- 
abdomen.  Abdominal  tenderness  is  commonly  present.  In  the  chronic 
cases  pain  is  not  a  conspicuous  symptom. 

Diarrhoea  is  the  main  feature  of  the  disorder.  It  may  exist  as,  (a) 
frequent,  watery,  brownish  colored,  unoffensive  acid  movements,  well 
mixed  with  brownish  sago-like  soft  mucus.  The  absence  of  fetor  is  largely 
due  to  the  fact  that  time  for  fermentation  and  decomposition  is  lacking. 
Microscopical  examination  shows  excess  of  undigested  food  remnants. 
On  standing  such  stools  show  gas  formation  and  develop  an  intense  putre- 
factive odor.  This  particular  form  of  diarrhoea  usually  attends  the  acute 
cases,  (b)  Less  frequent  soft  mushy  stools,  often  distinctly  pale  and 
putty-like  (pultaceous  stools),  very  offensive  when  passed.  At  times  no 
undue  frequency  is  to  be  observed.  There  is  an  intimate  mixture  of  fine 
sago-like  mucus.  The  pallor  is  due  to  undigested  fat;  the  mucus  and  fine 
gas  bubbles  to  fermented  carbohydrates.  Microscopically,  undigested 
food  particles  are  abundant.  Fat  droplets,  fatty  acid  crystals^  soaps, 
starch,  meat  fibres  are  in  excess.  Bile-stained  epithelium  and  mucus  can 
be  seen.  The  reaction  is  intensely  acid.  Gas  production  occurs  on  stand- 
ing. Neither  occult  nor  gross  blood  is  to  be  detected  in  uncomplicated 
catarrhs. 


ENTERITIS.  953 

Fetor  of  the  breath  and  a  pasty  tongue  are  common.  In  thin  subjects 
visible  peristalsis  may  be  seen.  The  pulse  is  usually  slow.  The  urine  is 
diminished  in  amount  and  contains  indican,  very  frequently  also  albumin 
and  casts. 

Diagnosis. — Abdominal  pain  and  tenderness,  diarrhoea,  the  presence 
in  the  movements  of  fine  particles  of  bile-stained  mucus  and  excess  of  undi- 
gested food  are  significant.  Fermentation,  acidity  and  pallor  of  the  stool 
are  indicative  of  intestinal  catarrh.  Occult  or  gross  blood  would  indicate 
ulcerative  or  hemorrhagic  conditions.  Large  flakes  or  masses  of  mucus 
occur  in  membranous  enteritis.  Time  and  the  Widal  reaction  will  distin- 
guish the  cases  with  fever  from  typhus  abdominalis. 

Prognosis. — In  the  acute  cases  the  outlook  is  mostly  favorable. 
Repeated  attacks  of  acute  enteritis  may  end  in  the  chronic  form. 
Even  protracted  cases  occasionally  terminate  in  recovery. 

Phlegmonous  Enteritis. — Acute  suppurative  inflammation  of  the 
submucous  tissue  of  the  small  intestine,  occurring  anywhere  in  its  course, 
either  as  a  primary  disease  or  as  a  secondary  affection  in  various  intestinal 
accidents. 

I.  Primary  Phlegmonous  Enteritis. — A  disease  of  very  rare  occurrence. 
Etiology. — Predisposing  Influences. — We  know  nothing  of  the  conditions 
likely  to  induce  primary  phlegmonous  enteritis.  The  Exciting  Cause. — 
Acute  bacterial  infection  by  pyogenic  organisms,  usually  the  Streptococcus 
pyogenes  or  the  Bacillus  coli  communis.  Symptoms. — The  symptoms  are 
those  of  acute  peritonitis.  There  is  no  definite  classical  picture  of  the 
disease.  Diarrhoea  is  not  a  necessary  accompaniment.  Diagnosis. — The 
diagnosis  has  not  been  made  during  life.  Prognosis. — The  disease  is 
invariably  fatal. 

II.  Secondary  Phlegmonous  Enteritis.  —  A  condition  occurring  in 
connection  with  various  intestinal  disorders.  Embolism,  carcinomatous 
and  tuberculous  ulceration,  intussusception,  strangulation  may  be  com- 
plicated by  phlegmonous  enteritis.  Etiology. — Predisposing  Influences. — 
The  above  conditions  predispose.  Exciting  Cause. — Infection  by  pyogenic 
organisms  as  the  result  of  an  infected  embolus,  thrombosis,  extensive 
ulceration,  or  complete  obstruction  of  the  intestine  from  any  cause.  Symp- 
toms.— The  symptoms  are  those  of  the  primary  disorder  plus  those  of  peri- 
tonitis. There  are  no  distinguishing  features  of  the  disease.  Diagnosis. — 
The  symptoms  of  peritonitis  superadded  to  those  of  the  existing  intestinal 
condition  may  suggest  phlegmon  formation.  The  differentiation  between 
developing  phlegmonous  enteritis  and  peritonitis  is  not  possible.  The 
PROGNOSIS  is  lethal.  Recovery  from  phlegmonous  inflammation  does 
not  occur. 

Diphtheritic  Enteritis. — Definition. — An  inflammatory  disorder  of  the 
intestine,  usually  secondary,  associated  with  necrosis,  ulceration,  and  the 
formation  of  pseudomembrane.  Etiology. — Predisposing  Influences. — 
Chronic  diseases  predispose  to  the  affection.  Cancer,  Bright's  disease, 
cirrhosis  of  the  liver  may  be  especially  mentioned.  Diphtheritic  enteritis 
is  frequently  a  terminal  infection.  Exciting  Causes. — Acute  infections, 
as  enteric  fever  and  pneumonia,  and  certain  poisons,  as  mercury,  lead,  and 
arsenic,  are  among  the  exciting  causes. 


954  MEDICAL  DIAGNOSIS. 

Symptoms.— The  condition  may  exist  without  s3'mptoms.  Thirst, 
fetor  of  the  breath,  loss  of  appetite,  diarrhoea,  ill-defined  pain,  dryness  of 
the  skin,  and  wasting  are  sj^mptoms  when  the  lesions  are  in  the  small 
intestine,  tenesmus  and  diarrhoea  when  the  lower  bowel  is  involved.  The 
toxic  cases  usually  present  the  very  acute  symptoms.  The  chnical  picture 
of  the  primary  affection  may  completely  mask  the  intestinal  condition. 
Fever  maj'  or  ma}^  not  be  present.  The  disease  may  last  for  many  weeks. 
Indicanuria,  increased  sulphate  excretion,  and  albuminuria  are  common. 
The  faeces  are  not  characteristic.  Poor  digestion  of  all  elements  is  evident 
and  the  stools  may  be  pale  from  undigested  fat,  frothy  and  fermenting 
from  the  starch  remnants,  and  intensely  fetid  from  decomposing  pro- 
teids.  Unaltered  blood  and  pus  may  be  present.  Occult  blood  can 
usually  be  detected. 

Differential  Diagnosis  — Catarrhal  Enteritis. — The  symptoms  in  diph- 
theritic enteritis  are  more  urgent.  Severe  pain,  bloody  and  purulent 
mucoid  stools  suggest  diphtheritic  enteritis.  The  primarj'-  infection  or  the 
history  of  chronic  or  acute  poisoning  should  arouse  suspicion  as  to  the 
nature  of  the  intestinal  affection.  Membranous  or  Mucous  Enterocolitis. — 
Diphtheritic  enteritis  is  an  inflammatory  necrosing  disease  wdth  a  necrotic 
fibrinous  membrane  formation.  Mucous  enterocolitis  is  a  neurosis  asso- 
ciated with  but  transient  if  any  inflammation  and  an  increased  mucus 
formation.  Diphtheritic  enteritis  is  usually  a  grave  disorder  associated 
with  wasting  and  serious  symptoms;  mucous  enterocolitis  often  allows 
progressive  increase  of  weight  and  strength.  The  stools  of  the  latter  condi- 
tion are  usually  normal  fecal  material  plus  mucus.  Save  in  an  acute  attack 
blood  is  not  present. 

Prognosis. — Occurring  as  a  terminal  infection  in  chronic  disorders  diph- 
theritic enteritis  usually  ends  fatally.  In  the  acute  infections  the  primary 
disease  is  the  important  element  in  prognosis.  The  diphtheritic  enteritis 
following  the  administration  of  poisons  is  always  serious  and  often  fatal. 

ii.  Diarrhoeal  Disorders  of  Children. 

Definition. — Acute  and  chronic  disturbances  of  the  gastro-intestinal 
tract  in  infants,  associated  with  diarrhoea  and  various  clinical  and  patho- 
logical conditions.  They  are  usually  the  result  of,  (1)  disordered  digestion, 
(2)  absorption  of  toxic  products,  (3)  acute  infection. 

Etiology. — Predisposing  Influences. — Feeble  and  poorly  developed 
infants,  those  suffering  from  illness,  and  those  nursed  by  ailing  mothers 
are  especially  predisposed  to  intestinal  disorders.  The  change  from  breast 
to  artificial  feeding,  particularly  in  the  summer  months,  exposes  the 
intestinal  tract  to  infection  and  favors  the  absorption  of  toxins. 

Exciting  Causes. — Improper  food,  proteid  or  carbohydrate  excess, 
the  ingestion  of  milk  contaminated  by  bacteria  and  their  products,  and, 
finally,  a  specific  bacterial  dysenteric  infection  through  the  milk,  water,  or 
other  means,  are  the  exciting  causes.  The  dysentery  due  to  the  Shiga 
bacillus  and  allied  organisms  includes  a  great  number  of  cases  formerly 
considered  due  to  intestinal  decomposition  and  toxaemia — probably  the 
majority  of  the  so-called  summer  diarrhoeas. 


DIARRHCEAL  DISORDERS  OF  CHILDREN.  955 

Symptoms. — Several  forms  of  infantile  diarrhoea  are  recognized: 
(1)  dietetic,  (2)  toxic  and  bacterial,  (3)  inflammator}^,  (4)  chronic. 

1.  Dietetic.  Acute  Gastro=enteritis.  —  Fever,  rapid  pulse,  anorexia, 
restlessness,  crying,  are  initial  phenomena.  Convulsions  may  occur. 
Vomiting  and  diarrhoea  soon  ensue.  The  abdomen  is  distended,  and 
there  are  evidences  of  abdominal  pain.  The  vomitus  is  not  character- 
istic. The  stools,  six  to  twelve  or  more  in  the  twenty-four  hours,  are  brown, 
watery  at  first,  and  in  the  mild  cases  becoming  greenish,  offensive,  with 
green-brown  mucus  and  fragments  of  undigested  milk  or  food.  In  the 
more  severe  cases  there  is  an  increase  of  fever,  together  wdth  prostration 
and  diarrhoea  and  persistent  offensive  green  acid  stools.  The  common 
organisms  of  the  intestine  are  always  present  in  abundance. 

2.  Toxic  and  Bacterial  Diarrhoeas. — Infection  or  toxaemia  may  be 
superadded  to  the  dietetic  gastro-enteritis.  More  commonly  the  toxic  and 
bacterial  diarrhoeas  occur  independently,  following  the  ingestion  of  infected 
milk,  or  W-thout  evident  cause.  Cholera  Infantum. — The  onset  is  abrupt  and 
characterized  by  convulsions,  restlessness  or  stupor,  marked  prostrat  on, 
rapid  wasting,  and  all  the  evidences  of  a  severe  toxaemia  or  infection. 
The  temperature  rises  rapidly  to  104°-105°  F.  (40°-55°  C.) ;  thirst  is  pro- 
nounced, and  the  skin  is  clammy  and  turgid,  or  inelastic  and  shrivelled 
in  consequence  of  the  loss  of  fluids  by  the  bowel.  Death  may  ensue  in 
twenty-four  to  forty-eight  hours.  The  bowel  movements,  brownish  or 
greenish  at  first,  but  soon  becoming  gray  and  watery  with  abundant 
mucus  and  flocculi,  are  incessant.  There  is  little  or  no  odor  and  the 
reaction  is  alkaline.  Blood  and  pus  are  unusual.  The  Shiga  and  allied 
dysentery  bacilli,  together  with  other  organisms,  are  present  in  these  cases. 

3.  Inflammatory  Diarrticeas. — Either  of  the  preceding  forms  may  be 
followed  by  a  localized  ulcerative  dysenteric  ileocolitis,  or  the  condition 
may  be  inflammatory  from  the  start.  Even  though  digestion  and  absorp- 
tion may  be  little  affected,  the  inflammatory  and  ulcerated  condition  of  the 
lower  i'.eum  and  colon  gives  rise  to  fever,  pain,  tenesmus,  and  frequent 
bloody  or  mucopurulent  stools.  Free  pus  or  blood,  usually  from  the 
lower  part  of  the  colon,  may  be  passed.  The  odor  of  these  stools  is  not 
necessarily  offensive  and  the  fecal  remnants  may  show  a  fair  degree  of 
digestion.  The  various  dysentery  bacilli  and  the  Streptococcus  pyogenes 
are  frequently  found  in  these  cases.  Diphtheritic  or  membranous  entero- 
colitis is  a  common  sequel. 

4.  Chronic  Diarrhoea. — Repeated  attacks  of  dietetic  diarrhoea  may  lead 
to  chronic  catarrhal  enteritis.  The  inflammatory  ileocolitis  may  persist 
for  months.  Failure  to  gain  weight,  loss  of  appetite,  a  dry  wrinkled  skin, 
nervousness,  and  general  evidences  of  failing  nutrition  are  evident.  Per- 
sistent catarrh  of  the  upper  bowel  is  characterized  by  five  or  six  loose 
greenish  daily  movements,  offensive,  and  with  excess  of  mucus.  Undi- 
gested food  is  easily  detected.  Fermentation  from  the  carboh\-drates  may 
be  demonstrable.  The  putrid  odor  of  albuminous  decomposition  may  be 
recognized  if  the  protcids  are  poorly  digested.  In  chronic  ileocolitis  pain 
frequently  occurs  upon  defecation.  Mucus  persists  in  large  quantities. 
Blood  and  pus  may  be  absent.  The  stools  may  have  resumed  their  normal 
brown  yellow  color.     Dysentery  bacilli  are  found  in  some  of  these  cases. 


956  MEDICAL  DIAGNOSIS. 

Diagnosis. — In  most  instances  the  diagnosis  is  evident.  Cases  with 
persistent  fever  may  require  a  Widal  reaction  to  distinguish  them  from 
typhoid.  In  the  chronic  cases  the  tuberculin  test  may  help  to  exclude 
intestinal  tuberculosis.  Bacteriological  examination  of  the  stools  is  neces- 
sary to  differentiate  the  various  forms.  Serum  diagnosis  has  not  yielded 
positive  results. 

Prognosis. — In  the  dietetic  forms  with  careful  treatment  the  prognosis 
is  good.  The  acute  toxic  and  infectious  cases  have  always  a  grave  prog- 
nosis; only  the  strong  infants  survive.  The  prognosis  in  the  inflammatory 
diarrhoeas  is  likewise  grave.  If  the  infant  survive  the'  acute  attack  there 
is  always  the  probability  of  an  ensuing  chronic  ileocolitis. 

In  the  chronic  diarrhoeas  only  exceptional  cases  recover,  and  often 
only  after  months.  Many  cases  ultimately  die  of  inanition  or  some  acute 
terminal  infection. 

iii.  Ulceration  of  the  Intestines. 

1.  Ulceration  Restricted  to  the  5mall  Intestine. — (a)  Duodenal  Ulcer; 
Peptic  Ulcer. — Non-malignant  ulcer  of  the  duodenum  above  the  papilla  of 
Vater  and  of  the  same  nature  as  gastric  ulcer. 

Etiology. — Irregular  habits  in  regard  to  eating,  over-indulgence  in 
alcohol,  and  chronic  gastritis  with  hyperacidity  are  important  predisposing 
factors.  The  immediate  cause  is  obscure.  The  etiology  of  duodenal  ulcer 
is  the  same  as  that  of  gastric  ulcer,  and  the  two  conditions  are  frequently 
associated. 

The  ulcers  may  be  acute  or  chronic.  The  former  are  circular  or 
punched-out  and  more  or  less  superficial;  the  latter  often  funnel-shaped, 
with  thickened,  indurated,  and  sloping  borders.  Duodenal  ulcers  are 
mostly  near  the  pylorus  and  frequently  upon  the  anterior  wall  of  the  gut. 
Gradual  cicatrization  with  stenosis  and  dilatation  of  the  stomach,  obstruc- 
tion of  the  biliary  and  pancreatic  ducts,  hemorrhage  from  erosion  of  large 
arterial  trunks,  and  perforation  are  common. 

(b)  Peptic  Ulcer  of  the  Jejunum. — ^This  condition  occurs  after  gastro- 
jejunostomy, the  common  site  being  near  the  point  of  attachment  to  the 
stomach.  The  causes  are  the  same  as  those  which  lead  to  duodenal  peptic 
ulcer.  Hyperacidity  plays  an  important  role.  Perforation  may  occur 
with  circumscribed  or  general  peritonitis. 

Symptoms. — In  both  its  general  and  local  symptoms  duodenal  ulcer 
may  be  indistinguishable  from  gastric  ulcer.  Pain  is  less  common  in  duo- 
denal ulcer,  and  is  apt  to  be  late,  occurring  three  to  five  hours  after  eating. 
It  is  referred  to  the  right  hypochondrium.  Vomiting  and  dyspeptic  symp- 
toms are  less  frequent.  Hasmatemesis  may  never  occur,  the  blood  being 
passed  entirely  by  the  bowel.  Such  hemorrhages  and  the  resultant  anaemia 
may  be  the  only  symptoms  at  first  of  deep  ulceration.  There  may  be 
an  acutely  locaHzed  painful  area  as  in  gastric  ulcer.  The  test-meal  shows 
nothing  more  than  in  gastric  ulcer.  Inflation  and  other  modes  of  exam- 
ination show  nothing  distinctive. 

Diagnosis. — Sudden  hemorrhage  from  the  bowel  (tarry  stools)  or 
persistent  evidence  of   blood  in  the  stools  by  chemical  test  (occult  blood), 


ULCERATION  OF  THE  INTESTINES.  957 

rapid  or  slowly  progressive  anaemia,  pain  in  the  right  hypochondrium, 
occurring  some  hours  after  eating,  justify  the  suspicion  of  duodenal  ulcer. 
A  positive  diagnosis  may  be  impossible. 

Differential  Diagnosis. — Gastric  hyperacidity  with  pyloric  spasm 
and  gastralgia  are  to  be  considered.  The  occurrence  of  hemorrhage, 
gross  or  occult,  anaemia,  and  the  subsequent  changes  due  to  narrowing  of 
the  duodenum  are  important.  In  gall-stone  disease,  jaundice,  the  absence  of 
blood  in  the  faeces,  and  the  paroxysmal  character  of  the  pain  are  suggestive. 

(c)  Duodenal  Ulceration  Following  Extensive  Burns  of  the  Skin. — ^This 
form  of  intestinal  ulceration  occurs  in  about  6  per  cent,  of  all  fatal 
burns.  The  ulcers  may  be  single  or  multiple,  but  rarely  exceed  six  in  num- 
ber. The  usual  site  is  in  the  horizontal  portion  of  the  duodenum.  They 
are  long,  narrow,  and  irregular  in  outline  and  commonly  superficial.  They 
have  been  found  as  early  as  the  second  day  and  as  late  as  the  third  week, 
but  most  frequently  about  the  end  of  the  first  week.  They  are  more  com- 
mon in  burns  of  the  trunk  than  of  the  limbs,  and  in  females  than  males. 

Various  hypotheses  have  been  advanced  to  explain  the  restriction  of 
this  form  of  ulceration  to  the  duodenum.  Hunter  assumes  that,  as  a  result 
of  the  impairment  of  function  of  the  skin,  toxic  substances  capable  of 
causing  ulceration  of  the  duodenal  mucous  membrane  are  excreted  with 
the  bile.  Embolism  of  the  duodenal  arteries  and  destruction  of  the  anti- 
ferments  in  the  mucous  cells,  with  impairment  of  resistance  to  the  digestive 
power  of  the  gastric  juice,  are  other  explanations. 

2.  Ulceration  Peculiar  to  the  Large  Intestine. — (a)  Stercoral  ulcera- 
tion of  the  sigmoid  flexure  or  colon,  due  to  pressure  of  impacted  faeces, 
(b)  Dysenteric  ulceration. 

3.  Ulcerative  Conditions  Occurring  in  both  Small  and  Large  lntes= 
tines  include  tuberculous,  malignant,  syphilitic,  thrombotic,  embolic, 
and  simple  follicular  ulceration. 

The  ulceration  of  enteric  fever  is  fully  considered  in  the  section  on 
the  Infectious  Diseases. 

Etiology. — Predisposing  Influences. —  Any  exhausting  condition 
and  old  age  favor  the  development  of  simple  ulceration.  Tuberculous 
or  malignant  ulceration  may  be  primary  or  secondary. 

Exciting  Cause. — Pressure  of  the  impacted  faeces  is  the  exciting 
cause  in  stercoral  ulcer.  The  swallowing  of  tubercle  bacilli  in  the  sputum 
or  food  is  the  cause  of  primary  tuberculous  ulceration.  The  local  deter- 
mining cause  of  syphilitic,  malignant,  and  many  thrombotic  ulcerations 
is  unknown.  Embolic  ulceration  follows  the  blocking  of  arterial  twigs 
in  the  intestinal  wall.  The  exciting  cause  of  simple  follicular  ulceration 
is  often  an  acute  toxic  enterocolitis,  an  unchecked  diarrhoea,  or  persistent 
gastro-intestinal  abuse.  Syphilitic  and  tuberculous  ulceration  are  con- 
sidered in  the  section  on  the  diagnosis  of  the  specific  infectious  diseases. 

Symptoms. — General  symptoms  ar3  wasting,  anaemia,  thirst,  and, 
in  tuberculous  and  syphilitic  ulceration,  slight  fever.  Subnormal  tempera- 
ture is  more  frequent.  The  symptoms  of  an  associated  neoplasm  or  obstruc- 
tion are  to  be  considered. 

A  prominent  symptom  is  persistent  diarrhoea,  usuall}^  painless  if  the 
ulceration  is  in  the  small  intestine,  attended  with  pain  and  tenesmus  when 


958  MEDICAL  DIAGNOSIS. 

it  involves  the  large  bowel.  Abdominal  tenderness  is  generally  present. 
Mucus,  pus,  and  visible  blood  may  be  present  in  large  quantities  when 
the  affection  is  in  the  colon.  Thin  watery  movements  are  suggestive  of 
small  intestinal  ulceration.  Occult  blood  and  excess  of  undigested  food 
are  usually  demonstrable  in  the  stools.  Normal  digestion  of  food  sub- 
stances may  be  but  little  interfered  with  even  when  the  process  is  in  the 
small  bowel,  and  the  examination  of  the  faeces  may  fail  to  show  excess  of 
food  remnants.     Ulceration  in  the  ileum  may  be  unattended  by  diarrhoea. 

Physical  Signs. — A  scaphoid  abdomen,  palpable  thickening  of  the  trans- 
verse colon,  visible  peristalsis,  tenderness  or  pain  on  pressure,  particularly 
along  the  course  of  the  large  bowel,  in  some  cases  complete  absence  of  tym- 
pany may  be  observed.  The  physical  signs  of  a  neoplasm  may  coexist. 
Direct  inspection  of  the  sigmoid  and  descending  colon  may  show  the  ulcer- 
ating area  and  is  often  the  only  positive  proof  of  the  existence  of  colonic  ulcer. 

Diagnosis. — Direct.  —  No  combination  of  symptoms  is  conclusive 
evidence  of  ulceration.  Detection  by  means  of  the  Kelly  tubes  is  of  course 
final.  The  distinction  of  the  various  forms  of  ulceration  may  be  impossible 
without  direct  inspection  of  the  ulcerated  area.  Clinically  the  course  of 
stercoral  and  follicular  ulcers  is  usually  favorable  after  the  removal  of  the 
cause;  that  of  malignant  and  tuberculous  ulcerations  unfavorable.  Ster- 
coral ulcers  are  large,  few  in  number  or  single,  clean  cut,  show  little  or  no 
induration  or  inflammatory  reaction.  Follicular  ulcerations  are  apt  to  be 
numerous,  small,  and  distinctly  outlined.  Considerable  inflammation  of 
surrounding  tissue  is  usually  present.  Malignant  ulceration  is  usually 
attended  by  considerable  infiltration  of  adjacent  tissues.  Scrapings  from 
the  surface  may  show  characteristic  microscopical  findings.  Tuberculous 
ulceration  of  the  lower  bowel  is  unusual.  The  tuberculous  ulcer  is  dis- 
tinctly marked;  tubercles  may  be  seen.  Scrapings  may  show  tubercle 
bacilli,  giant  cells,  or  characteristic  microscopical  tubercles.  Amoebae  coli 
are  present  in  the  faeces  in  the  ulceration  of  amoebic  dysentery. 

Differential. — Acute  and  Chronic  Intestinal  Catarrh. — The  persist- 
ence of  the  symptoms,  the  more  marked  wasting,  anaemia,  and  cachexia 
suggest  ulceration.  Direct  examination  by  means  of  specula  affords,  in 
many  cases,  the  only  sure  means  of  differentiation.  The  presence  of 
small  tissue  fragments  in  the  faeces  is  evidence  of  ulceration.  Occult 
blood  may  be  present  in  both  conditions.  The  Intestinal  Neuroses. — The 
more  serious  general  symptoms,  the  presence  of  blood,  mucus,  and  pus, 
and  direct  examination  of  the  bowel  are  of  diagnostic  value. 

Prognosis. — The  outlook  is  usually  favorable  in  stercoral  and  follic- 
ular ulceration.  The  course  of  malignant  and  tubercular  disease  of  the 
bowel  is  usually  uninfluenced  by  treatment.  The  prognosis  in  syphilitic, 
thrombotic,  and  embolic  ulcerations  is  uncertain.  The  majority  of  such 
conditions  are  only  recognized  post  mortem. 

iv.  Intestinal  Stenosis  and  Obstruction. 

Narrowing  and  occlusion  of  the  lumen  of  the  intestine  due  to  a  variety 
of  causes,  and  occurring  anywhere  in  the  course  of  the  bowel  from  the 
pylorus  to  the  rectum. 


INTESTINAL  STENOSIS  AND  OBSTRUCTION.  959 

1.  Stenosis  or  Incomplete  Obstruction. — Etiology. — Predisposing 
Influences. —  Previous  acute  inflammatory  conditions  and  malignant 
disease  are  the  most  important.  Women,  for  obvious  reasons,  are  espe- 
cially predisposed  to  intestinal  stenosis;  their  greater  liability  to  enterop- 
tosis  also  increases  their  liability  to  stenosis  from  the  kinking  or  twisting 
of  misplaced  intestines. 

Exciting  Causes. — The  direct  causes  are  many  and  may  be 
enumerated  according  to  the  location  of  the  narrowing.  In  the  small 
intestine  the  cicatrices  of  duodenal  ulcers,  gall-bladder  and  common  bile- 
duct  disease,  diseases  of  the  head  of  the  pancreas,  cancer  of  the  duodenum, 
jejunum,  or  ileum,  omental  and  peritoneal  adhesions,  and  accidents,  as 
hernia,  adhesions  or  compression  caused  by  new  growths,  and  involvement 
of  the  gut  in  inflammatory  diseases  of  the  appendix  or  pelvic  organs  are 
the  most  common  causes.  In  the  large  intestine  peritoneal  and  appen- 
dicular adhesion,  adhesions  to  the  gall-bladder,  adhesions  to  and  com- 
pression by  pelvic  tumors  are  common  causes  of  stenosis.  Cicatricial 
narrowing  following  dysenteric  and  stercoraceous  ulceration  is  an  occa- 
sional cause.  Tuberculous  ulceration  of  the  large  bowel  is  less  often  followed 
by  stenosis,  while  syphilis  of  the  rectum,  with  ulceration  and  resulting 
narrowing,  is  a  frequent  cause.  Cancerous  invasion  of  the  rectum  and  sig- 
moid flexui'e  is  one  of  the  most  common  causes  of  intestinal  stenosis. 

Symptoms. — General. — General  symptoms  in  intestinal  stenosis  may 
depend  upon  the  cause  more  than  upon  the  narrowing  of  the  bowel. 
Anaemia,  wasting,  and  loss  of  appetite  occur  early  in  cancerous  stricture 
and  in  tuberculous  and  syphilitic  disease,  whether  the  stenosis  is  of  extreme 
grade  or  not.  In  the  mechanical  stenosis  due  to  pressure  and  adhesions, 
unless  they  are  near  enough  to  the  stomach  to  cause  early  dilatation 
and  vomiting,  wasting  may  not  occur  and  anaemia  may  be  long  absent. 
Mental  and  physical  depression  are  usually  marked  in  persistent  stenosis. 
Thirst  is  a  common  symptom;    oliguria  occurs. 

Local  Symptoms. — ^The  situation  is  important.  The  fluid  contents 
of  the  upper  bowel  may  be  easily  forced  through  an  opening  which  would 
be  occluded  or  readily  obstructed  by  the  solid  faeces  of  the  lower  bowel. 
Stenosis  above  the  ileum  sooner  or  later  produces  a  dilatation  of  the 
stomach  with  marked  local  gastric  symptoms.  Stenosis  in  the  colon  is 
likely  to  be  attended  by  constipation,  a  symptom  not  common  in  narrow- 
ing at  a  higher  level.  Finally,  tenesmus  and  intensely  painful  muscular 
contractions  are  limited  to  stenoses  of  the  large  bowel. 

Stenosis  of  the  Duodenum  and  Jejunum. — Distention  after  eating, 
eructations,  gradually  increasing  and  persistent  nausea,  and  finally  vomit- 
ing are  common  local  symptoms.  Persistent  biliary  vomiting  suggests 
stenosis  below  the  papilla  of  Vater,  while  symptoms  of  disturbed  hepatic 
and  pancreatic  function  occur  when  the  common  and  pancreatic  ducts 
are  involved  in  the  lesion  causing  obstruction.  Painful  contractions  of 
the  intestine  are  not  usual  in  stenosis  of  the  upper  parts  of  the  small  intes- 
tine. The  vomitus  is  that  of  gastric  dilatation;  it  is  not  fecal.  Bile  is 
present  under  the  conditions  just  mentioned.  Pancreatic  ferments  maj' 
be  recognized.  Blood  tests  may  be  positive  if  ulceration  exists.  The 
faeces  are  not  distinctive.     Associated  occlusion  of  the  bile  and  pancreatic 


960  MEDICAL  DIAGNOSIS. 

ducts  may  show  unabsorbed  fat  and  undigested  proteids,  and  carbohy- 
drates in  excess.    Blood  tests  will  be  positive  if  there  is  ulceration. 

Stenosis  of  the  Ileum. — Distention  following  the  intake  of  food  is  less 
common.  The  stomach  is  not  usually  dilated.  Nausea  and  vomiting 
of  gastric  and  intestinal  contents  occur,  but  not  continuously.  Stenosis 
situated  low  in  the  ileum  may  be  associated  with  a  slightly  fecal  smelling 
vomitus.  Painful  contractions  of  the  bowel  do  not  often  occur,  but  in 
some  cases  persistent  crampy  pain  with  moderate  distention  is  the  only 
symptom.  Many  ileal  stenoses  never  reveal  themselves  till  a  sudden 
occlusion   produces   an   acute    obstruction. 

Stenosis  of  the  Large  Bowel. — Distention  of  extreme  degree  may  be 
present,  particularly  if  the  stenosis  is  very  low.  Constipation  is  the  rule, 
or  constipation  alternating  with  diarrhoea.  Vomiting  occurs  occasionally, 
but  is  only  fecal  when  it  has  persisted  for  some  hours  and  acute  obstruc- 
tive symptoms  have  supervened.  Tenesmus  and  painful  muscular  con- 
tractions of  a  periodic  type  are  characteristic  of  lower  bowel  stenosis. 
With  ulceration  blood  is  present  in  the  faeces.  There  is,  however,  no 
characteristic  stool  in  stenosis  of  the  lower  bowel. 

Physical  Signs. — Inspection. — The  existence  of  ansemia  and  cachexia, 
and  wasting  are  to  be  noted.  Marked  distention  is  often  apparent 
in  stenosis  of  the  large  bowel.  Stenosis  of  the  small  bowel  is  less  apt 
to  give  rise  to  extreme  distention.  A  distended  stomach  may  be 
apparent  in  cases  of  duodenal  stenosis.  Inspection  frequently  shows  a 
tense  intestinal  tube  (intestinal  rigidity)  or  several,  one  above  the  other 
(ladder  pattern),  and  these  rigid  distended  parts  may  further  show 
energetic  peristaltic  movements  running  up  to  and  ending  in  the  obstruc- 
tion and  sometimes  bringing  a  stenosing  tumor  into  view.  The  colon  or 
its  sigmoid  flexure  may  be  clearly  outlined.  The  latter  may  occupy  the 
whole  abdomen.  Inspection  may  also  reveal  tumors,  a  protruding  hernia, 
fulness  in  the  hernial  tracts^  and  the  scars  of  abdominal  operations  which 
suggest  adhesions  or  constricting  bands.  Palpation. — The  rigidity  of 
an  intestinal  tube  above  a  stenosis  is  easily  appreciated.  Peristalsis  with 
muscular  hypertrophy  and  a  stenosing  tumor  of  the  bowel  may  be  felt. 
Abdominal  tumor,  hernia,  adherent  scars,  and  the  like  can  be  readily 
examined.  Percussion  is  of  limited  value.  Auscultation,  beyond 
allowing  us  to  hear  fluids  trickling  through  an  aperture  and  to  conclude 
that  it  is  still  patent,  does  not  afford  any  aid  in  diagnosis. 

Inflation  of  the  stomach  in  the  endeavor  to  determine  duodenal  steno- 
sis gives  no  clear  result.  Inflation  of  the  large  bowel  may,  in  thin  subjects, 
reveal  a  stenosis  in  the  upper  part  of  the  sigmoid  flexure.  Stenosis  of  the 
descending  colon  or  transverse  colon  may  become  evident,  but  as  a  general 
rule  the  natural  distention  above  the  stenosis  is  more  distinctive.  Rectal 
examination  in  intestinal  stenosis  may  reveal  the  occluding  mass  of  a  pel- 
vic tumor,  narrowing  of  the.  anus  and  lower  rectum  due  to  stricture,  or 
the  rough,  hardened,  ulcerating  edges  of  a  malignant  growth.  Vaginal 
examination  may  at  times  reveal  palpable  tumors  or  stenosing  condi- 
tions in  the  pelvis  or  adjoining  intestines.  Proctoscopic  and  sigmoido- 
scoPic  examination  will  show  the  presence  of  stenosing  conditions, 
cicatrizing  ulcers,  syphilitic  or  fibroid  stricture,  or  the  narrowing  of  the 


INTESTINAL  STENOSIS  AND  OBSTRUCTION.  961 

intestinal  tube  from  outside  pressure.  The  X-rays  after  bismuth  injec- 
tion or  ingestion  may  yield  important  diagnostic  facts.  A  well-outlined 
sigmoid  or  colon  may  show  acute  kinking,  a  tumor,  or  constriction 
preventing  the  passage  of  the  bismuth  beyond  a  certain  point  even 
after  many  hours.  Less  accurate  information  must  be  expected  in 
stenosis   of  the  small   intestine. 

Diagnosis. — Direct. — Distention,  abdominal  pain,  cramp-colic,  tenes- 
mus, constipation,  or  alternating  diarrhoea  suggest  stenosis  of  the  large 
bowel.  Persistent  gastric  symptoms  and  gastrectasis,  recurrent  vomiting 
with  no  evidence  of  pyloric  tumor  or  pyloric  obstruction,  and  continuous 
biliary  vomiting  direct  attention  to  the  small  bowel  as  the  seat  of  trouble. 
The  recognition  of  an  intestinal  tumor,  the  appearance  of  intestinal  rigidity, 
intestinal  patterns,  visible  peristalsis,  and  visible  and  palpable  muscular 
hypertrophy  make  the  diagnosis  sure.  Fecal  vomiting,  which  usually 
indicates  that  the  condition  has  passed  from  stenosis  to  complete 
obstruction,  localizes  the  obstruction  a  very  short  distance  either  above 
or  below  the  ileocsecal  valve. 

Differential. — Nervous  Dyspepsia,  Nervous  Flatulence  and  Vomiting, 
Enteralgia. — Gastric  dilatation  as  seen  in  duodenal  stenosis,  intestinal 
rigidity,  intestinal  patterns,  and  visible  and  palpable  intestinal  peristalsis 
do  not  occur  in  the  neuroses.  Vomiting  in  the  neuroses  is  easy, 
is  apt  to  occur  immediately  after  eating,  and  the  vomitus  is  usually 
undigested,  odorless  food.  General  symptoms  with  the  exception  of  wast- 
ing are  less  marked.  Lead  Colic. — ^The  diagnosis  may  be  impossible,  since 
temporary  stenosis  undoubtedly  takes  place  during  the  spasmodic  con- 
traction. Marked  anaemia,  with  the  early  symptoms  of  intestinal  disorder, 
and  a  blue  line  on  the  gums  may  be  the  only  distinguishing  features. 
Persistent  Vomiting  of  Alcoholism,  Locomotor  Ataxia,  Gastroxynsis. — In  these 
conditions  the  general  symptoms  are  practically  absent.  The  history  is 
different,  and  in  tabes  characteristic  ocular  and  nervous  phenomena  are 
present.  The  vomitus  in  these  conditions  consists  of  mucus  and  a  watery 
gastric  secretion,  and  never  contains  food  remnants  or  has  a  fecal  odor,  no 
matter  how  persistent  and  profuse  it  may  be.  Distention  of  the  Intes- 
tines (Paretic  Distention)  of  Acute  Fever;  Idiopathic  Dilatation  of  the  Colon. 
— In  these  conditions  stenosis,  pain,  coHc,  complete  constipation,  and 
vomiting  are  absent,  though  faint  visible  peristaltic  and  intestinal  pat- 
terns may  sometimes  be  seen.  Obstruction  hypertrophy  and  palpable 
muscular  contraction  do  not  occur. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  stenosis. 
Cancerous  stenosis,  unless  a  diagnosis  has  been  made  in  time  to  allow 
resection,  is  fatal.  Any  simple  stenosis  may  terminate  suddenly  in  a  fatal 
obstruction,  but  the  majority  can  be  reheved  by  operation. 

2.  Complete  Obstruction. — Many  chronic  stenoses  end  in  acute 
obstruction.  Various  accidents,  strangulation,  twistings  of  the  bowel, 
volvulus,  etc.,  produce  the  same  results — complete  occlusion  of  the 
bowel,  the  retention  of  flatus  and  intestinal  contents,  and  the  sudden 
development  of   serious  symptoms. 

Etiology. — Predisposing  Causes. — Chronic  Stenosis. — Bands  of  adhe- 
sion and  open  hernial  canals  constitute  predisposing  factors. 

61 


962  MEDICAL  DIAGNOSIS. 

Exciting  Causes. — Excesses  at  table  or  accumulation  of  the  residua 
of  coarse  food  or  of  other  material  may  suddenly  block  the  narrowed  gut. 
Twisting  of  the  bowel,  various  hernial  accidents,  and  intussusception 
are  immediate  causes.  The  settling  of  a  large  pelvic  tumor  is  a  not 
uncommon  direct  cause  of  acute  obstruction.  Foreign  bodies,  gall-stones, 
accumulation  of  parasites,  and  impaction  of  faeces  are  also  direct  causes. 
Almost  any  acute  abdominal  inflammation  may  give  rise  to  acute 
obstruction. 

Symptoms. — The  general  symptoms  are  marked  and  severe.  In  simple 
stenosis,  so  long  as  a  narrowed  opening  remains  patent,  general  symp- 
toms may  be  absent.  Large  collections  of  fecal  material  may  accumulate 
without  causing  marked  discomfort,  but  the  moment  the  obstruction 
becomes  complete  serious  symptoms  supervene.  Rise  in  the  pulse- 
rate,  increased  vascular  tension,  slight  elevation  of  temperature  followed 
by  the  signs  of  prostration  and  collapse,  pallor,  sweating,  facies  abdom- 
inalis,  thready  pulse,  and  shallow  respiration  constitute  a  symptom-com- 
plex at  once  alarming  and  significant.  Thirst  and  oliguria  are  constant, 
intense  grinding  pain,  eructations,  nausea,  and  persistent  vomiting,  at  first  of 
gastric  juice,  later  of  gastric  fluid  commingled  with  bile  or  intestinal  con- 
tents and  bile,  and,  when  the  obstruction  is  below  the  ileocsecal  valve,  of 
distinctly  fecal  material,  speedily  occur.  The  vomitus  in  obstruction  of  the 
lower  ileum  may  have  a  faintly  fecal  odor.  Distention  is  a  constant  phe- 
nomenon and  is  more  marked  the  lower  the  obstruction.  Volvulus  and 
intussusception  may  be  accompanied  by  the  passage  of  blood,  and  in  sigmoid 
obstruction  tenesmus  with  bloody  mucous  discharges  occur.  Neither  faeces 
nor  flatus  are  passed  per  rectum.  In  unrelieved  cases  peritonitis  rapidly 
develops  with  intestinal  paresis,  generalized  pain,  and  marked  meteorism. 

Diagnosis.  —  Direct.  —  Grave  general  symptoms,  abdominal  pain 
with  intense  exacerbations,  tenesmus,  nausea,  eructations,  persistent 
vomiting  eventually  becoming  of  a  fecal  character,  absolute  failure  to 
pass  flatus  and  faeces,  distention,  intestinal  patterns,  rigidity,  and  tumefac- 
tion of  the  intestine  as  the  contraction  reaches  the  obstruction  are  the 
main  diagnostic  features.  Changes  in  the  urine  such  as  the  appearance  of 
excess  of  sulphates  (indican)  are  not  diagnostic.  Leucocytosis  is  not 
constant  and  therefore  not  an  important  diagnostic  feature. 

Differential. — There  are  but  few  conditions  which  simulate  acute 
obstruction.  Thrombosis  of  the  mesenteric  vessels,  acute  pancreatitis,  and 
acute  enteritis  with  relaxation  of  the  intestinal  coils,  pain,  and  vomiting, 
may  be  mentioned.  The  absence  of  intestinal  patterns,  rigidity,  and  visible 
and  palpable  peristalsis  are  of  value  in  differentiating  these  conditions 
from  acute  obstruction  in  cases  seen  prior  to  the  development  of  peri- 
tonitis and  paralytic  distention.  Acute  appendicitis  with  peritonitis  may 
closely  resemble  acute  obstruction.  A  history  of  attacks  of  pain  in  the 
region  of  the  appendix  is  often  obtained.  The  diagnosis  may  be  difficult. 
Spontaneous  relief  is  rare.  Early  surgical  intervention  is  imperative. 
In  neglected  cases  death  ensues  in  the  course  of  three  to  six  days. 

Obstruction  of  the  large  bowel  from  accumulation  of  hardened  faeces 
is  rarely  complete.  Fecal  obstruction  can  be  differentiated  from  stenosis 
due  to  other  causes  by  the  recognition  of   the  accumulated  masses,  the 


DILATATION  OF  THE  INTESTINES.  963 

comparative  mildness  of  the  general  and  local  symptoms,  the  absence  of 
marked  visible  and  palpable  intestinal  peristalsis,  and  the  relief  afforded 
by  judicious  therapeutic  measures. 

V.  Dilatation  of  the  Intestines — Idiopathic  Dilatation  of 

the  Colon. 

Definition. — Chronic  dilatation  of  the  colon  and  sigmoid  flexure,  not 
due  to  stricture  or  accumulation  of  faeces. 

Etiology. — Predisposing  causes  are  unknown.  A  history  of  chronic 
constipation  is  usually  obtained.  The  condition  usually  occurs  in  quite 
young  persons  and  children.  The  pseudocyesis  of  middle-aged  women 
depends  largely  upon  dilatation  of  the  colon  and  sigmoid  flexure. 

Exciting  Causes. — Fecal  accumulation  plus  paretic  distention  of  the 
bowel  occurring  repeatedly  produces  the  condition.  Spasmodic  contraction 
of  the  rectum  must  coexist.  Idiopathic  dilatation  due  to  structural 
abnormalities  is  a  probable  cause. 

Symptoms. — The  general  health  may  be  but  little  affected.  Acute 
symptoms  rarely  occur.  Extreme  distention  gives  rise  to  respiratory  and 
cardiac  oppression.  Constipation  is  the  rule,  but  diarrhoea  occurs.  The 
most  prominent  symptom  is  distention.  Pain,  colic,  and  obstructive 
symptoms  are  absent.  The  distress  that  accompanies  distention  of  the 
small  intestine  is  not  observed  in  idiopathic  dilatation  of  the  colon.  Enor- 
mous distention  of  the  abdomen,  thinning  of  the  abdominal  walls,  the 
presence  of  linese  atropicae,  and  glazing  of  the  skin  are  seen.  With 
marked  wasting  of  the  abdominal  walls  the  outline  of  the  sigmoid  flexure 
rising  from  the  pelvis  and  reaching  to  the  costal  margin,  or  the  outline 
of  the  colon,  can  be  made  out.  Peristalsis  is  not  pronounced.  Palpation 
shows  the  distention  to  be  gaseous.  No  resistance  or  solidity  is  felt;  no 
fluctuation  wave  obtained.  Percussion  gives  a  marked  tympany  every- 
where, even  in  the  loins  up  to  the  base  of  the  lungs  behind,  and  often 
shows  an  obliteration  of  the  liver  dulness  in  front.  The  passage  of  a  soft 
rubber  tube  into  the  sigmoid  flexure  relieves  distention  by  allowing  the 
exit  of  air  and  shows  what  part  of  the  bowel  is  affected.  Reinflation 
through  the  tube  produces  a  gradual  ballooning  and  outlining  of  the  sig- 
moid or  colon.  Examination  by  means  of  the  speculum  shows  merely  the 
relaxed  condition  of  the  colon  when  the  air  is  expelled. 

Diagnosis. — Direct. — The  absence  of  serious  local  and  general  symp- 
toms, constipation,  extreme  chronic  distention  with  outlining  of  the  sigmoid 
or  parts  of  the  colon,  the  disappearance  of  distention  on  passing  the  rectal 
tube,  and  the  results  of  inflation  are  characteristic. 

Differential. — The  genera!  symptoms  and  the  relief  of  the  disten- 
tion by  the  tube  differentiate  dilatation  of  the  colon  horn  gastredasis. 
The  shape  and  position  of  the  stomach  are  radically  different.  Distention 
of  the  Small  Intestine  due  to  Obstruction  or  Paretic  Conditions  of  the  Mus- 
culature.— The  general  symptoms  of  disease  of  the  small  intestine  are  more 
marked.  Intestinal  patterns  are  smaller  and  more  numerous;  peristalsis 
(save  in  paretic  distention)  may  be  seen.  Distention  of  the  Large  Bowel 
due  to  Stricture,  Malignant  Growth,  etc. — The  distention  due  to  obstruction 


964  MEDICAL  DIAGNOSIS. 

is  associated  with  signs  of  associated  muscular  hypertrophy.  Visible  or 
palpable  active  peristalsis,  pain,  and  colic  are  common.  General  symp- 
toms rapidly  develop.  The  obstruction  can  often  be  recognized  by  the 
speculum  or  examining  finger,  or  upon  palpation  through  the  abdominal 
wall.  Fluid  Accumulations. — Bulging  of  the  flanks,  movable  dulness  on 
turning,  fluctuation  wave,  flatness  on  percussion  readily  distinguish  fluid 
accumulation  from  gaseous  distention. 

Prognosis. — The  disease  in  itself  is  rarely  fatal.  In  the  idiopathic 
cases  death  commonly  occurs  early  in  life.  General  treatment  has 
little  effect.  Removal  of  the  distended  sections  of  the  colon  and 
sigmoid    flexure    has    been    tried. 

vi.  Appendicitis. 

Definition. — Inflammation  of  the  vermiform   appendix. 

The  conception  of  appendicitis  is  a  modern  one,  dating  from  the 
studies  of  Reginald  Fitz  (1886).  It  includes  and  explains  the  facts  relat- 
ing to  foreign  bodies  in  the  appendix;  catarrhal,  diffuse,  purulent,  and 
necrotic  inflammation  of  that  organ;  ulceration,  gangrene,  cyst  formation, 
and  abscess  of  the  appendix;  chronic,  recurrent,  and  obliterative  inflam- 
mation; peri-appendicular  abscess,  typhlitis,  perityphlitis,  and  iliac  phleg- 
mon; and  local  and  general  peritonitis  having  its  starting-point  in  the 
ileocsecal  region. 

These  conditions  constitute  phases  in  the  evolution  of  a  single  proc- 
ess— appendicitis.     The  central  fact  is  infection  of  the  appendix. 

The  infection  may  be  a  local  manifestation  of  a  general  infection,  as, 
for  example,  influenza  or  pneumonia;  or  a  purely  local  process,  as  in  the 
case  of  foreign  bodies,  fecal  concretions,  the  extensions  of  an  inflammation 
from  the  caecum,  or  when  injury  to  the  appendix  results  from  strains  or 
blows;  and  finally  the  infection  may  be  associated  with  a  specific  local 
lesion  in  a  general  disease,  as  when  typhoid  ulceration  involves  the  lymph 
tissue  in  the  appendix.  Kelynak  (1903)  suggested  that  acute  appendicitis 
is  a  metastatic  inflammation  arising  from  a  distant  primary  focus  of 
infection.  Other  observers,  notably  Apolant  and  Kretz,  have  recently 
advanced  the  opinion  that  ''appendicitis  begins  as  a  metastatic  disease 
of  the  adenoid  tissue,  and  that  the  lymphatic  apparatus  of  the  throat 
and  nose  is  to  be  regarded  as  the  most  frequent  primary  localization  and 
portal  of  entry  of  the  infection."  The  recognition  of  the  unity  of  the 
process  under  varying  etiological  conditions  and  in  varying  clinicopatho- 
logical  manifestations  is  the  key  to  its  diagnosis  and  treatment. 

Etiology.  —  Predisposing  Influences.  —  Appendicitis  is  the  most 
important  and  one  of  the  most  common  of  the  acute  diseases  of  the  intes- 
tine. There  are  no  especial  causal  relations  connected  with  country,  race, 
social  conditions,  or  occupation,  save  that  it  has  been  held  that  those  whose 
occupations  involve  habitual  strain  and  heavy  lifting  suffer  more  com- 
monly than  others.  About  half  the  cases  occur  before  the  twentieth  year. 
It  is  rare  in  infancy  but  common  in  childhood  and  adolescence.  Cases 
have  been  observed  as  late  as  the  seventh  and  eighth  decades.  It  is  equally 
common  in  the  two  sexes.     The  symptoms  have  occasionally  followed  a 


APPENDICITIS.  965 

fall  or  blow  upon  the  abdomen.  Indiscretion  in  diet,  especially  over- 
eating, and  exposure  to  cold  and  fatigue  are  conditions  frequently 
mentioned  in  the  anamnesis.  The  acute  infections,  in  particular  influ- 
enza, pneumonia,  and  rheumatic  fever,  sometimes  are  attended  with  or 
followed  by  appendicitis.  A  majority  of  the  cases,  however,  arise  in 
ordinary  health  without  any  obvious  or  discernible  determining  cause. 
Two  or  three  cases  in  the  same  house  at  or  about  the  same  time  have 
occasionally  been  observed. 

The  Exciting  Cause. — Various  pyogenic  organisms  have  been  found 
in  the  early  lesions,  among  which  Bacterium  coli  communis  and  Strepto- 
coccus pyogenes  are  common.  A  lesion  of  the  mucosa,  caused  by  the  pres- 
ence of  a  foreign  body,  fecal  concretions,  retained  secretions,  or  traumatism, 
probably  constitutes  the  point  of  entrance  for  pathogenic  bacteria. 

Nature  of  the  Pathological  Process. — The  character  of  the  lesions  is 
determined  by  the  intensity  of  the  infection  and  the  reaction  of  the  tissues 
involved.  Broadly  speaking,  the  lapse  of  time  between  the  onset  of  the 
attack  and  the  condition  at  any  given  hour  has  a  most  important  bearing 
upon  the  anatomical  diagnosis;  that  is  to  say,  the  early  lesions  are 
relatively  simple  and  limited,  the  later  complex  and  extensive.  But  to 
this  rule  there  are  many  exceptions.  In  a  large  group  of  cases,  the  so- 
called  catarrhal  cases,  the  inflammation  runs  a  favorable  course,  resolu- 
tion takes  place  in  a  short  time,  and  in  a  few  days  the  patient  is  conva- 
lescent. But  the  recovery  is  by  no  means  always  complete  in  the  sense  of 
an  anatomical  restitutio  ad  integrarn.  The  inflammation  subsides  but  the 
appendix  remains  infected  and  lesions  of  a  chronic  and  progressive  nature 
persist- — infiltrations  of  the  mucosa  and  submucosa,  connective-tissue 
overgrowth,  local  atrophies  involving  especially  the  longitudinal  and  cir- 
cular muscular  fibres,  stricture-like  narrowings,  retained  secretions,  cyst 
formation,  angular  kinking,  adhesions,  and  other  deformities.  It  is  in  such 
cases  that  the  teasing  pains  known  as  appendicular  colic  occur,  in  which 
there  is  persistent  discomfort  and  frequent  tenderness  in  the  right  lower 
quadrant,  in  which  inflammatory  flare-ups  recur,  and  in  which  at  any 
time  necrosis,  perforation,  abscess  formation,  or  general  peritonitis  may 
suddenly  arise.  They  constitute  the  cases  of  so-called  recurrent  appendi- 
citis, an  unfortunate  and  misleading  term  since  this  form  of  the  disease 
is  in  point  of  fact  essentially  chronic  with  occasional  exacerbations — a 
smouldering  fire  with  now  and  then  an  ominous  puff  of  flame.  On  the 
other  hand  there  are  cases  in  which  the  symptoms  of  onset  are  urgent, 
and  necrosis  and  perforation  follow  in  the  course  of  a  few  hours.  Many 
of  the  cases,  however,  make  a  substantive  recovery  and  live  on  without 
subsequent  attacks.  Others,  which  constitute  a  large  proportion  of  all 
cases,  go  on  more  or  less  rapidly  from  bad  to  worse,  terminating  in  abscess 
formation  and  chronic  invalidism,  or  general  peritonitis  and  death. 

The  natural  history  of  appendicitis  is  indicated  in  the  following  table. 

The  course  of  the  attack  may  be  interrupted  and  in  a  majority  of  the 
cases  its  more  serious  events  and  unfavorable  terminations  arrested  by 
early  surgical  intervention. 

Symptoms. — The  significance  of  the  clinical  phenomena  becomes  more 
apparent  from  a  careful  consideration  of  the  following  pathological  data: 


966 


MEDICAL  DIAGNOSIS. 


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APPENDICITIS.  967 

Catarrhal  inflammation  of  the  appendix  may  be  acute,  subacute,  or 
chronic.  The  mucosa  is  slightly  involved,  being  s-wollen,  injected,  and 
the  seat  of  an  increased  secretion.  Inflammatory  thickening  may  cause 
retention  of  the  secretion  and  persistence  of  the  infection.  In  the  subacute 
form  symptoms  may  be  absent.  In  the  acute  form  they  are  of  variable 
intensity,  consisting  of  pain  and  tenderness  in  the  right  lower  quadrant  of 
the  abdomen,  together  with  loss  of  appetite,  nausea,  and  occasional  fever, 
which  is  usually  of  slight  intensity  and  brief  duration.  In  the  chronic  form 
there  is  persistent  tenderness  with  a  sense  of  thickening  upon  deep  palpa- 
tion, vague  and  often  intractable  gastro-intestinal  symptoms,  neurasthenia, 
and  in  some  instances  an  associated  mucous  colitis. 

Acute  diffuse  inflammation  is  more  common.  The  infection  extends 
from  the  mucosa  to  the  deeper  structures.  There  is  inflammatory  thick- 
ening and  hypersemia  which  involves  the  serous  investment.  Erosion  and 
ulceration  of  the  mucosa  are  common.  The  symptoms  are  more  severe 
than  in  the  acute  form  and  the  duration  of  the  attack  is  prolonged. 

Acute  suppurative  inflammation  may  supervene.  There  may  be 
purulent  infiltration  of  the  wall  of  the  organ,  or  the  lumen  may  be  occluded 
so  that  the  pus  distal  to  the  stricture  forms  an  abscess  cavity.  The  symp- 
toms are  now  more  severe  and  a  mass  may  be  felt  through  the  abdominal 
wall.  An  extension  of  the  purulent  infection  or  a  small  perforation  may 
be  followed  by  peri-appendicular  suppuration  and  cause  a  distinct  fluc- 
tuating tumor.  Septic  phenomena  are  often  present,  as  irregular  fever, 
sweating,  rapidly  developing  anaemia,  and  gastro-intestinal  symptoms, 
especially  nausea  and  vomiting.  In  many  of  the  cases,  however,  these 
symptoms  do  not  occur.     Fever  in  particular  may  be  wholly  absent. 

Ulceration  may  follow  catarrhal  or  diffuse  inflammation  and  cause 
more  or  less  extensive  subacute  local  peritonitis  with  adhesions.  More 
rarely  it  may  cause  perforation  with  abscess  formation.  The  lesion 
advances  slowly  and  is  far  less  likely  than  gangrene  to  cause  general 
peritonitis.  There  are  no  special  symptoms  of  ulceration  other  than  those 
■due  to  the  subacute  circumscribed  adhesive  peritonitis  which  it  causes, 
namely,  local  pain,  tenderness,  rigidity,  and  a  more  or  less  well-defined 
tumor  mass. 

Gangrene  is  common.  It  may  occur  in  the  course  of  a  few  hours  after 
the  symptoms  of  onset.  In  a  case  in  which  pain  was  first  felt  after  the  bath 
at  eight  in  the  morning,  the  whole  appendix  was  found  necrotic  upon 
operation  at  five  in  the  afternoon.  Instances  of  this  kind  are  by  no 
means  exceptional.  More  commonly  gangrene  takes  place,  in  unrecognized 
cases  or  those  in  which  operation  is  refused,  in  two  or  three  days  or  later. 

The  necrotic  process  may  involve  the  tip,  or  a  circumscribed  patch, 
or  the  entire  organ,  or  it  may  be  confined  to  the  region  of  its  attachment 
to  the  caecum.  The  appendix  may  slough  off  and  be  found  loose  in  the 
pus  of  an  appendicular  abscess.  When  the  necrotic  tip  has  previously 
become  adherent  to  a  neighboring  hollow  organ,  as  the  colon  or  bladder, 
a  fistulous  communication  may  be  found.  The  appendix  has  in  some 
instances  perforated  into  a  hernial  sac.  The  necrosis  has  occasionally 
involved  the  wall  of  an  artery,  as  one  of  the  iliacs,  to  which  adhesions 
have    formed,    and   led    to   fatal   hemorrhage.      Perforation,    which   only 


968  MEDICAL  DIAGNOSIS. 

occasionally  occurs  in  the  acute  diffuse  and  suppurative  forms,  is  the  usual 
outcome  of  the  gangrenous  variety.  The  opening  is  commonly  single, 
but  multiple  perforations  may  occur.  When  previously  formed  adhesions 
confine  the  escaping  contents  of  the  appendix,  an  abscess  is  found  which 
varies  in  size  and  may,  in  the  absence  of  operation,  ultimately  discharge 
into  the  bowel  or  bladder,  vagina,  or  externally. 

Chronic  appendicitis  constitutes  a  common  condition  when  the  acute 
symptoms  subside  without  operation.  The  appendix  may  be  thickened 
and  deformed,  adherent  to  the  gut,  or  embedded  in  a  mass  of  irregularly 
puckered  peritoneal  adhesions.  Its  lumen  may  be  more  or  less  completely 
obliterated,  or  it  may  be  converted  into  a  series  of  cysts  separated  by 
stricture-like  occlusions,  or,  finally,  it  may  contain  foreign  bodies  or  fecal 
concretions.  There  are  cases  in  which  no  symptoms  are  present,  but  it  is 
more  common  to  find  occasional  pain,  persistent  tenderness,  and  intestinal 
symptoms.  When  acute  exacerbations  of  these  symptoms  occur  the 
condition  is   known   as  recurrent   appendicitis,  falsely  so  called. 

In  another  group  of  cases  chronic  appendicitis  takes  the  form  of  a 
progressive  primary  fibrosis,  a  progressive  involution  process,  not  char- 
acterized by  symptoms  and  terminating  in  complete  atrophy  of  the  organ. 

The  bodies  found  in  the  lumen  of  the  inflamed  appendix  are,  as  a  rule, 
to  which  there  are  few  exceptions,  fecal  in  character.  The  pus  varies  in 
amount  and  consistence.  It  may  be  soft  and  easily  expressed,  or  consist 
of  dense,  compact  masses  resembling  date-stones  or  grape  seeds.  A  series 
of  three  or  even  more  such  masses  may  occupy  the  canal  of  the  appendix. 
Sometimes  there  is  only  one,  which  is  short  and  rounded,  or  elongated  and 
curved.     Of  foreign  bodies  the  most  common  are  pins. 

The  symptom-complex  of  acute  appendicitis  is  most  variable.  Cer- 
tain symptoms  are,  however,  suggestive,  their  association  significant. 
The  chief  of  these  are  pain,  tenderness,  and  gastro-intestinal  disturbance. 
Of  subordinate  importance  are  fever,  muscular  rigidity,  deep  induration, 
and  leucocytosis.  We  cannot  be  satisfied  with  an  affirmative  reply  to  the 
question:  Has  this  patient  appendicitis?  We  must  ask  ourselves  further: 
What  stage  in  its  evolution  has  the  process  reached?  Is  the  appendix 
alone  affected?  Are  there  signs  of  abscess  formation?  Is  there  local 
adhesive  peritonitis  without  or  with  pus?  Are  there  signs  of  a  beginning 
general  peritonitis?     In  other  words.  What  are  the  lesions? 

1.  Pain. — The  pain  is  usually  sudden,  mostly  severe.  It  is  some- 
times sharp  and  stitch-like;  sometimes  dulj.  and  aching.  It  is  often  coliclcy; 
almost  always  continuous  with  exacerbations.  It  is  usually  referred  to  the 
right  lower  quadrant  of  the  abdomen,  but  may  be  diffuse  or  central.  In 
the  chronic  cases  a  diffuse  central  pain  is  very  often  present  for  weeks  or 
months  before  the  pain  in  the  right  iliac  fossa  is  felt.  It  may  be  referred 
to  the  region  of  the  gall-bladder  or  to  the  right  lumbar  region,  or  extend 
in  these  directions;  or  it  may  extend  in  a  similar  way  to  the  perineum  or 
right  testicle.  Under  these  circumstances  the  pain  of  appendicitis  has  been 
mistaken  for  biliary  or  renal  colic.  These  referred  pains  have  been  ascribed 
to  the  position  of  the  appendix,  which  has  been  found  in  some  instances 
elongated  in  the  direction  of  the  liver  or  kidney,  in  others  downwards 
into  the  pelvis. 


APPENDICITIS.  969 

2.  Tenderness. — Firm,  deep  pressure  over  the  affected  area  usually 
causes  pain.  A  circumscribed  spot  situated  at  the  intersection  of  a  line 
drawn  from  the  umbilicus  to  the  anterior  superior  spine  of  the  ilium 
and  a  second  line  corresponding  to  the  outer  border  of  the  right  rectus 
muscle,  first  described  by  McBurney  and  known  as  McBurney's  point,  is 
in  well-marked  cases  decidedly,  even  exquisitely,  tender  to  the  pressure  of 
a  single  finger.  Deep  pressure  with  the  open  hand  upon  the  left  side  of  the 
abdomen  frequently  causes  or  aggravates  the  pain  in  the  right  iliac  fossa. 
The  patients  usually  assume  the  dorsal  decubitus  with  the  right  knee 
flexed,  and  pain  is  elicited  or  increased  by  extending  the  limb. 

3.  Gastro-intestinal  Symptoms.  —  There  are  loss  of  appetite, 
thirst,  nausea,  and  very  often  vomiting  which  ceases  in  the  course  of  some 
hours.  Constipation  is  the  rule.  Diarrhoea  occasionally  occurs  in  cliildren. 
The  patients  are  often  able  to  recall  the  eating  of  an  unusually  hearty 
meal  or  some  indigestible  article  of  diet,  or  undue  exertion  or  exposure 
after  food,  and  attribute  pain  and  tenderness  to  indigestion  or  coUc  or  a 
bilious  attack. 

4.  Fever. — An  initial  chill  or  chilliness  is  very  rare.  It  is  said  that 
fever  is  always  present  at  the  onset.  If  so,  it  is  very  often  transient  and 
has  disappeared  before  the  case  comes  under  medical  observation.  Fre- 
quently the  temperature  is  normal  when  the  patient  is  first  seen,  and  in 
favorable  cases  remains  so.  Many  cases  show  subfebrile  temperatures  not 
reaching  101°  F.  (38.5°  C),  and  fever  of  irregular  type— 102°-3°  F.— is 
not  uncommon.  There  are  cases  in  which,  with  abscess  formation  or  gen- 
eral peritonitis,  the  temperature  remains  low,  and  others  in  which  fever 
gradually  subsides  and  the  patient  enters  upon  convalescence  without 
serious  symptoms.  Too  great  reliance  upon  the  thermometer  may  prove 
misleading. 

5.  Muscular  Rigidity. — Spastic  tension  of  the  abdominal  wall  upon 
the  right  side,  especially  over  the  rectus  muscle,  is  common  in  severe  cases. 
In  many  cases  this  symptom  is  not  present.  Its  presence  is  suggestive 
of  a  beginning  local  peritonitis. 

6.  Induration. — Upon  deep  palpation  a  circumscribed  sensation  of 
resistance  may  frequently  be  detected.  This  sign  is  often  well  defined  and 
situated  at  or  near  McBurney's  point.  In  very  rare  instances  the  thick- 
ened appendix  may  be  distinctly  recognized  upon  palpation.  In  other 
cases  there  is  a  diffuse  ill-defined  boggyness  with  some  impairment  of 
resonance  upon  percussion.  Upon  the  supervention  of  pus  the  signs  of  a 
solid  or  fluctuating  tumor  are  characteristic.  Necrosis  and  perforation  may 
take  place  without  either  induration  or  a  palpable  tumor,  especially  in  the 
early  gangrenous  cases. 

7.  Leucocytosis. — In  appendicitis  unaccompanied  by  suppuration, 
gangrene,  or  serous  inflammation,  there  is  usually  little  increase  in  the 
leucocytes.  In  cases  which  have  gone  on  to  abscess  formation,  necrosis, 
and  local  or  general  peritonitis,  leucocyte  counts  of  15,000  or  more  per 
cubic  millimetre  are  the  rule.  Normal  counts  or  slight  leucocytosis  may 
occur  in  cases  characterized  by  early  gangrene  and  perforation, — so-called 
fulminant  appendicitis, — and  in  suppurative  cases  in  which  absorption 
does  not  take  place  from  the  abscess  cavity. 


970  MEDICAL  DIAGNOSIS. 

S.  Inconstant  and  therefore  unimportant  symptoms  are  vesical 
irritability,  oliguria,  and  albuminuria.  As  in  man}^  other  acute  inflam- 
matory affections,  there  is  moderate  early  anaemia  of  secondary  type.  In 
cases  attended  with  prolonged  suppuration,  with  sepsis,  ansemia  becomes 
pronounced  with  a  reduction  of  haemoglobin  to  30  or  40  per  cent,  and  an 
erythrocyte  count  of  3,000,000  per  cubic  millimetre  or  less. 

The  course  of  a  case  of  simple  appendicitis  terminating  favorably  is 
usually  as  follows:  The  gastro-intestinal  symptoms  subside,  the  tongue 
cleans,  and  the  constipation  ceases  spontaneously.  The  appetite  and 
strength  return.  The  pain  gi-adually  disappears,  but  tenderness  outlasts 
it  for  some  days  or  a  week  or  two.  Local  induration  progressively 
diminishes  and  convalescence  is  soon  fully  established.  The  persistence 
of  a  distinct  circumscribed  tumor  is  very  liable  to  be  followed  by 
recurrent  outbreaks. 

Abscess  and  peritonitis  are  sequels  of  appendicitis. 

Abscess. — The  conditions  revealed  at  operation  shed  much  light  upon 
the  development  and  course  of  appendicular  abscess.  Perforation  either 
as  the  result  of  ulceration  or  necrosis  is  the  common  cause  of  peri-appen- 
dicular  suppuration.  In  exceptional  cases  it  occurs  in  consequence  of 
general  suppurative  inflammation  of  the  appendix.  Pus  may  be  found  in 
the  course  of  two  or  three  days,  but  more  commonly  towards  the  close  of  a 
week.  The  symptoms  are  aggravated.  There  are  more  or  less  pronounced 
signs  of  sepsis  and  fever  of  irregular  type.  There  are,  however,  cases  in 
which  fever  is  wholly  absent.  The  pain  and  tenderness  are  often  increased. 
The  abscess  cavity  is  usually  in  relation  with  the  appendix  and  the  adjacent 
coils  of  intestine,  which  are  adherent  among  themselves  as  the  result  of 
local  plastic  peritonitis.  In  some  of  the  recurrent  cases  there  are  one  or 
more  small  collections  of  pus  in  an  irregular  mass  formed  by  dense  adhesions 
and  puckering  of  the  wall  of  the  gut.  More  commonly  the  abscess  cavity 
is  single  and  its  size  corresponds  to  the  duration  of  the  case.  When  small 
and  deeply  seated,  especially  if  below  the  pelvic  line,  it  may  elude  external 
palpation  but  be  detected  upon  vaginal  examination.  As  a  rule,  it  forms 
a  palpable  or  visible  tumor  of  variable  size  in  the  right  iliac  fossa,  which 
in  some  cases  is  distinctly  fluctuating.  The  pus  shows  the  usual  ten- 
dency to  burrow  and  may  discharge  into  the  bowel,  vagina,  or  bladder, 
or  externally. 

Peritonitis. — General  infection  of  the  peritoneum  may  at  once  result 
from  early  necrosis,  prior  to  the  formation  of  circumscribing  adhesions, 
or  later  from  the  rupture  of  already  formed  adhesions.  In  the  fulminant 
cases  the  symptoms  of  general  peritonitis  may  follow  those  of  appendicitis 
so  rapidly  that  it  is  not  always  possible  to  determine  the  nature  of  the 
primary  process.  Ordinarily  the  onset  of  peritonitis  is  attended  by  sudden 
aggravation  of  the  previous  symptoms.  The  pain,  tenderness,  and  rigidity 
become  more  marked  and  extend  over  the  entire  abdomen.  Nausea  and 
vomiting  are  more  severe.  The  pulse  becomes  small  and  rapid,  the  tongue 
dry,  and  the  urine  scanty  or  suppressed.  After  a  time  meteorism,  absence 
of  peristaltic  movement,  dorsal  decubitus  with  flexed  thighs,  and  the 
characteristic  facies  complete  a  well  recognized  clinical  picture.  Cessation 
of  pain  and  a  clear  mind  are  the  heralds  of  death. 


APPENDICITIS.  971 

Diagnosis. — Dikect. — The  recognition  of  acute  appendicitis  rests 
upon  the  association  of  sudden  pain  and  tenderness  in  the  right  iliac  region 
with  nausea  or  vomiting.  The  presence  of  a  circumscribed  tumor  or  deep 
resistance  and  rigidity  of  the  right  rectus  muscle  are  significant.  The 
age  of  the  patient  is  suggestive,  since  appendicitis  is  very  common  before 
and  comparatively  rare  after  thirty.  Conditions  having  some  resemblance 
to  appendicitis  are  to  be  carefully  excluded,  as,  for  example,  hepatic  and 
renal  colic,  dysmenorrhoea,  and  tubo-ovarian  disease.  The  diagnostic 
importance  of  the  blood  counting  may  be  readily  overestimated. 

Differential. — 1.  Cholecystitis. — When  the  inflamed  appendix  lies 
upwards,  the  pain  and  tenderness  may  suggest  gall-bladder  disease.  In 
the  latter  careful  physical  examination  will  usually  reveal  increased  dul- 
ness  and  circumscribed  tenderness  in  the  region  of  the  gall-bladder,  and  a 
history  of  recurrent  attacks  without  tendency  to  inflammatory  tumor 
or  abscess  formation.  2.  Renal  Colic. — It  is  only  in  the  rare  cases  in  which 
the  appendix  extends  backwards  that  uncertainty  arises.  The  pain  of 
renal  colic  is  usually  more  severe  and  more  distinctly  paroxysmal  than 
that  of  appendicitis.  It  arises  in  the  lumbar  region,  extends  forward  and 
downward  towards  the  groin,  and  is  attended  by  retraction  of  the  testicle. 
The  diagnosis  in  some  cases  of  persistent  kidney  colic  with  hydronephrosis 
is  very  difficult.  The  X-ray  examination  may  be  of  service.  Dietel's 
crises  in  floating  kidney  present  remote  resemblances  to  acute  appendi- 
citis. 3.  Dysmenorrhoea. — Menstrual  colic,  especially  in  an  hysterical  girl, 
may  suggest  appendicitis,  but  the  seat  of  the  pain,  the  period  in  the  month, 
recurrence,  the  absence  of  a  tumor,  or  the  stigmata  of  hysteria  are  signif- 
icant. 4,  Disease  of  the  Right  Tube  and  Ovary. — A  careful  vaginal  exam- 
ination is  necessary.  The  recognition  of  salpingitis  or  an  enlarged,  tender, 
prolapsed,  or  adherent  ovary,  together  with  a  history  of  menstrual  derange- 
ments or  previous  pelvic  pain  would  be  of  diagnostic  importance.  The 
fact  that  such  conditions  are  frequently  associated  with  an  infected  appen- 
dix is  by  no  means  to  be  overlooked.  5.  Mucous  colitis  is  sometimes  asso- 
ciated with  chronic  appendicitis  without  distinctive  signs  of  the  latter 
affection.  In  such  a  case  I  have  seen  a  diseased  appendix  removed  with 
decided  improvement  in  the  mucous  disease  and  general  health.  6.  Local 
abscess  in  the  ciBcal  region  associated  with  malignant  disease  of  the  gut 
cannot  always  be  distinguished  from  appendicular  abscess.  The  anamnesis 
is  important.  An  exploratory  incision  may  be  necessary.  The  situation 
of  the  tumor  and  oedema  in  perinephric  abscess  are  of  diagnostic  importance. 
7.  Intussusception,  volvulus,  and  other  forms  of  intestinal  obstruction  pre- 
sent in  the  beginning  only  remote  resemblances  to  appendicitis.  Ster- 
coraceous  vomiting,  so  significant  in  these  conditions,  does  not  occur  in 
appendicitis,  nor  do  the  tenesmus  and  bloody  stools  common  in  intus- 
susception, especially  in  children,  nor  the  sausage-like  tumor,  mostly  on 
the  left  side,  nor  the  invaginated  gut  upon  rectal  examination.  8.  Enteric 
Fever. — There  is  no  real  difficulty  in  well-defined  cases.  Both  the  pain 
and  tenderness  are  milder,  vomiting  is  rare,  fever  is  higher  and  the 
temperature  tends  to  run  a  typical  course,  and  headache  is  a  prominent 
symptom.  Later  splenic  tumor,  rose  spots,  disproportion  between  the 
pulse-frequency  and  temperature,  and  the  results  of  laboratory  methods  are 


972  MEDICAL  DIAGNOSIS. 

conclusive.  The  occasional  occurrence  of  typhoid  ulceration  of  the  appendix 
and  of  appendicitis  as  an  intercurrent  affection  in  enteric  fever  is  not  to 
be  overlooked.  Perforation  of  the  appendix  may  occur  in  the  second  or 
third  week  or  during  convalescence.  9.  General  Peritonitis. — In  the  absence 
of  a  history  of  the  case  the  peritonitis  which  follows  acute  appendicitis 
cannot  be  differentiated  from  that  due  to  other  causes. 

Prognosis. — The  mortahty  is  stated  to  be  2  per  cent,  of  all  cases,  but 
the  general  statistics  are  without  value  since  the  death-rate  is  dependent 
upon  extremely  variable  data  relating  to  diagnosis  and  operation.  The 
death-rate  in  early  operations  is  low.  The  statistics  vary  from  2  to  10  per 
cent,  according  to  the  time  of  operation.  The  immediate  recognition  of  the 
condition  may  be  of  vital  importance  to  the  patient.  In  cases  character- 
ized by  recurrence,  operation  in  a  quiescent  interval  is  attended  with 
comparatively  slight  risk.  The  outlook  in  neglected  cases  is  grave.  The 
patient's  general  health  may  be  undermined  by  prolonged  suppuration 
and  sepsis,  or  death  may  follow  pylephlebitis  or  hemorrhage  from  an  artery 
or  vein.  A  very  large  proportion  of  cases  in  which  early  operation  is  neg- 
lected die  of  peritonitis.  The  fact  that  the  course  of  the  lesion  in  any  given 
case  can  neither  be  foreseen  from  the  beginning  nor  controlled  by  any  other 
sure  means,  constitutes  full  justification  for  early  operation. 

vii.  Enteroptosis. 

Definition. — Falling  forward  or  dragging  downward  of  the  intestines 
from  stretching  of  their  mesenteric  attachments,  practically  always  affect- 
ing the  large  intestine,  and  frequently  associated  with  ptosis  of  the 
stomach,  liver,  and  kidneys — splanchnoptosis  or  Glenard's  disease. 

Etiology. — See  Gastroptosis. 

Symptoms. — The  general  symptoms  are  often  the  only  symptoms. 
The  condition  may  exist  for  years  without  producing  discomfort.  The 
inherent  weakness  of  the  tissues  which  support  the  abdominal  viscera  is 
in  turn  aggravated  by  the  gastro-enteroptosis.  Persistent  weakness, 
abdominal  distress,  pain  in  the  back  and  loins,  headache,  torpor,  dulness 
are  common.  The  patients  are  always  neurasthenic.  Hyperchlorhydria 
or  hypochlorhydria  may  occur.  The  local  symptoms  are  varied.  Abdom- 
inal discomfort,  burning  sensation,  the  weight  of  the  prolapsed  abdominal 
organs,  colicky,  irregularly  recurring  pains,  nausea,  anorexia,  constipation, 
diarrhoea,  abdominal  distention  are  symptoms  of  enteroptosis.  Obstruction 
from  kinking  is  rare.  Many  of  the  so-called  cases  of  intestinal  indigestion 
belong  here.     Mucous  diarrhoea  and  mucous  stools  are  not  uncommon. 

Physical  Signs. — These  have  been  described  under  gastroptosis.  In 
enteroptosis  the  transverse  colon  is  the  part  of  the  intestine  mostly  affected 
and  most  readily  demonstrated.  Even  on  inspection  the  outline  of  the 
displaced  bowel  may  be  evident  at  and  below  the  umbilicus.  Peristalsis 
from'  right  to  left  may  be  observed.  Palpation  will  frequently  reveal 
displacement  of  the  liver  and  kidneys.  At  times  the  spasmodically 
contracted  transverse  colon  can  be  clearly  felt. 

Diagnosis. — Direct. — The  abnormal  position  of  the  colon,  displace- 
ments of  other  organs,  and  diastasis  recti  are  diagnostic  features. 


INTESTINAL  INDIGESTION.  973 

Inflation  with  the  tube  passed  high  up  will  often  clearly  distend  the 
colon  in  its  various  positions.  Simultaneous  distention  of  the  stomach 
prevents  errors.  The  X-ray  examination  after  bismuth  injections  may 
be  of  confirmatory  value. 

Differential, — Gastroptosis. — These  conditions  commonly  occur 
together.  The  absence  of  gastric  symptoms  and  the  normal  position  of 
the  stomach  on  inflation  may  be  observed  in  exceptional  cases.  Malignant 
Disease  of  the  Bowel. — The  long  history  of  enteroptosis,  ptosis  of  other 
organs,  and  diastasis  recti,  absence  of  marked  anaemia  or  cachexia,  absence 
of  a  tumor  mass  with  palpable  muscular  contraction,  absence  of  occult 
blood  in  the  stools  are  in  favor  of  enteroptosis. 

Prognosis.' — The  condition  may  never  cause  trouble.  A  suitable 
abdominal  support  may  relieve  the  symptoms  but  cannot  permanently 
restore  a  prolapsed  intestine  to  its  normal  position. 

viii.  Intestinal  Indigestion. 

Definition. — Disorders  of  digestion  in  the  intestine,  usually  due  to 
deficiency  of  the  pancreatic  ferments  and  characterized  by  the  excretion 
of  abnormal  amounts  of  the  various  food  matters  ingested. 

Etiology.  —  Predisposing  Influences.  —  Nervous  disorders  of  the 
stomach  or  intestine  predispose  to  intestinal  indigestion. 

Exciting  Causes. — Anacidity  of  the  gastric  juice,  obstruction  of 
the  bile-ducts,  pancreatic  ducts,  chronic  intestinal  disorders,  chronic  appen- 
dicitis, and  dietetic  errors  are  causes  of  intestinal  indigestion.  The  definite 
cause  that  in  many  instances  apparently  interferes  with  the  "secretin" 
production  and  the  pancreatic  supply  is  unknown. 

Symptoms. — The  general  symptoms  may  be  those  of  a  neurosis: 
headache,  coated  tongue,  persistent  loss  of  weight  without  obvious  cause 
or  without  symptoms.  Habitual  inability  to  digest  certain  articles  is  fre- 
quent. Pain  in  various  regions  of  the  abdomen,  flatulence,  and  burning 
sensations  are  common.  Constipation,  diarrhoea,  or  pultaceous  stools 
may  occur.  Foul-smelling  flatus  and  fseces  that  decompose  and  ferment 
on  standing  are  usual. 

Physical  Signs. — Abdominal  distention  may  occur  as  the  sign  of 
active  intestinal  fermentation.  Tenderness  can  usually  be  elicited. 
Examination  of  the  fseces  shows  excess  of  fat  and  fatty  acids,  and 
much  undigested  proteid,  or  carbohydrate  (see  Fseces).  The  various 
tests  (bead  test,  desmoid  test,  absorption  tests)  show  impaired  digestion 
and  absorption. 

Diagnosis.  —  Direct.  —  Chronic  abdominal  distress  and  symptoms 
of  disturbance  of  nutrition,  evacuation  of  abnormal  amounts  of  undigested 
material  as  proved  by  chemical  and  microscopical  tests,  absence  of  phys- 
ical signs  of  neoplasm,  absence  of  blood  from  the  stools  and  of  fever  are 
important  diagnostic  features. 

Differential.  —  Intestinal  Neuroses.  —  The  differentiation  is  often 
impossible  as  a  neurosis  may  coexist  with  the  intestinal  indigestion.  The 
condition  of  the  fseces  is  important.  Mucous-  stools  must  be  distinguished 
from  undigested  material.     Neoplasm;   Ulceration. — Chronicity,  absence  of 


974  MEDICAL  DIAGNOSIS. 

blood  from  the  faeces,  absence  of  physical  signs  of  obstruction  or  tumor, 
the  persistent  presence  of  undigested  material  in  the  fseces  indicate 
intestinal   indigestion. 

Prognosis. — If  the  cause  can  be  removed  resumption  of  normal  diges- 
tive power  may  return.  The  withholding  of  certain  forms  of  food, — fat, 
carbohydrate  or  proteid,  as  indicated  by  the  fseces, — may  be  continually 
necessary.     JMany  cases  persist  unrelieved  by  treatment. 

ix.   Intestinal  Neuroses. 

Definition. — Disorders  of  sensation  and  of  the  secretory  and  motor 
functions  of  the  intestine. 

Etiology. — Predisposing  Influences. — All  conditions  which  pre- 
dispose to  functional  nervous  disorders  may  be  considered  as  predisposing 
influences.  ,.  . 

Exciting  Causes. — Shock  or  emotional  outbreaks  may  precipitate 
an  intestinal  neurosis.  The  more  common  exciting  causes  are  strain, 
worry,  irregular  habits  of  life,  and  dietetic  errors. 

Symptoms. — Symptoms  common  to  all  intestinal  neuroses  are  nervous 
depression,  exhaustion,  and  derangements  of  the  normal  function,  sallow- 
ness  of  the  complexion,  and  emaciation.  When  the  digestive  function  of 
the  intestines  is  not  impaired  a  physical  appearance  of  well-being  is  often 
seen.  There  is  rarely  any  evidence  in  the  faeces  of  impaired  digestive 
activity.  Common  sensory  symptoms  are  a  feeling  of  weight  or  distention 
in  the  abdomen,  the  subjective  perception  of  the  intestine  in  peristalsis, 
persistent  general  discomfort  or  soreness  in  the  intestines,  and  colicky 
pains  which  are  often  severe.  These  pains  may  simulate  appendicitis, 
biliary,  renal,  or  lead  colic,  or  the  tabetic  crises.  Motor  disturbances  give 
rise  to  nervous  diarrhoea,  intestinal  rumblings  and  gurglings,  or  to  spas- 
modic contractions  of  the  bowel  with  constipation  and  pain.  Explosive 
flatulence  is  a  common  motor  neurosis.  Retention  of  intestinal  air  or 
gases  and  distressing  flatulent  distention  is  frequently  the  result  of  intes- 
tinal spasm.  Reverse  peristalsis  with  fecal  vomiting  as  a  motor  neurosis 
is  rare.  Few  secretory  neuroses  are  recognized.  Diarrhoea  and  consti- 
pation are  often  due  to  motor  causes.  Membranous  or  mucous  enteritis 
and  colitis  are  practically  the  only  secretory  neuroses.  The  main  features 
of  these  affections  are  severe  abdominal  pain,  constipation,  and  the  passage 
of  large  amounts  of  mucus,  unformed  and  jelly-like,  in  opaque,  firm  flakes, 
or  in  large  tubular  casts.  Bile-stained  mucus  is  said  to  come  from  the  small 
intestine;    the  paler  variety  from  the  large. 

Several  motor  neuroses  may  occur  in  association.  Physical  exami- 
nation usually  yields  negative  results.  In  typical  cases  the  abdomen  may 
be  scaphoid.  Tenderness  is  common,  particularly  along  the  course  of  the 
colon.  It  is  often  marked  over  the  caecum.  In  mucous  colitis,  redness 
of  the  mucosa  and  excess  of  mucus  can  be  seen  on  examination  with 
the  speculum. 

Diagnosis. — Direct. — Persistent  intestinal  distress  in  a  neurotic 
individual,  the  absence  of  the  local  signs  of  obstruction  or  neoplasm,  the 
absence  of  anaemia  and  cachexia,  a  normal  condition  of  the  faeces  as  to 


INTESTINAL  NEOPLASMS.  975 

their  constitutent  fats,  carbohydrates,  and  proteids,  abnormal  amounts 
of  mucus,  and  the  absence  of  parasites  and  their  ova  justify  the  suspicion 
of  a  neurotic  basis  for  the  intestinal  disorder. 

Differential. — Intestinal  Obstruction. — A  neurosis,  even  when  asso- 
ciated with  severe  pain,  constipation,  and  distention,  rarely  shows  general 
symptoms,  such  as  rapid  pulse  and  collapse.  Fever  is  absent,  vomiting 
is  less  usual;  local  signs  of  obstruction  are  absent.  The  bowels  are  usually 
easily  opened  by  the  proper  means.  The  detection  of  mucus  in  the  stools 
in  large  amounts  or  in  tubular  form  is  important  evidence  in  favor  of  a 
neurosis.  Intestinal  New  Growths. — Tuberculosis  of  the  intestine,  anaemia, 
and  cachexia  are  unusual  in  neuroses;  local  signs  are  absent.  Tests  for 
blood  in  the  stools  are  negative.  The  general  neurotic  condition  of  the 
patient  is  a  most  important  feature.  In  gall-stone  colic  subsequent  jaun- 
dice, bile-stained  urine,  and  detection  of  gall-stones  in  the  faeces  are 
important  diagnostic  points.  Rapid  pulse,  fever,  and  persistent  tenderness 
over  the  liver  are  usual  in  gall-stone  attacks.  In  renal  colic  hsematuria 
and  occurrence  of  fever  may  be  the  only  distinguishing  features;  in  lead 
colic  anaemia,  "blue  line,"  persistent  constipation,  and  a  history  of 
exposure  are  important.  With  tabetic  crises  other  features  of  tabes  are 
present,  for  example,  absent  knee-jerks,  Argyll-Robertson  pupil,  ataxia. 
Appendicitis. — Cases  of  intestinal  neurosis  are  sometimes  operated  upon 
as  appendicitis.  The  differentiation  in  some  of  the  chronic  cases  may  be 
extremely  difficult.  In  the  neuroses  leucocytosis  and  muscular  rigidity 
do  not  occur.  Since  mucous  colitis  is  the  condition  most  likely  to  simulate 
appendiceal  disease  mucous  stools  should  be  carefully  looked  for. 

Prognosis. — The  intestinal  neuroses  are  refractory  to  treatment  and 
often  require  years  of  careful  management.  Confirmed  cases  are  often 
unrelieved  by  any  form  of  general  or  local  treatment. 

X.   Intestinal  Neoplasms. 

New  growths  or  tumors  of  the  intestines,  principally  malignant.  Benign 
tumors,  lipomata,  adenomata,  myomata,  polypoid  growths  also  occur. 

L  Malignant  Growths. — Carcinomata. — Cancer  of  the  intestines  may 
involve  any  part  of  the  bowel  from  the  duodenum  to  the  rectum.  The 
large  bowel  is  more  frequently  affected  and  especially  the  rectum.  The 
growths  are  usually  primary  and  tend  to  assume  the  annular  form  and  to 
ulcerate,  producing  obstruction  and  hemorrhage. 

Symptoms. — The  general  symptoms  of  mahgnant  disease  of  the  intes- 
tines are  loss  of  appetite  and  strength,  persistent  and  rapid  loss  of  weight, 
early  and  severe  anaemia,  and  rapidly  developing  cachexia.  In  many 
cases  local  symptoms  are  not  recognized  for  a  considerable  time,  a  fact 
which  lends  importance  to  the  general  early  derangements  of  health. 
The  earlier  local  symptoms  are  those  of  partial  obstruction  and  ulceration, 
colic,  flatulent  distention,  and  vomiting  if  the  growth  is  in  the  duo- 
denum, tenderness  when  it  is  situated  in  the  large  bowel.  Malignant 
disease  in  the  duodenum  soon  produces  obstructive  dilatation  of  the 
stomach  with  its  characteristic  symptoms.  Persistent  biliary  vomiting 
indicates  obstruction  below  the  papilla  of  Vater.     Duodenal  cancer  is  often 


976  MEDICAL  DIAGNOSIS. 

associated  with  occlusion  of  the  common  bile  and  pancreatic  ducts.  Pain 
in  the  neighborhood  of  the  growth  itself,  apart  from  the  recurring  colic 
of  the  obstruction-hypertrophy,  is  only  marked  in  large-bowel  cancers, 
and  is  of  a  dull  aching  or  intense  gnawing  character.  Hsematemesis  may 
occur  in  duodenal  cancers.  Black,  tarry,  or  bright  hemorrhagic  stools 
are  seen  in  the  cases  in  which  the  growth  is  situated  lower  down.  Diar- 
rhoea, constipation,  or  dysenteric  symptoms  may  be  present  in  cancer  of 
the  lower  bowel.  Later  local  symptoms  are  those  of  complete  obstruction, 
perforation,  and  metastatic  deposits  in  the  glands  of  the  abdomen,  in  the 
liver,  and  elsewhere. 

Physical  Signs. — Careful  and  repeated  inspection  and  palpation 
are  necessary.  Important  signs  are  distention,  particularly  marked  in 
low-lying  tumors,  intestinal  patterns,  visible  peristalsis,  and  a  visible  or 
palpable  tumor.  Transmitted  pulsation  from  the  aorta  may  occur.  Pal- 
pation with  the  fiat  of  the  hand,  superficial  at  first,  then  deep,  slowly  cover- 
ing the  whole  abdomen,  is  important  in  obscure  cases.  Small  tumors  may 
escape  observation.  Tumors  of  the  duodenum  may  be  central  and  do  not 
move  with  the  diaphragm;  tumors  of  the  jejunum  and  ileum  are  also 
usually  central,  but  may  appear  in  other  regions,  and  are  often  freely  mov- 
able. Tumors  of  the  caecum  and  transverse  colon  are  movable  but  not  so 
freely  as  those  of  the  sigmoid  flexure.  Contraction  of  hypertrophied  mus- 
culature, causing  tension  and  hardening  of  the  tumor  mass,  may  be  fre- 
quently observed.  Movement  of  the  tumor  mass  with  respiration  and 
with  postural  changes  is,  in  the  absence  of  adhesions,  common  to  all  tumors 
of  the  intestine  save  those  situated  in  the  duodenum  and  at  the  colonic 
flexures  and  rectum,  and  is  readily  appreciated  by  the  examining  hand. 
Palpable  pulsation  suggestive  of  an  aneurism  may  be  obtained  over  a 
tumor  in  relation  with  the  abdominal  aorta  or  the  large  iliac  vessels.  Tumor 
of  the  sigmoid  may  drop  into  the  pelvis  and  be  felt  upon  examination  per 
rectum  or  per  vaginam.  During  contraction  of  the  intestine  and  forcing 
of  the  intestinal  contents  through  the  narrowing  lumen,  loud  and  sharp 
gurgling  is  often  heard.  Inflation  of  the  stomach,  slapping  the  abdomen 
with  a  cold  wet  towel  will  at  times  start  up  muscular  action  in  the  intes- 
tine and  produce  physical  signs.  Inflation  of  the  sigmoid  flexure  and 
colon  may  bring  a  tumor  into  view,  or  the  signs  of  stenosis  of  the  bowel 
may  appear.  The  X-ray  examination  frequently  affords  evidence  of  the 
presence  and  situation  of  a  tumor.  The  characteristics  of  the  vomitus 
in  cases  where  the  disease  is  situated  in  the  duodenum  are  those  of 
pyloric  obstruction.  The  significance  of  biliary  vomiting  has  been  dis- 
cussed.    Occult  blood  is  present  when  ulceration  has  occurred. 

The  faeces  present  no  characteristic  signs.  Occult  blood  is  always 
present  with  ulceration  and  is  suggestive  when  local  signs  and  symptoms 
are  absent.  Bloody  mucous  discharges  and  mucopurulent  stools  are 
frequent  in  tumors  of  the  lower  bowel.  Carcinomatous  tissue  fragments 
are  sometimes  found  in  the  stools  when  ulceration  of  the  growth  has 
taken  place.  The  physical  signs  presented  in  examination  by  means  of 
the  proctoscope  and  sigmoidoscope  are  obstruction  to  the  passage  of  the 
tubes,  localized  or  annular  thickening,  thickened  and  ulcerated  areas. 
Small  tissue  fragments  may  be  removed  and  examined. 


ANOMALIES  OF  THE  LIVER.  977 

Diagnosis. — Direct. — Loss  of  appetite,  persistent  wasting,  progres- 
sive anaemia  are  suggestive.  Signs  of  obstruction,  pain,  colic,  vomiting, 
distention,  visible  peristalsis,  visible  and  palpable  contractile  tumor  are 
indicative  of  a  new  growth  in  a  muscular  organ,  as  the  intestine.  Occult 
blood  in  the  faeces  or  vomitus  is  an  important  sign  of  ulceration. 

Differential. — IS! on-malignant  Partial  Obstructions. — The  history  of  old 
inflammatory  abdominal  conditions  may  be  suggestive  of  non-mahgnant 
obstruction.  Absence  of  progressive  anaemia  and  cachexia  is  an  important 
point.  The  absence  of  hemorrhage,  either  occult  or  gross,  particularly  if 
the  condition  has  persisted  for  some  time,  is  in  favor  of  a  non-malignant 
condition.  A  tumor  is  rarely  visible  or  palpable  in  non-malignant  obstruc- 
tion save  just  at  the  point  of  obstruction  and  at  the  time  of  contraction  of 
the  hypertrophied  musculature.  Impacted  Fceces,  Scybala,  etc. — There  is 
absence  of  anaemia  and  cachexia,  wasting  is  unusual,  signs  of  obstruction 
are  commonly  wanting.  The  evidences  of  hypertrophied  intestinal  mus- 
culature do  not  appear.  Visible  peristalsis  is  only  present  when  obstruc- 
tion is  complete.  Occult  blood  is  not  present  nor  do  hemorrhages  take 
place  unless  laceration  of  the  mucosa  of  the  rectum  or  anus  has  occurred. 
The  scybalous  tumor  masses  may  be  multiple  and  follow  the  course  of  the 
large  bowel.  They  are  not  contractile  but  doughy  and  can  at  times  be 
broken  in  situ.  They  can  usually  be  removed  by  proper  measures  and 
are  often  readily  distinguished  by  sigmoidoscopic  examination. 

Prognosis. — The  outlook  in  intestinal  carcinomata  is  hopeless  unless 
the  condition  is  early  recognized  and  the  case  submitted  to  operation. 
In  disease  of  the  lower  bowel,  an  artificial  anus — colostomy — may  prolong 
life  for  months;  acute  secondary  accidents,  as  rupture  of  the  bowel  and 
complete  obstruction,  occur. 

Sarcomata. — Sarcomata  of  the  intestine  are  rare.  They  attain  larger 
size,  are  less  circumscribed  and  of  more  rapid  growth  than  carcinomata.  The 
general  symptoms  of  anaemia  and  cachexia  progress  with  alarming  rapidity. 
Stenosis  of  the  bowel  does  not  occur,  since  the  growth  diffuses  through  large 
areas  of  the  submucosa,  hence  visible  peristalsis  and  contractile  tumor 
masses  are  rarely  observed.  Hemorrhage  is  less  common.  The  small 
intestine  and  the  rectum  are  the  favorite  locations  of  intestinal  sarcomata. 

2.  Benign  Tumors. — The  benign  tumors,  principally  polypi,  occur  most 
frequently  in  the  rectum  and  large  bowel.  Hemorrhage  and  tenesmus  are  the 
most  marked  features.  The  diagnosis  of  these  and  other  benign  tumors  that 
lie  out  of  reach  of  the  sigmoidoscope  must  be  attended  with  difficulty. 
Only  when  they  reach  large  size  do  they  produce  signs  of  obstruction. 

III.  DISEASES  OF  THE  LIVER, 
i.  Anatomical  Anomalies  of  the  Liver. 

The  contour  of  the  liver  is  modified  by  the  shape  of  the  thorax  and 
the  pressure  of  adjacent  organs.  Abscess  and  tumors  within  the  substance 
of  the  hver,  as  echinococcus,  gummata,  and  malignant  growths,  cause 
departures  from  the  normal  form  of  the  organ.  In  transposition  of  the 
viscera  the  shape  of  the  liver  is  the  reverse  of  normal.  The  convex  anterior 
surface  is  frequently  marked  by  parallel  depressions  corresponding  to  the  ribs. 
62 


978  MEDICAL  DIAGNOSIS. 

Remarkable  changes  in  shape  are  produced  by  the  permanent  pres- 
sure of  clothing — corset  liver;  lacing  liver.  That  portion  of  the  right  lobe 
which  is  below  the  groove  of  compression  may  reach  to  the  level  of  the 
crest  of  the  ilium.  It  is  separated  from  the  main  portion  of  the  organ  by 
a  deep  depression,  the  result  of  pressure  atrophy,  which  produces  in  many 
cases  great  thinning,  and  in  extreme  cases  an  entire  disappearance  of  the 
liver  tissue,  so  that  the  corset  lobe  is  connected  with  the  liver  by  a  flat 
band  of  connective  tissue  containing  only  bile-ducts  and  blood-vessels. 
The  portion  thus  separated  not  only  occupies  an  abnormal  position,  but 
it  is  also  more  or  less  freely  movable  according  to  the  degree  of  atrophy  of 
the  compressed  part.  It,  therefore,  frequently  simulates  floating  kidney, 
intestinal  tumor,  or  other  movable  tumors  occasionally  found  in  this  situ- 
ation, especially  when  a  loop  of  intestine  has  found  its  way  into  the  groove. 
From  these  conditions  it  is  to  be  differentiated  by,  (a)  its  ascent  and  descent 
with  the  respiratory  movements  of  the  diaphragm;    (b)  its  continuity  with 

the  liver  as  demonstrable  in  many  cases  by 
percussion;  (c)  the  continuous  border  of  the 
anterior  inferior  surface  of  the  liver  and  the 
corset  lobe  as  recognized  upon  repeated,  care- 
ful palpation,  and  finally,  (d)  by  the  presence 
of  the  notch  or  angle  in  the  border  at  the  point 
where  the  groove  terminates  anteriorly. 
Another  deformity  produced  by  the  habitual 
pressure  of  clothing  consists  in  an  elongation  of 
the  entire  right  lobe  downward.  This  change 
may  be  mistaken  for  enlargement  of  the  organ. 
These  changes  are  common  in  women  but 
comparatively  infrequent  in  men — belt  liver. 
Various  changes  in  the  position  of  the 

Fig.  313. — Corset  liver.  •,.  ,  ,  rni  n 

liver  are  encountered.  ihese  are  usually 
the  result  of  continuous  pressure.  Rotations  upon  the  transverse  axis  may 
occur  forward  from  the  pressure  of  the  clothing  or  backward  from  the  pres- 
sure of  abdominal  tumors.  The  entire  organ  is  frequently  displaced  down- 
ward, as  in  emphysema,  pleural  effusion,  or  subphrenic  abscess,  and  upward 
by  ascites,  massive  tympany,  or  ovarian  or  other  abdominal  tumors. 

ii.  Movable  Liver. 

Hepar  Mobilis;   Hepatoptosis. 

Definition. — Marked  displacement  of  the  liver  with  abnormal  mobility. 

Etiology. — A  slight  degree  of  mobility  occurs  in  enteroptosis  and 
after  large  and  long-continued  ascites.  True  floating  liver  is  extremely 
rare.  It  is  associated  with  atrophy  and  relaxation  of  the  abdominal  walls 
and  separation  of  the  abdominal  muscles,  and  large  hernias  in  which  the 
sac  encloses  many  coils  of  intestines.  The  traction  that  the  abdominal 
wall  in  pendulous  abdomen  exerts  upon  the  liver  by  means  of  the  liga- 
mentum  teres  is  a  concomitant  cause.  Mechanical  violence  such  as  severe 
exertion  or  vomiting,  persistent  cough,  falls,  tight  lacing,  and  rapid  emacia- 


JAUNDICE— ICTERUS.  979 

tion  have  been  regarded  as  etiological  factors  in  floating  liver.  The  fre- 
quency of  these  events  as  compared  with  the  extreme  infrequency  of 
floating  liver  renders  it  in  a  high  degree  improbable  that  they  play  the  part 
assigned  to  them  in  the  causation  of  the  latter  condition.  Therefore  it  is 
likely  that  floating  liver  can  only  occur  in  cases  of  congenital  tendency  to 
relaxation  and  elongation  of  the  ligaments  of  the  organ,  or  in  which  an 
actual  mesohepar  is  present. 

Symptoms. — There  is,  as  a  rule,  no  tenderness  upon  pressure.  Pain 
is  a  common  symptom.  It  is  referred  to  the  right  hypochondrium  and 
the  epigastrium,  and  extends  to  the  right  shoulder  and  lumbar  region. 
It  is  dull  and  dragging,  and  intensified  by  sudden  movements.  Spon- 
taneous paroxysmal  pain,  bearing-down  sensations,  attacks  of  colic,  with 
belching,  meteorism,  and  constipation,  and  anomalous  abdominal  sen- 
sations are  common.  The  pain  is  usually  relieved  by  firm  pressure  upon 
the  tumor  or  by  lying  down.  Respiratory  disturbances  and  palpitation 
occur.  Hemorrhage  from  the  stomach  and  bowels,  ascites,  hemorrhoids, 
and  oedema  of  the  legs  and  feet  have  been  observed.  Jaundice  is  rare, 
but  the  skin  usually  has  a  subicteroid  hue. 

Physical  Signs. — The  abdominal  tumor  occupies  the  right  side  and 
may  extend  as  low  as  the  pubic  arch.  The  convex  surface  is  directed  for- 
ward and  the  entire  organ  is  rotated  to  the  right.  The  contour  may  be 
made  out  upon  palpation.  In  the  dorsal  decubitus  the  liver  may  be 
replaced  by  gentle  pressure  unless  fixed  by  adhesions — an  extremely  rare 
condition.  Upon  percussion  when  the  liver  is  dislocated  the  pulmonary 
resonance  passes  directly  into  the  tympany  due  to  the  intestines  which 
have  found  their  way  into  the  space  between  the  liver  and  the  diaphragm. 

Diagnosis.  —  A  direct  diagnosis  rests  upon  the  position  of  the 
tumor,  its  contour,  its  large  size,  and  the  possibility  of  replacing  the 
dislocated  liver  in  its  normal  position.  The  diagnosis  is  greatly  obscured 
by  the  presence  of  ascites  and  by  the  diminished  mobility  resulting  from 
adhesions  in  the  abnormal  position. 

The  DIFFERENTIAL  DIAGNOSIS  involves  the  consideration  of  a  greatly 
thickened  mesentery  and  tumor  of  the  kidney.  Neither  of  these  tumor 
masses  is  associated  with  tympanitic  resonance  in  the  normal  area  of  liver 
dulness,  nor  can  either  of  them  be  made  by  manual  pressure  to  pass  into 
the  normal  position  of  the  liver.     Floating  liver  occurs  chiefly  in  women. 

iii.  Jaundice — Icterus. 

This  symptom-complex  has  been  described  in  a  previous  section  and  the 
mechanism  and  significance  of  obstructive  and  toxaemic  jaundice  discussed. 
The  following  special  forms  are  of  clinical  interest: 

1.  Icterus  Psychicus  (Icterus  ex  Emotione). — Sudden  jaundice  has 
been  attributed  to  anger,  fright,  terror,  and  a  gross  insult.  Associated 
symptoms  are  anxiety,  epigastric  distress,  and  diarrhoea.  The  jaundice 
passes  away  in  a  short  time.  The  cases  are  not  well  authenticated  and 
no  wholly  satisfactory  explanation  has  been  adduced  for  emotional  jaundice. 

2.  Hereditary  Icterus. — The  cases  are  rare  and  may  be  regarded 
as  clinical  curiosities.     Icterus  neonatorum  has  been  observed  in  every 


980  MEDICAL  DIAGNOSIS. 

member  of  large  families  in  two  generations.  Another  group  includes 
cases  of  jaundice  in  a  mother  and  three  of  her  children,  appearing 
in  childhood  and  persisting  for  years  without  other  evidences  of  ill 
health.  The  jaundice  was  of  mild  type.  There  was  no  enlargement 
of  the  liver  or  spleen. 

3.  Icterus  Gravidarum. — Women  in  adanced  pregnancy  occasion- 
ally suffer  from  a  form  of  catarrhal  jaundice  due  to  the  pressure  exerted 
upon  the  under  surface  of  the  liver  by  the  enlarged  uterus.  Fecal  accumu- 
lation acts  as  an  additional  cause  of  bile  stasis,  and  the  deformities  of  the 
liver  resulting  from  lacing  increase  the  tendency.  The  death  of  the  foetus 
or  miscarriage  may  occur.     The  jaundice  disappears  after  parturition. 

4.  Icterus  Menstrualis. — Mild  icterus  has  frequently  been  observed 
just  prior  to  and  during  menstruation.  When  the  discharge  becomes  free 
the  jaundice  abates.  Enlargement  of  the  liver  and  decolored  faeces  have 
been  noted. 

5.  Biliousness.  —  Many  persons,  whose  health  is  otherwise  good, 
occasionally  suffer  from  gastro-intestinal  derangements,  with  headache, 
furred  tongue,  sensations  of  depression  and  malaise,  and  a  subicteroid 
discoloration  of  the  conjunctivae  or  skin.  Relief  of  these  symptoms  follows 
abstinence  from  food  and  mild  purgation. 

6.  Starvation  Jaundice.  —  Subicteroid  discoloration  of  the  con- 
junctivae and  skin  is  frequently  present  in  persons  who  for  any  reason  are 
unable  to  take  food  for  several  days.  This  is  witnessed  in  insane  persons 
who  refuse  food,  and  in  stricture  of  the  oesophagus,  whether  spasmodic 
or  organic. 

7.  Syphilitic  Jaundice. — Icterus  appears  in  certain  cases  of  severe 
syphilis  coincidently  with  the  secondary  eruption.  Its  symptomatic  char- 
acter is  shown  by  its  prompt  disappearance  under  antisyphilitic  treatment. 
This  form  of  jaundice  is  to  be  differentiated  from  accidental  jaundice, 
such  as  occurs  in  tertiary  syphilis  as  a  consequence  of  diffuse  hepatitis 
or  gumma  of  the  liver,  and  from  a  coincident  catarrhal  jaundice. 

8.  Icterus  Follow^ing  the  Extravasation  of  Blood. — Yellowness 
of  the  conjunctivae  and  skin  may  be  observed  after  large  hemorrhages  into 
the  skin  or  cavities  of  the  body  in  scurvy,  and  after  injuries  or  in  lesions 
of  the  genital  tract  in  women.  The  jaundice  appears  after  several  days, 
is  not  intense,  and  gradually  fades  in  the  course  of  some  days  or  weeks. 
Bile  pigments  are  present  in  the  urine. 

9.  Icterus  Following  HiEMOGLOBiN^EMiA. — This  variety  of  jaundice 
is  very  marked  after  the  attacks  of  haemoglobinuria  which  follow  exposure 
to  cold  or  overexertion  in  persons  suffering  from  malaria  or  syphilis.  Fever, 
splenic  enlargement,  haemoglobinuria,  and  jaundice  constitute  the  symptom- 
complex.     The  urine  contains  bile  pigments. 

;  10.  Toxic   Icterus. — A   large   number   of   poisons   are   followed   by 

icterus.  Among  them  the  following  are  important:  arseniuretted  hydrogen, 
certain  mushrooms,  toluylendiamin,  glycerin,  the  bile  acids,  the  chlorates, 
aniline  and  its  derivative  acetanilide,  and  the  nitrites.  Filix  mas  and 
santonin  may  cause  a  yellow  discoloration  of  the  skin.  Icterus  follows 
poisoning  by  phosphorus  and  lead.  A  very  rapid  icterus  develops  after 
snake  bite. 


ICTERUS  NEONATORUM.  981 

11.  Infectious  Icterus.  —  Yellow  fever  and  relapsing  fever  are 
characterized  by  marked  icterus.  Septic  conditions  and  pneumonia  are 
frequently,  enteric  fever  occasionally,  attended  by  jaundice. 

12.  Epidemic  Icterus. — When  a  number  of  persons  living  under  the 
same  conditions  develop  jaundice,  as  occasionally  occurs  in  boarding 
schools,  camps,  barracks,  or  prisons,  the  term  epidemic  jaundice  is  war- 
ranted. Many  large  and  small  epidemics  have  been  described  in  the  liter- 
ature. These  epidemics  are  usually  of  short  duration;  in  a  few  instances 
they  have  lasted  several  months.  The  disease  commonly  assumes  the 
guise  of  ordinary  catarrhal  jaundice  and  runs  a  benign  course;  in  some 
instances  it  is  severe  and  many  deaths  occur.  In  pregnant  and  parturient 
women  the  prognosis  is  grave.  Epidemic  icterus  has  been  attributed  to 
atmospheric  or  climatic  influences,  dietetic  faults,  and  infectious  causes. 
A  combination  of  these  agents  m^ay  be  operative. 

13.  Postvaccinal  Jaundice.  —  In  rare  instances  jaundice  has 
appeared  in  groups  of  cases  among  revaccinated  persons.  The  jaundice  has 
occurred  at  intervals  of  a  few  days  to  several  months.  It  has  been  attrib- 
uted to  wound  infection.  This  form  of  epidemic  jaundice  is  rare  and  its 
association  with  vaccination  is  probably  accidental.  It  is  much  more 
likely  due  to  other  local  influences  affecting  groups  of  persons  who 
happen  to  have  been  vaccinated. 

iv.  Icterus  Neonatorum — Physiological  Icterus. 

Definition. — A  variety  of  icterus  common  in  the  new-born  occur- 
ring independently  of  any  particular  disease  or  lesion  and  pursuing  a 
favorable  course. 

Etiology. — This  affection  occurs  in  about  one-half  of  all  babies.  It  is 
more  common  in  foundling  hospitals  than  in  private  practice,  in  premature 
infants  than  in  those  born  at  term,  in  boys  than  girls,  and  in  cases  where 
parturition  has  occurred  under  chloroform.  The  pathogenesis  of  the  con- 
dition is  not  clear.  It  has  been  attributed  to  rapid  destruction  of  erythro- 
cytes after  birth,  to  stasis  in  the  smaller  bile-ducts,  to  resorption  of  bile 
from  the  intestine,  and  to  oedema  of  the  periportal  connective  tissue. 

Symptoms. — The  jaundice  appears  upon  the  second  or  third  day 
after  birth  and  first  upon  the  face  and  chest,  rapidly  extending  to  the 
rest  of  the  body.  It  fades  more  or  less  rapidly  in  the  course  of  ten  or  twelve 
days.  The  general  condition  of  the  child  is  otherwise  normal.  The  urine 
is  normal  and  does  not  contain  bile  pigment  in  solution.  The  stools,  after 
the  discharge  of  meconium,  have  their  usual  golden-yellow  color.  The 
pulse-frequency  is  not  lowered. 

Diagnosis.  —  Direct.  —  The  comparative  mildness  of  the  jaundice 
and  the  complete  absence  of  serious  symptoms  suffice  to  establish  the  nature 
of  the  affection.  Its  gradual  disappearance  within  two  or  exceptionally 
as  late  as  three  or  four  weeks  is  not  followed  by  recurrence. 

Differential. — In  the  following  forms  of  jaundice  in  the  new-born 
the  discoloration  is  more  intense  and  associated  with  serious  symptoms: 
(a)  congenital  absence  of  the  common  or  hepatic  duct;  (b)  congenital 
syphilitic  hepatitis,  in  which  the  characteristic  external  lesions  of  syphilis 


982  MEDICAL  DIAGNOSIS. 

are  also  manifest,  and  (c)  septic  infection  by  way  of  the  umbilical  vein, 
a  fatal  form  of  sepsis  associated  with  phlebitis  and,  in  some  instances, 
with  umbilical  hemorrhage.  Icterus  may  occur  in  the  new-born  as  a  result 
of  obstruction  of  the  bile-ducts,  acute  fatty  degeneration  of  the  livor,  and 
epidemic  hsemoglobinuria. 

Prognosis. — The  physiological  icterus  of  the  new-born  is  never  fatal. 

V.  Acute  Yellow  Atrophy. 

Malignant  Jaundice;    Icterus  Gravis. 

Definition. — An  acute  disease  characterized  anatomically  by  diffuse 
necrosis  of  the  liver-cells  with  great  diminution  in  the  size  of  the  organ, 
and  clinically  by  intense  jaundice  and  cerebral  symptoms. 

Etiology.  —  Predisposing  Influences.  —  Acute  yellow  atrophy  is 
rare.  It  is  more  common  in  women  than  in  men  in  the  proportion  of 
about  8  to  5.  This  difference  is  in  part  explained  by  the  fact  that  preg- 
nant women  are  frequently  affected  after  the  fourth  month  or  at  the  time 
of  parturition.  The  greater  number  of  cases  occur  between  the  twentieth 
and  fortieth  years.  Acute  yellow  atrophy  is  comparatively  rare  among  chil- 
dren. It  has  been  observed  to  follow  osteomyeHtis,  erysipelas,  sepsis, 
enteric  and  relapsing  fever,  and  syphilis.  It  has  been  attributed  to  ptomaine 
and  mushroom  poisoning,  to  alcohol  and  to  chloroform,  to  fright,  and 
to  profound  depressing  emotions.  The  symptoms  caused  by  phosphorus 
poisoning  resemble  those  of  acute  yellow  atrophy,  but  the  conditions  are 
neither  etiologically  nor  pathologically  identical.  In  rare  instances  acute 
yellow  atrophy  has  occurred  as  an  intercurrent  disease  in  hypertrophic 
cirrhosis,  bile  stasis,  and  fatty  degeneration  of  the  liver. 

The  Exciting  Cause. — The  actual  pathogenic  principle  is  unknown. 
Various  micro-organisms,  especially  streptococcus  and  Bacillus  coli,  have 
been  found  in  the  liver,  but  in  many  of  the  cases  examined  no  bacteria  have 
been  present. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size,  flaccid,  and 
folded  upon  itself.  Its  capsule  is  wrinkled  and  of  a  dirty  yellowish-green 
color.  Upon  section  the  surface  is  mottled  and  the  outlines  of  the  lobules 
are  indistinct.  These  are  yellowish  masses  surrounded  by  a  dark  reddish 
tissue,  the  latter  representing  a  more  advanced  stage.  Microscopically 
the  hepatic  cells  are  indistinct,  bile  stained,  and  in  all  stages  of  granular 
and  fatty  degeneration  and  necrosis.  The  capillary  vessels  and  bile-ducts 
are  destroyed,  with  resulting  minute  hemorrhages  and  extravasation  of  bile. 

Symptoms. — The  attack  usually  begins  as  an  acute  gastric  catarrh, 
which  is  shortly  followed  by  more  or  less  intense  jaundice  with  clay- 
colored  stools — the  initial  stage.  In  the  course  of  some  days  or,  less  fre- 
quently, two  or  three  weeks,  during  which  the  symptoms  have  remained 
comparatively  mild,  the  second  stage  sets  in  suddenly  with  vomiting,  rest- 
lessness, stupor,  delirium,  convulsions,  and  coma.  Hemorrhages  into  the 
skin  and  from  mucous  surfaces  are  common.  The  jaundice  becomes  more 
intense.  Pregnant  women  usually  abort.  There  may  be  pain  in  the  region 
of  the  liver.    The  temperature  is  normal  or  subnormal,  rising  toward  the 


CATARRHAL  JAUNDICE.  983 

end.  Exceptionally  there  is  marked  fever  throughout  the  attack.  The 
tongue  is  coated  and  dry.  The  action  of  the  heart,  normal  or  slow  in  the 
initial  stage,  becomes  rapid  and  feeble  in  the  second  stage,  with  enfeeble- 
ment  of  the  first  sound  and  not  rarely  a  soft,  blowing,  systolic  murmur. 
The  liver,  which  is  enlarged  in  the  first  stage,  undergoes,  with  the  develop- 
ment of  the  cerebral  symptoms,  a  rapid  diminution  in  volume.  There  may 
be  complete  absence  of  hepatic  dulness,  as  the  flaccid  organ  folds  upon 
itself  and  falls  away  from  the  abdominal  wall,  coils  of  intestines  taking  its 
place.  The  splenic  dulness  is  increased.  The  abdomen  is  very  sensitive, 
particularly  in  the  epigastric  zone,  and  there  is  spontaneous  pain.  The 
urine  is  slightly  decreased,  contains  bile  pigments,  generally  small  quan- 
tities of  albumin  and  tube-casts.  Products  of  disordered  metabolism, 
such  as  leucin,  tyrosin,  and  sarcolactic  acid,  are  also  present.  Urea  is  much 
diminished  and  the  percentage  of  nitrogen  present  as  ammonia  correspond- 
ingly increased.  Leucin  and  tyrosin  are  sometimes  absent  from  the  urine. 
Albumoses  are  sometimes  present  in  small  amounts. 

Diagnosis. — Direct. — Intense  jaundice,  vomiting,  diminished  area 
of  liver  dulness,  hemorrhages,  enlarged  spleen,  grave  cerebral  symptoms, 
together  with  leucin  and  tyrosin  in  the  urine,  constitute  a  characteristic 
symptom-complex.  The  initial  stage  cannot  be  distinguished  from  ordi- 
nary gastroduodenal  catarrh  with  jaundice. 

Differential.  —  Hypertrophic  Cirrhosis.  —  In  rare  cases  there  are 
intense  cerebral  symptoms,  but  enlargement  of  the  liver,  fever,  the  absence 
of  leucin  and  tyrosin,  and  the  long  course  of  the  disease  prior  to  acute 
cerebral  symptoms  are  distinctive. 

Acute  Phosphorus  Poisoning. — The  symptoms  may  be  almost  iden- 
tical, particularly  in  respect  of  hemorrhages,  jaundice,  and  decrease  in 
liver  dulness,  but  the  gastric  symptoms  are  usually  more  intense  and  set 
in  directly  after  the  ingestion  of  the  poison  without  a  prodromal  or  initial 
stage,  the  icterus  rather  abruptly  on  the  third  day,  and  leucin  and  tyrosin 
are  said  to  be  absent  from  the  urine.  A  dilated  transverse  colon  may  so 
displace  the  liver  upward  as  to  simulate  atrophy,  but  the  gradual  reduction 
in  the  area  of  liver  dulness  from  day  to  day  is  most  significant. 

Prognosis. — The  disease  is  almost  always  fatal.  The  outlook  is  more 
unfavorable  when  cerebral  symptoms  occur  early.  The  duration  of  the 
illness  varies  from  a  few  days  to  two  or  three  months.  About  half  the  cases 
die  between  the  fifth  and  fourteenth  days,  about  one-third  within  five 
weeks.  The  duration  of  the  characteristic  stage  varies  from  one  or  two 
days  to  a  week.  In  the  cases  that  run  a  favorable  course  the  cerebral 
symptoms  are  less  violent  and  the  duration  of  the  disease  is  prolonged. 

vi.  Diseases  of  the  Bile  Passages  and  Gall=bladder. 

CATARRHAL  JAUNDICE. 

Icterus   Gastroduodenalis;    Icterus   Simplex. 

Definition.^ — Jaundice  due  to  swelling  and  mucus  in  the  intestinal 
portion  of  the  common  duct,  the  result  of  the  extension  of  gastro- 
intestinal   catarrh. 


984  MEDICAL  DIAGNOSIS. 

Etiology. — Predisposing  Influences. — Catarrhal  jaundice  is  a  com- 
mon affection  and  is  probably  always  associated  with  catarrhal  inflam- 
mation of  the  duodenal  mucosa.  All  conditions  which  predispose  to  the 
latter  affection  therefore  favor  its  occurrence.  Chief  among  these  are 
chronic  alcoholism,  chronic  gastric  catarrh,  conditions  favoring  portal 
obstruction,  chronic  valvular  disease,  and  chronic  nephritis.  Malaria  is 
a  well-recognized  cause.  The  affection  also  frequently  occurs  in  connec- 
tion with  the  acute  infections,  particularly  enteric  fever  and  pneumonia. 

Age  exerts  an  important  predisposing  influence.  Catarrhal  jaundice 
is  a  disease  of  young  persons  and  is  rare  in  middle  and  advanced  age.  It 
is  common  in  children  after  the  second  year.  In  adult  life  it  is  more  common 
in  males  than  females. 

The  Exciting  Cause. — The  immediate  cause  is  usually  an  acute 
indigestion,  sudden  cold  or  exposure,  or  unusual  physical  strain  with  irreg- 
ular meals.  In  many  cases  no  causal  factor  can  be  discovered.  When  a 
number  of  persons  are  exposed  to  the  same  local  influences,  as  in  a  school,^ 
a  circumscribed  epidemic  of  catarrhal  jaundice  may  occur. 

Morbid  Anatomy. — The  mucous  membrane  of  the  terminal  portion, 
of  the  common  duct  is  swollen  and  the  ampulla  of  Vater  may  be  obstructed 
by  a  plug  of  tenacious  mucus.  It  is  possible  that  the  catarrhal  process 
may  invade  the  smaller  ducts,  but  of  this  we  have  no  definite  knowledge. 

Eppinger  recently  found  in  the  case  of  a  girl  who  was  instantly  killed 
by  an  accident  on  the  ninth  day  of  an  attack  of  catarrhal  jaundice  that 
the  portion  of  the  common  duct  which  lies  within  the  wall  of  the  intestine 
was  impermeable  and  that  the  occlusion  was  due  to  hyperplasia  of  the 
lymphoid  tissue  of  the  mucosa  of  the  duct.  It  is  probable  that  certain 
cases  of  catarrhal  jaundice  are  due  to  inflammatory  swelling;  others  to 
"the  presence  of  a  plug  of  tenacious  mucus,  and  yet  others  to  a  hyperplastic 
condition  of  the  lymphoid  tissue  which  surrounds  the  mucous  glands  of 
the  appendix  in  varying  proportion  in  different  individuals. 

Symptoms. — In  many  cases  the  jaundice  is  preceded  by  epigastric 
distress,  loss  of  appetite,  a  coated  tongue,  and  nausea  and  vomiting.  Not 
rarely  there  are  also  present  headache,  vertigo,  mental  depression.  Fever 
is  not  common,  but  the  temperature  may  reach  101°-102°  F.  (38.3°-38.9° 
C).  The  bowels  are  constipated  and  the  stools  hght  in  color  but  rarely 
entirely  free  from  bile  pigment.  The  urine  contains  bile  pigments  and  is 
scanty  and  sedimentary  but  not  often  albuminous.  Hyaline  casts  are 
common.  The  skin  and  conjunctivae  are  more  or  less  deej^ly  jaundiced, 
but  the  olive  green  of  chronic  jaundice  does  not  occur.  The  nervous  symp- 
toms of  jaundice  are  present  in  varying  degree,  especially  pruritus  and 
drowsiness.  Slowing  of  the  pulse  and  respiration  is  less  frequent.  The 
liver  is  usually  slightly  enlarged.  The  gall-bladder  is  rarely  palpable. 
Slight  enlargement  of  the  spleen  is  not  uncommon.  There  are  cases  in 
which  the  above  symptoms  do  not  occur  and  the  patient's  knowledge  of 
his  being  jaundiced  is  obtained  from  the  looking-glass  or  the  inquiries  of 
his  friends.  The  duration  of  the  affection  is  from  two  to  six  or  eight 
weeks,  the  jaundice  gradually  fading,  the  bile  pigment  first  reappearing 
in  the  stools,  next  disappearing  from  the  urine  and  finally  from  the 
sclera.      There  are  cases  of  catarrhal  jaundice  which  last  two   or  three 


CHRONIC  ANGIOCHOLITIS.  985 

months  with  remissions  and  exacerbations,  but  the  diagnosis  in  such 
cases  must  be  guarded,  especially  in  elderly  persons. 

Diagnosis.— Direct. — The  diagnosis  may  usually  be  made  without 
reserve  from  the  youth  of  the  patient,  his  previous  fair  health,  the  symp- 
toms of  gastric  catarrh,  the  moderate  intensity  of  the  jaundice,  and  the 
short  duration  of  the  affection. 

Differential. — The  diagnosis  from  cirrhosis,  cholelithiasis,  carcinoma^ 
and  Weil's  disease  is  considered  under  those  respective  headings,  to  which 
the  reader  is  referred.  It  is  important  to  remember  that  catarrhal  jaundice 
is  rare  in  old  persons  and  that  a  jaundice  persisting  beyond  six  or  eight 
weeks  can  only  be  regarded  as  catarrhal  after  a  rigid  process  of  exclusion 
in  regard  to  all  other  possible  causes. 

Prognosis. — The  outlook  in  simple  uncomplicated  catarrhal  jaundice 
is  highly  favorable.     It  is  a  benign  affection. 

CHRONIC  ANGIOCHOLITIS. 

Definition.  —  Chronic  inflammation  of  the  bile-ducts.  It  may  be 
catarrhal  or  suppurative. 

1.  Chronic  catarrhal  cholangitis  may  occur  as  a  sequel  of  acute  catarrh. 
It  is  always  combined  with  obstruction  of  the  common  duct,  and  is  there- 
fore an  associated  condition  in  cholelithiasis,  parasites,  cancer,  stricture, 
and  compression  of  the  common  duct  from  without.  The  obstruction  may 
be  complete  or  incomplete. 

(a)  Complete  Obstruction. — The  bile  passages,  the  gall-bladder,  and 
the  intrahepatic  ducts  are  dilated  and  contain  clear  mucus,  which  is  usually 
sterile.  The  patients  are  persistently  and  deeply  jaundiced.  Fever  is 
commonly  absent. 

(b)  Incomplete  Obstruction. — There  are  one  or  more  calculi  in  the 
common  duct  and,  as  a  rule,  in  the  gall-bladder,  or  there  is  pressure  from 
the  outside.  The  bile  may  escape  in  small  amounts  continuously,  or  the 
obstruction  may  be  intermittent.  The  bile  passages  and  gall-bladder  are 
not  usually  greatly  dilated.  They  contain  a  thin,  bile-stained  mucus. 
The  jaundice  may  vary  in  intensity  and  the  stools  show  the  presence  of 
bile  pigments.  Febrile  attacks, — hepatic  fever, — characterized  by  chills^ 
rapid  rise  of  temperature,  and  profuse  sweating,  are  common  in  this  form 
of  obstruction  and  are  doubtless  caused  by  infection. 

2.  Suppurative  cholangitis  affects  the  large  and  small  ducts.  In  the 
majority  of  the  cases  the  gall-bladder  is  also  involved.  There  is  dilatation 
of  the  bile  passages  and  particularly  of  the  common  ducts.  The  walls  are 
thickened.  The  intrahepatic  ducts  are  much  dilated,  and  minute  collec- 
tions of  pus  mixed  with  bile  are  formed  by  the  suppurating  ducts  and 
disintegrating  hepatic  tissue.  There  is  usually  distention  of  the  gall- 
bladder, which  is  filled  with  pus,  occlusion  of  the  cystic  duct,  and  adhesive 
inflammation  of  the  gall-bladder  to  adjacent  parts.  Suppurative  cholan- 
gitis constitutes  one  of  the  most  serious  complications  of  cholelithiasis. 
It  occurs  also  in  consequence  of  the  presence  of  foreign  bodies,  as  fish  bones, 
or  intestinal  parasites,  as  ascarides,  which  find  their  way  into  the  ducts 
from  the  intestine,  and  in  connection  with  cancer  of  the  ducts.  It  is  a 
somewhat  rare  sequel  of  enteric  fever,  pyaemia,  and  dysentery. 


986  MEDICAL  DIAGNOSIS. 

The  onset  is  insidious.  The  symptoms  vary  in  intensity  and  are  iiot 
always  characteristic.  As  a  rule  they  are  severe,  consisting  of  jaundice, 
enlargement  of  the  liver,  pain  and  tenderness  in  the  region  of  the  gall- 
bladder, which  is  often  distended,  fever  of  septic  type,  and  a  marked 
leucocytosis.  There  is  commonly  a  history  of  biliarj^  colic.  Pylephle- 
bitis, endocarditis,  purulent  meningitis,  and  peritonitis  are  occasional 
complications. 

The  diagnosis  of  suppurative  cholangitis  rests  upon  a  history  of  gall- 
stones, jaundice,  intermittent  fever  of  hectic  type,  tenderness  and  pain  in 
the  region  of  the  gall-bladder.  The  fever  is  to  be  distinguished  from  malaria 
by  the  leucocytosis,  the  variable  periodicity,  and  above  all  by  the  absence 
of  blood  parasites.  A  tender  point  in  the  region  of  the  twelfth  dorsal  verte- 
bra, 2.5  to  3  cm.  from  the  middle  line,  may  be  present  in  inflammation  of 
the  bile-ducts  (Boas).  In  cases  occurring  in  association  with  the  acute 
infections  jaundice  may  be  absent  or  slight.  The  differential  diagnosis 
between  certain  cases  of  suppurative  cholangitis  and  abscess  of  the  liver 
may  be  attended  wdth  difficulty.  In  favor  of  the  latter  condition  are 
absence  of  jaundice,  slight  fever  or  even  subnormal  temperature,  and  the 
absence  of  tenderness  and  pain  in  the  region  of  the  gall-bladder. 

The  outlook  is  highly  unfavorable.  The  reestablishment  of  biliary 
drainage  by  the  escape  of  the  stone  or  its  removal  by  operation  may  be 
followed  by  recovery.  In  a  case  recently  under  my  observation  operation 
failed  and  there  were  many  small  calculi  pocketed  in  abscess  cavities 
throughout  the  liver. 

VARIOUS  LESIONS  OF  THE  BILE  PASSAGES. 

It  is  convenient  to  consider  ulceration,  perforation,  stricture,  and 
fistulse  of  the  bile-ducts  in  connection  with  cholelithiasis,  which  is  their 
usual  cause. 

The  lumen  of  the  common  duct  may  be  partially  or  completely 
occluded  by  the  seeds  of  fruit  and  by  certain  parasites,  among  which 
lumbricoid  worms  are  common  and  echinococci  and  distomata  rare  causes 
of  obstruction  in  man. 

Obstruction  by  pressure  from  without  is  more  common.  Carcinoma 
or  fibroid  thickening  of  the  head  of  the  pancreas,  or,  in  rare  instances, 
cancer  of  the  pylorus,  enlarged  lymph-glands,  abdominal  tumors,  and 
aneurism  of  the  coeliac  axis  may  compress  the  common  duct. 

The  symptoms  have  already  been  described  in  connection  with  com- 
plete and  incomplete  obstruction  under  the  heading  Chronic  Angiochohtis. 
Complete  permanent  occlusion  of  the  common  duct  terminates  in  death. 
The  conditions  which  cause  occlusion  by  pressure  from  without  are  usually 
fatal.  The  diagnosis  of  the  cause  of  the  obstruction  may  be  difficult. 
Colic,  with  variable  jaundice  and  intermittent  fever,  suggests  cholehthiasis. 
Cancerous  disease  in  the  rectum  or  genito-urinary  tract,  or  the  stomach 
or  intestines,  points  to  secondary  glandular  infiltration  as  the  cause  of 
biliary  stasis  and  jaundice.  Accessible  groups  of  lymph-nodes  and,  in 
particular,  the  clavicular  lymphatic  glands  may  also  be  enlarged.  The  gall- 
bladder is  frequently  distended  and  may  be  distinctly  palpable. 


INFLAMMATION  OF  THE  GALL-BLADDER.  987 


INFLAMMATION  OF  THE  GALL-BLADDER;    CHOLECYSTITIS. 

The  condition  maj'  be  acute  or  chronic. 

1.  Acute  Cholecystitis. — The  inflammation  may  be  catarrhal,  sup- 
purative, or  phlegmonous.  These  forms  sometimes  represent  different 
degrees  of  intensity. 

Etiology.  ■ —  Acute  cholecystitis  is  commonly  due  to  gall-stones.  It 
may,  however,  result  from  bacterial  invasion  in  the  absence  of  cholelithiasis. 
It  is  common  in  the  infectious  fevers  and  a  subacute  form  is  very 
often  met  with  in  enteric  fever.  The  usual  pathogenic  organisms  are 
the  colon  bacillus,  the  bacillus  of  Eberth,  the  pneumococcus,  strepto- 
coccus, and  staphylococcus.  The  condition  is  frequently  associated  with 
cholangitis  and  dilatation  of  the  bile  passages.  The  gall-bladder  is  usually 
distended.  In  subacute  cases  of  long  duration  distention  may  be  pre- 
vented by  fibrous  thickening  of  the  walls.  Adhesions  with  the  adjacent 
parts  of  the  liver  or  the  omentum  or  colon  may  take  place.  The  cystic 
duct  is  frequently  occluded  even  in  the  absence  of  an  impacted  calculus. 
The  enlargement  sometimes  takes  place  upward  and  inward  and 
there  is  no  palpable  tumor.  The  contents  may  be  a  thin,  dark-greenish 
mucus,  or  mucopurulent,  purulent,  or  hemorrhagic.  Perforation  may 
take  place,  with  abscess  formation  limited  by  the  adhesions  or  into  the 
peritoneal  cavity. 

Symptoms. — In  the  milder  forms  there  may  be  simply  some  tumefac- 
tion with  dulness,  circumscribed  tenderness,  and  a  rise  of  temperature. 
This  form  is  common  in  enteric  fever.  The  severe  forms  are  ushered  in 
with  intense  paroxysmal  pain  in  the  region  of  the  gall-bladder,  the  epi- 
gastrium, or  in  the  right  upper  quadrant  of  the  abdomen.  With  this  are 
associated  nausea  and  vomiting,  arrest  of  peristalsis,  rigidity  of  the  abdom- 
inal muscles  and  especially  of  the  rectus  upon  the  right  side,  and  fever. 
The  enlarged  gall-bladder  may  be  sometimes  recognized  upon  palpation 
and  percussion,  but  as  a  rule  the  extreme  tenderness  interferes  with 
physical  examination.  In  the  absence  of  gall-stones  jaundice  does  not 
commonly  occur. 

Diagnosis.  —  Direct.  —  The  milder  forms  are  readily  recognized;  in 
the  more  severe  cases  the  condition  is  often  very  obscure.  The  anamnesis 
is  important.  The  above  symptom-complex  occurring  in  a  patient  who 
has  had  attacks  of  hepatic  colic  or  cholecystitis,  or  who  is  convalescent 
from  enteric  fever  or  pneumonia,  is  significant.  The  recurrent  forms  are 
readily  diagnosticated.  It  is  important  to  remember  that  cholecystitis 
may  occur  without  gall-stone  disease. 

Differential. — The  condition  may  simulate  acute  obstruction  of 
the  bowels  or  appendicitis.  While  these  conditions  may  be  differentiated 
from  acute  cholecystitis  by  characteristic  symptoms  in  a  large  proportion 
of  the  cases,  there  are  instances  in  which  the  actual  organ  affected  has  been 
revealed  only  upon  operation. 

Prognosis. — The  outlook  depends  upon  the  intensity  of  the  inflam- 
matory process.  The  purulent  and  phlegmonous  forms  are  usually  fatal. 
Timely  surgical  intervention  may  be  the  means  of  saving  life.  The  danger 
of  perforation  is  to  be  constantly  borne  in  mind. 


988  MEDICAL  DIAGNOSIS. 

2.  Chronic  Cholecystitis. — The  common  cause  of  chronic  cholecystitis 
is  cholehthiasis.  The  disease  may  arise  in  consequence  of  extension  of  the 
infiammation  in  cholangitis.  The  muscular  and  connective-tissue  elements 
of  the  wall  are  involved.  When  the  contents  undergo  resorption,  or  escape 
through  the  cystic  duct  or  by  way  of  a  fistulous  opening,  the  thickened 
wall  contracts  and  the  gall-bladder  becomes  permanently  reduced  in  size. 
Its  walls  under  these  circumstances  are  sometimes  the  seat  of  calcareous 
changes.  Pericholecystitis  may  develop  with  diffuse  swelling  around  the 
organ,  and  later  fluctuation.  The  cystic  duct  may  be  completely  occluded 
by  a  calculus  or  by  cicatrices.  The  bile  is  then  absorbed,  the  mucous 
membrane,  however,  continues  to  secrete  an  abnormal  mucus,  and  the 
gall-bladder  undergoes  gradual  distention  with  thickening  of  its  walls 
and  sometimes  more  or  less  extensive  peritoneal  adhesions.  The  contained 
liquid  may  be  light  in  color  and  bile-free, — dropsy  of  the  gall-bladder, — - 
or  it  may  be  pus — empyema.    Gall-stones  are  frequently  present. 

Symptoms. — When  the  dilatation  is  slight  the  gall-bladder  extends 
below  the  border  of  the  liver  but  cannot  be  palpated  unless  the  abdominal 
walls  are  thin.  As  the  enlargement  proceeds  it  constitutes  a  palpable 
pear-shaped  tumor,  which  is  movable  from  side  to  side  and  may  be  dis- 
placed backward  by  moderate  pressure,  but  which  resumes  its  position 
when  the  pressure  is  withdrawn.  The  enlarged  gall-bladder  moves  upward 
and  downward  with  the  respiratory  play  of  the  diaphragm  and  partakes 
of  the  movements  of  the  liver.  It  may  be  greatly  enlarged  and  elongated, 
and  instances  have  been  noted  in  which  the  contents  have  amounted  to  a 
litre.  When  the  fundus  presents  toward  the  abdominal  wall  and  a  loop 
of  intestine  has  found  its  way  into  the  space  between  the  fundus  and  the 
liver,  the  condition  may  simulate  an  echinococcus  or  ovarian  cyst  or 
hydronephrosis.  If  the  walls  of  the  abdomen  are  thin  and  relaxed,  the 
tumor  formed  by  a  dilated  gall-bladder  may  be  visible.  Urgent  as  the- 
symptoms  attending  the  disease  which  has  caused  the  dilatation  may 
have  been,  the  condition  itself  usually  causes  no  important  subjective 
symptoms.  When  pain  and  tenderness  are  present  they  are  commonly- 
due  to  local  adhesions  and  peritonitis. 

Diagnosis. — Direct. — The  diagnosis  may  be  difficalt.  The  anamnesis, 
the  palpable  and  visible  tumor  connected  with  the  liver  and  partaking  of 
its  movements,  its  cystic  nature,  its  elasticity,  its  gourd-shaped  outline, 
its  mobility  and  tendency  to  at  once  resume  the  position  from  which  it 
has  been  manipulated  constitute  adequate  data  for  a  positive  diagnosis. 
The  nature  of  the  contents  can  only  be  ascertained  by  their  removal. 
For  this  purpose  an  exploratory  coeliotomy  can  be  performed, — never  an 
exploratory  puncture,  which  is  attended  with  the  danger  of  the  escape  of 
a  portion  of  the  fluid  into  the  peritoneal  sac. 

Differential. — The  diagnosis  from  an  echinococcus  cyst  may  be 
attended  with  great  difficulty.  The  hemispherical  form,  more  restricted 
movements,  and  hydatid  thrill  are  significant.  In  hydronephrosis  the 
deeper  origin,  relatively  slighter  mobility,  except  in  floating  Iddney,  and 
the  outline  are  of  diagnostic  importance,  and  the  occasional  disappearance 
of  the  tumor  with  great  diuresis  seen  in  intermittent  hydronephrosis  would 
be  distinctive.     Ovarian  cysts  spring  from  the  pelvis  and  can  be  shown 


CHOLELITHIASIS.  989 

by  vaginal  and  bimanual  examination  not  to  be  connected  with  the  liver 
but  with  the  uterus. 

Prognosis. — In  many  cases  it  is  favorable  after  the  tumor  has  ceased 
to  enlarge  and  is  of  moderate  size.  The  inconvenience  resulting  from  its 
presence  and  pressure  upon  adjacent  organs,  and  the  danger  of  adhesions 
and  fistula  formation,  and,  in  particular,  the  danger  of  rupture  justify  drain- 
age or  excision,  which  is  often  followed  by  complete  restoration  to  health. 

CANCER  OF  THE  BILE=DUCTS  AND  GALL-BLADDER. 

Primary  malignant  disease  of  the  gall-bladder  is  commonly  asso- 
ciated with  gall-stones — 70  to  100  per  cent,  according  to  various  statistics. 
The  symptoms  of  the  condition  often  gradually  supervene  upon  those 
caused  by  biliary  calculus.  The  fundus  is  often  the  starting-point  of  the 
growth,  which  early  becomes  manifest  as  a  dense  tumor  in  the  region  of 
the  gall-bladder,  developing  downward  and  toward  the  median  line,  and 
not  movable  by  reason  of  firm  adhesions  and  implication  of  the  surround- 
ing tissue.  The  mass  may  attain  large  dimensions.  The  gall-bladder  is 
sometimes  greatly  distended.  The  condition  is  much  more  common  in 
males  than  females  and  commonly  appears  after  the  fortieth  year  of  hfe. 
Pain  is  a  prominent  symptom.  It  is  often  paroxysmal  but  continues 
throughout  the  intervals.  There  is  also  more  or  less  tenderness.  Jaundice 
is  present  in  a  majority  of  the  cases.  It  may  be  due  to  implication  of  the 
ducts  or  to  pressure  upon  their  walls. 

Primary  cancer  of  the  bile  passages  is  comparatively  rare.  The  com- 
mon duct  is  usually  the  starting-point  of  the  growth,  which  may  involve 
the  walls  of  the  ampulla  of  Vater  and  invade  the  hepatic  and  cystic  ducts. 
There  is  rarely  a  palpable  tumor.  Jaundice  occurs  early  and  is  persistent. 
If  the  carcinomatous  infiltration  involves  the  portal  vein  ascites  results. 
There  is  often  profound  anaemia,  but  early  cachexia  may  not  be  present. 
Cholsemia  is  a  common  terminal  condition.  Extension  to  the  liver  gives 
rise  to  symptoms  characteristic  of  carcinoma  of  that  organ. 

CHOLELITHIASIS. 

Gall-stone  Disease. 

Definition. — A  condition  characterized  by  the  formation  and  presence 
of  bihary  calcuh  in  the  gall-bladder  or  bile  passages.  The  great  majority 
of  gall-stones  are  formed  in  the  gall-bladder. 

Etiology.  —  Predisposing  Influences.  —  All  conditions  which  give 
rise  to  the  stasis  of  bile  in  the  gall-bladder  predispose  to  cholelithiasis. 
The  outflow  of  bile  may  be  impeded  by  partial  or  complete  occlusion  of 
the  bile-ducts  by  catarrhal  swelling  of  their  mucous  membrane,  the  pres- 
ence of  calculi  or  parasites,  adhesions  in  the  region  of  the  porta,  or  compres- 
sion by  enlarged  lymph-glands,  the  head  of  the  pancreas,  or  the  duodenum. 
Atrophy  of  the  musculature  of  the  gall-bladder  from  distention  or  age  may 
lead  to  stagnation  of  the  bile.  Lacing  plays  an  important  part,  (a)  by 
restricting  the  movements  of  the  diaphragm,  (b)  by  causing  elongation 
of  the  liver,  displacement  of  the  gall-bladder,  and  bending  or  twisting  of 


990  MEDICAL  DIAGNOSIS. 

the  cystic  duct,  (c)  by  inducing  changes  in  the  anatomical  relations  which 
expose  the  cystic  duct  to  compression,  especially  when  there  is,  as  is  fre- 
quently the  case,  displacement  of  the  right  kidney,  and  (d)  by  causing 
gastroduodenal  catarrh  which  may  be  followed  by  cholangitis  and  chole- 
cystitis. Relaxation  of  the  abdominal  walls  and  enteroptosis  favor  the 
stagnation  of  bile  in  the  gall-bladder.  Lack  of  exercise,  prolonged  rest  in 
bed  in  convalescence  from  acute  or  in  chronic  disease,  and  sedentary  occu- 
pations constitute  predisposing  factors  of  importance,  especially  when 
combined  with  overfeeding  and  constipation.  Cardiac  affections,  and  in 
particular  mitral  stenosis,  predispose  to  gall-stone  disease  by  the  passive 
visceral  congestion  and  catarrhal  processes  to  which  they  give  rise  and 
by  the  sedentary  life  which  they  enforce.  There  are  great  differences  in 
the  prevalence  of  gall-stone  disease  in  different  localities  and  different 
countries,  as  determined  by  post-mortem  statistics, — a  fact  ascribed  to- 
local  differences  in  mode  of  life,  occupation,  and  the  influence  of  endemic 
diseases,  which  by  causing  gastro-intestinal  catarrh  may  become  indirect 
factors  in  the  production  of  calculi.  The  rare  cases  reported  in  the  new- 
born and  in  infancy  are  simply  clinical  curiosities.  The  disease  is  rare 
under  thirty.  The  liability  increases  progressively  after  forty.  Women 
suffer  more  frequently  than  rnen  in  the  proportion  of  3  to  2.  The  pressure 
of  the  pregnant  uterus  upon  the  bile-ducts  and  its  interference  with  the 
movements  of  the  diaphragm,  and  the  relaxation  of  the  abdominal  wall 
after  frequent  pregnancies  are  to  be  considered.  The  more  sedentary  life 
of  women  constitutes  a  predisposing  influence  of  importance. 

The  Origin  of  Gall-stones. — The  theory  of  Naunyn  is  generally 
accepted.  A  catarrhal  condition  of  the  mucosa  of  the  gall-bladder,  lead- 
ing to  an  increased  formation  of  cholesterin  and  lime  salts,  is  the  primary 
cause  of  the  formation  of  gall-stones.  This  lithogenous  catarrh  may  be 
produced  by  various  causes,  but  the  most  important  factor  in  its  produc- 
tion is  the  presence  of  various  bacteria.  Among  those  which  have  been 
isolated  are  the  colon  bacilli,  streptococci,  staphylococci,  pneumococci, 
and  typhoid  bacilli.  They  may  gain  access  to  the  gall-bladder  by  way  of 
the  blood,  or  from  the  intestine  by  way  of  the  common  and  cystic  ducts. 
They  have  been  demonstrated  in  the  centre  of  a  gall-stone.  Cholesterin, 
lime  salts,  and  bilirubin  deposited  around  collections  of  epithelial  debris 
and  bacteria  constitute  the  beginnings  of  biliary  calculi.  The  masses  thus 
formed  grow  in  size  by  the  gradual  accretion  of  similar  substances.  Gall- 
stones have  been  experimentally  produced  by  the  injection  of  cultures  of 
bacteria  into  the  gall-bladder  of  animals.  The  above  facts  account  for  the 
frequent  occurrence  of  cholelithiasis  after  the  acute  infectious  fevers, 
especially  enteric  fever. 

The  Chemical  and  Physical  Characters  of  Gall-stones. — Gall- 
stones are  composed  chiefly  of  cholesterin,  bilirubin  in  combination  with 
calcium,  and  calcium  carbonate.  These  constituents  are  present  in  vary- 
ing proportions.  Ordinary  calculi  consist  of  70  to  90  per  cent,  of  amorphous 
or  crystalline  cholesterin.  The  small,  dark  stones  found  in  the  ducts  are 
principally  composed  of  pigment  in  combination  with  calcium  and  calcium 
carbonate.  Free  bile  pigment  is  not  usually  present.  Traces  of  iron,  man- 
ganese, and  copper,  and  bile  acids  and  fatty  acids  are  also  present.     The 


CHOLELITHIASIS.  991 

• 

color  of  the  stones  is  not  uniform,  but  irregular,  and  depends  upon  the 
quantity,  character,  and  mode  of  deposit  of  the  pigment  which  they  con- 
tain. White  or  pale  fawn-colored  calculi  consist  of  nearly  pure  cholesterin. 
Other  stones  may  be  yellow,  greenish,  or  brown.  An  excess  of  pigment 
may  give  them  a  dark  reddish-brown  or  black  color.  The  cortex,  main 
body,  and  nucleus  are  usually  colored  differently.  The  consistency  also 
varies.  Cholesterin  stones  are  often  so  soft  that  they  may  be  crushed 
between  the  fingers.  Recently  formed  concretions  are  commonly  soft; 
older  ones  may  be  harder  with  a  soft  central  nucleus.  The  outer  layer 
may  be  hard  and  enclose  an  unformed  mass  of  cholesterin.  The  larger 
the  proportion  of  lime  salts  the  harder  the  calculus.  Section  usually  shows 
the  cholesterin  to  be  deposited  in  concentric  layers  with  radiating  crystal- 
line striae,  the  result  of  recrystallization. 

Gall-stones  vary  in  number  from  one  to  hundreds  or  even  a  thousand 
or  more.  Single  stones  are  usually  ovoid  and  may  be  of  large  size — 3  or  4 
cm.  or,  in  one  reported  instance,  7.5  cm.  in  long  diameter.  The  solitary 
stone  is  usually  closely  embraced  by  the  gall-bladder.  Multiple  calculi 
are  commonly  polygonal,  with  smooth,  faceted  surfaces,  and  owe  this  form 
to  the  pressure  exerted  among  themselves  while  soft.  Traces  of  faceting 
may  be  seen  in  the  small  calculi  numbered  by  hundreds  occasionally  met 
with.  It  sometimes  happens  that  a  small  number  of  ovoid,  unfaceted 
calculi  are  found.  They  are  of  the  dense  variety  and  consist  largely  of  the 
bilirubin-calcium  combination.  When  this  form  is  present  in  great  num- 
bers, the  individual  stones  are  not  larger  than  small  shot  and  are  spoken 
of  as  gall-sand.  Gall-stones  impacted  in  the  ducts  sometimes  undergo 
enlargement  by  further  accretions  of  cholesterin  and  lime  salts.  Stones 
are  found  in  this  situation  of  such  a  size  that  they  could  not  have  passed 
through  the  cystic  duct.  Small,  ovoid,  greenish-black  calculi  are  some- 
times found  in  the  intrahepatic  bile-ducts,  especially  in  cirrhosis  of  the 
liver.  In  a  majority  of  the  instances  they  are  all  of  the  same  variety 
and  composed  of  bilirubin-calcium.  In  fact,  in  cases  in  which  numerous 
gall-stones  are  present,  they  are  almost  always  all  of  the  same  variety. 

Symptoms. — The  subject  of  cholelithiasis  may  be  clinically  consid- 
ered under  the  following  headings:  gall-stones  quiescent  in  the  gall-bladder; 
the  symptoms  which  attend  the  passage  of  a  stone  through  the  ducts;  the 
symptoms  produced  by  the  permanent  obstruction  of  the  ducts;  ulcer- 
ative lesions  caused  by  gall-stones;    and  gall-stones  in  the  intestines. 

1.  Gall-stones  Quiescent  in  the  Gall=bladder. — In  a  great  majority  of 
cases  biliary  calculi,  so  long  as  they  remain  in  the  gall-bladder  in  which 
they  are  formed,  produce  no  symptoms.  Their  presence  in  this  viscus  is 
frequently  discovered  at  the  autopsy  in  cases  in  which  they  have  caused 
no  manifestations  whatever  during  life.  According  to  Kehr  symptoms 
occur  in  only  about  5  per  cent,  of  all  cases.  Persons  who  suffer  from 
repeated  attacks  of  biliary  coHc  frequently  have  no  trouble  from  them 
during  the  intervals.  In  a  small  proportion  of  the  cases  there  are  symptoms 
which  suggest  their  presence,  even  though  they  are  not  sufficiently  char- 
acteristic to  justify  a  positive  diagnosis.  When,  however,  such  symptoms 
occur  during  the  intervals  between  attacks  of  colic,  especially  when  such 
attacks  have  been  followed  by  the  passage  of  faceted  calculi,  their  signif- 


992  MEDICAL  DIAGNOSIS. 

• 

icance  is  clear.  These  symptoms  consist  of  subjective  sensations  of  weight 
in  the  right  hypochondrium,  aggravated  some  hours  after  taking  food, 
frequent  dull  pain  in  the  region  of  the  gall-bladder  radiating  toward  the 
right  shoulder  and  the  lumbar  region,  and  nervous  and  mental  derange- 
ments such  as  are  common  in  neurasthenia — depression,  irritability,  pre- 
cordial and  epigastric  distress,  and  headache,  coryza,  and  flying  neuralgic 
pains.  Upon  physical  examination  the  gall-bladder  may  sometimes  be 
found  to  be  enlarged  and  palpable,  and  in  very  rare  instances  a  fremitus 
caused  by  the  movement  of  multiple  calculi  among  themselves  may 
be  detected. 

Gall-stones  in  the  intrahepatic  ducts  rarely  give  rise  to  symptoms. 
If  numerous  or  large  they  may  occasion  pain,  enlargement  of  the  liver,  or 
jaundice,  but  these  symptoms  are. not  of  diagnostic  value.  When  infection 
takes  place  they  cause  diffuse  intrahepatic  cholangitis. 

2.  The  Symptoms  Attending  the  Passage  of  a  Qall-stone  Through  the 
Ducts. — Gall-stones  occasionally  become  arrested  in  the  cystic  or  the  com- 
mon duct  without  causing  pain.  Small  stones  may  traverse  these  passages 
without  giving  rise  to  colic.  This  has  been  observed  in  cases  in  which  the 
repeated  passage  of  larger  stones  is  inierred  to  have  caused  a  gradual 
dilatation  of  the  ducts.  When  stones  of  a  larger  size  are  passed  by 
the  bowel  in  the  absence  of  a  history  of  colic,  it  is  probable  that  they 
have  reached  the  intestine  by  way  of  a  fistulous  communication  with 
the  gall-bladder  or  ducts. 

Biliary  Colic. — Commonly  the  passage  of  a  gall-stone  is  attended  by  the 
symptoms  of  gall-stone  colic.  The  attack  usually  begins  with  violent  pain  in 
the  right  hypochondrium  with  its  focus  of  intensity  in  the  region  of  the  gall- 
bladder. In  some  cases  the  pain  is  referred  to  the  epigastrium  or  the  lower 
thoracic  region,  or  on  both  sides,  or  to  the  right  mammary  region.  It  may 
radiate  toward  the  abdomen  or  back,  and  occasionally  to  the  right  shoulder. 
It  is  usually  agonizing  and  the  patient  groans  and  rolls  about  in  uncontrolla- 
ble distress,  or  he  may  twist  his  body  to  the  right,  or  sit  with  his  thighs  and 
knees  strongly  flexed  and  his  body  bent  forward  so  as  to  relax  the  abdomr 
inal  muscles.  There  may  be  temporary  remissions  of  pain  which  are  fol- 
lowed by  exacerbations  of  greater  violence.  The  gall-bladder  is  often 
palpable  and  tender,  and  the  liver  may  be  somewhat  enlarged,  with  ten- 
derness over  the  hepatic  area.  Vomiting,  chills  or  chilliness,  a  rise  of  tem- 
perature sometimes  to  103°-104°  F.  (39.5°-40°  C),  profuse  sweating,  and 
great  general  relaxation  occur.  In  casp'^  ^'  arked  by  high  fever  there  may 
be  enlargement  of  the  spleen  and  febrile  albuminuria.  It  is  probable  that 
there  are  under  these  circumstances  bacterial  invasion  and  acute  chol- 
ecystitis. The  fact  that  the  symptoms  of  gall-stone  colic  are  sometimes 
present  in  acute  cholecystitis  without  gall-stones  is  not  to  be  overlooked. 
Jaundice  is  a  common  symptom.  It  does  not  occur  so  long  as  the  stone  is 
engaged  in  the  cystic  duct,  but  follows  the  lodgement  of  the  stone  in  the 
common  duct.  When  the  stone  is  of  small  size  and  passes  rapidly  through 
the  common  duct  into  the  intestine,  jaundice  may  not  occur.  In  any  case 
jaundice  does  not  occur  until  several  hours,  often  twenty-four,  have 
elapsed  from  the  beginning  of  the  attack.  It  is  usually  transient,  but 
may  persist  for  several  days  or  weeks.     The  jaundice  is  the  very  type  of 


CHOLELITHIASIS.  993 

obstructive  jaundice  and  is  associated  with  clay-colored  stools,  the 
presence  of  bile  pigments  in  the  urine,  itching  of  the  skin,  and  other 
characteristic   symptoms. 

The  duration  of  the  attack  varies  from  a  few  hours  to  several  days. 
When  the  stone  escapes  into  the  intestine  the  pain  ceases,  often  as  abruptly 
as  it  began,  leaving  some  degree  of  local  tenderness,  which  rapidly  subsides, 
and  lassitude,  from  which  the  patient  gradually  recovers.  Not  rarely  the 
stone  lodges  in  the  ampulla  of  Vater  and  acts  as  a  ball-valve,  causing  recur- 
rent attacks  of  pain  and  jaundice.  The  pain  is  a  true  coHc  caused  by  the 
spasmodic  contraction  of  the  musculature  of  the  bile-ducts  and  the  violent 
pressure  of  the  stone  upon  the  mucous  membrane.  The  swelling  and 
tenderness  of  the  gall-bladder  and  liver  are  due  to  bile  stasis  and  conse- 
quent distention  of  these  organs.  In  bacillary  invasion  there  is  the  super- 
added pain  of  inflammation.  Rare  accidents  are  fatal  syncope  and  the 
rupture  of  the  gall-bladder  into  the  peritoneal  sac.  Palpitation  and  pre- 
cordial distress  may  occur,  while  general  convulsions  and  hysterical  seizures 
are  occasionally  observed  in  neurotic  subjects. 

Direct  Diagnosis  of  Biliary  Colic.  —  The  diagnosis  rests  upon 
the  location  of  the  focus  of  pain,  its  radiation,  local  tenderness,  the  abrupt 
onset  of  the  attack,  vomiting,  chill  or  chilliness,  with  fever  and  the  symp- 
toms of  obstructive  jaundice.  The  history  of  previous  attacks  is  sugges- 
tive; the  presence  of  gall-stones  in  the  stools  is  conclusive.  Their  absence 
is,  however,  only  of  negative  importance  in  diagnosis.  It  may  be  due  to 
a  faulty  method  of  examination,  to  the  return  into  the  gall-bladder  of  a 
stone  which  has  engaged  in  the  cystic  duct,  to  cessation  of  muscular  spasm 
in  the  walls  of  the  ducts,  to  the  passage  of  the  stone  from  the  narrow  cystic 
duct  into  the  wide  common  duct  and  its  retention  there,  and,  finally,  to 
the  disintegration  of  the  stone  in  the  intestine. 

The  stools  must  be  thoroughly  stirred  with  a  large  quantity  of  water 
and  poured  through  a  fine-meshed  sieve.  The  coarser  particles  are  retained 
and  can  be  examined.  A  double  bag  of  netting  may  be  arranged  upon  a 
stout  wire  ring  like  a  landing  net  and  placed  in  the  bowl  of  the  water- 
closet.  The  faeces  may  be  washed  by  repeated  flushing  and  the  retained 
particles  examined  for  calculi.  If  they  are  not  at  first  found  every  stool 
should  be  examined  for  several  daj^s,  as  they  may  be  retained  in  the 
intestine  for  some  time.  Force  should  not  be  used  in  the  examination, 
since  recently  formed  biliary  calc."'''  -are  soft  and  may  readily  be  disin- 
tegrated in  handling  them.  The  seeds  of  various  fruits,  particles  of  bone, 
and  small  fecal  concretions  are  sometimes  brought  to  the  physician  as 
gall-stones,  and  the  rounded  saponaceous  masses  voided  after  the  ingestion 
of  large  quantities  of  olive  oil  are  frequently  mistaken  for  them,  but  these 
substances  never  contain  cholesterin  or  bile  pigment  in  quantity,  nor  do 
they  present  the  internal  structure  of  gall-stones. 

Differential  Diagnosis. — In  right-sided  renal  colic  the  pain  begins 
in  the  lumbar  region  and  radiates  toward  the  groin.  There  is  retraction 
of  the  testicle  and  pain  in  the  glans  penis.  Jaundice,  tenderness  in  the 
region  of  the  gall-bladder,  and  fever  are  not  usually  present.  A  calculus 
may  be  voided  by  way  of  the  urethra.  Peptic  ulcer  may  suggest  biliary 
colic.  The  pain,  however,  usually  follows  the  ingestion  of  food  and  is  burn- 
63 


994  MEDICAL  DIAGNOSIS.. 

ing  in  character,  passing  to  the  back.  The  vomiting  is  less  urgent  and 
the  vomitus  may  contain  blood.  There  is  localized  epigastric  tenderness 
and  anaemia.  Nervous  hepatic  colic  —  the  pseudobiliary  colic  of  nervous 
women — may  lead  to  an  erroneous  diagnosis.  The  pain  is  referred  to  the 
right  side  and  may  radiate  to  the  back  or  shoulder.  It  is  dull  and  dragging 
rather  than  colicky.  The  attack  follows  emotional  excitement  or  fatigue. 
There  may  be  tenderness  upon  pressure,  but  jaundice  does  not  occur. 
Intestinal  colic  is  relieved  by  belching,  the  passage  of  flatus,  or  defecation. 
It  is  more  generalized  and  less  intense  than  biliary  colic  and  not  followed 
by  jaundice.  Lead  colic  may  simulate  gall-stone  colic,  but  the  occupation 
of  the  patient  is  suggestive,  while  stubborn  constipation,  the  gingival  line, 
wrist-drop,  hard  arteries,  and  albuminuria  constitute  a  characteristic 
symptom-complex.     Jaundice  is  absent. 

3.  The  Symptoms  Caused  by  Permanent  Obstruction  of  the  Ducts  by  QaH= 
stones. — The  obstruction  may  involve  the  cystic  duct,  the  common  duct,  or 
the  hepatic  ducts. 

I.  Obstruction  of  the  Cystic  Duct. — Occlusion  of  the  cystic  duct 
by  a  calculus  or  by  the  contraction  of  a  cicatrix  following  ulceration  does 
not  always  cause  serious  symptoms.  It  is  liable  to  be  followed  by,  (a) 
dropsy  of  the  gall-bladder — hydrops  vesicce  fellece.  The  tumor  is  cystic 
and  gourd-shaped  or  pear-shaped,  its  narrow  extremity  being  at  its  con- 
nection with  the  liver.  The  contents  in  recent  cases  are  bile  mixed  with 
mucus  or  mucopus, — in  older  cases  a  clear,  thin  mucus  containing  albumin 
and  of  variable  reaction  to  litmus  paper.  The  tumor  projects  downward 
and  may  attain  large  dimensions.  It  is  freely  movable  from  side  to  side, 
unless  fixed  by  adhesions,  and  when  pushed  backward  turns  to  its  original 
position  as  soon  as  the  pressure  is  withdrawn.  When  the  belly  wall 
is  thin  and  relaxed  the  outline  of  the  distended  gall-bladder  may  be  visible, 
fluctuation  may  be  eHcited  upon  light  bimanual  percussion  and  palpation, 
and  when  there  are  many  calculi  present  gall-stone  crepitus  may  be  felt, 
(b)  Atrophy  of  the  Gall-bladder. — This  condition  frequently  follows  dropsy 
of  the  gall-bladder.  The  contents  undergo  gradual  resorption  and  the 
bladder  contracts  around  any  stones  that  it  may  contain,  or,  in  the 
absence  of  a  stone,  into  a  small  fibrous  mass,  or  there  may  be  diverticula 
in  which  calculi  are  embedded.  In  old  cases  of  this  kind  lime  salts  are 
sometimes  deposited  upon  the  mucosa  or  in  the  bladder  wall,  (c)  Acute 
cholecystitis,  usually  simple  but  in  rare  cases  phlegmonous,  (d)  Suppura- 
tive cholecystitis — empyema  of  the  gall-bladder.  The  gall-bladder  may  be 
greatly  enlarged  and  contain  as  much  as  a  litre  of  pus.  Perforation  may 
take  place  into  the  peritoneal  cavity;  more  commonly  adhesions  take 
place  with  abscess  formation. 

The  occurrence  of  these  conditions  may  constitute  the  first  direct 
evidence  of  cholelithiasis.  Under  no  circumstances  should  exploratory 
puncture  be  performed.     Aspiration  has  been  followed  by  fatal  results. 

II.  Obstruction  of  the  Common  Duct. — The  duct  may  be  occluded 
by  a  single  stone  in  the  ampulla  of  Vater  or  in  any  part  of  its  course  or  by 
a  number  of  stones  which  may  also  extend  into  the  cystic  and  hepatic  ducts. 
The  obstruction  may  be,  (a)  complete.  The  calculus  is  tightly  impacted 
in  the   common   duct,  or  a   large  stone  in  the   cystic  duct   compresses 


CHOLELITHIASIS.  995 

the  common  duct  at  its  upper  part  or  the  hepatic  duct.  There  is  complete 
bile  stasis  with  deep  and  persistent  jaundice  and  without  septic  phenomena. 
The  common  duct  behind  the  obstruction,  and  the  cystic  and  hepatic  ducts 
may  be  enormously  dilated  and  simulate  the  gall-bladder,  for  which  they 
have  been  mistaken.  The  condition  cannot  always  be  differentiated  from 
compression  of  the  duct  by  new  gi'owths,  though  pain,  a  history  of  biliary 
colic,  and  absence  of  dilatation  of  the  gall-bladder  are  in  favor  of  a  diagnosis 
of  complete  obstruction  by  gall-stones.  Or,  (b)  incom'plete.  In  this  form 
there  is  cholangitis,  which  may  be  simple  or  suppurative.  («)  Incomplete 
obstruction  with  non-suppurative  cholangitis.  There  may  be  a  single 
movable  calculus  in  the  diverticulum  of  Vater  or  in  the  duct  above  it, — 
ball-valve  mechanism, — or  a  small  faceted  stone  partially  impacted,  or 
a  series  of  stones.  The  ducts  above  the  obstruction  are  dilated,  but  the 
gall-bladder  is  often  contracted.  There  are  variations  in  the  degree  of 
jaundice  and  in  the  amount  of  bile  pigment  in  the  faeces.  The  liver  is  only 
slightly  enlarged  and  the  gall-bladder,  as  a  rule,  not  at  all  distended.  Finally 
there  are  irregular  attacks  of  fever  accompanied  with  demonstrable  enlarge- 
ment of  the  spleen.  In  well-marked  cases  of  ball-valve  calculus  the 
paroxysms  of  fever  are  irregularly  recurrent  and  resemble  attacks  of  ague. 
They  are  characterized  by  remarkable  rises  of  temperature, — 103°-106°  F. 
(39.5°-41.1°  C), — intense  chills,  profuse  sweating,  gastric  disturbances  and 
hepatic  tenderness  and  pain.  The  jaundice  is  variable  and  often  intense. 
The  resemblance  to  malaria  is  superficial,  the  periodicity  not  being  regular, 
the  blood  parasite  not  present,  and  quinine  useless.  This  fever  is  known  as 
hepatic  fever  or  the  hepatic  intermittent  fever  of  Charcot.  The  attacks  in 
many  instances  recur  after  irregular  intervals,  during  which  the  tempera- 
ture is  normal,  for  many  months. 

Courvoisier's  Law. — In  the  great  majority  of  cases  of  obstruction  of  the 
common  duct  by  gall-stone  the  gall-bladder  is  contracted;  in  the  majority 
of  cases  of  obstruction  from  other  causes  the  gall-bladder  is  dilated, 

(/?)  Incomplete  obstruction  with  suppurative  cholangitis.  The 
ducts  are  invaded  by  pyogenic  organisms.  The  suppurative  inflammation 
may  extend  to  the  intrahepatic  ducts — diffuse  intrahepatic  cholangitis — 
and  to  the  gall-bladder — empyema.  Abscess  of  the  liver  and  perforation 
of  the  gall-bladder  with  abscess  formation  may  occur.  There  are  septic 
phenomena.  The  hver  is  enlarged  and  tender;  jaundice  is  of  moderate 
intensity  and  persistent  and  there  is  fever  of  intermittent  or  remittent 
type.  The  course  of  the  disease  is  comparatively  short  and  the  termination 
fatal.  This  is  by  no  means  rare  as  a  terminal  condition  in  old  cases  of 
cholelithiasis. 

In  cholelithiasis  of  the  common  duct  there  is  frequently  an  asso- 
ciated catarrhal  or  interstitial  pancreatitis  and  Cammidge's  test  may  show 
characteristic  cr3'stals. 

4.  Ulcerative  Lesions  Caused  by  Gall-stones. — Biliary  fistulse  are  far 
from  uncommon.  Ulceration  of  the  bile  passages  may  occur  without 
symptoms.  As  a  rule,  however,  they  tend  to  grave  derangements  of  health. 
By  the  erosion  of  arterial  branches  in  the  course  of  the  formation  of  fistu- 
lous tracts  in  various  directions,  they  may  cause  hemorrhages  which  may 
be  latent  or  manifest  in  the  stools  or  vomit.     In  rare  instances  gall-stones 


996  MEDICAL  DIAGNOSIS. 

have  perforated  into  the  portal  vein.  Much  more  common  are  fistulous 
communications  with  the  intestinal  tract.  The  stomach  is  involved  com- 
paratively rarely,  the  duodenum  frequently,  the  small  intestine  much 
less  commonly,  while  fistulous  communications  with  the  colon  have  been 
occasionally  encountered.  There  are  instances  of  fistulse  involving  the 
ureters,  with  the  passage  of  stones  into  the  bladder  and  of  the  direct  pas- 
sage of  biliary  calculi  into  the  urinary  bladder.  Perforation  into  the  pleura 
and  into  the  lung  may  also  occur.  Cutaneous  fistulas  of  spontaneous  origin 
are  ver}^  uncommon,  though  they  are  by  no  means  rare  after  operation. 
They  usually  open  in  the  region  of  the  fundus  of  the  gall-bladder,  but  may 
appear  near  the  umbilicus  or  above  the  pubes.  The  formation  of  these 
ulcerative  tracts  is  always  preceded  by  adhesions  between  the  viscera 
directly  involved  and  followed  by  the  discharge  of  biliary  calculi  into 
the  distant  organ.  The  tracts  themselves  are  often  long  and  tortuous 
and  sometimes  there  are  diverticula  containing  gall-stones.  Abscess 
formation   is    common. 

5.  Qall=stones  in  the  Intestines. — When  by  way  of  the  common  duct, 
as  sometimes  may  occur,  or  by  a  fistulous  tract,  a  large  gall-stone  finds  its 
way  into  the  gut,  it  may  cause  intestinal  obstruction,  either  directly  or  by 
ulceration  followed  by  cicatricial  contraction.  The  obstruction  may  occur 
at  the  pylorus  and  cause  symptoms  suggestive  of  carcinoma.  More  com- 
monly it  is  in  the  lower  part  of  the  ileum.  In  the  region  of  the  caecum  the 
condition  may  simulate  appendicitis.  A  small  stone  may  enter  the  appendix 
or  a  diverticulum.  A  stone  in  the  colon  may  sometimes  be  recognized  upon 
rectal  examination. 

Diagnosis. — Cholelithiasis  is  recognized  during  life  in  a  small  propor- 
tion of  the  cases  only.  The  direct  diagnosis  while  the  gall-stones  remain 
quiescent  in  the  gall-bladder  may,  in  rare  instances,  be  made  by  the  dis- 
covery of  a  tumor  in  the  region  of  the  gall-bladder  in  which  gall-stones 
may  be  felt.  The  walls  of  the  bladder  may  be  thickened  by  chronic  inflam- 
mation or  the  seat  of  nodular  carcinomatous  growths.  The  differential 
diagnosis  between  an  enlarged  gall-bladder  and  a  tumor  of  the  kidney 
depends  upon  the  fact  that  the  former  may  be  pushed  backward  into  the 
abdomen,  but  directly  returns  to  its  former  position,  while  the  latter  will 
remain  in  the  position  into  which  it  is  replaced. 

Cholelithiasis  cannot,  as  a  rule,  be  demonstrated  by  the  X-rays,  since 
the  stones  are  mostly  composed  of  cholesterin  and  organic  matter  which 
do  not  cast  a  shadow,  and  such  shadows  as  are  cast  by  those  more  densely 
constituted  are  obscured  by  the  shadow  of  the  Hver. 

The  attack  of  colic  is  commonly  the  first  positive  sign  of  gall-stone 
disease.  The  symptoms  of  biliary  colic  and  the  differential  diagnosis 
between  that  affection  and  others  which  resemble  it  have  already  been 
discussed.  The  discovery  of  gall-stones  in  the  stools  constitutes  a  positive 
diagnostic  sign. 

Exploratory  puncture  of  the  gall-bladder  is  attended  with  the  danger 
of  the  escape  of  some  of  the  contained  fluid  into  the  peritoneum  and  a 
general  peritonitis.  It  is  therefore  to  be  emphatically  condemned.  An 
exploratory  operation  by  incision  is,  on  the  other  hand,  comparatively  safe 
and  wholly  justifiable  in  the  presence  of  obscure  and  dangerous  symptoms. 


AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  LIVER.     997 

Prognosis. — The  fact  that  in  a  large  majority  of  the  cases  no  symp- 
toms occur,  and  that  the  diagnosis  is  so  often  simply  a  post-mortem  finding, 
justifies  the  assertion  that  cholelithiasis  is  a  benign  disease.  Although  it  is 
so  often  latent  it  is  not,  however,  free  from  danger.  On  the  contrary,  the 
migration  of  the  stones  by  way  of  the  natural  passages  and,  to  a  greater 
extent,  by  artificial  channels  caused  by  ulceration  and  adhesions  may  be 
attended  by  great  suffering  and  serious  risk  of  life.  Even  under  these  cir- 
cumstances the  outlook  is  not  wholly  unfavorable.  AVhen  infection  of  the 
bile  passages  and  gall-bladder  has  taken  place  with  septic  fever,  especially 
when  empyema  of  the  gall-bladder,  suppurative  cholangitis,  or  abscess  of 
the  liver  has  occurred  as  a  complication,  the  prognosis  is  highly  unfavor- 
able. The  general  recognition  of  the  fact  that  cholelithiasis  is  a  surgical 
disease  has  rendered  the  prognosis  far  more  favorable  than  it  was  at  a 
period  when  the  sole  dependence  was  upon  drugs  and  mineral  waters. 

vii.  Affections  of  the  BIood=vessels  of  the  Liver. 

L  Anaemia. — Nothing  is  known  of  anaemia  of  the  liver  as  a  clinical 
condition. 

2.  HyperaEmia. — Two  forms  are  to  be  considered,  active  and  passive. 

(a)  Active  Hypersemia;  Congestion  of  the  Liver. — The  liver  is  one  of 
the  most  vascular  organs  of  the  body.  The  rapid  influx  of  blood  by  way 
of  the  portal  vessels  during  digestion  brings  about  a  physiological  hyper- 
semia  which  is  transient,  but  which  in  the  cases  of  persistent  overindulgence 
in  the  pleasures  of  the  table  may  become  the  cause  of  functional  or  even 
of  organic  changes.  Excessive  quantities  of  food,  strong  spices,  coffee, 
and  especially  alcohol  are  credited  with  causing  hypersemia  of  the  liver,  a 
condition  to  which  sedentary  habits  also  contribute.  The  condition  thus 
caused  constitutes  a  conspicuous  feature  in  general  plethora  and  obesity,  and 
is  frequently  associatQ,d  with  gout,  gravel,  and  glycosuria.  Toxic  agencies 
such  as  are  present  in  the  acute  fevers  and  malaria,  and,  indirectly,  the  mode 
of  life  common  among  Europeans  in  tropical  climates  are  causal  factors. 

Symptoms. — The  manifestations  of  active  hypersemia  of  the  liver  are 
indefinite  and  rarely  present  alone.  They  consist  of  sensations  of  pressure 
and  fulness  in  the  right  hypochondrium  and  epigastrium,  which  may 
amount  to  actual  pain  and  are  sometimes  intensified  by  movement,  deep 
respiration,  and  pressure.  They  are  associated  with  the  evidences  of  enlarge- 
ment of  the  organ  and  certain  symptoms  of  deranged  digestion,  such  as 
epigastric  weight,  heart -burn,  flatulence,  and  fulness  in  the  head.  In 
some  instances  a  periodical  recurrence  of  this  group  of  morbid  phenomena 
accompanies  the  return  of  menstruation  or  the  suppression  of  the  flow, 
or  the  arrest  of  an  habitual  hemorrhoidal  flux.  A  slight  icterus  frequently 
accompanies  the  attack  of  hypersemia  of  the  liver.  The  tendency  to  the 
development  of  organic  disease  as  a  result  of  permanent  hypersemia  is  to 
be  considered. 

(b)  Passive  Congestion. — This  form  of  hypersemia  is  much  more  com- 
mon. All  conditions  which  favor  the  accumulation  of  blood  in  the  venous 
system  and  the  transference  of  blood-pressure  from  the  arterial  to  the 
venous  side  of  the  circulation  lead  to  passive  hypersemia  of  the  liver,  which 


998  MEDICAL  DIAGNOSIS. 

constitutes,  in  fact,  an  important  part  of  the  general  visceral  congestion 
characteristic  of  such  states.  Cardiac  affections,  both  valvular  and  myo- 
cardial, especially  when  the  power  of  the  right  ventricle  is  diminished, 
are  important  etiological  factors.  Pulmonary  diseases  which  cause  mechan- 
ical interference  with  the  pulmonary  circulation,  such  as  acute  and  chronic 
bronchitis,  emphysema,  consolidation  of  the  lung  from  exudate  or  sclerosis, 
tumors,  and  extensive  pleural  effusion  or  adhesions,  also  give  rise  to  pas- 
sive hepatic  congestion,  partly  by  reducing  the  calibre  of  the  pulmonary 
vessels  and  partly  by  restricting  the  respiratory  excursus.  Deformities  of 
the  spinal  column  may  act  in  the  same  way.  Local  hypersemia  is  seen  in  the 
corset  liver  in  the  part  separated  from  the  main  organ.  The  liver  is  enlarged, 
dense,  and  of  a  deep  brownish-red  color — the  cyanotic  or  cardiac  liver. 
Later  it  may  be  contracted,  owing  to  the  overgrowth  of  connective  tissue. 

Symptoms. — In  the  early  stages  symptoms  are  absent  or  subordinated 
to  those  of  the  general  condition.  Later  epigastric  fulness,  especially  after 
eating,  dyspeptic  disturbances  and  hemorrhoids  occur.  Haematemesis 
may  occur.  The  portal  obstruction  may  cause  ascites.  A  mild  jaundice  is 
common.  The  stools  may  be  clay-colored,  and  bile  pigments  may  be 
present  in  the  urine.  Physical  examination  shows  the  liver  to  be 
enlarged.  It  is  usually  tender,  especially  below  the  arch  of  the  ribs  or 
upon  pressure  with  the  flat  hand.    Liver  pulsation  is  often  present. 

Diagnosis. — The  passive  hypersemic  liver  varies  in  size,  whereas  the 
enlargement  of  the  liver  from  other  lesions  is  persistent.  This  fact,  con- 
sidered in  connection  with  the  various  etiological  factors  above  enumerated, 
has  great  diagnostic  significance. 

3.  Diseases  of  the  Portal  Vein.  —  (a)  Occlusion  or  narrowing  of 
THE  portal  vein  may  be  caused  by,  (1)  acute  or  chronic  inflammation 
of  the  vessel  wall  or  by  its  invasion  by  a  neoplasm;  (2)  compression  from 
without  by  tumors,  enlarged  lymph-glands,  gall-stones,  or  the  cicatricial 
contraction  of  the  adjacent  parts,  especially  such  as  result  from  syphilis 
and  tuberculosis;  (3)  mechanical  obstruction  caused  by  Distoma  haema- 
tobium; and  finally  (4)  from  other  causes  not  clearly  understood,  (b) 
Thrombosis. — The  foregoing  conditions  cause  slowing  of  the  blood  stream 
in  the  portal  vein  and  thus  favpr  thrombus  formation,  which  may  occur 
in  cirrhosis,  syphilis  of  the  liver,  malignant  growths  involving  the  wall  of 
the  vein,  hyperplasia  of  the  lymph-glands  in  the  porta,  compression  or 
perforation  of  the  walls  of  the  vessel  by  hepatic  calculi,  parasite  invasion, 
and  arteriosclerosis.  The  coagulation  forms  a  wall-thrombus,  which  may 
partially  or  wholly  occlude  the  vein,  (c)  Adhesive  Pylephlebitis. — In 
rare  instances  a  collateral  circulation  is  established,  the  thrombus  becomes 
thoroughly  organized,  and  the  vein  is  converted  into  a  fibrous  cord. 

Symptoms. — The  condition  manifests  itself  by  acute  symptoms  which 
may  supervene  in  the  course  of  hepatic  cirrhosis,  chronic  peritonitis,  or 
abdominal  tumor,  or  occur  suddenly  in  persons  apparently  well.  These 
symptoms  consist  of  sudden  intense  epigastric  pain  with  haematemesis, 
melsena,  followed,  in  the  course  of  a  few  days,  by  ascites  and  enlargement  of 
the  spleen.    Icterus  is  sometimes  present. 

(d)  Suppurative  Pylephlebitis. — This  condition  is  due  to  infection 
by  pyogenic   bacteria.      It  is  secondary  to  intestinal   ulceration  such  as 


ABSCESS  OF  THE  LIVER.  999 

occurs  in  dysentery,  enteric  fever,  or  tuberculosis,  to  suppurative  foci,  as 
appendicitis,  pelvic  abscesses,  ischiorectal  abscess,  inflamed  hemorrhoids,  or 
fistula.  Multiple  abscess  formation  occurs  within  the  branches  of  the  portal 
vein.  Septic  phenomena  are  rapidly  developed.  They  consist  of  irregular 
chills,  fever  of  rapid  and  extreme  oscillation  of  temperature,  colliquative 
sweating,  and  profound  asthenia.  Local  symptoms  are  not  constant.  There 
may  be  tenderness  and  pain  over  the  liver  and  spleen,  the  latter  being 
enlarged.     Icterus  is  not  usually  marked. 

4.  Diseases  of  the  Hepatic  Artery. — (a)  Dilatation  occurs  in  cir- 
rhosis of  the  liver,  (b)  Sclerotic  changes  in  the  wall  are  common.  These 
conditions  are  of  pathological  rather  than  of  clinical  interest,  (c)  Aneurism 
is  infrequent.  A  number  of  cases  have  been  studied  cHnically.  The  diag- 
nosis is  obscure.  Important  symptoms  are  pain,  hemorrhage  from  the 
bowel  and  uterus.  A  pulsating  tumor  has  never  been  found.  The  cases 
closely  simulate  gall-stone  disease  or  duodenal  ulcer.  The  combination  of 
the  symptoms  of  these  two  conditions  is  of  diagnostic  significance.  Death 
may  occur  suddenly  from  hemorrhage  into  the  gastro-intestinal  tract  or 
into  the  peritoneum. 

5.  Diseases  of  the  Hepatic  Veins. —  (a)  Dilatation  occurs  when  the 
right  heart  is  permanently  dilated  and  hypertrophied.  (b)  Stenosis  is  far 
less  common.  It  may  be  due  to,  (1)  compression  by  tumors,  especially 
gummata  and  enlarged  lymph-nodes ;  (2)  disease  of  the  vessel  walls ;  (3) 
thrombosis;  and  (4)  embolism.  The  symptoms  are  obscure  and  the  clin- 
ical diagnosis  is  uncertain.  The  spleen  is  palpable,  the  liver  enlarged,  and 
ascites  occurs,  (c)  Thrombosis  may  occur  as  a  result  of  stenosis,  (d)  Emboli 
may  pass  into  the  hepatic  veins  from  the  right  auricle  when  the  blood  current 
is  reversed,  as  may  occur  in  tricuspid  insufficiency.  The  subsequent  course 
of  embolism  and  thrombosis  of  the  hepatic  veins  varies  according  to  the 
nature  of  the  cause  of  the  occlusion,  namely,  whether  it  be  simple,  infected, 
or  the  result  of  malignant  disease.     Infarcts  are  occasionally  encountered. 

viii.  Abscess  of  the  Liver^ — Suppurative  Hepatitis. 

Definition. — Suppuration  within  the  liver,  either  in  the  parenchyma 
or  in  connection  with  the  blood-vessels  or  bile  passages. 

The  following  forms  occur:  (1)  solitary  abscess,  (2)  embolic  or  pysemic 
abscesses,  (3)  suppurative  pylephlebitis,  (4)  suppurative  cholangitis,  (5) 
local  abscess  formation  caused  by  foreign  bodies  or  parasites. 

The  distinction  sometimes  made  between  primary  and  secondary 
abscesses  of  the  liver  cannot  always  be  observed.  Those  abscesses  due  to 
traumatism  or  the  extension  of  suppurative  processes  from  the  gall-bladder 
or  bile-ducts  are  primary;  those  in  which  infection  has  taken  place  by  way 
of  the  blood  stream  are  secondary. 

Etiology. — Predisposing  Influences. — Residence  in  the  tropics,  espe- 
cially when  associated  with  excesses  at  table  and  overindulgence  in  alcohol, 
amoebic  dysentery,  cholelithiasis,  appendicitis,  traumatism  in  the  region  of 
the  liver  and  blows  upon  the  head,  ulceration  of  the  intestines  and  suppu- 
rative processes  in  the  pelvis,  general  sepsis  with  metastatic  abscesses,  and 
echinococcus  cysts  in  the  liver  are  all  predisposing  factors  of  importance. 


1000  MEDICAL  DIAGNOSIS. 

The  Exciting  Cause. — Infection  of  the  liver  substance,  the  blood- 
vessels, the  bile-ducts,  or  the  gall-bladder  by  pyogenic  organisms  is  the 
direct  cause  of  hepatic  abscess.  The  avenues  of  infection  are  the  portal 
vein,  the  hepatic  vessels,  the  common  duct,  and  penetrating  wounds  or 
fistulous  tracts.  The  organisms  found  in  hepatic  abscess  comprise  Amoebae 
dysenteriae,  streptococci,  colon  bacilli,  pneumococci,  typhoid  bacilli, 
Bacillus  pyogenes,  and  actinomyces. 

Morbid  Anatomy. — Tropical  abscess  is  usually  solitary,  though  two  or 
more  abscesses  are  occasionally  encountered.  When  single,  the  abscess  is 
commonly  situated  in  the  right  lobe,  extending  to  the  upper  surface,  less 
frequently  toward  the  concave  surface  of  the  organ.  Recent  abscesses,  as 
seen  at  the  surface  of  the  liver,  are  of  a  grayish-yellow  color  with  a  well- 
defined  outline.  In  a  more  advanced  stage  the  walls  are  shreddy  and 
necrotic  and  contain  a  greenish-  or  reddish-brown  viscid  pus  commingled 
with  blood,  in  which  there  are  fragments  of  liver  tissue.  This  fluid  shows 
fatty  and  granular  detritus,  cellular  elements,  occasionally  Charcot-Leyden 
crystals,  and  amoebae,  which  are  also  present  in  the  tissue  forming  the  wall. 
Cultures  are  commonly  sterile.  The  abscess  wall  consists  of  an  inner  necrotic 
layer,  a  middle  layer  in  which  there  is  proliferation  of  connective  tissue, 
and  an  outer  layer  of  intense  hyperaemic  tissue.  The  chronic  abscesses 
frequently  have  an  extremely  dense  wall.  Rupture  may  occur  into  the  lower 
lobe  of  the  right  lung,  into  the  pleura  (causing  an  empyema),  into  the  vena 
cava,  the  portal  or  hepatic  veins,  or  into  the  stomach,  intestine,  peritoneum, 
pericardium,  or  externally.  Perforation  into  the  right  kidney  is  a  rare 
event.  Traumatic  abscess  is  usually  single  and  has  no  distinctive  anatom- 
ical characters.  Pyaemic  abscesses  are  almost  always  multiple  and  may  be 
very  numerous.  When  large  they  are  due  to  the  coalescence  of  several  small 
cavities.  The  infected  emboli  find  their  way  to  the  liver  through  the  hepatic 
artery  or  form  infected  thrombi  in  the  portal  vein.  Echinococcus  cysts 
undergo  suppurative  changes  as  the  result  of  infection  following  trauma 
or  inflammation  of  the  bile  passages.  The  abscesses  may  be  of  great  size, 
and  contracted  hydatids,  dead  scolices,  shreds  of  the  cyst  wall,  fat,  and 
bilirubin  may  be  found  in  the  pus. 

Symptoms. — 1.  Solitary  Abscess. — This  condition  is  common  among 
Europeans  in  the  tropics  and  chiefly  affects  males.  It  occurs  also  in  the 
temperate  zones.  It  is  almost  always  associated  with  amoebic  dysentery, 
though  cases  occur  in  which  no  history  of  dysentery  can  be  obtained.  The 
abscess  may  present  no  definite  symptoms  and  finally  reveal  its  presence 
by  rupture  which  may  prove  fatal.  The  principal  symptoms  are  fever, 
pain,  tenderness,  and  septic  phenomena.  Enlargement  of  the  liver  may 
be  demonstrated.  The  temperature  is  irregular.  There  is  paroxysmal 
fever  of  intermittent  type,  sometimes  of  regular,  sometimes  of  irregular, 
periodicity,  the  temperature  frequently  falling  to  subnormal  ranges. 
Rigors  are  followed  by  rises  of  temperature  to  103°-105°  F.  (39.5°-40.5°C.), 
followed  by  copious  sweating.  The  condition  frequently  simulates  a 
malarial  intermittent  fever.  In  the  chronic  cases  fever  may  be  absent. 
Pain  referred  to  the  region  of  the  liver,  the  back,  the  epigastrium,  or  the 
right  shoulder  is  a  common  symptom.  It  is  often  associated  with  sen- 
sations of  weight  and  dragging  in  the  right  hypochondrium,  much  increased 


ABSCESS  OF  THE  LIVER.  1001 

when  the  patient  turns  upon  his  left  side,  and  with  tenderness  upon  pres- 
sure at  the  costal  margin  in  the  mammillary  line.  The  shoulder  pain  is 
due  to  irritation  of  the  terminal  filaments  of  the  right  phrenic  nerve  which 
are  distributed  to  the  capsule  of  the  liver.  The  stimulus  is  transmitted 
to  the  fourth  cervical,  which  anastomoses  with  the  phrenic  and  sends 
sensory  branches  to  the  shoulder.  The  facies  of  the  patient  is  sallow, 
pallid,  muddy,  and  faintly  icteroid.  Irregular  diarrhoea,  digestive  dis- 
turbances, and  great  mental  depression  are  common.  Leucocytosis  is 
sometimes  present,  often  absent,  and  therefore  not  usually  of  diagnostic 
value.  Enlargement  of  the  liver  is  most  marked  in  the  right  lobe  and 
upward.  This  condition  is  in  contrast  with  many  diseases  of  the  liver 
in  which  the  enlargement  is  in  a  downward  direction,  as  fat  infiltra- 
tion, hypertrophic  cirrhosis,  and  carcinoma.  The  upper  margin  of  liver 
dulness  is  usually  higher  in  the  back  near  the  spine  than  anteriorly.  In 
extensive  abscess  formation  the  lower  margin  of  the  liver  may  extend  a 
hand's  breadth  below  the  edge  of  the  ribs.  The  entire  right  hypochon- 
drium  may  bulge,  the  ribs  protrude  and  be  widely  separated,  and  fluctua- 
tion may  be  detected.  Palpation  may  be  painful.  The  margin  of  the 
liver  is  felt  to  be  rounded  and  blunt,  the  superficial  venules  over  the  liver 
may  be  dilated,  and  there  may  be  circumscribed  cyanosis  with  oedema. 
Upon  deep  respiration  a  friction  fremitus  may  sometimes  be  detected. 
Perforation  into  the  lung  may  occur  or  amoebic  infection  through  the 
diaphragm  without  rupture.  The  base  of  the  right  lower  lobe  shows  signs 
of  consolidation,  there  is  intense  paroxysmal  cough,  with  characteristic 
expectoration  resembling  anchovy  sauce  and  containing  Amoebae  coli  in 
varying  numbers  and  actively  motile.  The  color  of  the  expectoration  is 
due  to  altered  blood.  The  sputum  may  be  blood-tinged  or  bright  red  and 
very  abundant.  It  may  contain  pus  and  shreds  of  liver  tissue.  Recovery 
may  take  place  in  the  course  of  several  weeks.  Perforation  into  the  pleura 
causes  empyema  with  characteristic  symptoms  and  physical  signs;  into 
the  pericardium  is  followed  by  fatal  collapse;  into  the  stomach  gives  rise 
to  vomiting  of  blood-tinged  fetid  pus;  into  the  intestine  to  the  presence  of 
pus  in  the  stools.  Coincident  with  the  escape  of  pus  in  these  various 
directions  there  is  sudden  subsidence  of  the  liver  tumor,  together  with 
sensations  of  collapse.  Rupture  into  the  vena  cava  is  followed  by  rapid 
death  with  symptoms  of  asphyxia.  In  the  rare  cases  of  perforation 
of  a  liver  abscess  into  the  pelvis  of  the  right  kidney,  the  urine  con- 
tains pus  of  a  brownish-red  color  which  may  show  the  presence  of 
liver-cells   or   blood-corpuscles. 

2,  Embolic  or  Py^emic  Abscesses. — The  multiple  small  abscesses 
in  the  liver,  which  occur  in  some  cases  of  general  septicopyaemia,  may  cause 
pain  and  tenderness  in  the  hepatic  region  and  a  slight  subicteroid  discolor- 
ation of  the  skin.  When  these  symptoms  are  superadded  to  the  rigors, 
high  temperature,  sweating,  and  prostration  of  the  septic  condition,  and 
especially  when  a  suppurative  focus  can  be  discovered,  the  diagnosis  of 
metastatic  abscesses  in  the  liver  may  be  made. 

3.  Suppurative  Pylephlebitis. — The  clinical  manifestations  are  the 
same  as  in  pyaemic  abscess.  The  liver  is  enlarged  and  tender,  there  is  fever 
of  septic  type,  and  a  muddy,  icteroid  skin. 


1002  MEDICAL  DIAGNOSIS. 

4.  Suppurative  Cholangitis. — The  history  of  attacks  of  gall-stone 
colic  or  of  the  recovery  of  gall-stones  from  the  stools,  and  the  symptoms  of 
cholangitis  or  the  presence  of  a  distended  gall-bladder  are  important  for 
the  diagnosis. 

5.  Foreign  Bodies  and  Parasites. — Needles  have  penetrated  the 
wall  of  the  CESophagus  or  stomach  and  entered  the  liver  substance,  causing 
abscess.  A  needle  or  a  fish-bone  has  been  known  to  perforate  a  branch 
of  the  portal  vein  and  give  rise  to  pylephlebitis.  The  part  played  by 
echinococcus  cysts  in  producing  liver  abscess  has  been  described.  The 
IDenetration  of  round  worms  into  the  common  duct  and,  less  commonly, 
the  presence  of  flukes  have  caused  suppurative  processes.  These  parasites 
probably  act  merely  as  carriers  of  pyogenic  germs. 

Diagnosis. — Direct. — Abscess  of  the  liver  is  often  latent  and  wholly 
overlooked,  notwithstanding  the  fact  that  the  patients  almost  always 
present  the  appearance  of  serious  illness.  This  is  due  to  the  fact  that 
local  symptoms  may  be  altogether  absent  or  subordinated  to  those  of  the 
primary  disease.  When  pain,  tenderness,  and  enlargement  of  the  liver  are 
present,  and  a  source  of  infection  can  be  found  in  the  structures  tributary 
to  the  portal  vein;  or  a  focus  of  purulent  inflammation  elsewhere;  or  when 
there  is  a  history  of  traumatism  involving  the  liver,  or  of  bone  injury, 
especially  injury  to  the  bones  of  the  skull,  or  of  cholelithiasis,  a  positive 
diagnosis  may  be  made.  Nevertheless  the  symptoms  are  frequently  obscure, 
and  the  diagnosis,  even  when  abscess  is  suspected,  cannot  in  many  cases 
be  positively  determined.  This  statement  is  especially  true  of  abscesses 
of  moderate  size  centrally  situated  in  the  substance  of  the  liver,  and  of 
the  multiple  small  abscesses  which  occur  in  general  septic  conditions  and 
in  acute  cholangitis  and  pylephlebitis.  Of  positive  diagnostic  import  are 
pain  referred  to  the  region  of  the  liver  and  the  right  shoulder,  enlargement 
of  the  liver  in  an  upward  direction,  bulging,  particularly  when  circum- 
scribed, and  fluctuation.  Examination  by  the  X-rays  yields,  as  a  rule, 
unsatisfactory  results,  owing  to  the  density  of  the  liver,  but  in  exceptional 
cases  may  be  of  service. 

Differential.  —  The  following  conditions  are  to  be  considered: 
(a)  Malarial  Fever. — The  regularly  intermittent  fever  often  closely  simu- 
lates malarial  fever,  but  the  absence  of  marked  splenic  enlargement  and 
of  the  malarial  blood  parasite,  and  the  failure  of  quinine  to  control  the 
fever  are  of  diagnostic  significance,  (b)  Right-sided  Empyema. — When 
the  abscess  ruptures  into  the  pleura  an  empyema  is  produced,  but  perfora- 
tion of  the  lung  commonly  follows,  and  the  true  nature  of  the  condition 
is  revealed  upon  the  expectoration  of  pus  resembling  anchovy  sauce  and 
containing  amoebae.  (c)  Subphrenic  Abscess. — The  downward  displace- 
ment of  the  liver,  the  fact  that  the  lower  border  of  the  lung  descends  upon 
deep  inspiration,  and  a  history  of  gastric  ulcer  may  be  of  service  in  the  dif- 
ferentiation from  hepatic  abscess.  When  gas  is  also  present, — pyopneumo- 
thorax subphrenicus. — the  diagnosis  is  less  difficult,  (d)  Abscess  of  the 
Abdominal  Wall. — Perforation  through  the  abdominal  wall  presents  little 
difficulty.  A  mural  abscess  may  closely  simulate  liver  abscess.  Such 
lesions,  usually  associated  with  tuberculosis  of  the  ribs,  are  superficially 
situated,  and  an  exploratory  needle  does  not  follow  the  movements  of 


FATTY  LIVER.  1003 

respiration.  The  liver  is  not  enlarged,  (e)  Empyema  of  the  Gall-bladder. — 
The  situation  of  the  tumor,  its  gourd-like  outline,  and  some  degree  of 
lateral  movement  upon  pressure  are  important  points  in  diagnosis,  (f) 
Echinococcus  Cysts. — Slowness  of  growth,  absence  of  fever  and  signs  of 
inflammation,  very  obscure  fluctuation,  and  the  hydatid  thrill  are  char- 
acteristic of  these  cysts.  When  thej^  become  infected  the  differential 
diagnosis  from  hepatic  abscess  is  attended  with  great  difficulty.  The 
presence  of  hooklets  or  shreds  of  cyst  walls  in  the  pus  is  of  positive  diag- 
nostic significance,  (g)  Abscess  of  the  Left  Lobe. — An  abscess  in  this  posi- 
tion is  uncommon.  It  may,  in  the  absence  of  inflammatory  symptoms, 
simulate  carcinoma  ventriculi,  from  which  it  may  be  distinguished  by 
the  age  of  the  patient,  the  history  of  the  case,  an  examination  of  the  gastric 
contents,  and  the  presence  of  foci  of  infection  in  the  intestines  or  elsew^here. 
(h)  Aneurism  of  the  Aorta. — Hepatic  abscess  to  which  the  movements  of 
the  aorta  are  transmitted  may  simulate  an  aneurism  in  the  region  of  the 
coeliac  axis.  In  abscess  the  pulsation  is  to  and  fro,  not  expansile,  diastolic 
shock  is  absent,  a  bruit  is  not  heard,  and  the  pain  is  less  severe  and  par- 
oxysmal than  in  aneurism  and  has  a  different  focus  of  maximum  intensity, 
(i)  Hepatic  Fever. — The  intense  fever  with  chills  and  sweating  which  occurs 
in  certain  cases  of  gall-stone  disease  is  frequently  regarded  as  due  to  abscess 
of  the  liver.  It  is  now  known  that  this  symptom  may  occur  in  the  absence 
of  suppuration.  The  fever  occurs  in  paroxysms,  which  may  have  a  regular 
periodicity  or  recur  at  irregular,  often  prolonged,  intervals,  during  which 
there  is  complete  apyrexia  and  the  nutrition  may  be  fairly  well  maintained. 
The  varying  jaundice,  which  is  intensified  during  the  febrile  attacks,  is  sug- 
gestive, and  the  long  duration  of  the  condition  is  of  diagnostic  importance. 

Exploratory  puncture  may  be  made  in  a  doubtful  case.  The  patient 
must  be  etherized  and  the  skin  cleansed  as  in  any  surgical  operation.  The 
aspirator  needle,  which  should  be  of  large  calibre,  should  be  introduced 
at  the  suspected  point  in  the  infra-axillary  region  or  over  the  area  of 
hepatic  dulness  behind.     Repeated  puncture  may  be  necessary. 

Prognosis. — The  outlook  in  pysemic  abscesses  is  ominous.  In  diffuse 
suppurative  cholangitis  and  pylephlebitis  and  in  traumatic  abscess  it  is 
highly  unfavorable.  In  solitary,  tropical  abscess  it  is  much  more  hope- 
ful. Recovery  may  take  place  after  aspiration  or  incision.  In  the  more 
chronic  cases  of  solitary  abscess,  perforation  into  the  lung  or  the  intestine 
or  through  the  skin  may  be  followed  by  recovery.  In  individual  cases 
marked  septic  phenomena,  persistence  of  dysenteric  symptoms  or  of  sup- 
puration in  pelvic  abscess  or  bone  disease,  the  supervention  of  amyloid 
disease,  and  the  development  of  cachexia  are  highly  unfavorable.  The 
danger  of  rupture  into  the  vena  cava,  the  pericardium,  or  the  peritoneum 
renders  the  prognosis  uncertain. 

ix.  Fatty  Liver. 

Definition. — This  term  is  used  to  designate  all  conditions  charac- 
terized by  an  abnormal  increase  in  the  fat  of  the  liver. 

Under  physiological  conditions  the  fat  in  the  liver-cells  varies  and 
is  dependent  upon  the  amount  and  character  of  the  food.     The  ingestion 


1004  MEDICAL  DIAGNOSIS. 

of  large  quantities  of  fat  is  followed  by  an  increase  of  fat-globules  in  the 
peripheral  cells  of  the  acini.  This  increase  is  transient,  disappearing  in 
the  course  of  several  hours. 

Pathologically  two  different  forms  of  fatty  liver  occur — fatty  infiltra- 
tion and  fatty  degeneration.  These  forms  sometimes  coexist.  Fatty 
infiltration  is  the  result  of  an  increased  deposit  of  fat  in  the  parenchyma 
of  the  liver  in  the  absence  of  fatty  change  in  the  protoplasm  of  the  cells. 

Fatty  degeneration  consists  of  a  destruction  of  the  protoplasm  of  the 
cells  with  fat  accumulation. 

Etiology. — Fatty  infiltration  occurs  in  general  obesity  and  in  persons 
who  habitually  consume  inordinate  amounts  of  fats  and  carbohydrates; 
at  the  middle  periods  of  life;  and  in  many  women  after  the  menopause. 
It  is  common  in  conditions  in  which  there  is  deficient  oxidation,  marked 
anaemia,  advanced  phthisis,  or  the  cachexias.  Chronic  alcoholism  leads 
to  fatty  degeneration  of  the  liver  by  interfering  with  the  oxygenation  of 
fats  and  carbohydrates,  the  oxygen  being  largely  required  for  the  com- 
bustion of  the  alcohol  consumed.  Fatty  degeneration  is  caused  by  certain 
poisons,  as  phosphorus,  the  toxin  of  acute  yellow  atrophy,  and  arsenic, 
mercury,  and  antimony. 

Morbid  Anatomy. — The  ordinary  fatty  liver — fatty  infiltration — is  uni- 
formly enlarged  and  may  reach  double  the  normal  weight.  It  is  smooth,  of  a 
pale  yellow  or  drab  color,  and  greasy.  In  fatty  cirrhosis  the  surface  shows 
irregular  granular  prominences.  On  section  the  light  yellow  color  and  empty 
blood-vessels  are  noticeable  and  the  knife  is  smeared  with  grayish-white  fat. 
Microscopically  the  cells  are  distended  with  small  and  large  fat  droplets. 

Symptoms. — Clinically  fatty  infiltration  is  to  be  distinguished  from 
fatty  degeneration.  In  the  former  the  parenchyma  is  not  degenerated 
but  simply  contains  an  excess  of  fat.  The  hepatic  functions  are  therefore 
maintained,  and  general  s^^mptoms  do  not  occur.  In  the  latter  the  liver- 
cells  are  affected  by  a  degenerative  process,  their  functions  are  no  longer 
performed  normally,  and  grave  symptoms  are  present,  as  in  acute  yellow 
atrophy,  q.v.,  and  phosphorus  poisoning.  The  symptoms  in  fatty  infiltra- 
tion are  not  well  defined.  The  appearance  of  the  patient  and  the  symp- 
toms referable  to  other  organs  are  dependent  upon  the  primary  disease. 
Jaundice  does  not  occur.  The  stools  may  be  light-colored  or  even  whitish- 
gray,  and  putty-like  in  consistency.  The  urine  does  not  contain  bile  pig- 
ments in  excess.  Hemorrhoids  may  occur,  but  the  signs  of  portal  obstruc- 
tion are  not  common.  In  obese  persons  the  ph3^sical  signs  are  often 
obscure,  but  in  phthisis  and  cachectic  conditions  the  greatly  enlarged  liver 
may  be  sometimes  visible  through  the  belly  wall  and  almost  always  recog- 
nized upon  palpation.  It  is  smooth,  with  a  rounded  lower  border,  pro- 
jecting far  below  the  margin  of  the  ribs,  and  is  painless. 

Diagnosis. — Slight  grades  of  fatty  liver  cannot  be  recognized  during  life. 
When  the  condition  is  well  developed  it  is,  except  in  the  case  of  great  obesity, 
easy  of  recognition.  The  great  enlargement,  smooth  surface,  and  nearly  nor- 
mal contour  are  characteristic.  The  underlying  disease,  as  anaemia,  phthisis, 
the  various  cachexias,  is  of  diagnostic  importance.  The  soft  consistence 
enables  us  to  exclude  amyloid  liver,  leukaemic  tumors,  and  hyperaemia. 

Prognosis. — Fatty  liver  is  a  secondary  pathological  condition,  and 
the  prognosis  is  that  of  the  primary  disease. 


CHRONIC  INTERSTITIAL  HEPATITIS.  1005 

X.  Chronic  Interstitial  Hepatitis. 

Cirrhosis   of  the  Liver. 

Definition. — A  chronic  disease  of  the  Hver  due  to  various  toxic  or 
infectious  causes,  mechanical  irritation,  or  stasis  of  blood  or  bile,  and 
characterized  by  an  overgrowth  of  the  interstitial  connective  tissue  of 
the  organ. 

It  is  of  interest  to  investigate  the  etymological  significance  of  this 
unfortunate  word  "cirrhosis,"  originally  selected  by  Laennec  to  describe 
an  anatomical  peculiarity  of  the  contracted  liver  far  from  constant,  and 
subsequently  applied  to  changes  in  other  viscera  attended  by  an  over- 
growth of  connective  tissue,  so  that  there  have  been  those  who  have  spoken 
of  cirrhosis  of  the  kidney,  cirrhosis  of  the  lungs,  and  the  like.  The  word 
is  derived  from  the  Greek  xtppo^,  tawny  or  orange-yellow,  the  color  of  the 
liver  substance  in  some  of  the  cases.  It  has  nothing  whatever  to  do,  save 
by  a  remote  and  misleading  association,  with  the  sclerotic  changes  due  to 
hyperplasia  of  connective-tissue  stroma. 

The  difficulties  in  the  diagnosis  of  hepatic  cirrhosis  are  not,  as  in  most 
other  diseases,  accidental.  They  do  not  arise  from  the  peculiarities  of 
individual  cases.  They  are  essential  and  due  to  the  fact  that  no  definition 
can  be  framed  that  at  once  pathologically  and  clinically  includes  all  the 
cases.  This  arises  from  Laennec's  choice  of  a  term  descriptive  of  an  incon- 
stant phenomenon  and  without  pathological  significance.  "Cirrhosis"  is 
conspicuous  among  the  nosological  terms  that  hamper  medicine  and 
obstruct  the  progress  of  knowledge.  If  it  could  be  erased  from  the  list  of 
diseases  our  conception  of  the  various  conditions  to  which  it  is  applied 
would  be  greatly  simplified.  The  one  underlying  lesion  common  to  all  of 
them  is  an  overgrowth  of  the  fibrous  tissue  of  the  liver.  The  term  chronic 
interstitial  hepatitis  is  at  once  descriptive  of  the  anatomicopathological 
condition  and  sufficiently  comprehensive  to  include  all  the  cases.  Its 
more  general  use  is  to  be  desired. 

Etiology. — The  etiological  relations  of  individual  cases  may  be  indi- 
cated by  qualifying  adjectives: 

(a)  In  general  toxic,  and  in  particular  alcoholic,  plumbic,  gouty, 
diabetic,  rachitic,  and  the  like.  We  must  include  here  forms  of  interstitial 
hepatitis  due  to  chronic  phosphorus  poisoning  and  the  abuse  of  condiments. 
The  assumption  that  intestinal  autointoxication  gives  rise  to  interstitial 
hepatitis  requires  confirmation. 

(b)  In  general  infectious;  in  particular  the  specific  febrile  infections, 
are  occasionally  followed  by  chronic  interstitial  hepatitis.  Malaria  pro- 
duces similar  changes,  and  syphilis  gives  rise  to  three  well-characterized 
forms,  namely,  diffuse  syphilitic  hepatitis,  commonly  congenital,  gummata 
which  undergo  fibroid  transformation,  and  an  extensive  perihepatitis 
with  increase  in  connective  tissue  of  the  portal  canals. 

(c)  Mechanical  irritation.  The  long-continued  exposure  to  an  atmos- 
phere laden  with  dust  particles  such  as  produce  pneumonoconiosis,  whether 
these  be  mineral  or  metallic,  may  also  give  rise  to  an  inflammatory  process 
in  the  connective  tissue  of  the  liver. 


1006  MEDICAL  DIAGNOSIS. 

(d)  Congestive;  the  chronic  hypersemia  of  the  blood-vessels  occurring 
in  heart  disease  gives  rise  to  an  interstitial  hepatitis — the  cardiac  liver. 

(e)  Obstructive,  the  result  of  chronic  obstruction  in  the   bile-ducts. 
Pathology   and   Classification.— Vaughan,  in  a  recent  study  of  the 

subject,  concludes  that  so-called  atrophic  and  hypertrophic  cirrhosis  are 
not  different  forms  of  the  same  disease  but  wholly  different  diseases. 
He  states  that  the  former  is  known  as  atrophic  cirrhosis  because  from  its 
earliest  possible  recognition  the  liver  is  less  than  normal  in  size;  while 
the  hypertrophic  is  known  as  such  because  at  every  stage  of  the  disease 
the  liver  is  larger  than  normal;  that  the  atrophic  is  known  as  venous  cir- 
rhosis because  of  the  early  and  constant  involvement  of  the  intrahepatic 
branches  of  the  portal  vein,  the  hypertrophic  as  biliary  cirrhosis  because 
of  the  early  appearance  and  constancy  of  icterus;  that  in  atrophic  cirrhosis 
the  primary  destructive  changes  are  in  the  hepatic  cells,  while  in  hyper- 
trophic cirrhosis  the  epithelium  of  the  gall-ducts  is  the  site  of  the  primary 
involvement;  that  the  former  might  be  known  as  toxic,  the  latter  as  in- 
fective cirrhosis. 

This  clear-cut  classification,  while  in  some  respects  convenient  and 
while  it  provides  categories  for  well-marked  cases  of  widely  different  mor- 
bid conditions,  by  no  means  meets  the  requirements  of  all  the  cases  and 
does  not  appear  to  be  wholly  justified  upon  etiological,  anatomical,  or 
clinical  grounds.  There  are  cases  of  atrophic  cirrhosis  in  the  causation  of 
which  alcohol  plays  no  part,  and  cases  of  hypertrophic  cirrhosis  in  hard 
drinkers.  My  clinical  experience  leads  me  to  believe  that  alcohol  is  a  very 
common  cause  of  the  latter  form  of  cirrhosis. 

Cases  of  cirrhosis  of  the  liver  without  jaundice  and  with  the  evidences 
of  a  high  degree  of  portal  obstruction,  in  which  the  liver  is  normal  in  size 
or  slightly  enlarged,  are  by  no  means  rare.  In  addition  to  these  there  is 
the  fatty  cirrhosis  common  in  beer-drinkers.  There  is  a  large  group  of 
cases  in  which  the  symptoms  are  neither  those  of  the  atrophic  nor  the 
hypertrophic  form.  These  are  designated  mixed  forms,  and  are  thought 
to  be  due  to  the  coexistence  of  the  two  forms,  the  toxic  and  the  infective, 
in  the  same  individual.  On  the  other  hand,  Hawkins  of  St.  Thomas's 
Hospital,  in  the  article  on  cirrhosis  of  the  liver  in  Allbutt's  System,  expresses 
the  opinion  that  the  terms  "atrophic"  and  "hypertrophic"  are  scarcel}^ 
worth  retaining.  "The  former,"  he  observes,  "has  lost  much  of  its 
fitness  now  that  statistics  show  that  the  hob-nailed  liver,  to  which  it  was 
originally  applied,  is  not  necessarily  small,  but  is  often  increased  both  in 
size  and  weight,"  while  "the  phrase  hypertrophic  cirrhosis  has  become  so 
complicated  by  the  postulate  of  a  biliary  cirrhosis  that  its  significance  is 
vague  and  uncertain."  Hawkins  does  not  recognize  a  vascular  or  toxic 
form  corresponding  to  the  atrophic  form  of  writers — Laennec's  cirrhosis — 
and  a  biliary  or  infectious  form — Hanot's  cirrhosis, —  but  states  that  "  two 
forms  of  cirrhosis  of  the  liver  are  induced  by  the  excessive  use  of  alcohol." 
These  two  forms  are  separated  both  in  their  morbid  anatomy  and  in  their 
clinical  features.  In  the  first,  which  is  by  far  the  more  common,  the  newly 
developed  fibrous  tissue  is  "multilobular,"  that  is,  it  tends  to  surround 
large  groups  of  hepatic  lobules.  This  form  is  commonly  associated  with 
ascites  but  seldom  with  jaundice.     In  the  second  and  less  common  form 


CHRONIC  INTERSTITIAL  HEPATITIS  1007 

of  alcoholic  cirrhosis  the  new  tissue  is  mostly  developed  around  single  lobules 
and  the  condition  is  properly  described  as  '' unilobular, "  There  is  little 
tendency  to  ascites,  while  jaundice  is  common. 

In  this  connection  may  be  mentioned  Flexner's  researches  in  regard 
to  the  new  tissue  in  cirrhosis  of  the  liver.  He  found  both  the  white  fibrous 
tissue  and  the  elastic  tissue  increased  and  the  chief  distinction  between 
the  histology  of  the  atrophic  and  hypertrophic  cirrhosis  to  depend  upon 
the  degree  of  extralobular  growth  and  the  freedom  with  which  the  lobules 
are  invaded,  and  that  "in  hypertrophic  cirrhosis  there  would  appear  to 
be  less  interlobular  growth  and  an  earlier  and  finer  intralobular  growth." 

Symptoms. — Clinically  not  all  forms  of  interstitial  hepatitis  can  be 
recognized.  The  symptoms  are  often  vague  and  referable  to  other  organs, 
especially  those  of  the  gastro-intestinal  tract.  In  many  of  the  cases  the 
condition  during  life  can  only  be  suspected,  the  morbid  phenomena  being 
those  of  the  primary  disorder.  Direct  physical  signs  are  available  for 
diagnosis  only  when  there  are  definite  changes  in  the  size  or  contour  of 
the  liver.  Hence  the  cases  of  chronic  interstitial  hepatitis,  whatever  their 
course,  must  be  arranged  in  three  groups  according  as  the  liver  is  found 
upon  physical  exploration  to  be,  (a)  of  about  the  normal  size,  (b)  atrophic, 
and  (c)  hypertrophic. 

(a)  Since  there  are  no  characteristic  symptoms  in  many  cases  of  chronic 
interstitial  hepatitis,  and  since  in  many  of  the  cases  the  liver  remains  of 
normal  size  throughout  and  is  always  of  normal  size  until  the  disease 
has  made  some  progress,  it  follows  that  the  diagnosis  is  impossible  in 
a  considerable  proportion  of  the  cases  and  in  the  earlier  stages  of  all  cases. 
The  most  that  can  be  done  is  to  assume  that  when  certain  etiological 
factors,  as  alcoholism,  malaria,  valvular  disease  of  the  heart  with  failing 
compensation,  are  operative,  and  more  or  less  well-pronounced  gastrohepatic 
symptoms  present,  the  patient  may  have  an  interstitial  hepatitis.  The 
diagnosis  under  such  circumstances  must  be  purely  an  anatomical  one, 
and  this  is  frequently  the  case  in  the  fatty  form  of  interstitial  hepatitis 
in  which  symptoms  directly  referable  to  the  liver  are  often  absent,  and 
not  rarely  in  the  multilobular  form  either  with  or  without  atrophy.  In 
the  latter  instance  the  true  nature  of  the  malady  may  reveal  itself  in  sudden 
copious  hsematemesis  or  in  the  peculiar  toxaemia  caused  bj^  the' entrance  of 
portal  blood,  which  has  not  traversed  the  liver,  into  the  general  circulation. 

When,  however,  there  are  decided  changes  in  the  size  of  the  liver 
the  state  of  affairs  is  wholly  different.  The  interstitial  hepatitis  reveals 
itself  not  only  in  physical  signs,   but  also  in  symptoms  of  significance. 

(b)  The  liver  is  diminished  in  size — Laennec's  cirrhosis.  A  high 
degree  of  atrophy  may  occur,  provided  the  collateral  circulation  has  been 
established,  without  the  development  of  ascites  or  other  symptoms  which 
attract  the  attention  of  the  patient  to  the  liver.  As  a  general  rule,  howevei-, 
the  malnutrition,  vomiting,  the  enlargement  of  the  spleen,  hemorrhoids, 
the  distended  superficial  abdominal  veins,  and  the  increased  girth  caused 
by  the  ascites  are  diagnostic.  It  is  of  cardinal  importance  also  to  remem- 
ber that  all  these  phenomena  can  occur  in  an  interstitial  hepatitis  in  which 
the  liver  is  not  only  not  atrophic  but  even  somewhat  enlarged.  Under 
these  circumstances  jaundice  is  not  usually  present. 


1008 


MEDICAL  DIAGNOSIS. 


(c)  The  liver  is  increased  in  size.  The  hypertrophic  form  of  chronic 
interstitial  hepatitis, — Hanoi's  disease, — like  the  forms  already  consid- 
ered, may  present  extreme  difficulties  in  diagnosis  in  its  early  stages. 
The  liver  may  be  as  yet  of  normal  size.  The  early  icterus  may  resemble 
that  of  catarrhal  jaundice — a  resemblance  heightened  by  its  fluctuation 
or  temporary  disappearance,  and  by  the  occurrence  of  fever.  The  recur- 
rence or  persistence  of  the  jaundice,  its  intensity,  and  the  presence  of  bile 

in  the  stools  are  of  diagnostic 
1  importance.  When  the  disease  is 
established  the  uniform  enlarge- 
ment of  the  liver,  the  splenic 
tumor,  the  deep  and  persistent 
jaundice,  and  the  occasional 
attacks  of  fever  are  diagnostic. 
The  fever  is  of  subcontinuous  or 
remittent  type  and  extends  over 
periods  of  days  or  weeks.  Chills 
and  sweating  are  not  common,  as 
in  the  fever  of  impacted  gall-stone 
— Charcot's  or  true  hepatic  fever. 
Diagnosis. — Direct. — The 
diagnosis  of  well-defined  cirrhosis 
of  the  liver,  the  terminal  condi- 
tion, is  usually  a  simple  matter. 
Whether  it  be  the  atrophic  form 
of  Laennec  or  the  hypertrophic 
form  of  Hanot,  the  symptom- 
complex  in  most  of  the  cases  is 
characteristic.  In  the  former  the 
pinched  face  with  its  distended 
venules  and  muddy  or  subicteroid 
hue, — fades  hepatica, — the  spare 
chest  and  thin  arms,  the  distended 
belly  with  its  conspicuous  super- 
ficial veins,  and  the  diminished 
area  of  liver  dulness  leave  no 
doubt  of  the  nature  of  the  malady. 
In  the  latter  the  jaundice,  the 
fairly  well-preserved  nutrition,  the 
big  liver  without  ascites,  and  occa- 
sional irregular  fever  render  the  diagnosis  equally  clear.  The  two  conditions 
are  clinically  distinct  because  they  are  the  manifestations  of  essentially 
different  pathological  lesions.  The  one  thing  that  these  lesions  have  in  com- 
mon is  an  overgrowth  of  the  interstitial  connective  tissue  of  the  liver.  It 
might  be  said  that  they  have  nothing  in  common  clinically  save  that  they 
are  diseases  of  the  liver.  Yet  they  are  described  respectively  as  the  atrophic 
form  and  the  hypertrophic  form  of  the  same  affection,  hepatic  cirrhosis. 
The  diagnosis  of  hepatic  capsulitis — the  capsular  cirrhosis  of  authors — 
is  usually  attended  by  insuperable  difficulties.     The  symptoms  are  those 


Fig.  314. — Ascites  due   to  atrophic    cirrhosis   of    the 
liver. — Jefferson  Hospital. 


NEW  GROWTHS  IN  THE  LIVER.  1009 

of  the  atrophic  form  of  chronic  interstitial  nephritis.  Jaundice  is  not 
usually  present.  The  kidneys  are  granular.  This  condition  may  be  asso- 
ciated with  perisplenitis  and  proliferative  peritonitis. 

Differential. — Adhesive  pylephlebitis  closely  resembles  the  atrophic 
form  of  interstitial  hepatitis.  The  etiological  factors  and  the  rapidity  with 
which  the  peritoneal  effusion  develops  and  reforms  after  tapping,  as  was 
shown  in  a  case  recently  in  my  service  in  the  Pennsylvania  Hospital,  are 
important  in  the  differential  diagnosis.  It  is  said  that  thrombosis  of  the 
portal  vein  is  followed  by  an  atrophy  of  the  liver,  which  renders  the  diag- 
nosis difficult.  In  the  cases  that  have  come  under  my  observation  death 
has  occurred  in  the  course  of  a  few  weeks,  and  t»he  liver  was  of  normal  size. 

Prognosis. — In  the  atrophic  form  the  outlook  is  highly  unfavorable. 
From  the  time  at  which  the  diagnosis  can  be  made  the  duration  of  the 
disease  does  not  usually  exceed  a  year  or  two,  often  not  more  than  a  few 
months.  Atrophic  cirrhosis  in  advanced  stages  has  been  found  post  mortem 
in  cases  in  which  no  characteristic  symptoms  were  present  during  life. 
Life  has  been  much  prolonged  in  some  of  the  successful  cases  of  omentopexy. 

In  the  hypertrophic  form  the  disease,  after  it  has  reached  a  stage  in 
which  a  positive  diagnosis  can  be  made,  runs  an  unfavorable  course.  The 
progress  is  often  slow  and  the  disease  for  a  long  period  may  not  continu- 
ously prevent  the  patient  from  conducting  his  business  or  taking  part  in 
the  ordinary  affairs  of  life. 

xi.  New  Growths  in  the  Liver. 

Neoplasms  of  the  liver  are  benign  and  malignant.  The  benign  are 
fibroma  and  angioma;  the  malignant  are  carcinoma,  sarcoma,  and  malig- 
nant adenoma.     Carcinoma  and  sarcoma  may  be  primary  or  secondary. 

1.  Benign  New  Growths. — These  are  of  no  great  clinical  importance. 

(a)  Fibromata.  —  These  tumors  consist  of  dense  connective  tissue 
and  are  frequently  found  post  mortem.  They  are  usually  small  and  cause 
no  symptoms  during  life.  In  very  rare  instances  they  are  of  larger  size, 
and  when  so  situated  as  to  compress  the  bile  passages  and  prevent  the 
discharge  of  bile  into  the  intestine  they  may  cause  cholangitis  and  death 
from  cholsemia. 

Diagnosis. — In  a  suspected  case  an  exploratory  laparotomy  should 
be  performed  in  the  hope  that  the  tumor  may  be  found  and  removed. 

(b)  Angiomata. — These  vascular  tumors  are  also  described  under 
the  terms  cavernomata  and  telangiectasis.  They  are  commonly  multiple 
and  of  small  size,  causing  no  symptoms.  They  may  be  found  at  all  ages 
and  have  been  observed  in  the  foetus.  In  very  rare  instances  they  are 
solitary  and  of  large  size, — an  orange, — the  pregnant  uterus.  They  then 
give  rise  to  pressure  symptoms. 

Diagnosis. — Small  angiomata  cannot  be  recognized  by  clinical  methods. 
In  some  instances  the  surface  of  the  liver  is  nodular.  A  large  tumor  giving 
rise  to  distressing  pressure  symptoms  may  justify  a  diagnosis  by  exclusion. 
Its  true  nature  can  only  be  positively  determined  by  an  exploratory  incision. 

Prognosis. — The  outlook  is  favorable  as  regards  life.  Large  solitary 
angiomata  have  been  successfully  resected. 

64 


1010  MEDICAL  DIAGNOSIS. 

2.  Malignant  Tumors  of  the  Liver.  —  Cancer  of  the  gall-bladder 
and  bile-ducts  and  its  relation  to  cancer  of  the  liver  has  already  been 
considered. 

Malignant  tumors  of  the  liver  are  of  great  clinical  importance. 

(a)  Carcinoma  Hepatis. — Carcinoma  invades  the  liver  less  frequently 
than  the  uterus,  the  stomach,  or  the  breast.  Cancer  of  the  liver  may  occur 
at  any  age  and  has  been  observed  in  the  new-born.  A  number  of  cases  of 
primary  carcinoma  of  the  liver  have  been  observed  in  children.  The  part 
played  by  heredity  in  cancer  of  the  liver  is  uncertain.  About  17  per  cent, 
of  the  cases  show  hereditary  predisposition.  Half  the  cases  are  first 
observed  after  the  fortieth  year.  Primarj^  cancer  of  the  liver  is  more 
common  in  men  and  is  frequently  associated  with  cirrhosis.  Secondary 
cancer  is  much  more  frequent  in  women,  a  fact  attributed  to  the  remark- 
able tendency  to  cancer  of  the  uterus,  ovaries,  and  breasts.  Primarj' 
cancer  is  common  in  the  gall-bladder,  rare  in  the  parenchyma  of  the 
organ.  The  frequent  association  of  gall-stone  disease  with  cancer  of  the 
gall-bladder  and  bile-ducts  is  attributed  to  the  chronic  irritation  caused 
by  the  presence  of  calculi. 

Primary  carcinoma  presents  three  principal  types:  (i)  Massive 
Carcinoma. — The  liver  is  greatly  enlarged,  its  surface  usually  smooth. 
On  section  the  growth  is  sharply  contrasted  with  the  normal  tissue  which 
surrounds  it.  It  is  grayish-white  and  not  usually  softened.  It  is  of  verj^ 
great  size  and  at  first  solitary,  though  later  surrounded  by  smaller  metas- 
tatic nodules,  (ii)  Nodular  Carcinoma. — Round,  grayish-white,  or  yellow 
nodules  of  cancerous  tissue  of  varying  size  are  irregularly  scattered 
throughout  the  liver.  The  occasional  occurrence  of  one  large  mass  sur- 
rounded by  numerous  smaller  and  less  dense  nodules  makes  it  probable 
that  the  former  is  the  original  seat  of  the  disease.  The  liver  is  not  usually 
greatly  enlarged.  Sclerotic  changes  are  common  and  the  organ  may  be 
reduced  in  size.  Transitional  forms  between  massive  and  nodular  cancer 
occur.  (iii)  Adenocarcinoma  with  Cirrhosis. — The  liver  is  usually  con- 
tracted but  may  be  enlarged.  The  surface  is  dark  green,  with  irregularly 
distributed  yellowish  nodules  of  varying  size  beneath  the  capsule.  The 
adenomata  appear  throughout  the  liver  substance  as  small  round  masses 
varjang  in  size  from  a  millet-seed  to  a  pea.  Sometimes  only  a  single  tumor 
is  present. 

Secondary  Carcinoma. — The  liver  may  be  enormously  enlarged.  Nod- 
ules are  present  upon  its  surface,  which  may  often  be  felt  and  seen  through 
the  abdominal  walls.  They  may  be  dense  or  soft,  and  frequently,  in  con- 
sequence of  retraction  of  the  connective  tissue,  are  distinctly  umbilicated — 
Farre's  tubercles.  The  tumors  are  irregularly  scattered  throughout  the 
substance  of  the  organ.  They  are  usually  light  in  color,  grayish-white  or 
greenish,  and  sharply  defined,  both  on  the  surface  and  in  the  interior  of 
the  liver,  from  the  surrounding  liver  substance,  which  is  often  hj'-persemic. 
The  nodules  themselves  are  often  hemorrhagic.  They  may  be  present  in 
such  numbers  as  almost  completelv  to  replace  the  hver  parenchyma. 

Histologically  the  primary  cancers  are  epitheliomata;  the  secondary 
cancers  are  of  the  same  structure  as  the  respective  primary  growths — as 
a  rule,  alveolar  or  cylindrical  carcinomata. 


NEW  GROWTHS  IN  THE  LIVER.  1011 

(b)  Sarcoma. — Sarcoma  of  the  liver  is  much  less  common  than  car- 
cinoma. Primary  sarcoma  is  very  rare.  Most  of  the  cases  are  secondary, 
though  the  primary  growth  may  be  so  small  as  to  be  easily  overlooked. 
Melanosarcoma  is  the  must  common  and  most  important  variety.  It 
appears  in  rare  cases  as  a  primary  tumor.  As  a  rule,  it  is  secondary  to 
pigmented  sarcoma  of  the  eye  or  skin.  The  primary  growth  is  of  diag- 
nostic importance.  The  secondary  sarcomata  of  the  liver  sometimes  form 
enormous  tumors.  They  occur  either  as  large  nodular  masses  throughout 
the  Hver  or  as  diffuse,  infiltrating  growths.  In  the  latter  form  the  enlarge- 
ment of  the  liver  is  less  marked.  On  section  the  surface  is  black  or  marbled. 
They  constitute  part  of  a  widely  extended  metastatic  process  in  which 
many  viscera  are  often  involved. 

Symptoms  of  Malignant  Disease  of  the  Liver. — The  condition  may  be 
latent,  especially  when  the  growth  develops  centrally  or  in  the  diaphrag- 
matic surface  of  the  hver,  or  the  symptoms  may  be  overshadowed  by  those 
of  the  primary  tumor.  When  a  primary  cancerous  growth  in  any  organ, 
as  the  breast,  stomach,  or  rectum,  is  present  or  has  been  removed,  the 
secondary  nature  of  a  neoplasm  in  the  hver  is  obvious.  When  no  such 
growth  is  discoverable,  it  is  not  alwaj^s  possible  to  determine  whether 
cancer  of  the  liver  is  primary  or  secondary.  Loss  of  appetite  and  nausea 
are  early  symptoms.  Vomiting  is  less  common.  Emaciation  and  loss  of 
strength  are  marked  and  progressive.  The  skin  loses  its  elasticity  and 
becomes  dry,  wrinkled,  and  of  a  muddy  color.  Sensations  of  fulness  and 
weight  in  the  epigastrium  and  right  hypochondrium  are  followed  by  pain 
which  extends  to  the  chest  and  right  shoulder.  The  liver  is  commonly 
enlarged,  tender  upon  pressure,  and  nodular.  In  some  cases  of  primary 
cancer,  and  in  those  cases  in  which  cirrhosis  is  marked,  the  liver  may  be  of 
normal  size  or  even  contracted.  Persistent  jaundice  is  present  in  more 
than  half  the  cases.  It  is  intense  when  there  is  compression  of  the  common 
duct.  Ascites  is  much  less  frequent.  It  occurs  as  the  result  of  compression 
of  the  portal  vein,  or  its  invasion  by  the  growth,  advancing  cirrhosis,  or 
extension  of  the  growth  to  the  peritoneum.  The  anaemia  is  progressive. 
(Edema  of  the  feet  or  general  oedema  occurs;  there  are  signs  of  metastasis 
to  the  pleurse  and  peritoneum.  Fever  of  continuous  or  remittent  type 
occurs  and  death  results  from  asthenia.  The  blood  shows  the  changes  of 
secondary  anaemia  which  may  be  of  high  grade.  Poikilocytosis  may  be 
present.     Profuse  diarrhoea  may  cause  concentration  of  the  blood. 

Physical  Signs. — Inspection. — The  abdomen  is  distended,  especially 
in  the  epigastric  zone  and  upon  the  right  side.  In  advanced  cases  the 
nodular  surface  and  even  the  umbilication  of  the  nodules  may  be  visible 
through  the  emaciated  abdominal  wall.  The  superficial  veins  are  usually 
enlarged.  Palpation. — The  enlargement  may  be  recognized  and  the 
border  felt  some  distance  below  the  margin  of  the  ribs.  When  the  left 
lobe  is  affected,  a  distinct  tumor  may  be  felt  in  the  epigastrium.  The 
surface  is  commonly  irregularly  nodular,  with  an  uneven  margin  and  dis- 
tinct central  depressions  in  many  of  the  nodules.  In  cases  of  diffuse  infil- 
tration the  sui'face  is  usually  smooth.  It  is  also  hard.  Enlargement  of 
the  superficial  lymph-nodes,  especially  the  inguinal,  supraclavicular,  and 
cervical  nodules,  is  common.     When  slight  it  is  not  due  to  metastasis  and 


1012  MEDICAL  DIAGNOSIS. 

not  of  diagnostic  importance.  Actual  metastasis  with  decided  enlargement 
of  the  left  supraclavicular  gland  occasionally  occurs  in  malignant  disease 
of  the  abdominal  organs.  Percussion. — The  upper  and  lower  limits  of 
dulness  may  be  determined  and  the  progress  of  the  growth  estimated,  the 
presence  and  increase  of  ascites  observed,  and  pleural  and  peritoneal  new 
growths  recognized.    The  spleen  is  not  usually  enlarged. 

Diagnosis.  —  Direct.  —  Enlargement  of  the  liver,  which  may  be 
smooth  or  nodular,  and  in  particular  when  the  nodules  are  umbilicated; 
cachexia;  compression  symptoms  in  the  territory  of  the  portal  vein  or 
vena  cava — ascites,  oedema;  in  the  territory  of  the  bile  passages — jaun- 
dice; signs  of  metastasis  in  the  pleurae,  lungs,  or  peritoneum,  constitute  a 
characteristic  symptom-complex.  In  the  presence  of  a  primary  growth 
or  the  history  of  one  removed,  the  direct  diagnosis  may  be  made.  In  the 
absence  of  such  a  primary  growth  the  diagnosis  remains  uncertain  in 
proportion  as  one  or  more  of  the  above  groups  of  clinical  phenomena  are 
ill  defined  or  absent.  The  Rontgen  rays  may  be  of  great  service  in  the 
diagnosis  of  doubtful  cases  in  which  localized  dense  neoplasms  exist  in 
regions  inaccessible  to  the  ordinary  means  of  clinical  examination. 

Sarcomata  of  the  liver  are  mostly  secondary  growths.  In  melano- 
sarcoma  the  primary  growths  are  commonly  in  the  choroid  or  the  skin. 
The  enlargement  is  rapid  and  reaches  a  high  grade.  Multiple  tumors  are 
often  present  in  the  skin,  and  metastases  are  widely  extended.  Melanuria 
is  an  inconstant  but  important  symptom.  The  liver  tumor  may  not  develop 
until  some  months  after  the  removal  of  an  eyeball,  as  in  a  case  of  mine 
in  the  Philadelphia  Hospital. 

Differential. — Fatty  Liver. — The  uniform  enlargement  and  smooth 
surface  are  suggestive  of  cancerous  infiltration,  especially  in  the  fatty  liver 
of  emaciation  and  cachexia.  But  the  soft  consistency  of  the  enlarged  liver, 
its  slow  growth,  and  the  absence  of  jaundice  are  important.  Amyloid 
Liver. — A  history  of  suppuration  or  syphilis,  enlargement  of  the  spleen, 
urinary  phenomena,  in  particular  albumin  and  casts  which  take  the  iodine 
test,  and  a  less  rapid  and  marked  cachexia  are  diagnostic.  Gummatous 
nodules  may  greatly  embarrass  the  diagnosis.  Echinococcus  of  the  Liver. — 
Ordinary  echinococcus  cysts  are  little  likely  to  be  confounded  with 
malignant  disease.  The  enlargement  with  hard  nodules  upon  the  surface, 
characteristic  of  multilocular  echinococcus,  may  give  rise  to  uncertainty, 
especially  as  jaundice  and  ascites  are  frequent  in  both  conditions.  The 
slow  progress  of  multilocular  echinococcus,  the  enlargement  of  the  spleen, 
and  the  slight  tendency  to  cachexia  are  important  in  the  differentiation. 
Exploratory  puncture  may  bring  away  softened  material  containing 
cholesterin  and  hsematoidin  crystals.  Chronic  Interstitial  Hepatitis  — 
Hypertrophic  Cirrhosis. — The  absence  of  emaciation  and  cachexia,  of 
pain  and  tenderness,  and  of  a  primary  focus  are  of  diagnostic  importance. 
The  enlarged  liver  is  less  dense  than  in  infiltrated  cancer  and  the  jaundice 
more  variable  in  intensity.  Atrophic  Cirrhosis. — The  muddy  complexion 
or  jaundice,  wasting,  ascites,  and  other  signs  of  portal  obstruction  common 
to  the  two  affections  may  cause  great  uncertainty.  Differential  points  are 
an  alcoholic  history,  tardy  course,  enlargement  of  the  spleen,  and  the 
absence  of  primary  malignant  disease  in  other  organs  in  cirrhosis.     That 


PANCREATITIS.  1013 

form  of  hepatic  cancer  with  cirrhosis  in  which  the  liver  is  reduced  in  size 
cannot,  in  the  absence  of  a  primary  focus  or  metastasis,  be  recognized 
during  hfe. 

Prognosis. — The  outlook  is  in  the  highest  degree  unfavorable.  The 
duration  of  the  disease  rarely  exceeds  eighteen  months.  Secondary  cancers 
run  a  much  more  rapid  course  than  the  forms  associated  with  cirrhosis. 
Resection  of  malignant  growths  in  the  liver  has  been  performed. 

IV.  DISEASES  OF  THE  PANCREAS, 
i.  Hemorrhage  into  the  Pancreas. 

The  hemorrhage  usually  occurs  as  a  manifestation  of  the  necrosis 
incident  to  acute  pancreatitis.  There  are  instances,  however,  in  which 
large  hemorrhage  into  the  organ  and  adjacent  structures  has  occurred  in 
the  absence  of  inflammation. 

The  etiology  is  that  of  acute  hemorrhagic  pancreatitis.  The  condition 
occurs  in  middle  life. 

Symptoms. — The  onset  is  sudden.  The  patients  are  usually  in  their 
ordinary  health.  In  some  instances  there  have  been  digestive  symptoms 
or  previous  attacks  of  biliary  colic.  Pain  is  intense  and  located  in  the 
upper  part  of  the  abdomen.  It  is  sharp,  sometimes  colicky,  and  increases 
in  severity.  It  is  accompanied  by  nausea  and  vomiting,  which  are  frequent 
and  intractable  but  not  followed  by  relief.  The  patient  becomes  restless, 
anxious,  and  depressed.  The  surface  is  cold  and  covered  with  a  clammy 
sweat.  The  pulse  is  feeble,  rapid,  and  thready.  The  appearance  of  the 
patient  is  that  common  in  internal  hemorrhage.  There  is  epigastric  ten- 
derness followed  by  tympany  which  is  usually  moderate.  The  temperature 
is  normal  or  subnormal,  the  patient  falls  into  syncope  which  terminates 
fatally  in  the  course  of  twenty-four  or  forty-eight  hours, 

ii.  Acute  Pancreatitis. 

(a)  ACUTE  HEMORRHAGIC  PANCREATITIS. 

Definition. —  The  term  acute  hemorrhagic  pancreatitis  is  employed 
to  designate  a  rapidly  developing  destructive  procesS; — necrosis, — accom- 
panied by  hemorrhage  into  the  substance  of  the  organ  and  adjacent  parts, 
and  in  nearly  all  cases  by  disseminated  areas  of  fat  necrosis.  In  some 
instances  there  is  no  evidence  of  inflammation;  in  others  there  are  inflam- 
matory changes. 

Etiology. — Predisposing  Influences. — It  is  in  the  highest  degree 
probable  that  cholelithiasis  is  the  chief  predisposing  influence  to  acute 
hemorrhagic  pancreatitis.  This  hypothesis  is  supported  by  the  following 
facts:  It  has  been  experimentally  shown  that  similar  lesions  are  produced 
by  the  injection  of  bile  into  the  gland  by  way  of  the  duct  of  Wirsung; 
the  condition  is  of  common  occurrence  in  individuals  suffering  from  chol- 
ehthiasis;  biliary  calculi  are  present  in  the  bile-ducts  or  in  the  duodenum 
in  a  large  proportion  of  the  cases;  and  an  impacted  gall-stone  has  been 


1014  MEDICAL  DIAGNOSIS. 

found,  as  in  a  case  reported  by  Halstead  and  quoted  by  Opie.  at  the  duo- 
denal opening  of  the  ampulla  of  Vater  not  of  sufficient  size  to  occlude 
either  the  common  duct  or  the  pancreatic  duct,  and  thus  converting  them 
into  a  continuous  closed  channel. 

The  Exciting  Cause. — The  statement  of  Opie  that,  "While  at  pres- 
ent it  cannot  be  denied  that  other  causes  may  produce  the  condition,  only 
one  etiological  factor  has  been  demonstrated,  namely,  the  impaction  of 
a  gall-stone  in  the  diverticulum  of  Vater,  diverting  bile  into  the  pancreatic 
duct"  is  unquestionably  true.  The  immediate  cause  then  is  a  mechanical 
one.  The  bile  and  the  pancreatic  secretion  are  present  at  low  pressure, 
but  the  bile  is  forced  into  the  pancreatic  duct  by  the  contractions  of  the 
gall-bladder,  and  in  some  of  the  cases  the  walls  of  the  pancreatic  duct 
have  been  stained  with  bile. 

In  the  cases  in  which  no  evidence  of  gall-stone  disease  is  found  upon 
post-mortem  examination  two  conditions  may  occur:  first,  a  neoplasm 
interfering  with  the  discharge  of  the  bile  into  the  duodenum;  and  second, 
occlusion  of  a  narrow^  canal  between  the  ampulla  of  Vater  and  the  duo- 
denum by  catarrhal  swelling  or  a  plug  of  tenacious  mucus. 

Symptoms. — No  sharp  line  of  demarcation  can  be  drawn  between 
acute,  gangrenous,  and  suppurative  pancreatitis,  which  are  in  fact  con- 
secutive processes  in  cases  in  which  death  does  not  take  place  rapidly. 
The  attack  may  have  been  preceded  by  attacks  of  biliary  colic,  or  it  may 
supervene  upon  such  an  occurrence.  Again,  since  anatomical  studies  of  the 
relative  diameter  of  the  common  duct  and  the  canal  leading  from  the 
diverticulum  of  Vater  into  the  duodenum  have  shown  that  a  small  calculus 
readily  passing  through  the  common  duct  may  fully  occlude  the  duodenal 
opening,  the  onset  of  the  symptoms  of  acute  pancreatitis  may  constitute 
the  first  clinical  phenomena  of  gall-stone  disease. 

There  is  little  to  add  to  the  terse  and  graphic  description  of  Fitz: 
"'  It  (the  attack)  begins  with  intense  pain,  especially  in  the  upper  abdomen, 
soon  followed  by  vomiting,  which  is  likely  to  be  more  or  less  obstinate, 
and  not  infrequently  by  sHght  epigastric  swelling  and  tenderness  with 
obstinate  constipation.  A  normal  or  subnormal  temperature  may  be 
present,  and  symptoms  of  collapse  precede  by  a  few  hours  death,  which 
is  most  likely  to  occur  between  the  second  and  fourth  days."  Nausea  is 
marked  and  continues  between  the  attacks  of  vomiting.  The  vomitus  is 
not  characteristic.  It  does  not  at  first  contain  bile.  Collapse  symptoms 
occur  early  and,  considered  in  connection  with  the  above  symptoms  and 
the  rapidly  fatal  result,  suggest  acute  poisoning. 

Diagnosis. — Direct. — The  diagnosis  rests  upon  the  sudden  occur- 
rence of  the  foregoing  symptoms  in  an  adult  who  has  suffered  from 
chronic  gastroduodenal  catarrh  or  from  attacks  of  biliary  colic;  the 
location  of  the  pain  and  tenderness  in  the  upper  abdomen;  the  absence 
of  the  distinct;  board-like  rigidity  characteristic  of  earl}'  peritonitis 
and  an  early  high  leucocytosis.  Da  Costa,  in  seven  counts  in  four 
cases  at  the  German  Hospital  in  Philadelphia,  found  a  leucocj^tosis 
ranging  from  11,000  to  30,000.  If  the  patient  survives,  circumscribed 
epigastric  fulness,  v/hich  may  be  tense  and  tympanitic  or  dull  upon 
percussion,   may  develop. 


PANCREATITIS.  1015 

Opie  has  suggested  that  the  fat-splitting  ferment,  which,  free  in  the 
tissues,  causes  the  fat  necrosis,  may  be  excreted  by  the  kidneys,  and, 
using  the  ethyl  butyrate  method  of  Castle  and  Loevenhardt,  which 
depends  upon  the  power  of  a  fat-splitting  ferment  to  decompose  that 
substaace  with  the  liberation  of  butyric  acid,  was  able  in  one  instance 
to  demonstrate  the  presence  of  a  marked  acid  reaction,  while  a  control 
specimen  remained  unchanged.^ 

Differential.  —  Acute  Poisoning.  —  The  anamnesis  is  important. 
In  poisoning  by  meat  or  fish  a  number  of  persons  are  usually  simulta- 
neously affected.  There  is  a  period  of  prodromes  consisting  of  languor, 
nausea,  and  griping  pain  in  the  belly.  The  attack  begins  suddenly  with 
chilliness,  faintness,  and  headache.  Collapse  symptoms  supervene  with 
vomiting  and  diarrhoea,  which  is  often  uncontrollable.  In  poisoning  by 
corrosive  chemicals  the  surrounding  circumstances,  certain  marks  upon 
the  lips  and  garments,  and  the  behavior  of  the  patient  are  important. 
Collapse  is  preceded  by  intense  pain  in  the  stomach,  followed  by  colic 
and  in  many  instances  by  diarrhoea.  Strangulated  Hernia. — In  a  doubtful 
case  the  sites  of  hernial  tumors  are  to  be  carefully  examined;  the  history 
is  important;  constipation  and  fecal  vomiting  are  significant.  Intestinal 
Obstruction. — In  acute  obstruction  we  find  constipation,  abdominal  pain, 
and  vomiting.  The  pain  is  at  first  colicky,  later  continuous  and  severe. 
Vomiting  is  an  early  symptom.  Nausea  is  less  marked  than  retching. 
The  vomitus  consists  at  first  of  the  stomach  contents,  then  of  bile-stained 
mucus,  and  finally  of  a  darkish  liquid  with  a  fecal  odor.  In  many  cases 
neither  faeces  nor  flatus  are  passed  by  the  bowel;  in  some  the  contents  of 
the  bowel  below  the  constriction  are  voided.  Abdominal  tenderness  and 
tympany  come  on  later.  If  the  obstruction  be  seated  in  the  small  bowel 
the  distention  may  be  slight,  but  it  is  not  confined  to  the  epigastrium. 
Pain  and  tenderness  are  later  symptoms  and  are  not  circumscribed.  Col- 
lapse symptoms  are  not  usually  at  first  present.  There  is,  as  a  rule,  a  very 
high  leucocytosis,  60,000  or  more.  Acute  hemorrhagic  pancreatitis  is 
very  often  mistaken  for  intestinal  obstruction.  Embolism  of  the  Larger 
Mesenteric  Vessels — Infarction  of  the  Bowel. — This  accident  gives  rise  to 
sudden  colic,  nausea,  vomiting,  and  bloody  diarrhoea.  The  condition 
resembles  acute  obstruction,  marked  tympanites  develops,  and  death 
occurs  in  collapse.  Perforative  Peritonitis. — The  differentiation  becomes 
apparent  when  the  symptoms  are  enumerated.  In  perforation  of  an  ulcer 
of  the  stomach,  bowels,  or  gall-bladder,  necrosis  of  the  appendix,  rupture 
of  an  abscess  of  the  liver,  spleen,  kidney,  or  Fallopian  tube,  chilliness  or 
rigor,  intense  abdominal  pain,  and  exquisite  tenderness  are  early  symptoms. 
The  pain  and  tenderness  are  general  but  more  intense  as  a  rule  in  the  region 
of  the  perforating  lesion.  There  is  early  spastic  contraction  of  the  abdom- 
inal muscles  upon  one  or  both  sides — a  very  significant  sign.  The  patient 
assumes  and  maintains  an  attitude  by  which  the  tension  of  the  abdominal 
muscles  is  diminished,  and  lies  with  his  head  and  shoulders  elevated  and 
his  thighs  and  legs  strongly  flexed.  Later  the  tension  relaxes,  the  abdomen 
becomes  tympanitic,  and  both  pain  and  tenderness  abate.  When  there 
is   a   history  of  gall-stone  disease  the  differential  diagnosis   becomes   as 

1  Diseases  of  the  Pancreas,  Opie,  1903,  p.  322. 


1016  MEDICAL  DIAGNOSIS. 

important  as  it  is  obscure.  Absence  of  muscular  tension,  circumscribed 
pain  and  tenderness  in  the  epigastrium,  and  early  profound  collapse  are 
suggestive  of  pancreatitis. 

Cammidge  found  that  in  cases  of  pancreatic  disease  a  peculiar 
substance,  probably  pentose,  is  present  in  the  urine  and  can  be  detected 
by  its  forming  long,  yellow,  flexible  crystals  arranged  in  sheaves  in  the 
presence  of  phenylhydrazine.  The  test  is  very  elaborate  and  can  onl}^ 
be  carried  out  in  a  laboratory. 

(b)  GANGRENOUS    PANCREATITIS. 

Etiology. — Necrosis  of  the  whole  or  a  portion  of  the  gland  may  follow 
hemorrhage  or  hemorrhagic  pancreatitis  in  the  cases  in  which  death  does 
not  occur  in  the  first  three  or  four  days.  The  tissue  of  the  pancreas  is  dry 
and  friable,  and  the  necrotic  organ  lies  nearly  free  in  the  omental  cavity. 
Death  usually  occurs  in  the  course  of  two  or  three  weeks.  There  are 
recorded  cases  in  which  the  necrotic  pancreas  has.  been  discharged  by 
way  of  the  rectum,  with  recovery. 

Symptoms. — The  clinical  symptoms  are  those  of  acute  hemorrhagic 
pancreatitis,  but  the  illness  is  of  longer  duration.  As  the  gangrenous 
pancreas  occupies  a  position  in  the  posterior  wall  of  the  lesser  peritoneal 
cavity,  peritonitis  ensues,  and  this  cavity  becomes  filled  with  pus  and 
necrotic  material.  These  changes  are  followed  by  fever,  delirium,  and 
the  general  symptoms  of  septic  infection. 

Diagnosis. — The  condition  cannot  be  positively  determined  during 
life.  A  probable  diagnosis  rests  upon  the  occurrence  of  the  symptoms 
of  acute  hemorrhagic  pancreatitis  with  a  prolongation  of  life,  and  the 
occurrence  of  septic  phenomena. 

(c)  ACUTE  SUPPURATIVE  PANCREATITIS— PANCREATIC  ABSCESS. 

Suppurative  inflammation  of  the  pancreas  presents  nothing  charac- 
teristic, with  the  exception  that  it  most  commonly  occurs  as  a  later  stage 
of  acute  hemorrhagic  and  gangrenous  pancreatitis.  There  may  be  a  single 
large  abscess,  multiple  small  abscesses,  or  diffuse  purulent  infiltration. 
The  lesser  peritoneal  cavity  may  be  distended  with  pus. 

Etiology. — Cholelithiasis  constitutes  a  predisposing  influence.  The 
actual  cause  of  the  disease  is  to  be  found  in  an  antecedent  hemorrhagic 
pancreatitis.     In  some  cases  the  condition  has  followed  traumatism. 

Symptoms. — The  clinical  manifestations  follow  those  of  acute  hem- 
orrhagic pancreatitis  and  are  the  result  of  the  invasion  of  the  necrotic 
pancreatic  and  peripancreatic  tissues  by  pus-producing  organisms.  There 
may  be  epigastric  prominence,  or  a  deep-seated  mass  may  be  felt  in  the 
median  line.  Irregular  chills  and  fever,  with  profuse  sweating  and  pro- 
gressive loss  of  flesh  and  strength,  occur.  In  some  instances  the  disease 
runs  a  protracted  course  with  irregular  fever,  epigastric  pain,  and  vomit- 
ing. Slight  icterus,  fatty  diarrhoea,  and  glycosuria  occur  in  some  cases. 
Perforation  into  the  stomach,  duodenum,  or  peritoneum  may  occur.  Portal 
thrombosis  has  been  noted. 


PANCREATITIS.  1017 

Diagnosis. — The  recognition  of  the  condition  is  extremely  difficult. 
Circumscribed  epigastric  prominence  or  a  resistant  deep-seated  mass  in 
connection  with  the  above  symptoms  is  suggestive.  The  gravity  of  the 
condition  justifies  surgical  diagnosis  by  an  exploratory  operation. 

Prognosis. — The  prognosis  in  the  acute  cases  is  uniformly  fatal,  death 
occurring  in  the  course  of  twenty-four  or  thirty-six  hours.  In  a  limited 
number  of  subacute  cases,  in  which  life  has  been  prolonged,  spontaneous 
recovery  has  occurred  with  the  discharge  of  a  portion  of  the  necrosed  gland 
by  the  bowel,  or  surgical  operation  has  been  followed  by  cure. 

iii.  Chronic  Pancreatitis. 

The  gland  undergoes  sclerotic  changes  as  the  result  of  chronic  inflam- 
mation. It  is  sometimes  diminished  in  size;  in  other  cases  it  is  larger  than 
normal,  and  may  form  a  palpable  epigastric  tumor.  Two  types  of  interstitial 
inflammation  have  been  distinguished — an  interlobar  and  an  interacinous. 

Etiology. — Predisposing  Influences. — Age  is  important.  Chronic 
pancreatitis  is  much  more  common  between  the  fortieth  and  sixtieth  years 
of  life  than  at  any  other  period.  The  disease  is  frequently  secondary  to- 
disease  of  the  intestine  and  bile  passages,  and  of  the  liver. 

Exciting  Cause. — Inflammatory  irritants  may  reach  the  organ  by 
way  of  the  duct  of  Wirsung  or  Santorini.  Obstruction  to  the  outflow  of 
the  pancreatic  secretion  may  be  followed  by  chronic  pancreatitis.  A  form 
of  interstitial  pancreatitis  of  the  new-born  occurs  in  syphilis.  A  history 
of  tuberculosis,  syphilis,  and  the  abuse  of  alcohol  may  frequently  be 
obtained.  The  association  of  cirrhosis  of  the  liver  with  chronic  pancreatitis 
has  been  noted. 

Symptoms. — The  symptoms  are  obscure,  and  the  condition  is  rarely 
recognized  during  life.  At  operations  for  surgical  diseases  involving  the 
gall-bladder  and  bile  passages  the  head  of  the  pancreas  is  not  infrequently 
found  enlarged  and  is  so  hard  as  to  suggest  malignant  neoplasm.  In  such 
cases  it  has  frequently  happened  that  the  patient  has  recovered  and  remained 
well  for  years.  Usually  there  is  a  history  of  epigastric  pain,  nausea,  and 
persistent  vomiting.  The  signs  of  arteriosclerosis  are  frequently  present. 
The  enlarged  head  of  the  pancreas  may  press  upon  the  common  bile- 
duct  and  produce  jaundice.  Fatty  diarrhoea,  glycosuria,  and  diabetes 
may  occur.  The  islands  of  Langerhans  are  the  source  of  a  glycolytic  fer- 
ment necessary  to  the  metabolism  of  the  carbohydrates.  Functional 
or  organic  disease  of  these  bodies  may  be  followed  by  an  accumulation 
of  glucose  in  the  blood  and  by  glycosuria  —  pancreatic  diabetes.  Minor 
functional  derangements  may  give  rise  to  alimentary  glycosuria,  that  is, 
glycosuria  following  the  ingestion  at  once,  while  fasting,  of  amounts  of 
glucose  less  than  about  200  grammes — the  quantity  which  can  be  taken  in 
health  without  causing  glycosuria. 

Hyaline  Degeneration  of  the  Pancreas. — Opie  has  especially  drawn 
attention  to  this  condition.  It  affects  chiefly  the  islands  of  Langerhans 
and  is  associated  with  diabetes  mellitus.  It  may  occur  as  an  inde- 
pendent condition,  or  may  be  associated  with  a  moderate  degree  of 
increase    in    the    interstitial    tissue,    or    arteriosclerosis.      It    is    equally 


1018  MEDICAL  DIAGNOSIS. 

common  in  the  two  sexes,  and  has  been  chiefly  observed  after  middle 
Hfe.  Chronic  interstitial  pancreatitis  of  the  interacinous  type  has  been 
present  in  the  -majority  of  the  cases. 

iv.  Pancreatic  Calculi. 

Pancreatic  lithiasis  is  a  rare  condition.  It  may  cause  chronic  inter- 
stitial pancreatitis,  dilatation  of  the  duct,  a  large  retention  cyst,  acute 
suppurative  inflammation,  or  finally,  as  in  the  case  of  cholelithiasis, 
carcinoma. 

Symptoms.  —  In  pancreatic  colic  the  pain  is  sudden,  intense,  and 
paroxysmal.  It  has  its  maximum  intensity  at  the  costal  margin  to  the 
left  of  the  middle  line,  and  passes  through  to  the  back.  Fatty  diarrhoea 
and  glycosuria  occur,  but  are  not  constant.  Vomiting  may  occur.  Pan- 
creatic calculi  are  in  some  instances  associated  with  gall-stone  disease. 

Diagnosis.  —  Direct. — -The  occurrence  of  the  above  symptoms  in 
paroxysms,  usually  at  intervals  of  months  or  years,  without  jaundice,  is 
suggestive.  The  presence  in  the  stools,  after  the  attack,  of  round,  smooth 
or  rough,  opaque,  white  calculi,  which  are  composed  chiefly  of  calcium 
carbonate,  renders  the  diagnosis  positive. 

Differential. — The  symptoms  when  small  stones  are  passed  may 
suggest  gastralgia  or  gastric  ulcer;  in  other  cases  cholecystitis  or  a  biliary 
calculus  in  the  cystic  duct.  The  focus  of  pain  upon  the  left  side  and  the 
character  of  the  stones,  if  passed,  are  diagnostic.  > 

V.  Pancreatic  Cysts. 

The  term  pancreatic  cyst  has  been  used  to  designate  any  cystic  tumor 
in,  or  associated  with,  the  pancreas,  although  such  tumors  differ  among 
themselves,  etiologically,  in  situation  and  in  clinical  features. 

Varieties. — Congenital  cystic  disease;  retention  cysts;  proliferative 
cysts;    hemorrhagic  cysts;    hydatid  cysts;  and  pseudocysts. 

Etiology. — Sex  is  without  influence,  the  condition  having  been  observed 
in  about  the  same  number  of  men  and  women.  Age  is  important,  the 
largest  proportion  of  cases  reported  being  between  twenty  and  forty 
years.  Cases  have  been  noted  in  the  new-born,  and  between  the  sixtieth 
and  seventieth  years.  The  greater  number  of  cysts  are  caused  by  trauma- 
tism, inflammation,  or  impacted  calculi.  They  may  occupy  any  part  of 
the  gland.  Congenital  cystic  disease  may  occur  in  the  pancreas  as  in  the 
kidney  and  liver.  The  causes  of  retention  cysts  are  the  impaction  of  cal- 
cuh,  cicatricial  stenosis,  pressure  upon  the  duct,  and  dislocation  of  a  part 
of  the  organ.  Proliferative  cysts  are  of  two  kinds:  simple,  or  cyst  adenoma, 
and  malignant,  or  cystic  epithelioma.  There  is  a  marked  tendency  to  hem- 
orrhage into  pancreatic  cysts.  Collections  of  blood  in  the  substance  of 
the  organ  are  characteristic  of  the  acute  forms  of  necrosis  and  inflamma- 
tion. Hydatid  cysts  are  exceedingly  rare.  Pseudocysts  are  circvimscribed 
collections  of  fluid  found  in  the  proximity  of  the  pancreas,  but  not  having 
their  origin  in  the  substance  of  the  gland.  They  commonly  occupy  the 
lesser  peritoneum. 


PANCREATIC  CYSTS.  1019 

The  fluid  is  usually  thick  and  viscid,  alkaline,  of  variable  color, 
clear,  milky,  yellow,  green,  or  brownish-black.  There  is  usually,  in  the 
colori^d  fluids,  an  admixture  of  blood.  The  specific  gravity  varies  from 
1.010  to  1.020  or  higher.  Serum  albumin,  paraglobuhn,  mucin,  and  urea 
are  present.  The  presence  of  fat-splitting,  proteolytic,  or  diastasic  ferments 
cannot  usually  be  demonstrated,  although  the  last  may  sometimes  be 
found.  The  secretion  of  the  chemically  inflamed  pancreas  may  contain 
only  traces  of  these  ferments,  and  cannot  find  its  way  into  the  cyst  unless 
there  is  free  communication  with  the  glandular  parenchyma.  Moreover, 
similar  ferments  have  been  demonstrated  in  the  contents  of  mesenteric 
and  ovarian  cysts.  The  discharge  from  a  fistula  resulting  from  ooeration 
may  contain  the  pancreatic  ferments. 

Symptoms  and  Signs. — In  small  cysts  symptoms  are  absent  or  indef- 
inite. In  larger  cysts  there  are  pressure  symptoms,  especially  epigastric 
discomfort,  weight,  and  fulness.  Pain,  especially  after  food,  confined  to 
the  upper  part  of  the  abdomen,  radiating  to  the  back  and  toward  the 
left,  vomiting,  and  constipation  occur.  Jaundice,  usually  slight,  may 
result  from  the  pressure  of  a  cyst  in  the  head  of  the  pancreas  upon  the  com- 
mon duct.  Light-colored  stools  containing  free  fat  and  much  undigested 
muscle  fibre  are  significant  but  by  no  means  constant.  Alimentary 
glycosuria  and  diabetes  occur  onl}^  in  cases  in  which  there  is  extensive 
destruction  of  the  gland. 

The  cystic  tumor  lies  behind  the  posterior  layer  of  peritoneum,  which 
forms  the  lesser  sac.  In  the  great  majority  of  cases  the  enlarging  tumor 
displaces  the  stomach  upward  and  to  the  right,  and  the  transverse  colon 
downward,  and  approaches  the  surface  below  the  greater  curvature  of 
the  stomach;  occasionally  it  presents  above  the  upper  border  of  the  stom- 
ach; and  finally  it  may  push  itself  between  the  layers  of  the  transverse 
mesocolon  and  force  the  transverse  colon  before  it,  or  displace  both  the 
transverse  colon  and  the  stomach  upward. 

The  tumor  occupies  the  epigastrium,  at  first  usually  to  the  left  of  the 
middle  line  between  the  costal  border  and  the  umbilicus.  It  may  lie  in 
the  middle  line,  or  more  rarely  to  the  right.  It  is  usually  smooth,  spher- 
ical or  oval,  elastic,  and  tense.  It  may  attain  enormous  dimensions  and 
reach  to  the  symphysis  pubis,  suggesting  an  ovarian  or  parovarian  cyst. 
It  is  commonly  immovable,  or  but  slightly  movable,  either  upon  pressure 
or  with  the  respiration,  but  in  rare  cases  may  be  feebly  so  in  consequence 
of  its  attachment  to  the  tail  or  body  of  the  pancreas  by  a  narrow  pedicle. 
When  small  it  may  resemble  a  solid  mass,  and  transmitted  aortic  pulsa- 
tion may  suggest  an  aneurism.  In  large  pancreatic  cysts  fluctuation  can 
almost  always  be  elicited.     There  is  flatness  upon  percussion. 

Diagnosis.  —  Diuect. — The  presence  of  a  cystic  tumor  located — or 
at  first  located — in  the  upper  abdomen  and  having  the  above  features  is 
of  diagnostic  significance.  Inflation  of  the  stomach  and  colon  may  be 
important,  especially  in  small  cysts.  The  contents  may  be  removed  for 
examination  by  aspiration — an  unsafe  procedure,  to  be  employed  only 
in  extreme  cases.  A  history  of  recent  traumatism,  as  a  kick  or  blow  upon 
the  epigastrium,  is  important. 


1020  MEDICAL  DIAGNOSIS. 

Differential. — Various  cystic  tumors  present  i^oints  of  resemblance 
to  pancreatic  cysts.  Among  the  more  important  are  the  following:  Ovarian 
Cysts. — Only  enormous  cysts  of  the  pancreas  can  give  rise  to  difficulties. 
Examination  of  the  pelvic  organs,  preferably  in  the  Trendelenburg  position, 
the  distention  of  the  colon  with  air,  and  the  history  of  the  case  will  remove 
every  doubt  even  in  those  cases  in  which  the  appearance  of  the  abdomen 
closely  resembles  that  caused  by  tumor  of  the  ovary.  Cysts  of  the  liver  are 
usually  hydatid.  When  in  the  left  lobe,  they  can  scarcely  be  differentiated 
from  pancreatic  cyst  except  by  aspiration  of  the  fluid  or  an  exploratory 
operation.  An  enormously  distended  gall-bladder  may  simulate  pancreatic 
cyst.  Cyst  of  the  suprarenal  capsule,  especially  upon  the  left  side,  may 
be  readily  mistaken  for  cyst  of  the  pancreas.  The  differential  diagnosis 
by  physical  signs  alone  is  not  possible.  Cysts  of  the  Kidney,  Hydrone- 
phrosis, Pyonephrosis. — The  tumor  moves  to  some  degree  with  respiration; 
it  is  distinctly  unilateral,  and  occupies  the  lumbar  region  rather  than  the 
epigastrium.  The  relation  of  the  colon  to  it  may  be  determined  by  per- 
cussion after  inflation.  Renal  symptoms,  such  as  aching  pain,  frequent 
micturition,  and  the  previous  disappearance  of  the  tumor  with  the  passage 
of  a  great  quantity  of  water,  or  hemorrhage  from  the  genito-urinary  tract, 
point  to  the  kidney.  Cysts  of  the  Mesentery. — These  tumors  are  character- 
ized by  their  location  near  the  umbilicus,  movability  in  a  lateral  or  rotary 
direction,  and  tympany  around  the  circumference  of  the  mass,  and  in  a 
band  across  it.  If  a  pancreatic  cyst  develops  between  the  layers  of  the 
transverse  mesocolon  the  band  of  resonance  will  be  due  to  the  colon. 
Omental  Cysts. — A  cyst  developing  in  the  omentum  directly  below  the 
stomach  would  push  the  stomach  up  and  the  transverse  colon  down.  By 
the  physical  signs  the  diagnosis  would  not  be  possible.  The  anamnesis 
and  the  general  symptoms  might  justify  a  provisional  diagnosis.  Cysts  of 
the  posterior  wall  of  the  stomach,  cysts  of  the  spleen,  and  certain  retroperitoneal 
cysts  are  of  very  rare  occurrence  and  present  unusual  diagnostic  difficulties. 
In  many  of  the  cases  the  differential  diagnosis  between  these  tumors  and 
cysts  of  the  pancreas  is  impossible. 

Prognosis. — The  condition,  if  early  diagnosticated  and  relieved  by 
operation,  usually  terminates  in  recovery.  To  this  statement  a  reservation 
must  be  made  in  regard  to  hemorrhagic  cysts. 

vi.  Tumors  of  the  Pancreas. 

Neoplasms  are  rare.  Sarcoma,  adenoma,  and  lymphoma  are  extremely 
infrequent.  Carcinoma  mostly  involves  the  head  of  the  organ,  is  often 
primary,  and  commonly  occurs  after  middle  life.  Miliary  tubercle  is  an 
accompaniment  of  acute  miliary  tuberculosis.  Syphilis  occurs  in  the  form 
of  chronic  interstitial  inflammation  or  gummata.  The  frequency  with 
which  the  head  of  the  organ  is  involved,  especially  in  carcinoma,  accounts 
for  certain  symptoms.  The  tumor  exerts  pressure  upon  the  common  bile- 
duct,  the  pancreatic  duct,  the  duodenum,  and  the  pylorus.  The  stomachy 
colon,  aorta,  vena  cava,  portal  vein,  superior  mesenteric  vein,  and  the 
splenic  artery  and  vein  may  also  be  compressed.  The  breaking  down  of 
the  growth  may  cause  perforation  of  any  of  these  organs. 


ASCITES.  1021 

Etiology.  —  Carcinoma.  —  Men  are  more  frequently  affected  than 
women.  The  condition  has  been  found  with  greatest  frequency  between 
forty  and  sixty  years. 

Symptoms. — In  some  cases  the  symptoms  are  obscure.  Generally 
epigastric  pain  radiating  to  the  back,  often  intense  and  aggravated  at 
night,  is  a  prominent  symptom.  Jaundice,  a  gall-bladder  tumor,  and 
enlargement  of  the  liver  are  common.  A  tumor  in  the  pyloric  region,  and 
fixed,  may  often  be  made  out.  There  is  rapid  wasting.  Constipation  is 
usual;  the  stools  are  large  and  contain  free  fat  and  undigested  muscle 
fibre  in  unusual  amount.  Sugar  may  be  present  in  the  urine,  and  the 
symptoms  of  diabetes  may  be  noted.  A  subnormal  temperature  also  occurs. 
A  dense  shadow  may  be  noted  upon  X-ray  examination. 

Diagnosis. — Direct. — The  occurrence  of  the  above  symptoms  with 
cachexia  renders  the  diagnosis  of  carcinoma  of  the  pancreas  positive. 

Differential.  —  In  default  of  a  definite  symptom-complex  the 
possibility  of  interstitial  pancreatitis,  or  malignant  disease  of  the  common 
duct,  the  liver,  or  the  pylorus  is  to  be  considered.  Chronic  Pancreatitis. — 
A  long  histor}'",  recurrent  painful  attacks,  and  epigastric  tenderness  are  in 
favor  of  benign  disease;  loss  of  flesh  is  less  marked  than  in  carcinoma, 
and  vascular  disturbances  and  dropsy  are  far  less  common.  Anaemia  is 
less  pronounced,  and  cachexia  is  absent.  Cancer  of  the  Bile-ducts. — There 
is  almost  always  a  history  of  gall-stone  disease.  If  the  duct  of  Wirsung  be 
involved  the  differential  diagnosis  cannot  be  made;  if  not,  the  destructive 
signs  of  pancreatic  disease,  especially  the  rapid  wasting,  will  be  absent. 
Cancer  of  the  Liver. — Enlargement  of  the  liver  with  nodules  upon  its  sur- 
face and  borders,  and  moderate  jaundice,  or  its  absence,  are  diagnostic. 
Cancer  of  the  Pylorus. — Marked  gastric  symptoms,  retention  vomiting, 
dilatation  of  the  stomach,  absence  of  free  hydrochloric  acid,  and  the 
presence  of  altered  blood  in  the  vomited  matters  are  against  pancreatic 
carcinoma  alone,   but  the  conditions  are  frequently  associated. 

V.   DISEASES  OF  THE  PERITONEUM, 
i.  Ascites. 

Abdominal    Dropsy — Hydroperitoneum. 

Definition. — An  accumulation  of  serous  fluid  in  the  peritoneal  cavity. 

Etiology. — General  Causes. — The  accumulation  may  be  part  of  a 
general  dropsy  caused  by  derangement  of  the  mechanism  of  the  circula- 
tion, as  in  disease  of  the  heart.  In  some  cases  of  heart  disease  the  drop- 
sical effusion  may  be  limited  to  the  peritoneum.  Ascites  occurs  also  in 
various  forms  of  hydraemia  and  in  advanced  renal  dropsy.  Local 
Causes. — Chronic  inflammation  of  the  peritoneum;  portal  obstruction; 
abdominal  tumors. 

Character  of  the  Ascitic  Fluid. — The  fluid  in  ascites  from  stasis  is  clear, 
yellowish  or  greenish-yellow,  alkaline  in  reaction,  of  a  specific  gravity 
of  1.010-1.015,  and  contains  in  solution  the  soluble  substances  of  the 
blood.     Red  blood-corpuscles  are  also  present,  usually  in  small  numbers. 


1022  MEDICAL  DIAGNOSIS. 

In  inflammatory  ascites  the  fluid  contains  flakes  of  fibrin,  other  masses 
of  coagulated  material,  large  numbers  of  pus-corpuscles  when  it  is  puru- 
lent, and  many  blood-corpuscles  when  it  is  hemorrhagic.  In  cancerous 
ascites  molecular  debris  and  cancer-cells  may  be  present.  Various  bac- 
teria, as  streptococci,  staphylococci,  colon  bacilh,  gonococci,  B.  typhosi, 
pneumococci,  and  tubercle  bacilh  may  also  be  present.  The  presence  of 
tubercle  bacilli  may  be  determined  by  inoscopy.  The  differential  diag- 
nosis between  transudation  and  exudation  cannot  always  be  made  from 
the  characters  of  the  fluid  alone.  For  this  purpose  neither  the  albumin 
percentage  nor  the  specific  gravity  avails.  Cytodiagnosis  is  far  less  useful 
in  the  determination  of  the  nature  of  peritoneal  than  that  of  pleural  effu- 
sions. The  effusion  in  cirrhosis  is  sometimes  darker  in  color  than  in  other 
conditions,  and  that  in  cancer  and  tuberculosis  is  usually  hemorrhagic. 
In  the  cells  of  carcinomatous  ascites  mitosis  is  more  common  than  in  other 
forms,  and  the  cells  in  melanotic  sarcoma  may  contain  pigment  granules, 
though  the  fluid  is  clear. 

Chylous  and  Chyliform  Ascites. — The  fluid  is  milky  in  appearance  and 
resembles  chyle.  Quincke  recognized  two  essentially  different  forms, 
one  a  transudate,  —  ascites  chylosus,  which  owes  its  characters  to  the 
actual  presence  of  chyle,  —  the  other  ascites  adiposus,  —  chyliform  or 
pseudochylous,  —  the  appearance  of  which  is  due  to  the  admixture  of  fat 
derived  from  the  metamorphosis  of  the  disintegrating  cells  of  an  inflam- 
matory exudate  or  the  endothelium.  Fat  is  present  in  both  forms  in 
minute  dust-like  particles.  In  chylous  ascites  there  are  very  few  cells  in 
a  state  of  fatty  degeneration.  In  chyliform  ascites,' on  the  other  hand, 
there  are  many  cells  containing  fat  granules.  The  presence  of  sugar  does 
not  justify  the  conclusion  that  a  milky  ascites  is  chylous,  since  it  has  been 
definitely  established  that  sugar  may  be  present  in  any  form  of  transudate 
or  exudate  in  the  serous  sacs.  Both  of  these  fluids,  subjected  to  agitation 
with  ether  after  the  addition  of  potassium  hydroxide,  clear  up  to  a  greater 
or  less  extent,  and  both  respond  to  the  osmic  acid  and  other  tests  for  fat. 
They  are  bacteria  free  and  do  not  undergo  decomposition  for  indefinite 
periods.  Upon  standing  they  separate  into  a  thick  sedimentary  layer, 
and  a  fatty,  cream-like  layer  at  the  top. 

Milky,  Non-fatty  Ascites. — The  fluid  resembles  the  fatty  forms,  but 
neither  microscopically  nor  clinically  reveals  the  presence  of  fat.  The 
milk-like  appearance  has  been  ascribed  to  various  proteid  and  mucoid 
substances,  and  to  lecithin,  but  the  subject  is  still  under  investigation. 

Hcemo peritoneum  may  result  from  traumatism  and  the  rupture  of 
viscera,  as  the  liver,  spleen,  or  mesentery.  It  occurs  also  in  extra-uterine 
fetation  and  the  rupture  of  aneurism.  Recurrent  hemorrhage  into  the 
peritoneum  has  been  observed  in  the  absence  of  assignable  cause.  Blood- 
stained fluid  may  be  present  in  acute  pancreatitis,  volvulus,  twisting  of 
the  pedicle  of  an  ovarian  cyst,  and  other  similar  conditions. 

Symptoms. — These  vary  according  to  the  amount  of  fluid.  Small 
amounts  occasion  no  discomfort,  and  the  gradual  accumulations  of  a  con- 
siderable ascites  may  not  be  realized  by  the  patient.  It  is  very  common  in 
the  ascites  associated  with  cirrhosis  of  the  liver  for  the  patient  to  first 
become  aware  of  his  condition  by  his  inability  to  make  his  waistband 


ASCITES.  1023 

meet.  Large  accumulations  of  fluid  give  rise  to  much  distress  by  pressure 
and  tension  of  the  abdominal  walls,  sensations  of  fulness  and  weight,  ami 
interference  with  the  play  of  the  diaphragm,  causing  dyspnoea  and  cyanosis. 
(Edema  of  the  lower  extremities  and  pudenda,  occurring  subsequently  to 
large  ascites,  is  due  to  interference  with  the  retui-n  of  the  blood  by  the 
pressure  of  the  fluid  upon  the  ascending  vena  cava,  and  interference  with 
the  action  of  the  heart  by  upward  pressure  against  the  diaphragm.  The 
superficial  venous  trunks — mammary,  epigastric — are  frequently  widened 
and  tortuous,  and  reveal,  upon  stripping,  the  upward  current  of  the 
contained  blood. 

Physical  Signs. — (See  Methods  of  Physical  Diagnosis,  Part  II.) 

Diagnosis. — Small  quantities  of  fluid  gravitate  into  the  pelvis  and 
fail  to  manifest  themselves  by  the  signs  elicited  upon  external  examina- 
tion. If  necessary,  the  patient  may  be  placed  in  the  knee-elbow  posture 
when  a  small  collection  of  ascitic  fluid  gravitating  into  the  most  dependent 
region  may  be  recognized  upon  percussion,  or  a  finger  may  be  lightly 
pressed  into  the  inguinal  ring,  the  patient  being  in  the  erect  posture. 
Gentle  tapping  will  cause  a  wave  which  is  felt  by  the  finger.  Again  the 
finger,  introduced  into  the  rectum  or  vagina,  the  patient  being  in  such  a 
position  that  the  fluid  gravitates  into  the  cul-de-sac  of  Douglas,  may 
perceive  the  fluctuation  produced  by  tapping  on  the  lower  part  of  the 
belly  wall.  Less  than  1500-2000  c.c.  cannot  be  detected  by  physical 
examination. 

Paracentesis  Abdominis. — The  patient  should  sit  on  a  chair  or  upon  the 
side  of  a  low  bed,  with  his  knees  separated  and  a  large  jar  or  small  tub 
between  his  feet.  The  puncture  should  be  made  in  the  median  line  midway 
between  the  symphysis  and  navel,  under  strict  antiseptic  jDrecautions, 
with  a  straight  trocar,  one-eighth  of  an  inch  in  diameter;  it  should  be 
determined  by  previous  percussion  that  an  intestinal  coil  does  not  lie 
beneath  the  point  at  which  the  patient  is  to  be  tapped.  Pressure  should 
be  applied  by  a  many-tailed  bandage  to  the  abdominal  wall  as  the  fluid 
escapes.  If  the  canula  becomes  obstructed  by  floating  intestine,  a  change 
in  direction  or  the  insertion  of  a  probe  will  clear  it.  Fluids  ma}^  be  allowed 
to  escape  until  the  flow  ceases.  A  strip  of  adhesive  plaster  may  be  placed 
over  the  opening,  some  oozing  from  which  is  likely  to  occur. 

Differential  Diagnosis. — Large  cysts  may  simulate  ascites.  The 
error  is  most  common  in  cysts  of  the  ovary;  much  more  rare  are  pancreatic 
cysts  of  such  size.  There  is  tympanitic  resonance  in  the  flanks,  and  the 
circular  or  oval  area  of  tympany  is  not  present  in  the  umbilical  region. 
Examination  per  vaginam  may  yield  important  information.  Enormous 
lipomata  have  been  mistaken  for  ascites.  There  is  an  obscure  sense  of 
fluctuation,  but  the  shifting  areas  of  tympany  characteristic  of  ascites 
do  not  occur.  The  condition  is  exceedingly  rare;  females  are  chiefly 
affected;  the  tumor  develops  in  middle  life,  and  is  of  slow  growth.  An 
overdistended  bladder  may  reach  to  the  umbilicus,  or  above  it,  and  has 
been  mistaken  for  ascites.  The  dribbling  of  urine, — incontinence  of  reten- 
tion,— and  the  outline  of  the  swelling  should  put  the  practitioner  upon  his 
guard.  The  catheter  will  at  once  settle  the  matter.  Encysted  injlammatory 
exudates,  when  large,  may  simulate  ascites,  especially  when  pain  and  fever. 


1024  MEDICAL  DIAGNOSIS. 

or  other  constitutional  symptoms,  are  no  longer  present.  In  most  cases 
the  careful  employment  of  the  methods  of  physical  examination  is 
adequate  for  the  diagnosis. 

ii.  Acute  General  Peritonitis. 

Definition. — Acute  diffuse  inflammation  of  the  peritoneum. 

Etiology. — The  peritoneum  is  peculiarly  exposed  to  local  and  general 
infection  by  traumatism,  extension  from  the  viscera  which  it  invests,  the 
perforation  of  hollow  viscera,  rupture  of  the  capsules  of  organs  or  the  walls 
of  abscesses,  and  by  way  of  the  lymph  channels  and  the  blood.  Peritonitis 
may  be  primary  or  secondary. 

1.  Primary  Peritonitis. — Infection  takes  place  by  the  blood  or  by  the 
lymph  stream,  and  not  as  the  result  of  any  lesion  of  the  viscera  with  which 
the  peritoneum  is  in  relation,  or  any  wound  or  surgical  operation.  Acute 
general  peritonitis  is  sometimes  attributed  to  exposure  to  cold  or  damp, 
and  has  then  been  described  as  rheumatic.  The  form  which  occurs  as  a 
terminal  event  in  renal  disease,  gout,  and  arteriosclerosis  is  more  common. 
Whether  or  not  these  forms  of  peritonitis — idiopathic  peritonitis — are 
in  the  strict  sense  primary  remains  unsettled. 

2.  Secondary  Peritonitis. — From  the  point  of  view  of  the  source 
of  infection,  three  groups  of  cases  may  be  recognized,  (a)  Those  in  which 
the  infection  of  the  peritoneum  takes  place  from  without  by  way  of  trau- 
matism or  surgical  operation,  (b)  Those  in  which  one  of  the  abdominal 
organs,  or  an  abscess,  ruptures  and  its  contents  are  discharged  into  the 
peritoneal  cavity.  Intestinal  perforation  is  the  most  common  accident  of 
this  kind,  (c)  The  cases  in  which  bacteria  find  their  way  through  the  wall 
of  the  intestine  in  the  absence  of  a  large  or  small  solution  of  continuity, 
or  enter  the  .peritoneal  cavity  by  way  of  the  lymph  channels,  as  in  certain 
forms  of  puerperal  peritonitis,  or  peritonitis  consecutive  to  infection  of 
the  pleura. 

Bacteriology  of  Acute  Peritonitis.  —  One  or  several  varieties  of 
bacteria  may  be  found  in  the  exudate — single  or  mixed  infection.  Those 
which  are  the  most  important  are  the  Streptococcus  pyogenes,  the  Dip- 
lococcus  pneumoniae,  and  the  Bacillus  coli  communis.  These  are  frequently 
present  alone  —  monoinfection.  In  rare  instances  the  Staphylococcus 
pyogenes  aureus  has  been  found  in  pure  culture  in  the  peritoneal  exudate. 
The  gonococcus  may  also  cause  peritonitis,  whether  in  simple  or  mixed 
infection  has  not  yet  been  positively  determined.  In  simple  infection 
the  following  organisms  have  also  been  found:  Micrococcus  lanceolatus, 
B.  pyocyaneus,  and  the  B.  influenzae.  In  so-called  primary — idiopathic — 
peritonitis,  and  in  postoperative  peritionitis,  simple  infection  is  much  more 
common  than  mixed  infection;  in  the  secondary  forms  mixed  infection 
is  more  common,  but  monoinfection  may  occur. 

Clinical  Etiology. — The  vast  majority  of  cases  which  arise  in  conse- 
quence of  disease  of  the  abdominal  or  pelvic  organs  invested  by  peritoneum, 
or  in  near  topical  relation  to  the  peritoneal  cavity,  are  demonstrably 
""secondary."  The  organs  most  commonly  involved  in  the  primary  affec- 
tion are  the  intestines  and  the  reproductive  organs  in  the  female. 


PERITONITIS.  1025 

Intestines. — In  the  order  of  frequency  and  importance,  lesions  of 
the  vermiform  appendix  stand  first.  Intestinal  ulceration,  especially  the 
ulcers  of  enteric  fever  and  peptic  ulcer  in  the  duodenum,  come  next.  Other 
forms  of  intestinal  ulcer,  as  tuberculous,  dysenteric,  diphtheritic,  are  less 
apt  to  cause  perforation,  and  when  this  accident  occurs  it  is  usually  into 
a  region  of  the  peritoneum  shut  off  by  adhesions  and  often  already  the 
seat  of  a  circumscribed  abscess.  Certain  forms  of  intestinal  ulcer,  both 
acute,  as  after  extensive  burns  of  the  surface,  or  peptic  ulcer,  and  chronic, 
as  those  which  occur  occasionally  in  scurvy  and  leukaemia,  show  no  ten- 
dency to  perforation.  Carcinoma  causes  chronic  adhesive  peritonitis 
and  circumscribed  abscess  formation,  but  scarcely  ever  acute  diffuse 
inflammation  of  the  peritoneum.  Acute  Occlusion  of  the  Bowel. — Volvulus 
and  strangulation  and  less  frequently  intussusception  give  rise  to  peri- 
tonitis. Chronic  stenosis  is  rarely  the  cause  of  this  condition.  Rupture 
of  the  bowel,  like  perforation,  is  at  once  followed  by  general  peritonitis. 

The  Stomach. — Peptic  ulcer  and  carcinoma  may  prove  the  point 
of  departure  for  acute  peritonitis.  Sudden  perforation,  before  adhesions 
have  formed,  may  occur;  more  commonly,  adhesions  with  adjacent  vis- 
cera take  place  as  the  result  of  a  local  peritonitis,  with  abscess  formation 
or  perforation  into  the  colon. 

Liver,  Gall-bladder  and  Bile  Passages. — Perihepatitis  and  local 
adhesive  inflammation  are  common  in  diseases  of  these  organs,  but  acute 
diffuse  peritonitis  is  infrequent.  It  may  result  from  rupture  of  an  abscess 
or  hydatid  cyst,  or  from  strangulation  or  acute  intestinal  obstruction 
caused  by  pericholecystitic  adhesions.  An  abscess  about  an  infected  gall- 
bladder has,  in  rare  instances,  ruptured  into  the  general  cavity  of  the 
peritoneum. 

The  Spleen. — Acute  diffuse  peritonitis  arising  from  disease  of  this 
organ  is  rare.  Rupture  of  the  capsule  from  traumatism,  and  the  rupture 
of  an  abscess  before  adhesions  to  neighboring  viscera  have  formed,  are 
the  two  principal  events. 

The  Pancreas. — Acute  hemorrhagic  pancreatitis  gives  rise  to  inflam- 
mation of  the  lesser  peritoneum,  and  when  the  patient  survives  for  a  period 
general  peritonitis  may  occur  by  extension.  The  rupture  of  a  pancreatic 
abscess  into  the  general  peritoneum  is  an  extremely  rare  event. 

Kidneys  and  Bladder. — Acute  diffuse  purulent  peritonitis  occa- 
sionally results  from  the  rupture  of  an  abscess  of  the  kidney.  Rupture 
of  a  hydronephrosis  may  not  be  followed  by  peritonitis,  if  the  urine  does 
not  contain  pathogenic  bacteria.  Perforation  of  the  bladder  as  the  result 
of  ulceration,  or  the  more  serious  forms  of  diphtheritic  ulceration,  may 
result  in  a  localized  abscess  or  in  acute  peritonitis. 

The  Genital  Organs. — Acute  gonococcus  peritonitis,  having  its 
starting-point  from  the  vas  deferens  or  seminal  vesicles,  is  exceedingly 
rare.  In  the  female,  however,  the  sexual  organs  constitute  the  most  fre- 
quent starting-point  of  acute  peritonitis.  Puerperal  peritonitis  is  the 
most  common  form.  Gonococcus  infection  is  an  extremely  common  cause 
of  pelvic  peritonitis,  and  occasionally,  in  young  girls,  of  acute  general 
peritonitis,  which  may  also  occur  in  children  suffering  from  vulvovaginitis 
by  extension  to  the  tubes. 

65 


1026  MEDICAL  DIAGNOSIS. 

Lesions  of  the  Abdominal  Parietes,  Mesenteric  and  Retro- 
peritoneal Glands,  and  Inflammatory  Disease  op  the  Other  Serous 
Cavities. — Peritonitis  sometimes  arises  in  consequence  of  inflammation 
or  suppuration  in  the  abdominal  walls,  the  burrowing  of  psoas  or  other 
abscesses,  rectal  disease,  or  caries  of  the  vertebra,  ribs,  or  bones  of  the 
pelvis.  It  may  also  be  secondary  to  disease  of  the  mesenteric  glands, 
especially  in  tuberculous  disease,  and  enteric  fever — pseudo-abscess. 
Pleurisy,  pulmonary  abscess,  gangrene  of  the  lung,  and  purulent  pericar- 
ditis may  be  followed  by  acute  general  peritonitis  in  consequence  of 
infection  through  the  diaphragm. 

Acute  Infectious  Diseases, — Acute  peritonitis  sometimes  occurs 
in  the  course  of  rheumatic  fever.  It  is  common  in  septic  conditions  and 
especially  in  puerperal  sepsis.  It  is  extremely  rare  in  the  continued  and 
eruptive  fevers,  and  when  it  occurs  in  the  course  of  these  infections  is 
secondary  to  some  local  lesion,  as  perforation  in  enteric  fever.  It  sometimes 
occurs  in  erysipelas,  especially  when  the  abdominal  walls  are  involved, 
in  influenza  of  the  gastro-intestinal  form,  and  in  pneumonia. 

Peritonitis  in  the  Fcetus  and  New-born. — A  septic  peritonitis 
of  the  foetus  arises  in  consequence  of  infection  from  the  mother  by  way  of 
the  placental  circulation.  Not  alone  the  peritoneum,  but  also  the  other 
serous  cavities,  the  pleurae,  pericardium,  and  meninges  are  affected.  In 
the  new-born,  infection  by  way  of  the  umbilical  wound,  usually  through 
the  lymph  channels,  is  a  frequent  cause  of  general  peritonitis. 

The  blood-vessels  of  the  peritoneum  in  recent  cases  are  more  or  less 
deeply  injected,  and  the  coils  of  intestine  distended  and  bound  together  by 
lymph.  The  exudate  may  be  fibrinous,  serofibrinous,  purulent,  gangrenous^ 
or  hemorrhagic.  The  fluid  exudate  varies  in  amount  from  a  few  small  col- 
lections of  clear  serum  among  the  adherent  loops  of  bowel  to  many  litres. 

Symptoms. — The  symptoms  of  peritonitis  in  general  may  be  arranged 
in  the  following  groups:  (a)  Symptoms  immediately  due  to  the  peritoneal 
inflammation, — pain  and  the  phenomena  denoting  the  presence  and  amount 
of  the  exudate,  (b)  Symptoms  caused  by  derangements  of  organs  and 
structures  implicated  in  the  process,  as  the  stomach,  intestine,  bladder,, 
abdominal  muscles,  and  diaphragm, — vomiting,  constipation,  meteorism^ 
frequent  and  painful  micturition,  early  rigidity,  and  late  paresis  of  the 
abdominal  walls,  hiccough,  (c)  Constitutional  or  toxsemic  symptoms: 
fever  with  its  attendant  phenomena,  circulatory  disturbances,  anaemia,, 
modifications  of  the  urine,  nutritional  disorders,  and  manifestations  of  sepsis. 
These  symptoms  show  great  variation  in  their  intensity  and  association  in 
the  different  forms  of  peritonitis  and  in  different  cases. 

(a)  Peritoneal  Symptoms. — Pain  and  tenderness  in  the  abdomen  charac- 
terize the  onset.  The  pain  is  severe  and  continuous,  the  tenderness  exquis- 
ite. In  non-perforative  cases  the  pain  gradually  reaches  its  maximum  ;  in 
perforative  cases  it  is  almost  always  extremely  severe  from  the  onset. 
In  enteric  fever  and  other  stuporous  states  the  occasional  absence  of  pain 
is  due  to  the  mental  condition.  The  pain  is  continuous,  and  not  only  is  it 
increased  by  pressure,  but  also  by  movement.  The  patient  lies  motionless 
in  the  dorsal  posture,  with  the  legs  and  thighs  flexed.  Respiration  is 
shallow,  rapid,  and  of  the  costal  type.     Cough  is  suppressed,  and  sneezing 


PERITONITIS.  1027 

is  attended  with  agonizing  pain.  To  this  persistent,  characteristic  pain  is 
superadded  coHc  due  to  intestinal  peristalsis,  and  recurring  in  paroxysms. 
The  pain  and  tenderness  may  be  present  uniformly  over  the  whole  abdo- 
men. It  is  very  often  most  intense  below  the  umbilicus.  Frequently, 
but  not  invariably,  these  symptoms  are  most,  intense  in  the  area  cor- 
responding to  the  starting-point  of  the  inflammation,  as  the  ileocsecal 
region,  the  pelvis,  or  the  epigastrium. 

A  fibrinous  exudate  sometimes  manifests  itself  by  a  friction  sound, 
usually  best  heard  in  the  upper  part  of  the  abdomen,  over  the  liver  or 
spleen.  A  fluid  exudate  gradually  collects  in  a  majority  of  the  cases. 
Its  presence  may  be  first  recognized  by  dulness  in  the  flanks.  As  it 
increases,  it  gives  rise  to  the  characteristic  physical  signs  described 
under  the  heading  "Physical  Diagnosis"  (see  Part  II). 

(b)  Visceral  Symptoms. — Vomiting  is  one  of  the  earliest  symptoms  in 
acute  peritonitis,  and  greatly  increases  the  pain.  It  usually  continues 
several  days,  not  ceasing  until  the  fatal  termination,  an  improvement  in 
the  patient's  condition,  or  the  outpouring  of  a  large  exudate.  In  the 
last  instance,  the  cessation  of  vomiting  may  be  an  unfavorable  sign.  The 
vomitus  consists,  at  first,  of  the  gastric  contents;  later,  of  a  bile-stained 
greenish  fluid,  and  in  some  instances  of  blackish  material  with  a  fecal  odor. 
Vomiting  may  be  absent  in  large  perforation  of  the  stomach.  Constipa- 
tion is  the  rule;  in  some  cases  the  bowels  move  spontaneously  every 
day  or  two;  in  puerperal  septic  peritonitis  diarrhoea  is  common.  Hiccough 
is  a  common  and  distressing  symptom. 

Muscular  rigidity,  the  result  of  reflex  irritation,  is  an  early  and 
extremely  valuable  sign  of  acute  peritonitis.  It  may  cause  retraction, 
even  a  scaphoid  abdomen,  and  by  restraining  peristalsis  may  diminish 
the  pain.  It  is  especially  marked  in  peritonitis  due  to  perforation.  In 
rapidly  fatal  cases  the  abdomen  may  be  flat  and  rigid  throughout  the 
entire  course  of  the  attack. 

Painful  micturition  is  due  to  traction  exerted  upon  the  inflamed  peri- 
toneum by  the  contractions  of  the  bladder.  Retention  of  urine  is  common, 
especially  in  men.  More  often  there  is  great  vesical  irritability,  with 
frequent  micturition.  The  urine  is  diminished,  high  colored,  and  often 
contains  albumin.  It  is  characteristic  of  acute  diffuse  peritonitis  that  the 
urine  contains  large  quantities  of  indican.  The  micro-organisms  which 
cause  the  disease  have  been  present.  As  the  rigidity  passes  away, 
meteorism  takes  its  place.  It  is  due  to  paresis  of  the  intestine,  and  may 
appear  early  in  the  disease,  especially  in  the  perforative  cases.  In  extreme 
cases  the  bowel  is  completely  paralyzed,  and  no  auscultatory  signs  of 
peristalsis  can  be  heard,  the  belly  is  enormously  distended,  especially  in 
its  upper  and  middle  segments,  and  the  skin  is  tense,  smooth,  and  glisten- 
ing. In  puerperal  peritonitis  the  distention,  owing  to  the  relaxation  of 
the  stretched  walls,  is  greater  than  in  other  forms.  The  splenic  dulness 
may  be  obliterated;  the  liver  dulness  is  greatly  diminished  and  may 
wholly  disappear  in  the  midclavicular  line;  the  diaphragm  is  pushed  up 
so  that  the  apex  beat  of  the  heart  may  be  felt  in  the  fourth  intercostal 
space.  The  obliteration  of  liver  dulness  in  the  front  of  the  body  may  be 
due  to  tympany  alone,  and  is  not,  therefore,  a  positive  sign  of  pneumo- 


1028  MEDICAL  DIAGNOSIS. 

peritoneum  or  of  the  perforation  of  an  air-containing  viscus.  If,  when 
the  patient  is  turned  upon  his  left  side,  dulness  disappears  in  the  axillary 
line,  there  is  free  air  in  the  cavity  of  the  peritoneum, 

(c)  General  Symptoms. — The  attack  begins,  in  a  majority  of  the  cases, 
with  chilKness  or  a  rigor.  Fever  follows,  but  is  not  constant  and  does 
not  conform  to  type.  The  temperature  may  rise  suddenly  to  a  consider- 
able height,  but  does  not  often  exceed  104°  F.  (40°  C),  or  it  maj^  gi-adually 
rise  for  several  days.  In  either  case  it  becomes  irregular  or  drops  to  normal 
as  the  attack  progresses.  As  death  approaches,  the  temperature  may  show 
rapid  oscillations.  In  perforative  peritonitis,  the  temperature  very  often 
drops  to  subnormal  ranges, — ten^erature  of  coUapse, — and  remains  there 
until  death.  The  pulse  is  rapid,  small,  and  wiry.  Its  frequency'  is  120-160 
per  minute  and  bears  no  constant  relation  to  the  temperature. 

Leucocj^osis  of  the  poljmuclear  neutropliilic  type,  18,000-40,000,  is 
found,  except  in  the  gravest  cases,  in  which  there  maj^  be  leucopenia. 

The  clinical  picture  of  acute  diffuse  peritonitis,  from  the  time  that 
the  disease  is  fully  established,  is  very  characteristic.  The  facies  indicates 
great  suffering  and  anxiety  and  presents  the  signs  of  collapse.  The  nose 
is  pinched  and  pointed,  the  eyes  are  sunken,  the  temples  flattened;  there 
is  cyanosis,  and  the  brow  is  wet  with  drops  of  sweat — facies  Hippocratica. 
The  patient  lies  motionless,  the  respirations  are  shallow  and  rapid,  the 
pulse  is  thi'eady,  the  knees  are  dra^^Ti  up,  the  hands  and  feet  cold  and 
shrunken. 

This  form  of  peritonitis  usually  terminates  fatally.  The  perforative 
forms  often  run  their  course  witliin  forty-eight  hours;  the  non-perforative 
forms  in  four  or  five,  or  sometimes  in  eight  or  ten,  daj's.  Exceptionally 
death  occurs  verj^  suddenly,  with  signs  of  cardiac  paralysis. 

Diagnosis. — Direct. — The  diagnosis  rests  upon  the  sudden  onset 
of  intense  abdominal  pain,  tenderness,  fever,  vomiting,  rigidity  of  the 
abdominal  muscles,  and  collapse  symptoms.  When  the  attack  is  fully 
developed  the  facies  and  attitude  are  very  suggestive.  Inquiry  into  the 
previous  health  will  often  reveal  the  primary  cause  of  the  attack.  It  is 
to  be  borne  in  mind  that  intestinal  perforation  and  disease  of  the  pehdc 
organs  in  females  are  the  most  common  primary  conditions.  A  history 
of  attacks  of  pain  in  the  iliac  region  suggests  perforating  appendicitis; 
of  pain  after  eating,  epigastric  tenderness,  heematemesis,  or  dark  blood 
in  the  stools,  peptic  ulcer;  of  recent  headache,  nose-bleeding,  prostration, 
and  diarrhcea,  the  ambulant  form  of  enteric  fever.  In  females  recent 
abortion  or  confinement,  acute  suppurative  disease  of  the  pelvic  viscera, 
or  salpingitis  are  common  antecedent  conditions.  In  enteric  fever  the 
signs  of  perforation  may  be  masked  b}'  the  patient's  mental  condition. 
In  many  of  the  cases  the  pre\T[ous  condition  cannot  be  determined. 

Differential. — The  following  conditions  are  often  mistaken  for 
peritonitis:  Acute  Enterocolitis. — The  pain  is  colicky,  and  less  continuous; 
the  tenderness  is  less  acute,  and  more  Hmited;  diarrhcea  is  a  more  prom- 
inent symptom,  and  early  rigidity  and  subsequent  tjmipany  are  not  so 
conspicuous.  In  the  severe  cases  there  may  be  a  very  marked  degree  of 
collapse.  Intestinal  ohst ruction,  volvuhis,  and  strangulation  may  not  only 
cause  peritonitis,  but  they  often  also  simulate  it,  the  symptoms  in  common 


PERITONITIS.  1029 

being  pain,  tenderness,  vomiting,  and  tympanites.  Muscular  rigidity  is 
not  so  marked,  local  distention  of  the  bowel,  violent  peristaltic  move- 
ments, and  the  more  tardy  development  of  tympany  and  collapse 
point  to  occlusion  of  the  bowel  rather  than  inflammation  of  the  peritoneum. 
Rupture  of  a  tubal  pregnancy  or  an  abdominal  aneurism  may  give  rise 
to  symptoms  suggestive  of  perforative  peritonitis.  The  history  is  very 
important.  Restlessness  and  air  hunger  are  much  more  marked  in  large 
internal  hemorrhage  than  in  inflammation.  Embolism  of  the  superior 
mesenteric  artery  may  be  attended  with  sudden  agonizing  pain,  frequent 
vomiting,  collapse,  and  tympany.  Acute  Hemorrhagic  Pancreatitis. — A 
history  of  gall-stone  disease  and  the  localization  of  pain  in  the  epigastrium 
are  important  in  the  diagnosis.  In  perforative  and  rupture  cases,  in  which 
the  peritoneum  is  suddenly  flooded  with  the  contents  of  the  intestine  or 
pus,  death  frequently  takes  place  from  shock  in  the  course  of  a  few  hours, 
before  an  actual  inflammation  has  time  to  develop.  Hysteria  may  mimic 
peritonitis. 

iii.  Acute  Circumscribed  Peritonitis. 

This  form  of  inflammation  of  the  peritoneum  is,  (1)  adhesive,  or 
(2)  purulent. 

1.  Adhesive  inflammation  is  of  very  frequent  occurrence  in  local 
disease  of  the  abdominal  organs.  It  is  usually  narrowly  circumscribed, 
and  unattended  by  other  immediate  symptoms  than  pain  and  tenderness, 
the  manifestations  of  the  primary  affection  dominating  the  clinical  picture. 
The  anatomical  changas  consist  in  vascular  injection,  fibrin  formation, 
and  slight  serous  exudation.  The  organs  involved  are  chiefly  the  liver, 
gall-bladder  and  bile  passages,  spleen,  stomach,  coils  of  intestines, 
the  appendix  vermiformis,  and  the  sexual  organs  in  the  female.  Peri- 
hepatitis, perisplenitis,  either  circumscribed  or  involving  the  whole  organ, 
belong  to  this  category.  Intestinal  adhesions  following  local  disease  or 
operation,  adhesive  inflammation  affecting  the  gall-bladder,  bile-ducts, 
duodenum,  and  the  pyloric  end  of  the  stomach,  or  a  similar  process  involv- 
ing the  Fallopian  tubes  or  ovaries  may  be  the  cause  of  distressing  subse- 
quent symptoms.  Tuberculous,  cancerous,  suppurative,  or  hydatid  disease 
may  be  the  cause  of  localized  peritonitis. 

2.  Purulent. — Infection  with  pus-producing  micro-organisms  may 
be  primary  and  cause  acute  suppurative  circumscribed  peritonitis,  or  it 
may  occur  later  and  lead  to  the  formation  of  localized  abscess  and  small 
pockets  of  pus  among  the  adhesions  and  other  lesions  resulting  from  the 
non-suppurative  form,  so  that  a  transitional  condition  may  be  recognized. 
There  are  certain  points  in  which  acute  suppurative  circumscribed  peri- 
tonitis preferably  arises;  among  these,  the  region  of  the  appendix,  the 
pelvic  organs  in  the  female,  and  the  lesser  peritoneum  are  most  important. 

(a)  Appendicular  Abscess. — The  most  common  cause  of  acute  cir- 
cumscribed suppurative  peritonitis  is  appendicitis — a  condition  fully 
described  under  the  heading  '^  Diseases  of  the  Intestines"  (q.  v.). 

(b)  Pelvic  Peritonitis.  —  Suppurative  inflammations,  septic,  tuber- 
culous, or  gonorrheal,  are  very  common.  They  result  in  the  formation 
of  perimetric  and  parametric  abscesses.     Salpingitis  and  abscesses  of  the 


1030  MEDICAL  DIAGNOSIS. 

broad  ligament  occur.  Suppuration  is  frequently  preceded  by  extensive 
adhesive  inflammation.  General  peritonitis  may  arise  by  extension  of 
the  infection,  or  by  rupture. 

(c)  Subphrenic  Peritonitis.  —  Inflammation  may  involve  the  lesser 
peritoneum  alone,  and  inflammatory  exudates  may  be  confined  to  its 
cavity.  Perforating  ulcers  of  the  stomach,  duodenum,  or  colon  are  some- 
times so  situated  that  they  communicate  directly  with  it,  and  into  it  pan- 
creatic hemorrhages  and  abscesses  may  be  discharged.  Effusions  into 
this  space  may  cause  an  oval,  smooth,  tense  tumor,  extending  into  the 
epigastric,  umbilical,  and  left  hypochondriac  regions,  and  simulating  a 
pancreatic  cyst.  The  physical  signs  vary  greatly  from  time  to  time,  accord- 
ing to  the  condition  of  the  adjacent  stomach.  If  the  latter  is  distended 
with  food,  the  line  of  demarcation  between  it  and  the  tumor  cannot  be 
made  out  either  by  percussion  or  palpation,  while  if  it  is  filled  with  gas, 
it  may  yield  tympanitic  resonance  over  the  greater  part  or  the  whole 
of  the  tumor,  causing  it  at  times  to  altogether  disappear.  A  subphrenic 
abscess  has,  in  rare  cases,  followed  pneumonia  or  empyema;  more  fre- 
quently it  results  from  an  appendicular  abscess,  a  renal  or  hepatic  abscess, 
or  trauma.     It  may  occur  in  connection  with  cancer  of  the  stomach. 

The  diagnosis  of  simple  subphrenic  abscess  is  difficult,  because 
the  signs  and  symptoms  are  very  frequently  indefinite.  The  sub- 
jective symptoms  attract  attention  to  the  upper  part  of  the  abdomen. 
Among  these  pain  is  most  important,  and  may  be  referred  to  the  right  or 
left  side,  the  back,  and  so  forth,  according  to  the  seat  of  the  abscess.  It 
may  be  localized,  or  radiate  into  the  abdomen  or  lower  thoracic  belt.  When 
the  pain  is  local  it  is  usually  associated  with  tenderness.  Circumscribed 
phenomena  in  the  epigastrium  or  left  hypochondrium  are  suggestive. 
Fluctuation  is  rare  and  present  only  when  the  abscess  is  superficial.  In 
rare  cases  there  is  circumscribed  oedema  of  the  overlying  skin. 

Pyopneumothorax  Subphrenicus  —  Leyden. — When  the  subphrenic 
abscess  is  due  to  a  perforating  peptic  ulcer  air  is  also  almost  always 
present  and  the  condition  simulates  pneumothorax. 

Symptoms. — The  nature  of  the  condition  is  obscure  and  in  a  majority 
of  the  cases  not  recognized  intra  vitam.  The  symptoms  vary  according 
to  the  cause.  The  pus  collection  between  the  liver  and  the  diaphragm, 
whether  in  relation  with  the  right  or  the  left  lobe  when  air  is  not  also  pres- 
ent, closely  simulates  an  encysted  empyema  at  the  base  of  the  pleural  sac. 
When  it  occurs  in  association  with  pneumonia,  or  empyema,  or  an  abscess 
in  a  neighboring  organ,  the  symptoms  of  the  primary  affection  are  more 
or  less  rapidly,  often  suddenly,  reinforced  by  those  of  the  new  affection, 
namely,  severe  epigastric  pain,  urgent  and  persistent  vomiting,  and  respir- 
atory embarrassment.  In  rapidly  developing  cases  shock  may  also  occur. 
Later  symptoms  are  chills,  irregular  fever  of  septic  type,  anaemia,  and 
rapid  wasting.  Burrowing  may  occur  into  the  pleura  or,  in  the  case  of 
pleural  adhesions,  into  the  lung,  with  paroxysmal  cough  and  copious 
purulent  expectoration.  When  caused  by  a  perforating  ulcer  of  the 
stomach  or  duodenum,  the  onset  is  abrupt,  with  great  pain,  and  the 
vomited  material  is  bilious  or  bloody.  When  the  abscess  cavity  con- 
tains gas,  the  diaphragm  may  be  forced  upward  upon  the  right  side  as 


PERITONITIS.  1031 

far  as  the  third  rib,  and  the  liver  displaced  downward;   when  upon  the 
left  side,  the  heart  is  displaced  upward. 

Diagnosis.  —  Subphrenic  pyopneumothorax  is  very  frequently  over- 
looked. The  physical  signs  are  those  of  pneumothorax  or  pyopneumo- 
thorax upon  the  right  or  left  side,  according  as  the  abscess  cavity  is  situated 
upon  the  right  or  the  left  side  of  the  suspensory  ligament.  The  antecedent 
symptoms,  in  the  majority  of  the  cases,  point  to  disease  of  the  abdominal 
organs  and  not  to  disease  of  the  lungs  or  pleurae.  Upon  forced  inspira- 
tion the  lower  border  of  the  compressed  lung  is  depressed  in  subphrenic 
abscess;  the  liver  is  usually  depressed  to  a  remarkable  degree,  and  its 
lower  border  is  distinctly  palpable.  The  heart  is  displaced  upward  rather 
than  laterally.  In  both  conditions  the  intercostal  spaces  may  be  either 
obliterated  or  bulging.  As  the  greater  number  of  cases  are  the  result  of 
perforating  peptic  ulcer,  the  local  symptoms  appear  very  suddenly,  while 
the  general  symptoms  are  usually  more  severe  than  in  ordinary  cases  of 
pneumothorax.  Exploratory  puncture  may  be  made  for  diagnostic  pur- 
poses. The  presence  of  material  from  the  gastro-intestinal  tract  at  once 
determines  the  differential  diagnosis.  The  position  of  the  diaphragm  may 
be  positively  determined  by  skiagraphy.  In  pyopneumothorax  it  forms 
the  floor,  in  pyothorax  subphrenicus  the  roof,  of  the  abscess  cavity. 

iv.  Chronic  Peritonitis. 

(a)  Local  Adhesive  Peritonitis.- — The  inflammation  of  the  peritoneum 
which  follows  operations  or  accompanies  local  disease  of  the  abdominal 
viscera  is  more  frequently  chronic  than  acute.  When  it  involves  coils  of 
intestines,  it  gives  rise  to  partial  stenosis  with  constipation  and  cohcky 
pains,  and  may  ultimately  be  the  cause  of  acute  obstruction  of  the  intestine 
by  strangulation. 

(b)  Diffuse  Adhesive  Peritonitis. — In  tuberculosis  and  general  car- 
cinomatous infiltration  of  the  peritoneum  the  adhesions  are  sometimes  so 
extensive  as  to  entirely  obliterate  the  cavity.  This  form  of  peritonitis  is 
rare  in  other  conditions,  but  has  been  encountered  in  tumors  of  the  peri- 
toneum, and  after  trauma.   It  occurs  also  in  syphilis  during  intra-uterine  life. 

Symptoms. — The  condition  may  not  be  attended  with  definite  symp- 
toms.    Pain  and  tenderness  are  usually  present. 

(c)  Chronic  Proliferative  Peritonitis. — There  is  great  thickening  of 
the  membrane,  without  extensive  adhesions.  Moderate  serous  effusion  may 
be  present.  The  mesentery  is  shortened,  and  the  omentum  may  be  rolled 
into  a  firm  transverse  tumor.  In  some  instances  there  is  a  general  chronic 
inflammation  of  the  serous  membranes, — Concato's  disease,  polyorrhom- 
enitis, — involving  with  the  peritoneum  both  pleurae  and  the  pericardium. 
This  form  of  peritonitis  occurs  in  the  subjects  of  chronic  alcoholism,  in 
chronic  passive  congestion,  and  in  tumors,  but  is  especially  associated  with 
cirrhosis  of  the  liver. 

Symptoms.  —  The  disease  may  be  latent,  the  symptoms  being  sub- 
ordinated to  those  of  the  primary  condition.  They  comprise  abdominal 
uneasiness  and  distention,  colicky  pains,  constipation,  and  diarrhoea. 
Jaundice  is  sometimes  present.     Ascites  may  occur,  or  the  shortening  of 


1032  MEDICAL  DIAGNOSIS. 

the  mesentery,  the  consequent  drawing  together  of  the  intestines  into  a 
tumor-hke  mass,  and  the  retracted  and  indurated  omentum  may  simulate 
tumors  of  various  abdominal  organs. 

Diagnosis.  —  The  direct  diagnosis  rests  upon  the  concurrence  of 
alcoholism,  cirrhosis  of  the  liver,  chronic  intestinal  disease,  chronic 
nephritis,  with  symptoms  of  peritoneal  disease,  and  ill-defined  tumor-like 
masses  in  the  abdomen.  It  is  confirmed  if  the  evidences  of  bilateral  chronic 
pleurisy  and  indurative  mediastinitis  are  present. 

The  Differential  Diagnosis. — This  relates  to  the  recognition  of 
the  condition,  notwithstanding  the  resemblance  of  some  of  its  features 
to  tumors  of  the  stomach,  liver,  or  other  abdominal  organs.  To  this  the 
vagueness  and  irregularity  of  the  symptoms  and  signs,  their  variations 
as  time  goes  on,  the  primary  affection,  and  the  evidence  of  chronic  disease 
in  the  other  serous  sacs  all  contribute.  The  anomalous  nature  of  the 
pseudotumors  and  their  independence  of  the  organs  may,  when  the 
effusion  is  not  too  abundant,  be  recognized  upon  careful  palpation. 

V.  Tuberculous  Peritonitis. 

Tuberculosis  of  the  Peritoneum. 

The  diagnosis  of  this  condition  has  been  fully  considered  under  the  appro- 
priate subcaption  of  Tuberculosis,  in  the  section  on  The  Infectious  Diseases. 
It  has,  in  recent  times,  acquired  peculiar  importance  in  consequence  of  the 
remarkable  success  attending  laparotomy  in  certain  forms  of  the  disease. 

vi.  New  Growths  in  the  Peritoneum. 

Neoplasms  of  the  peritoneum  are  rare.  They  comprise  benign  and 
malignant  tumors. 

1.  Benign  Tumors.  —  Cysts  of  various  kinds,  lipomata,  fibromata, 
myxomata,  angiomata,  and  other  rarer  forms  are  occasionally  encountered. 
They  may  occupy  any  region,  but  are  more  often  found  in  the  omentum 
and  mesentery  than  elsewhere.  They  are  single  or  multiple,  (a)  Cysts. — 
Cystic  tumors  are  found  in  the  omentum,  more  frequently  in  the  mesentery. 
Cysts  of  the  mesentery  may  be  classified  according  to  their  contents  into 
serous,  chylous,  hemorrhagic,  dermoid,  and  hydatid  cysts.  Serous  C5''sts 
are  very  rare.  They  may  be  single  or  multiple.  Chylous  cysts  contain 
a  milk-like  opaque  fluid  having  the  characteristics  of  chyle,  and  are  prob- 
ably due  to  the  retention  of  chyle  in  the  lacteals,  or  receptaculum  chyli. 
They  have  been  regarded  as  embryonic.  They  are  usually  found  in  the 
mesentery.  Hemorrhagic  cysts  are  commonly  the  result  of  trauma,  and 
contain  a  brownish-red  fluid.  They  may  be  chylous  or  of  peripancreatic 
origin.  Dermoid  cysts  containing  hair,  bone,  treth,  and  mucilaginous 
material  have  been  found  in  the  omentum  and  mesentery.  They  may  be 
multiple.  Hydatid  cysts  usually  occupy  the  omentum  or  mesentery. 
When  primary,  the  cyst  is  commonly  single.  Secondary  hydatid  disease 
of  the  peritoneum  is  much  more  common.  The  cysts  are  usually  multiple, 
and  may  be  present  in  enormous  numbers.     Mesenteric  and  omental  cysts 


NEW  GROWTHS  IN  THE  PERITONEUM.  1033 

vary  greatly  in  size.  They  may  reach  a  capacity  of  several  litres,  (b) 
LiPOMATA  are  met  with  in  the  subperitoneal  tissues  of  the  anterior  abdom- 
inal wall.  They  are  usually  small,  but  may  attain  such  size  as  to  simulate 
ascites.  They  may  also  develop  in  the  omentum  or  in  the  mesentery,  and 
grow  to  such  a  size  that  they  completely  fill  the  abdominal  cavity.  They 
may  be  of  retroperitoneal  origin.  They  occur  more  commonly  in  women, 
and  after  middle  life.  They  are  of  slow  growth  and,  yielding  an  obscure 
sense  of  fluctuation,  suggest  ascites,  (c)  Fibrous  tumors  of  the  perito- 
neum are  rare.  They  may  arise  from  the  omentum,  mesentery,  or  the 
pelvic  organs,  and  reach  the  size  of  the  closed  fist.  Other  benign  tumors 
are  exceedingly  rare. 

Symptoms. — Recurrent  vomiting,  constipation,  and  pain  may  pre- 
cede the  discovery  of  the  tumor,  which  may  occupy  various  positions 
and  may  be  single  or  multiple.  Mesenteric  tumors  are,  as  a  rule,  freely 
movable  and  may  thus  be  distinguished  from  pancreatic  cysts,  retroperi- 
toneal tumors,  and  tumors  of  the  uterus  and  its  appendages.  An  ovarian 
cyst  with  a  long  pedicle  may,  however,  be  very  movable.  Malignant  tumors 
early  contract  adhesions  and  are  usually  fixed.  The  differential  diagnosis 
between  mesenteric  and  omental  tumors  is  often  attended  with  insurmount- 
able difficulties.     It  can  as  a  rule  only  be  made  upon  abdominal  section. 

2.  Malignant  New  Growths. — These  are  primary  and  secondary. 
They  are  of  more  common  occurrence  than  the  benign  forms,  (a)  Most 
PRIMARY  MALIGNANT  GROWTHS  of  the  peritoneum  are  endotheliomata. 
Sarcomata  may  occur  in  rare  instances  as  primary  growths  starting  in 
the  mesentery  and  omentum.  They  may  reach  an  enormous  size,  (b) 
Much  more  common  are  secondary  carcinomata.  The  peritoneum  is 
involved  by  metastasis  from  distant  organs,  or  by  direct  extension  from 
organs  which  it  invests.  The  primary  growth  may  involve  the  mamma, 
pancreas,  stomach,  intestines,  especially  the.  colon,  and  the  rectum,  or 
the  uterus.  In  many  of  the  cases  of  diffuse  carcinomatous  growths  in  the 
peritoneum  there  are  the  signs  of  an  associated  inflammation — carci- 
nomatous peritonitis.  In  this  form  of  peritonitis  the  exudate  is  usually 
encysted.  It  may  consist  of  a  yellowish  serum,  or  a  blood-stained  fluid; 
it  may  be  chylous,  or  chyliform.  It  is  very  rarely  purulent.  Peritoneal 
carcinoma  is  more  common  in  middle  and  advanced  life  than  earlier.  It 
occurs  with  somewhat  greater  frequency  in  women  than  in  men. 

Symptoms. — Pain  may  be  absent  altogether.  When  present  it  is 
less  severe  than  in  other  forms  of  peritonitis.  Vomiting,  constipation 
with  attacks  of  diarrhoea,  hiccough,  and  tympanites  are  common  symp- 
toms. Fluid  exudate  may  be  absent,  scanty,  abundant,  freely  movable, 
or  encysted.  After  the  withdrawal  of  the  fluid,  irregular  and  ill-defined 
tumor  masses  may  be  recognized  upon  palpation,  especially  the  rolled 
omentum  lying  transversely  or  obliquely  across  the  upper  part  of  the 
abdomen,  as  a  firm  sausage-like  growth,  as  in  tuberculous  and  prolifera- 
tive peritonitis.  The  fluid  may  be  hemorrhagic,  and  contain  large  multinu- 
clear  cells,  or  groups  of  cells,  and  the  number  of  cells  showing  mitosis  is 
greater  than  in  simple  or  tuberculous  effusions  (Dock).  The  temperature 
is  usually  normal  or  subnormal.  Fever  is,  however,  sometimes  present. 
The  cachexia  may  be  marked,  and  emaciation  is  progressive. 


1034  MEDICAL  DIAGNOSIS. 

Diagnosis. — Direct. — With  the  evidences  of  the  primary  disease,  or 
the  history  of  the  removal  of  a  carcinomatous  breast  or  uterus,  the  diag- 
nosis may  be  made  without  difficulty.  The  age  of  the  patient,  the  presence 
of  nodular  masses  about  the  navel,  and  enlarged  inguinal  glands  are 
important.    If  no  primary  focus  can  be  found  the  diagnosis  may  be  obscure. 

Differential. — The  clinical  resemblance  to  tuberculous  peritonitis, 
as  regards  the  symptoms,  the  tumor  masses,  and  the  physical  signs,  may 
be  very  close.  As  a  rule,  the  multiple  nodules  of  cancer  are  larger  than 
those  of  tuberculosis.  Cancer  is  an  affection  of  the  later  periods  of  life, 
tuberculosis  of  the  peritoneum  of  its  earlier  periods.  But  to  this  rule 
there  are  many  exceptions.  Inflammation  and  sinus  formation,  with 
discharge  of  pus  from  the  navel,  sometimes  occurs  in  tuberculosis.  In 
the  absence  of  tuberculous  disease  elsewhere  the  diagnosis  becomes  diffi- 
cult, since  the  clinical  phenomena  of  tuberculous  peritonitis  not  only 
closely  resemble  those  of  carcinomatous  peritonitis,  but  both  have  features 
in  common  with  the  chronic  proliferative  form  and  diffuse  hydatids  of 
the  peritoneum.  In  the  last,  the  hydatid  fremitus,  and  booklets  in  the 
aspirated  fluid,  are  of  positive  diagnostic  value. 

vii.  Retroperitoneal  Sarcoma. 

Retroperitoneal  sarcoma  (Lobstein's  cancer)  is  a  rare  affection.  Steel 
finds  that  it  occurs  most  frequently  in  the  first,  fourth,  and  sixth  decades 
of  life.  Males  are  somewhat  more  commonly  affected  than  females.  The 
tumor  may  spring  from  the  lumbar  region,  on  the  right  side  somewhat 
more  frequently  than  the  left,  from  the  posterior  wall  of  the  abdomen 
near  the  attachment  of  the  mesentery,  or,  less  frequently,  from  the  pelvis. 
The  growths  may  arise  from  the  retroperitoneal  lymph-glands,  the  con- 
nective tissue  around  the  vessels,  or  from  the  remains  of  the  Wolffian 
body.  They  are  often  lobulated  and  are  very  prone  to  degeneration,  with 
hemorrhage  and  the  formation  of  pseudocysts. 

Symptoms. — Vague  digestive  derangements  and  dragging  abdominal 
pain  are  followed  by  pressure  symptoms,  such  as  neuralgic  pains  in  the 
lumbar  region,  abdomen,  legs,  and  genitalia,  and  then  oedema  of  the  lower 
extremities.  There  may  be  partial  occlusion  of  the  intestine.  In  a  case  of 
sarcoma  of  the  retroperitoneal  lymphatic  glands,  recently  under  my  observa- 
tion, none  of  these  symptoms  was  present.  There  are  the  signs  of  a  deep- 
seated  tumor,  situated  centrally  or  to  the  right  or  left  of  the  median  line, 
sometimes  moving  slightly  with  respiration,  more  commonly  fixed,  usually 
solid  but  sometimes  cystic — pseudocysts.  When  the  tumor  is  situated 
laterally,  it  is  obliquely  crossed  by  the  colon,  which  it  pushes  forward  as  it 
increases  in  size.     The  health  is  rapidly  impaired,  and  cachexia  develops. 

Diagnosis. — The  diagnosis  rests  upon  the  presence  of  the  above 
phenomena  in  association  with  a  rapidly  growing  central  or  lateral  tumor 
about  the  level  of  the  umbihcus.  The  differential  diagnosis  between 
retroperitoneal  sarcoma  and  tumors  arising  from  the  kidneys  and  sup- 
rarenal capsules  cannot  always  be  made. 


CATARRH.  1035 


X.       > 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

I.    DISEASES  OF  THE  NOSE, 
i.  Acute  Nasal  Catarrh. 

Coryza;   Acute  Rhinitis;    Cold,  or  Cold  in  the  Head. 

Definition. — Acute  catarrhal  inflammation  of  the  mucous  membrane 
of  the  nasal  cavities. 

Etiology. — Acute  nasal  catarrh  is  very  common.  It  is  in  most  instances 
an  independent  affection,  but  it  occurs  also  in  the  acute  infectious  diseases. 
It  often  follows  exposure  to  cold  or  damp,  especially  when  such  exposure 
is  partial,  as  in  wetting  the  feet,  or  sitting  upon  damp  ground.  It  frequently 
prevails  extensively  in  cold,  damp,  and  changeable  weather.  Such  local 
epidemics  are  to  be  distinguished  from  true  influenza  or  grippe,  to  which 
they  bear  a  superficial  resemblance.  House  epidemics  of  coryza  occa- 
sionally arise  under  circumstances  that  point  to  the  contagiousness  of  the 
affection.  Children  are  especially  prone  to  it.  It  occurs  in  infants  in  con- 
sequence of  gastric  or  intestinal  irritation,  indigestion,  or  the  presence  of 
intestinal  worms,  and  is  occasionally  the  result  of  injuries  inflicted  by 
foreign  bodies — buttons,  grains  of  corn,  pebbles,  peas,  cherry-pits,  and 
similar  objects — introduced  into  the  anterior  nasal  chambers.  It  results 
from  the  action  of  mechanical  or  chemical  irritants  upon  the  nasal  mucous 
membrane.  Among  these  are  dust,  smoke,  ipecacuanha,  and  the  fumes  of 
ammonia,  bromine,  and  iodine.  Annoying  coryza  often  follows  the  internal 
administration  of  iodine. 

Coryza  as  a  manifestation  of  acute  constitutional  infection  is  an  early 
and  prominent  symptom  of  measles,  influenza,  and  pertussis.  It  is  some- 
times associated  with  the  ophthalmia  of  the  new-born  as  the  result  of 
gonorrhoeal  infection  incurred  during  parturition,  and  occurs  as  an  early 
manifestation  of  congenital  syphilis. 

Symptoms. — The  attack  begins  suddenly,  with  chilliness  or  shivering, 
a  decided  feeling  of  malaise,  headache,  and  repeated  sneezing.  There  is 
feverishness,  with  slight  quickening  of  the  pulse,  a  dry  skin,  and  muscular 
pains.  The  nose  at  first  feels  dry  and  stuffy  and  mouth-breathing  is  neces- 
sary. The  sense  of  smell  is  lost,  that  of  taste  greatly  impaired;  the  voice 
acquires  a  peculiar  nasal  twang,  and  nursing  infants,  being  unable  to  breathe 
through  the  nose,  are  suckled  with  difficulty.  The  catarrhal  inflammation 
tends  to  involve  the  contiguous  mucous  tracts.  In  the  course  of  a  few 
hours  from  the  beginning  of  the  attack  there  may  be  a  flow  of  thin,  clear, 
irritating  mucus,  which  excoriates  the  edges  of  the  nostrils  and  the  upper 
lip  and  renders  the  use  of  the  handkerchief  painful.  Herpes  labialis  is 
common.  About  the  second  or  third  day  the  secretion  becomes  muco- 
purulent, opaque,  thick,  tenacious,   and  abundant,  and  tends  to  accumu- 


1036  MEDICAL  DIAGNOSIS. 

late  in  the  nasal  cavities.  The  swelling  of  the  mucous  membrane  subsides^ 
nose-breathing  is  re-established,  and  recovery  takes  place  within  a  week 
or  ten  days.  Repeated  attacks  of  the  acute  affection  tend  to  produce  the 
chronic  form  of  the  disease.  Most  of  the  cases  are  subacute,  with  symptoms 
of  moderate  intensity,  little  or  no  constitutional  disturbance,  and  run 
their  course  in  two  or  three  days. 

Diagnosis. — There  is  no  difficulty  in  the  diagnosis  of  simple  acute 
nasal  catarrh.  Healthy  new-born  infants  are  not  likely  to  suffer  from 
snuffles.  This  affection,  when  associated  with  ophthalmia,  is  due  to  the 
same  specific  infection.  When  due  to  syphilis  it  is  associated  with  charac- 
teristic lesions.  Acute  nasal  catarrh  in  children,  due  to  the  lodgement  of 
foreign  bodies,  is  prolonged,  and  the  discharge,  after  a  time,  is  frequently 
admixed  with  blood.  Furthermore,  it  is  almost  always  one-sided.  In  such 
cases  a  careful  examination  of  the  nasal  chambers  must  be  made.  The 
progress  of  a  case  of  measles  or  influenza  will  speedily  dissipate  any  uncer- 
tainty as  to  the  nature  of  the  acute  catarrh  with  which  each  of  these  diseases: 
begins.    The  coryza  of  iodism  ceases  upon  the  withdrawal  of  the  drug. 

ii.  Chronic  Nasal  Catarrh. 

Definition. — Chronic  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  nasal  cavities.  The  cases  may  be  arranged  in  three  groups — 
rhinitis  simplex,  rhinitis  hypertrophica,  and  rhinitis  atrophica. 

Etiology. — Repeated  attacks  of  acute  nasal  catarrh  may  end  in  the 
chronic  form  of  the  disease.  Habitual  exposure  to  cold  and  draughts,  a 
changeable  and  humid  atmosphere,  and  the  constant  inhalation  of  dust 
are  among  the  causes  of  chronic  rhinitis.  Insufficient  food,  inadequate 
clothing,  improper  ventilation,  want  of  sunlight  and  fresh  air,  and  other 
unhygienic  conditions  are  predisposing  influences.  Chronic  nasal  catarrh 
is  frequently  a  manifestation  of  local  syphilitic  or  tuberculous  processes. 
The  nasal  catarrh  of  early  fife  tends  to  assume  the  atrophic  form — a  fact 
which  emphasizes  the  importance  of  the  prompt  and  efficient  treatment 
of  every  case  of  rhinitis.  Congenital  asymmetry  of  the  nasal  fossae,  with 
marked  deflection  of  the  septum,  hypertrophy  of  the  adenoid  tissue  in 
the  vault  of  the  pharynx,  traumatism,  foreign  bodies,  and  nasal  polypi 
are  local  causes  of  chronic  nasal  catarrh. 

Simple  Chronic  Nasal  Catarrh  (Rhinitis  Simplex.) — This  term  is 
used  to  designate  the  transitional  condition  between  prolonged  or  neglected 
acute  catarrh  and  that  in  which  hypertrophic  or  atrophic  lesions  are  pres- 
ent. The  mucous  membrane  is  irritable  and  there  is  a  constant  sensation 
of  discomfort  in  the  nose.  Catarrhal  symptoms  follow  trifling  exposure. 
The  erectile  tissue  is  relaxed  and  is  readily  distended  with  blood,  so  that 
one  or  both  nostrils  are  frequently  occluded.  The  secretion  is  increased;  it 
is  variable  in  consistency,  being  sometimes  thin  and  watery,  sometimes 
thick  and  tenacious.  Upon  inspection  the  mucous  lining  of  the  nasal 
chambers  is  seen  to  be  red,  watery,  and  irregularly  swollen. 

Chronic  Hypertrophic  Nasal  Catarrh  {Rhinitis  Hypertrophica). — 
Obstructed  nasal  respiration,  constant,  often  abundant,  discharge  of  mucus 
or  mucopus,  frequent  sneezing,  nasal  cough,  hawking,  and  expectoration 


CATARRH.  1037 

of  tenacious  mucus,  dryness  of  the  throat,  habitual  mouth-breathing, 
especially  at  night,  and  disturbed  sleep  are  symptoms.  The  voice  has  a 
peculiar  nasal  quality,  and  the  hearing  is  very  frequently  impaired.  In 
infants  the  inability  to  take  nourishment  without  frequent  interruption 
for  respiration  leads  to  malnutrition,  and  the  nasal  obstruction  may  cause 
attacks  of  suffocative  spasm.  In  older  children  habitual  mouth-breathing 
begets  a  peculiar,  dull,  facial  expression,  mental  hebetude,  and  retardation 
of  the  development  of  the  thorax,  with  characteristic  deformities.  The 
mucous  membrane  of  the  nasal  chambers  is  congested  throughout,  and  its 
epithelial  and  subepithelial  tissues  are  hypertrophied.  The  characteristic 
lesion  consists  in  permanent  enlargement  of  the  turbinate  bodies.  There 
is  marked  increase  in  the  connective  tissue  with  cell  infiltration,  dilatation 
of  the  sinuses  of  the  erectile  tissue,  and  loss  of  contractility  in  their  walls. 
In  a  large  proportion  of  the  cases  hypertrophy  of  the  adenoid  tissue  in 
the  nasopharynx  and  catarrhal  or  follicular  pharyngitis  occur — naso- 
pharyngeal catarrh. 

Chronic  Atrophic  or  Dry  Nasal  Catarrh  {Rhinitis  Atrophica, 
Rhinitis  Fcetidus  Atrophicus,  Ozcena). — A  chronic  affection  of  the  nose, 
constituting  the  terminal  stage  of  neglected  cases  of  rhinitis  simplex  and 
rhinitis  hypertrophica.  It  is  characterized  by  atrophy  of  the  mucous 
membrane,  with  shrinkage  of  the  turbinated  bodies  and  diminution  of  the 
nasal  secretion,  which  becomes  mucopurulent  or  purulent  and  undergoes 
inspissation,  with  the  formation  of  adherent  and  frequently  offensive 
crusts.  Upon  inspection  grayish  crusts  are  seen,  the  removal  of  which 
exposes  a  smooth,  pale,  or  a  slightly  excoriated,  mucous  surface.  Actual 
ulceration  is  rare.  The  turbinate  bodies  are  greatly  reduced  in  size,  their 
sinuses  obliterated,  their  connective  tissue  contracted.  The  entire  lining 
membrane  of  the  nostrils  is  atrophied.  The  mucous  membrane  of  the 
pharynx  is  often  dry  and  glazed.  The  sense  of  smell  is  lost.  Ozsena  is 
present  in  a  large  proportion  of  the  cases,  but  not  in  all.  Odors  having 
the  same  intensity  and  foulness  are  occasionally  encountered  in  other 
affections  of  the  nose  attended  with  ulceration,  as  syphilis,  the  traumatism 
produced  by  foreign  bodies,  and  caries  and  necrosis  due  to  other  causes. 
Atrophic  rhinitis  is  more  common  in  females  than  in  males.  In  confirmed 
cases  the  outlook  as  regards  cure  is  hopeless;  as  regards  relief  from  the 
formation  and  retention  of  crusts  and  from  the  odor,  much  may  be  accom- 
plished so  long  as  a  judicious  treatment  is  persistently  followed  out. 

iii.  Autumnal  Catarrh. 

Hay  or  Rose  Cold;   Hay  Asthma;   Hay  Fever;   Summer  Catarrh;   Catarrhus 

^stivus;    Periodic  Coryza. 

Definition. — An  affection  of  the  upper  air-passages,  characterized 
by  irritability  of  the  mucous  membrane,  with  catarrhal  and  asthmatic 
manifestations,  by  the  abruptness  of  the  onset  of  the  attack,  which  recurs 
annually  at  or  near  a  fixed  date  in  the  spring,  summer,  or  early  autumn, 
and  by  its  immediate  cessation  upon  the  patient's  reaching  certain  localities 
or  upon  the  occurrence  of  frost. 


1038  MEDICAL  DIAGNOSIS. 

Etiology. — The  exciting  causes  are  certain  irritants  in  the  atmosphere 
which  act  upon  a  supersensitive  nasal  mucous  membrane  in  individuals 
of  neurotic  temperament.  Among  the  most  important  of  these  is  the 
pollen  of  various  plants.  This  is  not,  as  was  for  a  long  time  supposed, 
the  sole  cause  of  the  attack.  Inorganic  dust  of  various  kinds,  the  odors 
of  certain  flowers  and  other  substances,  emanations  from  animals,  as  the 
horse,  and  from  feathers  are  capable  of  intensifying  the  symptoms  during 
the  attack  and  also  of  inducing  similar  symptoms  at  other  seasons  of  the 
year.  The  intense  glare  of  the  summer  sun,  excessive  heat,  overexertion, 
and  indigestion  commonly  aggravate  the  attack.  That  these  agencies 
are,  as  has  been  affirmed,  exciting  causes  of  the  disease  is  questionable. 
Hay  fever  and  bronchial  asthma  are  not  only  closel}'  associated  clinically, 
but  they  also  resemble  each  other  in  respect  of  the  causes  b}^  which  the 
attack  may  be  excited.  Local  nasal  trouble  plays  an  important  part  in 
the  etiology  of  the  disease.  The  resemblance  to  asthma  in  this  respect 
is  striking.  The  causal  relation  between  nasal  disease  and  bronchial  asthma 
is  fully  recognized.  A  similar  relation  between  disease  of  the  nasal  mucous 
membrane  and  hay  fever  has  also  been  demonstrated.  The  lesions  are 
those  of  hypertrophic  rhinitis.  There  is  in  manj^  cases  deflection  of  the 
septum.  Superadded  to  these  is  the  presence  of  areas  of  hyperesthesia 
in  the  nasal  mucosa — hypersesthesia  often  so  exquisite  that  the  touch  of 
a  probe  will  instantly  excite  the  characteristic  train  of  symptoms.  This 
local  sensitiveness  is  an  almost  constant  factor  in  the  etiology  of  the  disease. 
Its  presence  in  persons  who  do  not  suffer  from  autumnal  catarrh  proves, 
however,  that  something  more  is  required;  that  is,  the  neurotic  constitu- 
tion. Males  suffer  more  frequently  than  females.  The  disease  may  develop 
at  any  period  in  life.  More  than  33  per  cent,  of  the  cases  begin  before  the 
age  of  twenty  years.  Dwellers  in  cities  are  especially  liable  to  the  disease, 
but  those  who  live  in  the  country  do  not  enjoy  exemption.  The  affection 
may  show  itself  wherever  the  pecuHar  irritants  which  excite  it  and  persons 
of  neurotic  constitution,  with  hypersesthetic  nasal  mucous  membranes, 
are  found  together.  There  are  certain  localities  in  which  the  disease  does 
not  prevail.  These  regions  are  usually  circumscribed  and  j^ossess  in  com- 
mon the  attribute  of  an  uncultivated  soil.  They  are  mostly  mountainous, 
as  certain  districts  in  the  White  Mountains,  the  Adirondacks,  and  the 
Catskills.  But  elevation  is  not  the  essential  factor.  ReHef  may  be  experi- 
enced in  any  wilderness,  at  certain  sea-shore  places,  on  islands,  or  at  sea. 

The  prominence  of  the  psychical  element  in  many  cases  is  remarkable. 
In  one  case  J.  N.  Mackenzie  induced  the  attack  by  means  of  an  artificial 
rose.  In  a  large  proportion  of  the  cases  recurrence  of  the  attack  takes  place 
year  after  year  on  a  certain  day  of  the  month — a  fact  for  which  no  rational 
explanation  bej^ond  the  hypothesis  of  expectant  attention  has  been  found. 

Symptoms. — The  attack  makes  its  annual  return  at  or  about  the 
same  date.  There  is  sometimes  a  period  of  prodromes  which  consist  of 
lassitude  and  nervous  irritability.  The  onset  is  abrupt.  Itching  of  the 
palate  and  throat  is  a  most  annoying  symptom,  both  common  and  charac- 
teristic. I  have  seen  cases  in  which,  year  after  year,  this  persistent  itching 
constituted  the  chief  local  symptom.  Frequent  uncontrollable  sneezing; 
nasal  obstruction;    free  rhinorrhcea,  usually  thin  and  watery,  sometimes 


EPISTAXIS.  1039 

mucopurulent;  great  irritation  of  the  eyes  with  itching  of  the  Hds  and 
lachrymation;  loss  of  the  sense  of  smell;  impairment  of  that  of  taste,  and 
not  rarely  disturbances  of  hearing,  constitute  the  usual  symptoms.  These 
occur  in  paroxysms  and  are  aggravated  by  changes  of  temperature,  by 
sunlight,  and  the  open  air.  Constitutional  disturbances  consist  of  sub- 
jective sensations  of  heat  and  cold,  great  lassitude,  complete  loss  of  appe- 
tite, and  sleeplessness.  After  a  time  the  catarrh  extends  to  the  bronchi 
and  the  patient  is  annoyed  by  cough;  asthmatic  symptoms  are  common 
and  add  greatly  to  the  distress  of  the  patient.  The  symptoms  vary  in 
localization  and  in  intensity,  and  in  the  same  person  in  succeeding  years. 
The  whole  duration  of  the  attack,  if  not  cut  short  by  change  of  climate, 
is  about  six  weeks.  The  autumnal  cases  usually  cease  abruptly  upon  the 
appearance  of  frost. 

Prognosis. — The  prognosis  is  favorable  as  regards  recovery  from  any 
given  attack  and  as  regards  length  of  life.  The  prognosis  as  regards  the 
recurrence  of  the  attack  is  much  less  hopeful. 

iv.  Epistaxis. 

Nose-bleed. 

Definition. — Bleeding  from  the  nasal  passages. 

Etiology. — Bleeding  from  the  nose  may  be  due  to  local  or  constitu- 
tional causes  or  to  a  combination  of  both.  In  children  its  occurrence  is 
favored  by  the  great  vascularity  of  the  nasal  mucous  membrane,  the  fre- 
quent presence  of  "hemorrhagic  spots,"  and  erosions  of  the  septum  caused 
by  picking  the  nose.  Other  local  causes  are  chronic  rhinitis,  intranasal 
ulceration,  new  growths,  the  presence  of  foreign  bodies,  and  various  kinds 
of  traumatism,  especially  contusions  of  the  face. 

In  fractures  involving  the  bones  of  the  face  and  cranium  blood  may 
escape  from  the  accessory  sinuses  or  from  the  middle  ear  by  way  of  the 
nose,  or  in  hemorrhage  from  the  lungs,  oesophagus,  or  stomach,  some 
part  of  the  blood  may  be  discharged  from  the  nose.  These  blood-losses^ 
not  from,  but  merely  hy  way  of,  the  nose,  do  not  in  a  strict  sense  constitute 
epistaxis — a  term  restricted  by  systematic  writers  to  hemorrhage  having 
its  source  within  the  nasal  passages. 

Among  the  constitutional  causes  are  exposure  to  extreme  coid  or 
undue  heat,  or  to  a  rarefied  atmosphere,  as  in  the  ascent  of  high  mountains 
and  in  balloon  ascensions.  It  frequently  occurs  in  both  sexes  at  the  age 
of  puberty.  It  may  result  from  the  suppression  of  the  menstrual  flow  or 
follow  the  sudden  arrest  of  a  habitual  hemorrhoidal  discharge.  It  is  of 
frequent  occurrence  in  anaemia  in  its  various  forms,  and  in  persons  of 
plethoric  habit.  The  tendency  to  nose-bleed  is  hereditary.  In  haemophilia 
nose-bleed  constitutes  a  common  manifestation  of  the  hemorrhagic  diath- 
esis. It  is  also  common  in  scurvy  and  purpura,  and  occurs  in  erysipelas, 
the  malarial  and  the  malignant  fevers,  and  in  nasal  diphtheria.  Slight 
nose-bleed  occurs  in  the  first  week  of  tj^phoid  fever  with  such  frequency 
as  to  acquire  diagnostic  importance.  Nose-bleed  not  infrequently  results 
from  the  congestion  and  shock  of  the  violent  convulsive  cough  of  pertussis. 


1040  MEDICAL  DIAGNOSIS. 

It  is  by  no  means  a  rare  symptom  in  advanced  disease  of  the  kidneys  and 
in  various  affections  of  the  liver.  In  the  venous  engorgement  of  cardiac 
and  pulmonary  diseases,  even  with  marked  cyanosis,  nose-bleed  is  uncom- 
mon.   Finally,  it  may  result  from  violent  mental  emotion. 

When  epistaxis  is  due  to  general  causes,  the  blood  escapes  by  capillary 
oozing  from  one,  rarely  two  or  three,  limited  areas  of  the  respiratory  por- 
tion of  the  cartilaginous  septum,  and  in  most  instances  it  proceeds  from 
one  side  only.  In  a  very  small  proportion  of  the  cases  it  comes  from  the 
turbinate  bodies  or  from  the  floor  of  the  nostril.  The  mucous  membrane 
is  deeply  congested,  of  a  violaceous-red  color,  and  shows  minute  spots 
of  ecchymosis. 

Symptoms. — Prodromes  sometimes  occur.  They  consist  of  giddiness, 
fulness  in  the  head,  and  a  sensation  of  dryness,  tickling,  or  obstruction  in 
the  nostrils,  which  impels  the  patient  to  more  or  less  forcibly  blow  the  nose. 
More  frequently  these  symptoms  are  absent,  the  bleeding  occurring  sud- 
denly and  without  warning.  The  blood  may  flow  in  drops  or  for  a  time 
in  a  continuous  stream.  Ordinary,  slight  nose-bleed  generally  ceases  in 
a  short  time  and  is  without  immediate  clinical  importance  whatever  may 
be  its  remote  significance.  The  graver  bleedings  may  be  protracted  for 
hours  or  days,  and  while  a  fatal  case  is  of  rare  occurrence,  serious  conse- 
quences are  likely  to  follow  profuse  hemorrhage.  The  arrest  takes  place 
by  clotting  at  the  point  of  oozing.  It  is  important  to  examine  the  pharynx, 
as  the  clot  in  the  nostril  may  lead  to  the  escape  of  blood  by  way  of  the 
posterior  nares  and  its  being  swallowed.  The  vomiting  of  blood  thus 
swallowed  may  be  mistaken  for  hsematemesis;  its  expulsion  by  cough,  for 
haemoptysis,  but  not  if  due  care  be  observed  in  the  investigation  of  the  case. 

II.  DISEASES  OF  THE  LARYNX, 
i.  Acute  Catarrhal  Laryngitis. 

Definition. — Catarrhal  inflammation  of  the  mucous  membrane  of  the 
larynx. 

Etiology. — ''Taking  cold,"  exposure  to  a  cold,  damp  atmosphere, 
overuse  of  the  voice  in  speaking,  shouting,  or  singing,  especially  under 
unfavorable  atmospheric  conditions,  as  in  crowded  and  badly  ventilated 
halls  or  in  the  open  air,  are  common  causes  of  acute  laryngitis.  It  may 
follow  the  inhalation  of  air  charged  with  smoke  or  irritating  gases  or  vapors. 
Less  frequently  it  is  due  to  the  lodgement  of  foreign  bodies,  the  action  of 
very  hot  liquids  or  corrosive  poisons,  or  external  violence.  It  occurs  as  a 
local  manifestation  of  measles,  influenza,  and  variola,  and  as  a  complica- 
tion in  other  acute  infectious  diseases,  as  scarlet  fever,  enteric  fever,  and 
erysipelas.  Catarrhal  laryngitis  is  frequently  associated  with  catarrh  of 
the  nasopharynx  and  bronchi.  The  predisposition  to  largynitis  varies 
greatly  in  different  families  and  individuals. 

Symptoms. — There  is  a  sensation  of  dryness  and  tickling  in  the  throat; 
the  inspiration  of  cold  air  and  talking  cause  pain.  Cough  is  a  prominent 
symptom.  It  is  tickling  and  hoarse,  or  "laryngeal"  in  character;  at  first 
dry,  later  attended  with  scanty  mucopurulent  expectoration,   which  in 


LARYNGITIS.  1041 

severe  cases  may  be  slightly  streaked  with  blood.  The  voice,  at  first  husky, 
grows  rapidly  hoarse,  and  at  length  may  be  completely  lost.  Dyspnoea  is 
not  common  in  adults,  but  it  is  a  very  frequent  symptom  in  early  life, 
usually  occurring  in  paroxysms  and  at  night.  In  severe  cases  cough  is 
very  harassing,  deglutition  is  painful,  and  there  may  be  urgent  dyspnoea. 
Laryngoscopic  examination  shows  that  the  mucosa  is  reddened  and  swollen, 
especially  between  the  arytenoid  cartilages  and  in  the  aryepiglottic  folds. 
When  the  inflammation  is  intense  the  vocal  cords  present  superficial 
erosions,  and  minute  hemorrhages  are  seen  at  various  points  of  the  laryngeal 
mucous  membrane.  A  scanty  exudation  of  altered  mucus  is  irregularly 
scattered  upon  the  surface.  In  phonation  there  may  often  be  observed 
imperfect  approximation  of  the  vocal  cords,  due  to  implication  of  the 
intrinsic  muscles  of  the  larynx  in  the  inflammatory  process. 

The  constitutional  symptoms  vary;  they  are  not  usually  severe. 
Moderate  fever,  with  headache  and  loss  of  appetite,  may  occur.  The  attack 
lasts  from  a  few  days  to  a  week  or  more  and  terminates  in  recovery.  Neg- 
lected cases  may  assume  the  chronic  form. 

ii.  Acute  Laryngitis  of  Children. 

Spasmodic  Croup;  False  Croup. 

The  special  feature  consists  in  paroxysmal  exacerbations,  suffocative  in 
character  and  occurring  at  night.  These  are  due  to  the  relative  smallness  of 
the  larynx  in  infancy,  the  narrowness  of  the  rima,  the  looseness  and  vascu- 
larity of  the  mucous  membrane,  and  the  greater  reflex  excitability  of  the  ner- 
vous system.  The  disease  is  a  common  one,  occurring  with  frequency  during 
the  first  dentition,  and  particularly  during  the  second  and  third  years. 

Etiology. — Exposure  to  cold  and  damp,  chilling  of  the  surface,  violent 
screaming,  the  inhalation  of  steam,  smoke,  and  dust,  and  indigestion  are 
causes  of  acute  laryngitis  in  infants.  It  occurs  more  frequently  in  the 
cold,  damp  months  of  winter  and  spring  than  in  the  summer  and  autumn. 
It  is  somewhat  more  common  in  male  than  in  female  children,  and  certain 
families  and  individuals  manifest  an  especial  liability. 

The  attack  may  come  on  abruptly  or  be  preceded  by  fretfulness,  loss 
of  appetite,  and  trifling  elevation  of  temperature,  huskiness  or  complete 
aphonia,  and  a  harsh,  croupy  cough.  Inspiration  is  prolonged  and  stridu- 
lous;  there  is  recession  of  the  suprasternal  and  supraclavicular  spaces; 
the  pulse  is  frequent  and  small,  and  the  lips  and  finger-tips  are  cyanotic. 
There  is  great  restlessness,  and  the  expression  indicates  anxiety  and  distress. 
The  attack  presently  passes  off,  either  spontaneously  or  after  the  adminis- 
tration of  simple  remedies.  The  child  presently  falls  asleep  again  and  rests 
until  morning;  or  the  attack  may  be  repeated  once  or  several  times  in  the 
course  of  the  night.  On  the  following  day  he  scarcely  seems  ill  and  plays 
about  as  usual,  but  toward  evening  the  croupy  cough  reappears  and  during 
the  night  the  attacks  of  croup  occur  as  before,  to  be  again  repeated,  as  a 
rule,  upon  the  third  and  rarely  upon  the  fourth  night,  but  with  diminishing 
severity.  After  that  there  remains  simply  a  trifling  bronchial  catarrh, 
which  in  the  course  of  a  few  days  disappears. 
66 


1042  MEDICAL  DIAGNOSIS. 

Diagnosis. — Direct. — Acute  laryngitis  of  the  adult  rarely  presents 
difficulty  in  diagnosis.  The  severer  cases  suggest  oedema  of  the  larynx — 
acute  laryngeal  oedema — while  those  attended  by  complete  loss  of  voice 
may  be  mistaken  for  hysterical  aphonia  or  paralysis  of  the  vocal  cords  due 
to  other  causes.     These  questions  are  at  once  settled  by  the  laryngoscope. 

Differential. — In  children  the  diagnosis  of  acute  laryngitis  is,  in 
certain  cases,  attended  with  serious  difficulty.  The  condition  is  to  be 
distinguished  from  laryngismus  stridulus  by  the  presence  of  fever,  the 
catarrhal  symptoms,  the  mode  of  onset,  the  character  of  the  paroxysms, 
their  nocturnal  occurrence,  the  hoarseness  and  loss  of  voice,  the  absence 
of  the  prolonged  crowing  inspiration  which  terminates  the  attack  of  laryn- 
gismus, and  the  course  and  duration  of  the  disease. 

The  diagnosis  between  spasmodic  croup  and  laryngeal  diphtheria — 
membranous  croup — may  be  for  a  time  impossible.  The  principal  points 
in  favor  of  spasmodic  croup  are  the  milder  character  of  the  constitutional 
symptoms  which  precede  the  signs  of  laryngeal  obstruction,  the  paroxys- 
mal nature  of  the  obstruction,  and  the  complete  relief  between  the 
attacks,  the  progressive  amelioration  of  the  symptoms  after  the  second 
night,  the  absence  of  exudation  upon  the  tonsils  and  adjacent  parts,  and 
the  absence  of  enlargement  of  the  cervical  nodes. 

Prognosis. — The  outlook  is  favorable.  The  most  alarming  symptoms, 
as  a  rule,  promptly  subside  after  the  emesis  caused  by  ipecac,  or  after  a 
warm  bath  and  the  proper  administration  of  simple  sedative  remedies. 

iii.  Subacute  Laryngitis. 

By  far  the  larger  number  of  cases  of  catarrhal  laryngitis  are  of  the 
mildest  type.  The  patients  are  not  ill;  the  only  symptoms  are  a  slight 
tickling  cough,  with  hoarseness  or  aphonia. 

The  condition  acquires  importance  from  its  great  relative  frequency; 
from  the  fact  that,  being  accompanied  by  trifling  subjective  symptoms, 
it  is  likely  to  be  neglected;  and,  finally,  because  in  many  cases  prolonged, 
habitual  exposure  to  the  original  cause,  or  use  of  the  voice  when  the  larynx 
is  slightly  congested  or  inflamed,  convert  a  passing  local  indisposition 
into  a  serious  disease.  In  fact  the  larger  proportion  of  cases  of  chronic 
laryngitis  arise  in  this  way. 

iv.  Chronic  Laryngitis. 

Etiology. — This  form  may  be  the  sequel  of  an  acute  attack;  more 
commonly  it  is  the  result  of  the  persistent  action  of  causes  which  give 
rise  to  subacute  catarrh.  Improper  use  of  the  voice  and  its  habitual  over- 
use in  singing,  public  speaking,  or  shouting  in  the  open  air  are  very  common 
causes  of  chronic  laryngitis.  It  is  sometimes  associated  with  chronic 
pharyngitis  and  especially  with  that  form  which  is  caused  by  habitual 
overindulgence  in  alcohol  and  tobacco,  with  certain  cases  of  marked 
obstruction  to  nasal  respiration,  and  cases  of  elongation  of  the  uvula. 
Chronic  laryngitis  is  more  common  in  males  than  in  females  and  is  especially 
a  disease  of  middle  life. 


LARYNGITIS.  1043 

Symptoms. — There  is  a  tickling  sensation  in  the  throat  accompanied 
by  a  desire  to  obtain  relief  by  coughing.  As  a  rule  pain  is  not  present  except 
after  prolonged  use  of  the  voice  or  coughing.  Many  patients  complain 
of  a  disagreeable  feeling  of  dryness.  The  voice  is  rough  and  hoarse  and 
at  times  almost  lost.  The  cough  is  ringing,  loud,  deep;  expectoration  is 
as  a  rule  scanty  and  tenacious,  but  occasionally  abundant  and  sometimes 
fetid.  Upon  laryngoscopic  examination  the  mucous  membrane  is  found 
irregularly  thickened  and  discolored,  but  the  redness  is  less  intense  than 
in  the  acute  form.  The  vocal  cords  are  of  a  grayish-red  color,  and  in  debili- 
tated and  cachectic  persons  there  may  be  seen  minute  superficial  erosions. 
The  epiglottis  is  in  many  cases  irregularly  thickened.  The  general  health 
is  often  impaired. 

Diagnosis. — The  local  sensations,  chronic  alteration  of  the  voice, 
and  peculiar  cough  suggest  the  true  nature  of  the  affection,  but  a  positive 
diagnosis  can  be  made  only  after  careful  laryngoscopic  examination.  In 
everj^  case  of  chronic  laryngitis  the  history  of  the  patient  in  all  particulars 
must  be  carefully  investigated  in  order  to  determine  whether  or  not  the 
local  affection  be  primary,  or  secondary  to  some  other  disease,  as  alcoholism, 
tuberculosis  or  syphilis. 

V.  GEdematous  Laryngitis. 

Acute  Laryngeal  (Edeina;   CEdema  of  the  Glottis. 

Etiology. — CEdema  of  the  mucous  and  submucous  tissues  of  the 
larynx  occasionally  occurs  as  a  serious  and  frequently  fatal  complication 
in  the  course  of  acute  catarrhal  laryngitis,  whether  due  to  cold  or  to  internal 
or  external  traumatism;  in  chronic  disease  of  the  larynx,  as  tuberculosis 
and  syphilis;  in  connection  with  perichondritis  of  the  larynx;  as  a  compli- 
cation of  severe  inflammatory  affections  of  neighboring  structures,  as  the 
tonsils,  parotid  glands,  or  the  cellular  tissue  of  the  neck;  in  the  course  of 
acute  infectious  diseases,  as  scarlatina,  typhoid  fever,  variola,  and  ery- 
sipelas; and,  finally,  as  an  extension  of  the  general  oedema  in  acute  or 
chronic  nephritis. 

Symptoms. — Rapidly  progressive  dyspnoea  is  the  chief  symptom. 
It  is  at  first  inspiratory;  later  also  expiratory.  Respiration  is  accompanied 
by  loud  stridor.  The  voice  becomes  husky  and  soon  fails.  Signs  of  impend- 
ing suffocation  supervene,  and  unless  relief  is  afforded  death  takes  place 
in  the  course  of  a  few  hours.  If  a  laryngoscopic  examination  prove  success- 
ful, the  epiglottic  and  aryepiglottic  folds  are  seen  to  be  greatly  swollen, 
the  latter  almost  meeting  laterally;  the  false  cords  are  also  oedematous. 
These  changes  can  be  felt  with  the  finger,  and  upon  depressing  the  tongue 
the  swollen  rim  of  the  epiglottis  may  sometimes  be  brought  into  view. 

The  diagnosis  is  unattended  with  difficulty  and  depends  upon  physical 
exploration. 


1044  MEDICAL  DIAGNOSIS. 

vi.  Pseudomembranous  Laryngitis. 

True  Croup;    Membranous  Croup;    Fibrinous  Laryngitis. 

Definition. — Inflammation  of  the  mucous  membrane  of  the  larynx. 
resulting  in  the  formation  of  a  pseudomembrane  or  pellicle  composed  of 
a  network  of  fibrin,  embracing  in  its  meshes  leucocytes  and  necrotic 
epitheHum. 

Etiology. — Any  agent  capable  of  destroying  the  protecting  epithelium 
of  the  laryngeal  mucous  membrane,  thus  permitting  the  escape  of  serum 
and  white  blood-corpuscles,  may  give  rise  to  the  formation  of  a  pseudo- 
membrane.  Hence,  this  form  of  laryngitis  may  result,  (a)  from  trauma- 
tism, as  the  inhalation  of  steam,  hot  smoke,  or  irritating  and  corrosive 
chemicals  in  the  form  of  vapor  or  solution;  (b)  from  the  action  of  certain 
pathogenic  micro-organisms. 

Pseudomembranous  laryngitis  occurs  at  all  seasons  of  the  year.  It 
especially  affects  j'oung  children  between  the  ages  of  two  and  six.  Cases 
in  children  under  two  and  over  seven  3'ears  of  age  are  much  less  common. 
Exceptionally  the  disease  occurs  at  a  later  period  of  life.  Boj^s  are  some- 
what more  liable  than  girls.  This  affection  frequently  occurs  as  a  compli- 
cation in  scarlet  fever  and  measles.  In  by  far  the  greater  number  of  cases 
it  is  a  manifestation  of  diphtheria. 

Symptoms. — The  symptoms  usually  develop  in  the  course  of  an  attack 
of  faucial  diphtheria  or  of  one  of  the  exanthemata.  Less  frequently  they 
arise  as  the  manifestations  of  a  primary  laryngeal  diphtheria.  They  point 
to  progressive  impairment  of  the  functions  of  the  larj^nx,  wdth  increasing 
obstruction  to  respiration  and  its  consequences,  and  consist  of  hoarseness, 
aphonia,  explosive  and  croupy  cough,  stridulous  respiration,  dj'spncea, 
recessions,  restlessness,  cyanosis,  and  stupor. 

Diagnosis. — Acute  progressive  laryngeal  stenosis  in  a  young  child  is 
nearly  always  due  to  pseudomembranous  laryngitis.  If  traces  of  the  exu- 
date can  be  discovered  upon  inspection  of  the  throat,  or  if.  upon  phj'sical 
examination,  there  can  be  detected  coarse  or  whistling  tracheal  ralesT  or 
finally,  if  shreds  of  membrane  are  expectorated  after  paroxysms  of  explosive 
cough,  the  diagnosis  becomes  sure.  It  is  equally  so.  in  the  absence  of 
such  confirmatory  evidence,  if  the  case  occur  in  a  locality  already  the  scene 
of  an  epidemic  of  diphtheria.  The  fact  that,  even  in  pseudomembranous 
laryngitis,  the  signs  of  obstruction  are  at  first  paroxysmal  and  followed 
by  intervals  of  partial  relief  must  alwaj's  be  borne  in  mind.  For  this  reason 
the  earl}^  differential  diagnosis  betw^een  this  disease  and  spasmodic  laryn- 
gitis is  not,  in  all  instances,  possible.  In  the  latter,  however,  the  intervals 
of  relief  are  more  complete  and  prolonged,  the  paroxysm  not  usually  recur- 
ring until  the  succeeding  night;  the  tendency  is  to  progressive  amelioration 
of  the  symptoms  rather  than  j^rogressive  aggravation,  and  the  signs  of 
grave  constitutional  disturbance  do  not  show  themselves. 

Prognosis. — Pseudomembranous  laryngitis  is.  in  the  absence  of  treat- 
ment, an  extremely  fatal  disease.  The  diphtheritic  form,  under  the  admin- 
istration of  antitoxin,  frequently  terminates  in  recovery.  It  is  therefore 
imperatively  necessary  to  at  once  employ  this  remedy. 


LARYNGITIS.  1045 

vii.  Tuberculous  Laryngitis. 

Laryngeal  Phthisis;    Throat  Consumption. 

Definition.— Inflammation  of  the  tissues  of  the  larynx  caused  by- 
local  tuberculosis. 

Etiology. — Tuberculosis  of  the  larynx  may  occur  as  a  primary  disease. 
Much  more  frequently,  however,  it  is  secondary  to  pulmonary  tuberculosis. 
When  the  earliest  symptoms  are  laryngeal,  the  disease  remains  for  a  time 
localized,  but  eventually  the  lungs  become  involved.  Secondary  tubercu- 
lous laryngitis  occurs  in  more  than  25  per  cent,  of  the  pulmonary  cases. 
The  laryngeal  symptoms  are  pronounced  and  the  lesions  extensive  and 
advanced  in  a  much  smaller  percentage.  A  majority  of  the  cases  occur 
in  males — a  fact  attributed  to  their  greater  hability  to  chronic  catarrhal 
laryngitis,  which  acts  as  a  predisposing  cause.  Not  every  case  of  chronic 
laryngitis  in  a  consumptive  individual  is  tuberculous.  The  mechanical  irri- 
tation of  frequent  and  severe  cough  and  the  contact  of  the  sputum  may 
cause  chronic  catarrhal  laryngitis,  which  is  aggravated  by  the  condition 
of  the  patient,  and  which  undoubtedly,  after  a  time,  predisposes  to  infec- 
tion. In  the  tuberculous  cases  the  mucous  membrane  is  of  a  grayish, 
pale  color,  irregularly  mottled  and  congested;  it  is  at  first  swollen  and 
studded  with  miliary  tubercles,  which  by  their  coalescence  form  scattered 
tuberculous  nodules.  These  nodules  undergo  caseation,  as  a  result  of 
which  there  form  more  or  less  extensive  superficial  ulcers,  which  show  a 
tendency  to  spread.  The  floor  of  these  ulcers  is  covered  by  a  grayish 
exudation,  and  they  are  surrounded  by  a  border  of  infiltrated  and  swollen 
tissue.  They  occur  most  frequently  upon  the  arytenoids,  in  the  inter- 
arytenoid  space,  upon  the  true  cords,  and  on  the  epiglottis.  The  destruc- 
tion of  tissue  extends  deeply,  implicating  the  submucosa,  and  in  severe 
cases  the  perichondrium  and  cartilages,  which  undergo  more  or  less 
extensive  necrosis — tuberculous  perichondritis  and  chondritis.  The  ulcers 
occasionally  extend  to  the  back  of  the  tongue,  to  the  pharynx,  to  the  upper 
part  of  the  oesophagus,  and  in  severe  cases  to  the  pillars  of  the  fauces  and 
the  tonsils.  Complete  erosion  of  the  true  cords  not  infrequently  occurs, 
and  the  epiglottis  is  often  destroyed  throughout  the  greater  part  of  its  extent. 

Symptoms. — The  earlier  symptoms  are  those  of  chronic  laryngitis 
due  to  other  causes.  There  is  slight  huskiness,  which  is  at  first  intermittent 
and  disappears  after  resting  the  voice.  It  soon  becomes  continuous,  and 
gives  place  to  a  peculiar  hoarseness,  which  in  the  advanced  stages  of  the 
disease  usually  passes  into  complete  aphonia.  Cough  is  tickling,  paroxys- 
mal, and  unproductive;  it  has  the  peculiar  quality  known  as  laryngeal, 
and  may  be  distinguished  in  the  same  patient  from  the  mere  nervous 
cough  of  bronchial  irritation.  It  is  not  at  first  distressing,  but  in  cases  of 
advanced  ulceration  it  becomes  husky  and  high-pitched,  and  is  attended 
with  pain.  Spontaneous  pain  is  not  very  common.  There  is  often  tender- 
ness upon  external  pressure.  Dsyphagia  is  a  prominent  and  most  distressing 
symptom  in  advanced  cases,  especially  when  the  epiglottis  is  involved, 
the  arytenoids  are  extensively  destroyed,  or  there  is  ulceration  of  the 
pharyngeal    wall.      In  such   cases  the   administration   of  nourishment  is 


1046  MEDICAL  DIAGNOSIS. 

attended  with  difficulty,  the  attempt  to  take  food  of  any  kind  giving  rise 
to  severe  pain,  urgent  paroxj^sms  of  cough,  and  frequentl}^  to  suffocative 
attacks.  The  difficulty  in  swallowing  adds  greatly  to  the  sufferings  of 
the  patient  and  constitutes  the  most  distressing  symptom  of  the  terminal 
stage  of  this  form  of  tuberculosis.  In  the  earlier  stages  the  laryngoscope 
reveals  the  appearances  due  to  chronic  laryngeal  catarrh.  There  is,  how- 
ever, greater  pallor  of  the  mucous  membrane,  together  with  some  thick- 
ening over  the  arytenoids.  Later  the  picture  is  characteristic.  The  vocal 
cords  are  thickened  and  eroded,  and  their  motility  is  impaired;  the  epiglottis 
and  arytenoid  are  infiltrated,  and  at  various  points  superficial  grayish 
ulcers  with  ill-defined  borders  are  seen;  finally,  deep  ulceration,  with 
extensive  loss  of  substance,  occurs. 

Diagnosis. — Direct. — In  the  earlier  stages,  especially  in  the  absence 
of  the  evidences  of  pulmonary  tuberculosis,  the  diagnosis  of  tuberculous 
laryngitis  cannot  always  be  made.  Pallor  of  the  laryngeal  mucous  mem- 
brane, thickening  of  the  arytenoids,  general  failure  of  health  on  the  part 
of  the  patient,  and  absence  of  response  to  local  and  constitutional  treat- 
ment lead  to  the  suspicion  of  tuberculous  disease.  This  suspicion  is  con- 
firmed by  the  appearance  of  the  characteristic  ulceration,  the  evidences 
of  pulmonary  tuberculosis,  or  the  detection  of  tubercle  bacilli  in  the  sputum 
or  the  exudate  scraped  from  the  floor  of  the  laryngeal  ulcer.  In  selected 
cases  the  tuberculin  tests  may  be  made. 

Differential. — The  diagnosis  between  tuberculosis  and  syphilis  of 
the  larynx  is,  in  certain  cases,  attended  with  some  degree  of  difficulty. 
In  this  connection,  the  greater  tendency  of  syphilis  to  invade  the  pharynx, 
the  fact  that  tuberculous  ulceration  of  the  larj^nx  is,  in  general,  progressive 
and  continuously  destructive,  while  syphilitic  ulceration  frequently  shows 
a  disposition  to  heal  at  one  point  while  advancing  at  others,  and,  finally, 
the  history  of  specific  inflammatory  or  ulcerative  lesions  in  other  parts  of 
the  body  in  syphilis  should  receive  due  consideration. 

Prognosis. — The  course  of  tuberculous  larj-ngitis  is,  as  a  rule,  in  the 
highest  degree  unfavorable.  While,  in  the  Hterature  of  the  subject,  cases 
of  marked  ameHoration,  or  even  of  cure,  especially  in  the  primary  form, 
are  reported,  the  disease  is  so  constant!}^  fatal  that  the  instances  in  which 
more  than  a  temporary  arrest  occurs  must  be  regarded  as  exceptional. 

viii.  Syphilitic  Laryngitis. 

Definition. — Inflammation  of  the  larynx,  occurring  as  a  manifestation 
of  s^^philis,  either  hereditary  or  acquired. 

Etiology. — The  larynx  is  very  frequently  involved  in  syphiHtic  inflam- 
mation. 

The  catarrhal  laryngitis  of  secondary  syphilis  presents  nothing  char- 
acteristic. Symmetrical  superficial  ulceration  of  the  true  and  false  cords 
occurs.  Mucous  patches,  when  present  elsewhere,  confirm  the  diagnosis, 
but  they  are  not  common  in  the  larynx. 

Much  more  frequent  and  important  are  tertiary  lesions.  Gummata, 
multiple  or  single,  develop  in  the  submucous  tissues.  They  may  undergo 
resolution,  or,   as  is  much  more  frequently  the  case,  they  break  down, 


LARYNGISMUS  STRIDULUS.  1047 

giving  rise  to  extensive  and  deep  ulceration,  which  ma}^  involve  the  carti- 
lages. Sometimes  the  disease  begins  as  a  perichondritis  attended  with 
suppuration,  and  rapidly  causing  necrosis  of  the  cartilages.  In  such  cases 
external  fistulae  maj'-  be  formed.  In  the  course  of  the  ulceration,  erosion 
of  the  walls  of  arterial  branches  may  give  rise  to  free  hemorrhage,  or  an 
acute  oedema  may  prove  rapidly  fatal.  The  gummata  develop  most  com- 
monly at  the  base  of  the  epiglottis  or  in  the  ventricles.  They  may  attain 
the  size  of  a  nut  and  occasion  serious  stenosis  of  the  larynx.  The  sclerosis 
which  attends  their  resorption,  or  the  cicatrices  resulting  from  the  healing 
of  the  ulcers,  are  often  the  occasion  of  marked  deformity  of  the  larynx,  with 
progressive  stenosis. 

The  gummatous  infiltration  of  inherited  syphilis  in  either  the  early 
or  the  later  form  leads  to  ulceration,  which  tends  to  extend  deeply  and 
involve  the  cartilages.  The  healing  of  such  ulcers  is  also  likely  to  be 
followed  by  cicatricial  stenosis  and  deformity. 

Symptoms. — Secondary  syphilis  of  the  larynx  gives  rise  to  hoarseness 
and  laryngeal  irritation.  The  symptoms  of  the  tertiary  lesions  are  of  the 
most  serious  character,  consisting  during  the  stage  of  active  ulceration  of 
aphonia,  cough,  pain,  dj^spncea,  dysphagia,  and  in  the  stage  of  cicatriza- 
tion of  a  more  or  less  grave  and  progressive  mechanical  obstruction  to 
respiration.  The  symptoms  show  themselves  in  the  hereditary  disease 
commonly  within  the  first  six  months  of  life;   exceptionally,  after  puberty. 

Diagnosis. — The  history  of  the  case  and  of  other  specific  cutaneous 
inflammatory  or  ulcerative  lesions,  or  the  presence  of  such  lesions  or  their 
scars,  renders  the  diagnosis  in  a  majority  of  the  cases  a  simple  matter. 

Prognosis. — Under  early  and  prolonged  antisyphilitic  treatment  the 
outlook  is  favorable.  With  the  general  improvement  the  laryngeal  symp- 
toms subside.     In  old  cases  with  stenosis,  tracheotomy  may  be  necessary. 

ix.  Laryngismus  Stridulus. 

Definition. — A  neurosis,  the  prominent  symptom  of  which  is  spasmodic 
closure  of  the  glottis,  associated,  in  severe  attacks,  with  spasm  of  the 
diaphragm  and  other  muscles  of  respiration.  The  relaxation  of  the  spasm 
is  accompanied  by  a  prolonged,  high-pitched,  crowing  inspiratory  sound, 
from  which  the  affection  receives  its  name. 

Etiology. — Laryngismus  stridulus  occurs  almost  exclusively  before 
the  end  of  the  third  year  of  life.  It  is  more  common  in  boys  than  in  girls. 
A  large  proportion  of  the  cases  occur  in  rhachitic  children,  but  those  in 
fair  health  may  develop  the  attack  without  warning.  The  paroxysm  may 
be  excited  by  a  variety  of  causes,  either  physical  or  emotional.  Among 
these  are  sucking,  sudden  movements,  violent  crying,  the  bath,  indigestion, 
and  dentition.  They  also  occur  in  the  absence  of  such  causes — on  waking 
from  sleep,  for  example — and  more  frequently  by  night  than  during  the 
•day.  The  seizure  may  present,  especially  in  older  children,  a  curious 
-appearance  of  being  voluntary,  and  is  sometimes  regarded  at  first  as  a  fit 
of  passion  or  of  holding  the  breath. 

Symptoms. — The  attack  may  be  preceded  by  an  occasional  catch  in 
the  breath  or  by  slight  crowing  sounds;    as  a  rule  it  comes  on  without 


1048  MEDICAL  DIAGNOSIS. 

premonitory  symptoms.  There  is  complete  arrest  of  respiration.  The 
chest  is  fixed,  the  head  thrown  back,  the  face,  at  first  pale,  quickly  becomes 
cyanotic,  the  eyes  are  wide  open  and  staring.  There  is  often  twitching 
of  the  facial  muscles.  In  the  severer  cases  there  may  be  opisthotonos, 
carpopedal  spasm,  or  general  convulsions.  The  attack  lasts  from  a  few 
seconds  to  a  minute  or  more.  Death  has  taken  place  during  the  paroxys-m 
from  prolonged  stoppage  of  respiration  or  from  impaction  of  the  epiglottis. 
As  the  cyanosis  deepens  the  spasm  jnelds;  the  air  slowly  enters  the  lungs 
again  through  the  relaxing  glottis,  with  the  characteristic  prolonged, 
high-pitched,  crowing  sound,  and  the  attack  ends  in  a  spell  of  coughing 
or  crying.  The  seizures  vary  greatly  in  severity  and  number.  After  a 
few  repetitions  they  may  cease  altogether,  or  they  may  come  on  very 
frequently  both  by  day  and  by  night,  and  recur  during  a  period  of  months. 

Diagnosis. — The  absence  of  fever,  hoarseness,  and  cough  in  the  inter- 
vals between  the  attacks,  the  suddenness  and  completeness  of  the  arrest 
of  breathing,  the  short  duration  of  the  paroxysm,  the  peculiar  prolonged 
crowing  inspiration  with  which  it  ends,  and  the  associated  convulsive 
phenomena,  taken  together,  form  a  characteristic  clinical  picture  not  to 
be  mistaken  for  any  other  malady.  When  death  occurs  in  the  paroxysm 
the  crowing  is  absent,  and  the  sudden  asphyxia  may  remain  unexplained. 

Prognosis. — As  regards  the  spasm  the  outlook  is  favorable,  the  fatal 
cases  being  few  in  number.  Children  who  suffer  from  laryngismus  stridulus 
are,  as  a  rule,  frail,  and  a  large  proportion  of  them  succumb  to  intercurrent 
disease. 

X.  Chronic  Infantile  Stridor. 

Definition. — The  chief  symptom  consists  of  an  almost  continuous 
coarse,  low-pitched,  inspiratory  stridor,  which  is  present  both  when  the 
child  is  awake  and  during  sleep. 

Etiology. — The  cause  is  unknown. 

Symptoms. — The  stridor  varies  in  intensity,  being  much  aggravated 
by  excitement.  It  sometimes  ceases  wholly  for  a  few  hours.  As  the  disease- 
gradually  passes  off,  it  occurs  only  at  intervals  and  when  the  child  is  lively 
or  excited.  Expiration  is  usually  normal;  it  may  be  accompanied  by  a. 
few  coarse  mucous  rales.  Retraction  of  the  thorax  does  not  often  occur,, 
and  when  present  is  slight.  In  one  case  only  have  I  encountered  faint 
cyanosis,  and  in  that  instance  there  were,  during  the  eighteen  months  of 
stridulous  breathing,  three  transient  general  convulsions.  The  case  ended 
in  recovery.  As  a  rule  the  affection  does  not  seem  to  interfere  with  the 
general  health  of  the  child. 

xi.  Paralysis  of  the  Laryngeal  Muscles. 

The  larynx  is  supplied  by  the  superior  laryngeal  and  inferior  or  recur- 
rent laryngeal  branches  of  the  vagus.  These  are  joined  by  branches  of 
the  sympathetic.  The  superior  laryngeal  nerves  supply  the  mucous  mem- 
brane of  the  upper  portion  of  the  larynx,  including  the  epiglottis,  as  far 
as  the  true  cords.  They  also  supply  the  cricothyroid,  the  thyro-epiglottic 
and  the  aryteno-epiglottic  muscles,  and  the  arytenoid  muscles  which  alsa 


PARALYSIS  OF  THE  LARYNGEAL  MUSCLES.  1049 

derive  motor  filaments  from  the  recurrents.  The  inferior  or  recurrent 
laryngeals  curve  around  the  arch  of  the  aorta  on  the  left  side  and  the  sub- 
clavian on  the  right,  and  ascend  between  the  trachea  and  oesophagus  to 
supply  the  laryngeal  mucous  membrane  below  the  cords  and  all  the  muscles 
of  the  larynx  except  the  cricothyroids.  The  superior  and  inferior  laryngeal 
nerves  on  each  side  communicate  with  each  other  in  two  places,  namely, 
at  the  back  of  the  larynx  and  on  the  side  of  the  larynx  under  the  ala  of  the 
thyroid  cartilage.  The  motor  filaments  of  these  branches  of  the  vagus 
are  derived  from  the  spinal  accessory. 

In  paralysis  of  the  laryngeal  muscles  the  lesion  may  be: 

1.  Central,  involving  the  nucleus  of  the  accessory  nerve  in  the  medulla. 
The  laryngeal  paralyses  of  this  group  arise  as  a  result  of  syphilis  affecting 
the  medulla  oblongata,  acute  and  chronic  bulbar  paralysis,  multiple  sclero- 
sis, and  locomotor  ataxia.  The  hysterical  paralyses  of  the  larynx  must 
also  be  regarded  as  of  cerebral  origin. 

2.  The  lesion  may  affect  the  fibres  of  the  recurrent  laryngeal  in  the 
course  of  the  vagus  or  the  accessory  nerve.  This  group  includes  the  cases 
in  which  the  paralysis  is  due  to  pressure  by  new  growths,  and  there  are 
cases  in  which  the  trunk  of  the  nerve  is  wounded  or  injured  in  surgical 
operations  above  the  point  at  which  the  recurrents  are  given  off. 

3.  The  lesion  may  directly  involve  the  laryngeal  nerves.  The  majority 
of  the  cases  of  laryngeal  paralysis  are  included  in  this  group.  The  recur- 
rents are,  by  reason  of  their  remarkable  course,  especially  liable  to  abnormal 
pressure  by  new  growths,  both  within  the  thorax  and  in  the  neck.  The 
left,  vvhich  curves  around  the  aorta,  is  exposed  to  greater  risk  of  injury 
than  the  right,  which  passes  no  lower  in  the  chest  than  the  subclavian. 
Either  may  be  included  in  the  dense  pleural  thickening  at  the  apices  which 
occurs  in  certain  forms  of  pulmonary  tuberculosis.  Paralysis  of  the  right 
is  in  rare  instances  caused  by  aneurism  of  the  subclavian  artery.  The 
left  is  likely  to  be  injured  by  the  pressure  of  an  aneurism  of  the  arch  of  the 
aorta,  a  mediastinal  tumor,  enlargement  of  the  bronchial  glands,  and  in 
rare  cases  of  a  massive  pericardia]  effusion.  Both,  as  they  ascend  between 
the  trachea  and  the  oesophagus,  are  occasionally  involved  in  carcinoma 
of  the  latter,  or  compressed  by  enlargement  of  the  thyroid  gland.  Paralysis 
of  the  recurrents  occurs  as  a  very  rare  sequel  of  diphtheria  and  as  a  result 
of  chronic  alcoholism. 

4.  The  lesion  may  be  confined  to  the  larynx.  The  loss  of  power  is 
purely  muscular  and  amounts  merely  to  a  paresis.  This  occurs  in  various 
diseases,  and  is  due  to  inflammatory  infiltration  of  the  submucous  tissues 
with  altered  nutrition  of  the  muscles. 

5.  Finally,  cases  of  laryngeal  paralysis  occui-  for  which  no  adequate 
cause  can  be  discovered. 

The  following  are  the  more  important  forms  of  larjmgeal  paralysis: 
1.  Complete  Paralysis  of  the  Recurrent  Nerve. — This  condition 
occurs  as  the  result  of  lesions  dividing  or  completely  destroying  the  recur- 
rent or  its  fibres  in  the  vagus,  or  as  a  manifestation  of  neuritis  due  to  diph- 
theria or  other  causes,  or  in  consequence  of  advanced  disease  in  the  medulla. 
It  may  be  unilateral  or  bilateral.  When  the  parah'sis  is  unilateral,  the 
vocal  cord  on  the  affected  side  occupies  the  median  or  so-called  cadaveric 


1050  MEDICAL  DIAGNOSIS. 

position,  and  is  motionless  upon  inspiration,  expiration,  and  attempts 
at  phonation.  In  phonation  the  vocal  cord  and  the  arytenoid  of  the  sound 
side  pass  beyond  the  median  line.  The  voice  is  harsh,  it  easily  breaks 
into  a  falsetto,  and  speaking  is  attended  with  effort.  The  cough  is  likewise 
harsh  and  brassy.  Dyspnoea  is  not  a  symptom.  In  complete  bilateral 
paralysis^a  very  rare  condition — the  cords  occupy  the  median  position 
and  are  immobile;  their  edges  are  slightly  concave,  as  the  aperture  is 
sufficiently  wide  for  respiration;  dyspnoea  is  absent  except  upon  exertion. 
Aphonia  is  complete  and  coughing  is  impossible. 

2.  Bilateral  Paralysis  of  the  Abductors. — The  posterior  crico- 
arytenoids are  involved.  This  form  of  laryngeal  paralysis  may  occur  as 
a  central  affection  in  the  course  of  bulbar  paralysis,  multiple  sclerosis, 
and  locomotor  ataxia.  It  may  be  produced  by  pressure  upon  both  vagi 
or  upon  both  recurrents.  It  is  encountered  as  a  rare  form  of  hysterical 
palsy.  Abductor  paralysis  may  follow  exposure  to  cold  or  may  arise  in 
the  course  of  a  laryngeal  catarrh.  The  cords  are  approximated  as  in  pho- 
nation. The  glottis  is  not  opened  in  inspiration;  on  the  contrary,  it  acts 
like  a  valve,  and  is  narrowed  by  the  pressure  of  the  air  to  a  small  slit.  In- 
spiration is  therefore  difficult,  prolonged,  and  stridulous,  while  expiration 
is  unimpeded.  Phonation  is  not  affected.  The  abihty  to  cough  remains. 
This  form  of  laryngeal  paralj^sis  is  rare,  but  is  attended  with  the  danger  of 
sudden  suffocation.  If  the  symptoms  are  progressive  and  the  dyspnoea  con- 
stant tracheotomy  becomes  necessary  and  the  tube  miust  be  constantly  worn. 

3.  Unilateral  Abductor  Paralysis. — One  cord  only  may  be  affected 
in  pressure-paralysis  involving  the  recurrent  of  one  side.  Aneurism  of 
the  arch  of  the  aorta,  exerting  pressure  upon  the  left  nerve,  is  by  far  the 
most  common  cause  of  this  condition.  The  right  nerve  is  especially  liable 
to  be  involved  in  pleural  thickening  and  retraction  of  the  apex  of  the  lung 
in  the  course  of  pulmonary  tuberculosis.  The  vocal  cord  on  the  affected 
side  remains  fixed  in  the  middle  line  during  inspiration.  The  voice  is 
sometimes  unaffected;  more  commonly  it  is  slightly  harsh  or  rough. 
Dyspnoea  and  stridor  are  not  often  present.  The  movements  of  the  other 
cord   are  normal. 

4.  Adductor  Paralysis, — In  the  more  common  forms  of  adductor 
paralysis  the  lateral  crico-arytenoids,  the  arytenoid,  and  the  thyro-aryte- 
noids,  are  implicated.  It  occurs  as  the  result  of  exposure  to  cold  or  from 
overuse  of  the  voice,  and  is  very  often  the  cause  of  loss  of  voice  in  catarrhal 
laryngitis;  it  is  the  usual  form  of  paralysis  in  hysterical  aphonia.  The 
laryngoscope  reveals  the  normal  position  and  movement  of  the  cords  in 
respiration  but  their  total  failure  to  approximate  on  attempts  at  phonation. 
There  is  neither  stridor  nor  dyspnoea;  ability  to  cough  is  not  affected, 
but  aphonia  is  complete.  Adductor  paralysis  may  be  partial.  It  is  com- 
monly bilateral,  but  in  exceptional  cases  unilateral.  In  bilateral  paresis 
of  the  thyro-arytenoids  the  glottis  does  not  close  completely  on  phonation, 
the  margins  of  the  cords  being  separated  by  an  oval  space.  If  one  cord 
only  is  affected  its  margin  remains  concave.  In  paralysis  of  the  arytenoid, 
which  seldom  occurs  alone,  the  vocal  cords  are  brought  together  in  their 
anterior  extent,  but  the  failure  of  the  arytenoid  cartilages  to  approximate 
leaves  a  narrow  triangular  opening  at  the  interarytenoid  space. 


BRONCHITIS.  1051 

III.  DISEASES  OF  THE  BRONCHI, 
i.  Bronchitis. 

Definition. — Inflammation  of  the  whole  or  anj^  part  of  the  bronchial 
mucous  membrane.  It  occurs  as  an  acute  or  chronic  disease.  It  is  bilateral 
and  usually  limited  to  the  larger  or  medium-sized  tubes.  When  it  extends 
to  the  smaller  and  terminal  bronchi  it  is  spoken  of  as  "capillary  bronchitis/' 
but  this  condition  is  always  associated  with  collapse  and  inflammation  of 
the  corresponding  air-vesicles,  constituting  bronchopneumonia. 

(a)  ACUTE  BRONCHITIS. 

This  very  common  affection  is  not  often  serious  in  the  middle  periods 
of  life.  In  mfancy  and  old  age  it  tends  to  involve  the  smaller  tubes  and  is 
often  a  fatal  disease. 

Etiology. — ChilHng  of  the  surface,  and  especially  wet  feet,  tend  to 
produce  engorgement  of  the  bronchial  vessels  and  the  microbic  infection 
to  which  bronchial  catarrhal  inflammation  is  due.  Overheated  dwellings, 
a  damp  or  dust-laden  atmosphere,  and,  in  rare  instances,  the  inhalation  of 
irritating  gases — chlorine,  bromine,  etc. — are  also  etiological  factors. 
Certain  persons  suffer  from  a  peculiar  susceptibility  and  develop  the  disease 
upon  sHght  exposure  to  its  causes.  It  very  often  arises  as  the  extension 
downward  of  an  ordinary  coryza,  the  result  of  "catching  cold,"  and  is 
common  in  damp,  cold,  and  changeable  weather,  when  it  often  prevails 
in  local  epidemics.  Acute  bronchitis  constitutes  an  important  element 
in  measles,  pertussis,  and  asthma,  and  is  frequently  met  with  in  the  ague 
fit  of  malaria,  and  early  in  the  course  of  enteric  fever. 

Pathology. — The  significance  of  the  cUnical  phenomena  rests  upon 
the  anatomical  changes,  which  in  the  main  consist  of  redness  and  conges- 
tion of  the  mucosa,  swelling  and  oedema  of  the  submucosa,  infiltration  of 
the  tissues  with  leucocytes,  desquamation  of  the  epithehum  in  its  ciliated 
and  embryonic  forms,  and  the  secretion  of  mucus  and  pus. 

Symptoms. — The  onset  is  frequently  characterized  by  symptoms  of 
constitutional  infection,  chilliness,  crawling  sensations,  fever, — 101°-103° 
F.  (38.5°-39.5°  C), — bodily  and  mental  depression,  languor,  and  pains  in 
the  back  and  limbs.  There  are  sensations  of  substernal  pain  and  constric- 
tion, a  rough,  dry,  and  sometimes  ringing  cough,  often  paroxysmal  and 
distressing,  and  much  uneasiness  and  pain  in  the  chest,  especially  along 
the  insertions  of  the  diaphragm.  In  the  course  of  a  day  or  more  the  cough 
loosens,  with  much  reKef  of  the  respiratory  symptoms  and  disappearance 
of  the  fever  and  other  evidences  of  constitutional  trouble.  The  expectora- 
tion becomes  free,  abundant,  and  mucopurulent,  and  later  purulent  and 
nummular. 

Physical  Signs. — Bronchitis  of  the  larger  tubes  may  yield  no  abnormal 
physical  signs.  The  percussion  sound  is  not  altered  in  an  uncomplicated 
acute  bronchitis.  Upon  auscultation  in  the  early  stage  drj^  rales,  sonorous 
and  sibilant,  are  heard  at  various  points  on  both  sides  of  the  chest.  They 
vary  in  size  and   quahty,   often  disappearing  after  efforts  of  coughing. 


1052 


MEDICAL  DIAGNOSIS. 


When  the  cough  becomes  loose  and  the  expectoration  fluid  and  abundant 
the  rales  become  moist  and  bubbling.  Rhonchal  fremitus  is  often  present, 
especially  in  children.  The  respiratory  murmur  is  vesicular,  never  bron- 
chial. If  the  bronchial  secretion  is  very  abundant,  there  may  be  slight 
temporary  dyspnoea  and  enfeeblement  of  the  vocal  fremitus,  both  of  which 
disappear  after  cough  with  free  expectoration.  The  intensity  and  course 
of  the  disease  are  variable.  The  attack  in  many  cases  scarcely  amounts 
to  an  illness.    Adults  in  previous  good  health  usually  recover  in  the  course  of 

a  few  days,  the  fever  sub- 
siding by  rapid  lysis,  and 
cough  and  expectoration 
gradually  diminishing. 

Diagnosis.  —  In  in- 
fants, the  aged,  and 
debilitated  persons  at  all 
periods  of  life,  there  is 
danger  that  the  bron- 
chial catarrh  may  invade 
the  fine  tubes  and  cause 
bronchopneumonia.  A 
daily  examination  should 
be  made  as  a  matter  of 
routine.  It  is  important 
alike  from  the  standpoint 
of  diagnosis,  prognosis, 
and  treatment  to  note 
whether  the  rales  are  dry 
or  moist,  since  these  qual- 
ities are  indicative  of  the 
physical  characters  and 
amount  of  bronchial 
secretion,  and  whether 
they  are  coarse,  medium- 
sized,  or  small,  since  vari- 
ations in  this  respect 
correspond  to  variations  in  the  diameter  of  the  tubes  involved.  Subcrepi- 
tant  and  crepitant  rales  at  the  bases  posteriorly,  together  with  faint 
vesiculobronchial  breathing  and  relative  dulness,  are  the  signs  of  extension 
to  the  finer  tubes.  With  these  signs  there  is  a  rise  of  temperature, 
increased  respiration  and  pulse-frequency,  restlessness,  slight  cyanosis,  and 
the  general  appearance  of  an  aggravation  of  the  illness. 

In  isolated  cases  of  measles  the  differential  diagnosis  cannot  be  made 
until  the  appearance  of  Koplik's  sign  or  the  exanthem;  in  pertussis  it 
cannot  be  affirmed  until  the  whoop  comes,  though  cough  in  paroxj^sms 
which  cause  vomiting  and  are  worse  at  night  is  suggestive.  Bronchitis  is 
by  no  means  rare  in  the  early  stage  of  enteric  fever,  and  there  are 
occasional  cases  in  which  for  a  few  days  cough  and  expectoration  are 
prominent  symptoms. 


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Fig,  315. — Acute  bronchitis,     Woraan  aged  50. — German  Hospital. 


BRONCHITIS.  1053 

(b)  CHRONIC  BRONCHITIS. 

The  affection  very  rarely  arises  as  the  termination  of  a  single  attack 
of  acute  bronchitis.  It  sometimes  follows  the  repeated  attacks  which 
result  from  continuous  exposure  to  the  cause  of  catarrhal  affections. 

Etiology. — Chronic  bronchitis  is  a  secondar}^  disease.  It  constitutes 
an  important  manifestation  of  certain  circulatory  derangements,  as  heart 
disease,,  thoracic  aneurism,  arteriosclerosis,  some  chronic  pulmonary  affec- 
tions, as  pneumoconiosis,  asthma,  and  emphysema,  and  constitutional 
conditions,  as  gout  and  chronic  ursemia.  Important  predisj^osing  influ- 
ences are  chmate  and  season.  The  winter  cough  of  elderly  and  invalid 
persons  is  well  known  and  is  often  absent  when  the  patients  are  able  to 
avoid  the  cold  and  changeable  weather  of  the  north  by  a  temporary  stay 
in  a  warm,  dry,  and  equable  climate.  The  influence  of  age  is  marked. 
Acute  bronchitis  is  a  disease  of  the  young;  chronic  bronchitis  a  disease 
of  the  old.  Chronic  bronchitis  is  more  common  in  men.  It  sometimes 
comes  on  in  women  at  an  early  age  without  obvious  cause  and  runs  an 
indefinite  course,  with  mild  symptoms  and  slight  secondary  changes — 
bronchiectasis  and  emphysema. 

Pathology. — The  lesions  are  not  evenly  distributed.  They  affect 
different  parts  of  the  bronchial  mucosa  in  varying  degree  and  in  irregular 
patches,  and  consist  of  loss  of  epithelium,  atrophy  of  the  glands  and  mus- 
cularis,  thinning  of  the  mucous  membrane,  and  dilatation  of  the  walls 
of  the  tubes.     Bronchiectasis  and  emphysema  gradually  come  to  pass. 

Symptoms. — There  is  cough  of  variable  severity,  less  troublesome 
in  dry  warm  weather  and  always  w^orse  in  the  cold  and  changeable  weather 
of  winter  and  early  spring.  There  are  often  paroxysms  in  the  morning, 
with  comparative  freedom  throughout  the  day.  In  some  cases  cough  is 
especially  troublesome  at  night.  The  sputum  has  no  constant  characters. 
It  differs  in  different  cases  and  at  different  times  in  the  same  case.  In 
the  dry  catarrh  expectoration  is  absent.  As  a  rule  it  is  abundant,  coming 
up  in  considerable  quantities  at  a  time.  Sometimes  there  is  a  little  tena- 
cious mass  of  clear  mucus  at  intervals.  Very  common  is  a  clear,  thin  fluid. 
In  the  advanced  cases  shortness  of  breath  is  common  upon  exertion.  It 
is  due  to  emphysema  and  to  some  extent  also  to  cardiac  weakness.  Fever 
is  absent.  There  is  no  pain.  The  general  health  is  often  good,  and  the 
patients  may  be  fully  able  to  attend  to  their  affairs.  The  disease  is,  how- 
ever, progressive,  and  tends  to  an  ultimate  dj'scrasia  with  advanced  emphy- 
sema, bronchiectasis,  and  dilatation  of  the  right  heart. 

Physical  Signs.— In  the  early  stages  the  physical  signs  do  not  differ 
from  those  of  the  stage  of  expectoration  in  acute  bronchitis.  Already 
perhaps  the  percussion  sound  has  the  vesiculotympanitic  quality.  There 
is  prolongation  of  the  expiratory  sound,  and  various  rales  are  heard,  some 
sonorous,  some  sibilant,  and  occasionally  moist  rales  of  ever}'  size.  At  the 
bases  posteriorly  there  are  heard  subcrepitant  and  crepitant  rales,  and  when 
there  is  much  fluid  secretion  there  may  be  slight  impairment  of  resonance. 

Clinical  Varieties.— (1)  Dry  Bronchitis;  Catarrhe  Sec. — This  form  is 
characterized  by  troublesome,  paroxysmal  cough,  with  slight  expectoration, 
sometimes  none  at  all.    It  is  not  uncommon  in  old  people  with  emphysema. 


1054  MEDICAL  DIAGNOSIS. 

(2)  Bronchorrhoea. — The  expectoration  is  profuse,  two  or  more  pints 
sometimes  being  brought  up  in  the  course  of  twenty-four  hours.  It  may 
be  thin  and  watery  — bronchorrhoea  serosa — or  thick  and  uniformly  purulent, 
or,  and  this  is  most  common,  it  may  consist  of  a  thin  pus  with  greenish 
clumps.  Bronchorrhoea  is  to  be  distinguished  from  bronchiectasis,  to  which, 
by  soakage  and  the  dilating  pressm^e  of  the  accumulating  secretion,  it 
tends  to  give  rise.    The  retained  fluid  may  undergo  decomposition. 

(3)  Putrid  Bronchitis. — Foul-smelling  expectoration  may  occur  in  a 
number  of  different  conditions.  These  comprise  anatomical  lesions  in 
which  secretions  are  retained,  as  bronchiectasis,  vomicae,  empyema  with 
bronchopulmonary  fistula,  and  pulmonary  abscess.  In  addition  to  these, 
there  is  a  special  form  of  bronchitis  characterized  by  sputum  having  the 
odor  of  decomposition.  This  form  is  comparatively  rare.  The  expectora- 
tion is  abundant,  of  a  dirty  yellowish-gray  color,  thin,  and  separates  upon 
standing  into  three  layers,  an  uppermost,  greenish-yellow  in  color,  con- 
sisting of  thin  froth,  a  middle  transparent  serous  layer,  and  an  opaque, 
purulent  sediment,  in  which  may  sometimes  be  found  small,  whitish-gray 
masses — Dittrich's  plugs.  Putrid  bronchitis  may  be  followed  by  aspira- 
tion pneumonia,  abscess,  or  gangrene.  It  can  be  differentiated  from 
bronchiectasis  only  when  the  latter  forms  cavities  sufficiently  large  to 
yield  characteristic  physical  signs,  the  sputa  being  practically  the  same 
in  the  two  conditions;  from  vomicae  by  the  presence  of  tubercle  bacilli 
in  the  sputum,  and  the  signs  of  a  cavity,  usually  in  the  neighborhood  of 
an  apex;  from  gangrene  by  the  presence  of  shreds  of  necrotic  pulmonary 
tissue,  and  finally,  from  empyema  communicating  with  a  bronchus,  by 
the  more  distinctlj^  purulent  sputa,  its  expectoration  in  larger  quantities 
at  a  time,  the  greater  readiness  with  which  it  is  brought  up  when  the  patient 
lies  upon  one — the  unaffected — side,  and  the  physical  signs,  which  indicate 
a  unilateral  and  circumscribed  lesion. 


(c)     FIBRINOUS  BRONCHITIS. 

Plastic  or  Crouvous  Bronchitis. 

Bronchial  casts  are  occasionally  found  in  infralaryngeal  diphtheria, 
in  croupous  pneumonia,  in  chronic  valvular  disease  of  the  heart,  and  in 
the  stadium  ultimum  of  pulmonary  tuberculosis.  They  have  also  been 
found  in  the  copious  albuminous  expectoration  which,  in  very  rare  instances, 
supervenes  upon  the  removal  of  a  pleural  effusion  by  aspiration.  After 
haemoptysis  branching  blood-casts  are  frequently  expectorated.  All 
these  conditions  are  to  be  distinguished  from  fibrinous  bronchitis,  a  form 
of  bronchitis  characterized  by  the  formation,  in  limited  branches,  of  casts 
or  moulds  of  the  bronchial  tubes  which  give  rise  to  urgent  dyspnoea  and 
are  expelled  in  violent  paroxysms  of  cough.  There  are  acute  and  chronic 
forms,  without  direct  etiological  relationship.  Acute  Fibrinous  Bron- 
chitis.— This  form  usually  occurs  as  an  intercurrent  affection  in  the  febrile 
infectious  diseases.  There  is  bronchitis  with  increasing  dyspnoea;  in  some 
cases  a  rise  in  temperature  and  chills  have  been  noted.  Casts  are  coughed 
up.     They  are  usually   arborescent,   sometimes   merely  a  straight  short 


BRONCHIECTASIS.  1055 

mould  of  a  single  tube,  with  its  terminal  subdivisions.  In  fatal  cases  the 
casts  have  been  found  in  the  tubes.  Chronic  Fibrinous  Bronchitis. — This 
form  occurs  as  a  primary  affection.  It  is  a  rare  disease.  It  is  more  common 
in  middle  life  and  in  men  than  in  women.  The  exciting  cause  is  unknown. 
The  attacks  recur  at  intervals  with  more  or  less  regularity  for  long  periods 
of  time.  There  are  signs  of  bronchitis,  with  fever.  Hsemoptysis  occurs. 
Dyspnoea  is  marked.  Cyanosis  may  be  present.  The  physical  signs  may 
be  localized  or,  if  diffuse,  they  are  intensified  over  the  affected  area.  There 
is  enfeeblement  or  absence  of  the  respiratory  murmur,  without  impairment 
of  resonance,  together  with  many  rales  on  coughing.  The  respiratory 
movement  upon  the  affected  side  is  diminished.  The  expectoration  of 
the  casts  is  attended  with  distressing  cough  and  suffocative  phenomena. 
They  are  usually  ejected  in  a  ball-like  coil  embedded  in  mucus  and  blood. 
Unrolled  they  appear  as  large,  whitish,  arborescent  forms,  of  which  the 
main  trunk  is  sometimes  2  cm.  in  diameter  and  as  many  as  10  cm.  in  length. 
On  cross  section  they  are  solid,  sometimes  with  a  minute  central  canal, 
circumferentially  stratified,  containing  minute  bubbles  of  air,  and,  in  some 
cases,  little  clots  of  blood.  Microscopically  there  are  present  red  and  white 
blood-corpuscles,  alveolar  epithelium,  and  in  some  cases  Charcot-Leyden 
crystals  and  Curschmann's  spirals.  Upon  the  expectoration  of  the  casts 
the  symptoms  are  immediately  relieved.  The  form  and  size  of  the  casts 
in  repeated  attacks  is  often  similar.  This  fact  would  only  justify  the  con- 
clusion that  the  same  bronchial  distribution  has  been  affected  when  the 
localization  of  the  physical  signs  has  occurred  in  the  same  region  of  the 
chest.  The  cause  of  the  cast  formation  in  limited  branches  of  the  bronchia 
and  its  recurrence  at  intervals  is  unknown. 

Prognosis. — In  acute  bronchitis  recovery  is  the  rule,  except  in  debil- 
itated persons  and  at  the  extremes  of  Hfe;  in  chronic  bronchitis  the  prog- 
nosis as  to  life  is  favorable,  as  to  recovery  unfavorable;  in  fibrinous 
bronchitis  the  prognosis  is  uncertain,  both  as  to  life  and  recovery. 

ii.  Bronchiectasis. 

Definition. — Dilatation  of  bronchial  tubes.  Dilatation  of  the  finer 
subdivisions  is  designated  bronchiolectasis.  Two  principal  forms  of  this 
anatomical  condition  are  recognized — the  cylindrical  or  fusiform,  and 
the  saccular  or  globular.  These  are  sometimes  present  in  the  same  lung. 
As  a  rule  there  are  several  dilatations  in  different  portions  of  both  lungs. 
Occasionally  the  bronchiectasis  is  single,  especially  in  chronic  bronchitis 
with  emphysema.  A  form  described  as  bronchiectasis  universalis  occurs 
as  a  congenital  condition  and  is  sometimes  encountered  in  chronic  inter- 
stitial pneumonia;  one  lung  only  is  affected.  The  bronchial  tubes  are 
represented  by  a  series  of  dilatations  surrounded  by  dense  sclerotic  lung 
tissue.  The  ordinary  forms  are  common  in  chronic  phthisis  affecting 
the  apex,  in  chronic  pleurisy  at  the  base,  and  in  emphysema.  They  vary 
greatly  in  size.  The  interior  of  bronchiectatic  cavities  is  lined  with  a 
smooth  membrane,  from  which  the  normal  cylindrical  epithelium  has 
disappeared.  At  the  dependent  parts,  as  the  result  of  accumulated  secre- 
tions, there  are  areas  of  ulceration.  All  the  layers  of  the  bronchial  wall 
are  stretched  and  atrophied.    The  contents  are  often  intensely  fetid.    Bron- 


1056  MEDICAL  DIAGNOSIS. 

chiolectasis  may  occur  as  an  acute  condition  after  the  febrile  infections. 
or  in  chronic  form  in  the  bronchitis  of  old  persons. 

Etiology. —  The  mechanical  factors  are  twofold:  (a)  weakening  of 
the  tone  of  the  bronchial  wall  as  the  result  of  impaired  nutrition,  and  soak- 
age  and  dilatation  in  consequence  of  the  pressure  of  the  contained  air  in 
severe  cough,  together  with  the  weight  of  accumulated  fluid  —  pulsion 
dilolation;  and  (b)  traction  upon  the  wall  of  bronchi  in  the  case  of  pleural 
adhesions  and  hyperplasia  of  the  connective-tissue  framework  of  the  lung 
as  in  pulmonary  cirrhosis — tension  dilatation. 

Symptoms. — In  large  dilatations  the  cough  and  expectoration  are 
characteristic.  After  several  hours,  usually  twenty-four,  during  which 
cough  has  been  slight  or  absent  altogether,  a  violent  and  prolonged  par- 
oxysm will  occur  with  profuse  expectoration.  The  attack  commonly 
comes  on  in  the  morning  and  often  follows  a  change  in  posture.  The 
expectoration,  which  varies  in  dail}^  quantity  from  250  to  750  c.c.  and 
may  reach  a  litre,  is  often  brought  up  in  repeated  mouthfuls.  This  phenom- 
enon is  due  to  the  fact  that  the  altered  mucosa  of  the  cavity  does  not 
react  to  the  gradually  accumulating  secretion.  When,  by  reason  of  the 
amount  or  upon  change  in  position,  there  is  an  overflow  into  the  communi- 
cating bronchus,  the  cough  reflex  is  immediately  excited  and  the  parox- 
ysm continues  until  the  accumulation  is  expectorated.  The  sputum  (see 
page  458).  Haemoptysis  is  common,  usually  slight,  occasionally  severe. 
Dyspnoea  and  cyanosis  upon  exertion  are  common.  Metastatic  abscess 
of  the  brain  and  septic  phenomena  occasionally  occur.  As  a  rule,  how- 
ever, the  condition  runs  a  chronic  course,  with  clubbing  of  the  finger- 
tips and  incurvation  of  the  nails, — drumstick  fingers, — and  in  some  cases 
a  fair  degree  of  health. 

Physical  Signs. — The  physical  signs  in  limited  bronchiectasis,  and 
in  the  acute  and  chronic  forms  of  bronchiectasis,  are  not  characteristic. 
When  the  dilatations  ai'e  sufficiently  large  and  superficially  situated 
they  yield  upon  examination  and  often  in  an  exquisite  manner  tympanitic 
or  amphoric  resonance,  the  cracked-pot  sound,  Wintrich's  phenomenon, 
and  an  intensification  of  the  vocal  fremitus  over  the  affected  area.  Whisper- 
ing pectoriloquy  may  be  present.  There  are  circumscribed  flattening 
over  the  bronchiectatic  cavity  and  diminished  respiratory  excursus  upon 
the  affected  side. 

Diagnosis. — Direct. — The  diagnosis  rests  upon  the  history  of  a  chronic 
pulmonary  affection;  the  signs  of  a  large  unilateral  cavity,  which  are 
gradually  effaced  as  the  secretion  reaccumulates,  and  suddenly  reappear 
after  several  spells  of  coughing  in  which  large  quantities  of  sputum  are 
ejected;  circumscribed  flattening;  and  limited  respiratory  movement 
upon  the  affected  side.  There  are  cases  in  which,  with  the  distinctive 
cough  and  expectoration,  the  dilatation  cannot  be  located  by  the  physical 
signs  or  the  X-rays,  and  others  in  which,  with  excessive  sputum,  only 
diffuse  dilatations  of  moderate  size  have  been  found  after  death. 

Differential. —  Vomicce. — The  anamnesis  is  suggestive.  In  favor 
of  the  phthisical  origin  of  the  cavity  are  its  location  in  the  upper  lobe, 
especially  if  the  opposite  apex  or  the  apex  of  the  lower  lobe  upon  the  same 
side  shows  signs  of  consolidation,  and  sputum  that  is  nummular,  oP;  if 


TRACHEOBRONCHIAL  STENOSIS.  1057 

fluid,  expectorated  at  relatively  short  intervals  and  in  smaller  amounts, 
and  containing  pulmonary  elastic  fibres.  If  tubercle  bacilli  are  present 
the  diagnosis  of  phthisis  is  positive.  The  frequent  association  of  phthisical 
cavities  with  bronchiectasis  must  be  borne  in  mind. 

Circumscribed  pyopneumothorax  with  bronchopulmonary  fistula, 
pulmonary  abscess,  pulmonary  gangrene,  and  putrid  bronchitis  present 
points  of  resemblance  to  bronchiectasis  so  close  that,  in  some  instances, 
the  differential  diagnosis  may  be  extremely  difficult.  The  anamnesis  is 
important.  In  pyopneumothorax  there  is  the  history  of  the  initial  sudden 
discharge  of  considerable  quantities  of  purulent  sputum;  in  abscess  and 
gangrene  a  history  of  sudden  development  and  rapid  course;  in  puti'id  bron- 
chitis a  history  of  chronic  bronchitis  without  special  unilateral  locahzation. 
Bronchiectasis  is  invariably  a  secondary  affection  of  gradual  development, 
and  more  frequently  situated  centrally  than  at  the  periphery  of  the  lung. 

Prognosis. — The  cavities  tend  to  enlarge.  When  a  single  large  cavity 
can  be  located  and  treated  by  drainage  and  other  appropriate  surgical 
measures,  the  expectation  of  relief  may  be  entertained. 

iii.  Tracheobronchial  Stenosis. 

Definition. — Narrowing  of  the  lumen  of  the  trachea  or  bronchial  tubes. 

Etiology. — The  lumen  of  the  tracheobronchial  tree  may  be  narrowed 
above  the  bifurcation  by  the  pressure  of  goitre,  oesophageal  or  mediastinal 
tumors,  and  aortic  aneurism;  both  above  and  below  the  bifurcation  by 
enlarged  tracheobronchial  glands  and  neoplasms,  especially  carcinoma; 
and  below  it  by  pericardial  effusion  and  enlarged  bronchial  glands.  It  is 
also  narrowed  by  conditions  which  arise  within  the  lumen  of  the  trachea 
or  bronchi,  among  the  most  important  of  which  are  the  following:  polypi 
and  other  new  growths;  acute  oedema  of  the  tracheobronchial  mucous 
membrane,  such  as  results  from  the  inhalation  of  irritating  fumes,  inflam- 
matory thickening  of  the  mucous  membrane;  croupous  exudates,  as  in 
infralaryngeal  diphtheria  and  in  fibrinous  bronchitis;  cicatrices,  especially 
in  syphilis;  exuberant  granulations  from  the  irritation  of  a  tracheotomy 
tube  and  foreign  bodies. 

Symptoms.  —  The  symptoms  differ  in  intensity,  according  to  the 
extent  of  the  obstruction  and  the  rapidity  with  which  it  comes  on.  They 
are  more  urgent  when  the  stenosis  is  sudden  and  when  it  is  tracheal.  They 
consist  of  inspiratory  dyspnoea,  suffocative  phenomena,  anxiety,  restless- 
ness, cyanosis,  a  tense,  full,  and  slow  pulse  with  inspiratory  intermission, 
and,  after  a  time,  venous  engorgement,  dilatation  of  the  right  heart,  visceral 
congestions,  and  diminution  or  complete  suppression  of  urine. 

Physical  Signs. — The  facies  and  attitude  differ  little  from  those  of 
laryngeal  obstruction.  There  is  inspiratory  retraction  of  the  supraclavicu- 
lar and  intercostal  spaces  and  of  the  epigastrium.  If  the  stenosis  be  tracheal 
these  signs  are  bilateral;  if  it  involve  a  main  bronchus  they  are  more  pro- 
nounced upon  the  affected  side.  Percussion  yields  hyperresonance  with 
a  slightly  tympanitic  quality.  The  absence  of  dulness  excludes  all  con- 
ditions of  inflammatory  exudate,  consolidation  of  the  lung,  pleural  effu- 
sion, or  new  growth  as  the  cause  of  the  dyspna^a.     The  vesicular  murmur 

67 


1058  MEDICAL  DIAGNOSIS. 

is  enfeebled  or  quite  inaudible;  bronchial  breathing  is  absent;  coarse 
dry  or  moist  rales,  often  heard  at  a  distance,  decrease  of  vocal  fremitus, 
and  a  faint  or  whispering  voice  are  important  phenomena  of  stenosis. 

Diagnosis. — The  differential  diagnosis  between  laryngeal  and  tracheo- 
bronchial stenosis  is  of  the  highest  practical  importance.  Among  the 
symptoms  which  point  to  the  larynx  as  the  site  of  the  obstruction  are  the 
abnormally  increased  respiratory  movements  of  the  larynx,  the  fixed 
attitude  with  the  head  somewhat  thrown  back,  and  the  peculiar  croupy, 
metallic  quality  in  the  respiration  and  cough — laryngeal  cough.  The 
question,  however,  is  immediately  settled  by  an  examination  with  the 
laryngoscope. 

Causal  Diagnosis. — The  examination  of  the  trachea  with  the  larjmgo- 
scope,  when  practicable,  will  determine  the  presence  or  absence  of  stenosis 
in  that  organ,  and,  when  present,  its  nature.  But  there  are  often  difficulties 
in  the  examination  which  are  insurmountable.  Goitre  is  manifest;  tumor 
of  the  oesophagus  is  associated  with  dysphagia;  mediastinal  new  growths 
and  aneurism  of  the  arch  of  the  aorta  are  attended  in  common  by  signs 
of  tumor,  with  displacement  of  the  anterior  border  of  the  lung  and  venous 
obstruction,  and  separately  by  signs  which,  in  the  case  of  aneurism 
when  present,  are  distinctive,  as  thrill,  diastolic  shock,  and  systolic  pulsa- 
tion. The  presence  of  enlarged  bronchial  glands  may  be  suspected  when 
tuberculous  lymph-nodes  are  elsewhere  present.  Malignant  disease  may 
be  suspected  when  there  are  intermittent  hemorrhagic  sputum,  enlarged 
lymphatics  in  the  neck  or  axilla,  and  an  otherwise  inexplicable  cachexia. 
A  history  of  syphilis  and  specific  lesions  of  the  palate  or  larynx  would 
lend  importance  to  the  assumption  of  cicatricial  stenosis.  The  recurrence 
of  attacks  of  fibrinous  bronchitis  with  the  expectoration  of  characteristic 
casts  renders  the  diagnosis  positive.  Foreign  bodies  are  easy  of  diagnosis. 
There  is  almost  always  a  history,  though  under  most  unusual  circumstances 
or  in  the  case  of  the  insane  no  history  can  be  obtained.  A  fixed  attitude, 
sudden  attacks  of  suffocation,  and  the  result  of  X-ray  examination  in  the 
case  of  metallic  and  certain  other  substances  are  of  diagnostic  importance. 

Prognosis. — In  tracheobronchial  stenosis  the  prognosis  is  as  variable 
as  the  cause. 

iv.  Bronchial  Asthma. 

Nervous  Asthma. 

Definition. — A  neurosis  characterized  by  paroxysmal  dyspnoea,  a  sense 
of  constriction  of  the  chest,  and  irregular  recurrence.  The  symptoms  and 
signs  denote  hypersemia  and  swelling  of  the  mucous  membrane  of  the  finer 
bronchial  tubes,  and  the  attack  may  be  produced  by  direct  or  reflex  irritation. 

Asthma  is  not  to  be  confounded  with  the  dyspnoea  of  cardiac  or  renal 
disease,  or  that  supervening  upon  exertion  in  emphysema  and  other  chronic 
affections  of  the  lungs  and  pleurae. 

Three  principal  hypotheses  are  advanced:  (1)  that  the  attack  is 
due  to  spasm  of  the  bronchial  muscles;  (2)  that  it  is  the  result  of  hyper- 
semia  and  turgescence  of  the  bronchial  mucosa;  (3)  that  it  is  caused  by  a 
peculiar  inflammation  of  the  bronchioles.     It  is  probable  that  all  three 


BRONCHIAL  ASTHMA.  1059 

of  these  conditions — namely,  swelling,  spasm,  and  exudate^nre  present  at 
the  same  time.  Other  views  of  less  importance  attribute  the  affection  to 
spasm  of  the  diaphragm  or  of  all  the  inspiratory  muscles.  It  has  been 
suggested  that  the  condition  is  similar  to  that  in  hay  fever,  with  special 
manifestations  due  to  differences  in  the  anatomical  site  of  the  lesions. 
The  sudden  onset  of  the  symptoms,  the  common  association  of  asthma  and 
hay  fever,  and  the  neurotic  constitution  of  the  subjects  of  these  affections 
lend  probability  to  this  opinion. 

Etiology. — Predisposing  Influences. — The  neurotic  temperament, 
which  is  transmitted  from  generation  to  generation,  frequently  carries 
with  it  the  tendency  to  asthma.  Asthma  and  epilepsy  are  sometimes 
associated.  Males  are  more  liable  to  the  affection  than  females.  Age 
plays  an  important  part  in  the  predisposition.  Asthma  usually  begins 
early  in  life,  often  in  childhood,  and  may  continue  throughout  life.  Pertussis 
is  sometimes  followed  by  asthma,  and  chronic  bronchial  catarrh  is  often 
accompanied  by  the  attacks.  These  attacks  are  sharply  differentiated 
from  the  dyspnoea  which  attends  exertion,  from  which  they  are  to  be 
distinguished.  Idiosyncrasy  is  important.  The  odors  of  certain  plants 
or  flowers,  hay,  artificial  perfumes,  ipecaciianha,  and  the  emanations 
from  animals,  as  the  horse  or  cat.  immediately  cause  the  attack  in  certain 
persons.  Violent  emotions,  especially  if  disagreeable,  may  act  in  the  same 
way.  Excesses  at  the  table  and  certain  articles  of  diet  may  be  followed 
by  the  outbreak.  Many  persons  remain  free  from  the  disease  in  the  city, 
but  at  once  suffer  in  the  country  or  in  some  particular  part  of  the  country, 
or  suffer  in  the  city,  but  miss  the  attacks  in  the  country  or  at  the  sea-shore. 
Others  cannot  use  a  feather  pillow  or  sleep  in  a  particular  room.  The 
most  common  source  of  reflex  irritation  is  to  be  found  in  the  mucosa  of 
the  upper  respiratory  tract.  Forms  of  rhinitis,  nasal  polypi,  hypertrophies 
of  the  inferior  turbinated  bones,  enlarged  tonsils,  or  adenoid  vegetations 
are  frequently  present  in  asthmatics  and  relief  very  often  follows  their 
proper  surgical  treatment.  The  causal  influence  of  uterine  and  ovarian 
disease  is  much  less  than  at  one  time  supposed.  In  old  cases  every  "  cold" 
may  be  attended  with  the  paroxysm. 

Symptoms. — The  health  is  often  excellent  in  the  intervals  between 
the  attacks.  The  onset  is  sometimes  preceded  by  prodromes,  among  which 
are  chilliness,  oppression  in  breathing,  dyspeptic  phenomena,  vesical 
irritability,  and  mental  depression.  The  attack  mostly  comes  on  at  night, 
the  patient  waking  from  sleep  with  distressing  difficulty  in  breathing,  and 
oppression.  There  rapidly  develops  a  paroxysm  of  the  most  urgent 
dyspnoea.  Inspiration  and  expiration  are  both  affected.  The  patient 
struggles  for  air.  The  respiratory  muscles,  and  especially  those  which 
aid  in  expiratory  efforts,  are  brought  into  forcible  action.  The  abdominal 
muscles  are  tense  and  board-like.  The  expiration  is  prolonged.  The 
face  is  pale,  the  expression  anxious,  and  the  patient  refuses  to  talk.  He 
may  rush  to  the  open  window  and  gasp  for  air,  with  his  arms  fixed  upon 
the  framie.  Small  quantities  of  high-colored  urine  are  passed  at  short 
intervals.  There  is  a  short,  dry  cough,  with  a  peculiar,  scanty,  viscid 
expectoration.  The  duration  of  the  attack  varies  from  a  bad  qu.arter  of 
an  hour  to  half  a  day  or  longer.    There  are  cases  in  which,  with  remissions 


1060  MEDICAL  DIAGNOSIS. 

and  exacerbations;  the  symptoms  last  for  thirty-six  or  forty-eight  hours. 
In  severe  paroxysms  air  hunger  becomes  urgent;  restlessness,  pallor,  and 
cyanosis  are  accompanied  by  sweating,  cold  extremities,  and  a  small, 
quick  pulse.  The  intensity  of  the  symptoms  now  abates;  the  cough  be- 
comes loose,  the  expectoration  fluid  and  free,  large  quantities  of  urine  may 
be  passed,  and  in  a  short  time  there  is  complete  relief.  The  patient  now 
usually  falls  asleep.  He  may  awake  quite  well  or  one  or  more  further 
attacks  may  follow.  Urticaria  and  in  rare  instances  angioneurotic  oedema 
have  been  observed  during  the  attack.  The  sputum  in  the  beginning  of 
the  attack  contains  Curschmann's  spirals,  Charcot-Leyden  crystals,  together 
with  many  leucocytes,  mostly  eosinophiles. 

Physical  Signs. — Inspection. — The  chest  has  the  inspiratory  form. 
It  appears  large  and  suggests  emphysema.  The  condition  is,  in  fact,  an 
acute  emphysema,  such  as  occurs  also  in  pertussis.  Under  these  circum- 
stances the  residual  air  is  increased  and  the  tidal  air  diminished,  and  in 
proportion  as  the  ratio  between  them  is  deranged  the  chest  becomes  fixed 
and  the  dyspnoea  urgent.  The  short,  quick  inspiration  and  the  prolonged 
expiration  are  of  diagnostic  importance.  Percussion. — In  mild  attacks 
the  signs  upon  percussion  are  little  modified,  the  change  amounting  simply 
to  a  moderate  hyperresonance,  but  in  severe  attacks  the  percussidn 
sound  is  vesiculotympanitic.  The  pulmonary  resonance  extends  down- 
ward two  or  three  interspaces  or  more,  the  superficial  cardiac  dulness 
is  much  diminished,  and  the  margins  of  the  overdistended  lungs 
scarcely  change  their  position  with  the  respiratory  movements.  Aus- 
cultation.— The  vesicular  murmur  is  enfeebled.  Great  numbers  of  sibi- 
lant and  sonorous  rales  are  heard  in  all  parts  of  the  chest,  and  often  from 
every  part  of  the  room.  These  rales  constantly  change  in  quality,  pitch, 
and  loudness,  and  are  much  more  prolonged  and  intense  upon  inspiration 
than  upon  expiration.  With  free  expectoration  the  rales  become  moist. 
The  attacks  recur  at  varying  intervals.  They  sometimes  come  on  in  a 
series  of  three  or  four  at  night,  with  catarrhal  symptoms  in  the  daytime. 

Diagnosis.  —  Direct.  —  The  clinical  picture  is  distinctive.  Among 
the  important  criteria  are  sudden  onset,  mostly  at  night;  expiratory 
dyspnoea;  acute  overdistention  of  the  thorax  as  shown  by  the  physical 
signs  upon  inspection  and  percussion;  scanty  expectoration  with  Cursch- 
mann's spirals  and  Charcot-Leyden  crystals;  loud  wheezing  and  groaning 
rales;  later  abundant  expectoration,  with  moist  rales  and  relief  of 
dyspnoea;  eosinophilia. 

Differential. — Emphysema  and  Chronic  Bronchitis. — The  associa- 
tion of  emphysema  and  bronchial  asthma  is  a  double  one.  The  asthmatic 
tends  to  become  emphysematous  on  the  one  hand,  while,  upon  the  other, 
attacks  of  asthma  are  common  in  emphysema.  The  obvious  relationship 
between  these  conditions  and  chronic  bronchitis  has  alread}''  been  indicated. 
Spasm  of  the  Glottis. — There  may  be  true  spasm,  as  in  the  laryngeal  crisis 
of  tabes.  The  dyspnoea  is  inspiratory  and  noisy,  the  respiratory  move- 
ments of  the  larynx  are  extensive.  The  lungs  are  not  overdistended, 
there  is  inspiratory  retraction  of  the  epigastric  zone,  and  the  peculiar 
cough,  rales,  and  expectoration  of  asthma  are  not  present.  Adductor 
spasm  is  of  short  duration,  while  the  paroxysm  of  asthma  is  often  pro- 


CIRCULATORY  DERANGEMENTS.  1061 

longed.  Laryngismus  Stridulus. — This  form  of  adductor  spasm  of  children 
is  characterized  by  apncea.  followed  upon  relaxation  by  a  long-drawn  inspi- 
ratory crowing  sound.  Cardiac  and  Renal  Dyspncea. — So-called  cardiac 
and  renal  asthma  have  nothing  in  common  with  true  asthma  except  dys- 
pnoea. To  call  them  asthma  is  a  nosological  error  alike  inconvenient  to 
the  teacher  and  misleading  to  the  student. 

Prognosis. — The  symptoms  are  often  alarming,  but  death  does  not 
occur  during  the  attack.  The  removal  of  the  sources  of  reflex  irritation 
in  the  upper  air-passages,  improvement  in  the  general  condition  of  the 
patient,  or  permanent  residence  in  a  suitable  climate  is  often  followed 
by  lasting  relief. 

IV.  DISEASES  OF  THE  PULMONARY  TISSUE, 
i.  Circulatory  Derangements. 

(a)  Pulmonary  Congestion.  —  Congestion  of  the  lungs  is  usually  a 
symptomatic  affection.     There  are  two  forms  —  active  and  passive. 

1.  Active  Congestion  of  the  Lungs. — The  inhalation  of  overheated 
air,  smoke,  and  other  irritating  substances,  and  overaction  of  the  heart 
may  cause  this  condition.  The  sudden  death  of  firemen,  open-air  orators, 
and  drunkards  after  exposure  has  been  ascribed  to  it.  The  symptoms 
comprise  great  dyspnoea,  oppression,  feeble  pulse,  and  cyanosis.  The 
physical  signs  are  restricted  respiratory  movements,  impaired  resonance, 
faint  vesicular  murmur,  and  fine  rales.  The  mechanical  interference  with 
the  circulation  in  pneumonia,  intense  bronchitis,  pleurisy,  and  tuberculosis 
leads  to  overdistention  of  the  capillaries  in  the  adjacent  lung  tissue — 
collateral  fluxion.  The  importance  of  this  condition  arises  chiefly  from 
the  danger  of  oedema. 

2.  Passive  Congestion. — Two  forms  are  recognized — mechanical  and 
hypostatic.  Mechanical  Congestion. — The  condition  is  most  marked  in 
the  dependent  portion  of  the  lungs.  The  essential  factor  is  an  obstacle  to 
the  return  of  the  blood  to  the  left  ventricle.  Its  occurrence  is  favored  by 
all  conditions  which  restrict  the  respiratory  expansion  and  contraction  of 
the  lungs  and  thus  interfere  with  the  normal  movement  of  the  blood  current 
in  the  pulmonary  vessels.  Mechanical  congestion  of  the  lungs  occurs  in 
mitral  stenosis  and  incompetency,  emphysema,  and  in  consequence  of  the 
pressure  of  tumors.  The  lung  undergoes  the  changes  known  as  brown 
induration.  So  long  as  compensation  is  maintained  this  condition  is  not 
marked  by  special  symptoms  of  importance.  When  it  is  lost,  dyspnoea, 
cough,  and  expectoration,  often  blood-stained  and  containing  alveolar  cells 
with  blood  pigment,  occur.  Hypostatic  Congestion. — The  bases  in  this 
condition  also  are  engorged  with  blood  and  serum.  The  condition  is  bi- 
lateral, one  side  being  usually  more  deeply  and  more  extensively  congested 
than  the  other.  Lobular  patches  may  be  airless,  and  bits  of  the  alTected 
tissue  may  sink  in  water.  To  this  extreme  condition  are  applied  the  terms 
splenization  and  hypostatic  pneumonia.  In  fact  there  are  frequently  pres- 
ent in  the  congested  regions  foci  of  bronchopneumonia.  Hypostatic  conges- 
tion is  common  in  protracted  acute  illness,  as  enteric  fever;  in  chronic  wast- 


1062  MEDICAL  DIAGNOSIS. 

ing  diseases,  as  tuberculosis  and  cancer;  in  injury  and  disease  of  the  brain, 
especially  apoplexy,  and  in  prolonged  coma.  There  are  no  characteristic 
symptoms  and  the  diagnosis  rests  upon  the  presence,  over  the  lower  lobes 
posteriorly,  of  impaired  resonance,  feeble  respiratory  sounds,  patches  of 
bronchovesicular  breathing,  and  small  mucous  or  subcrepitant  rales. 

(b)  Pulmonary  CEdema. — There  are  two  forms  of  oedema  of  the 
lungs — general  and  collateral. 

The  termination  of  intense  congestion  of  the  lungs  is,  in  many  cases, 
the  transudation  of  blood-serum  from  the  overdistended  capillary  vessels 
into  the  vesicles  themselves  and  their  walls.  The  escape  of  serum  into  the 
small  and  later  into  larger  bronchi  follows  and  is  of  clinical  importance. 
Pathologically  the  condition  is  one  of  serous  infiltration  of  the  pulmonary 
tissue,  with  accumulation  in  the  air-cells  and  bronchi.  The  cedematous 
lung  is  heavy,  pits  on  pressure,  and  exudes  abundantly  from  the  cut  surface 
clear  or  blood-tinged  serum. 

1.  General  (Edema. — (Edema  from  Engorgement;  Stasis  (Edema. — The 
oedema  is  bilateral  and  involves  the  whole  of  both  lungs.  The  bases  are 
especially  affected.  Causal  factors  are  overdistention  of  the  capillary 
vessels,  hydraemia  which  leads  to  nutritive  changes  in  the  walls  of  the 
vessels  and  a  weakened  left  ventricle.  The  condition  is  very  often  a  termi- 
nal one  and  accompanies  the  death  agony.  It  is  common  in  affections 
characterized  by  dropsies,  as  fatal  anaemias,  disease  of  the  heart  and 
kidneys,  especially  the  cardiorenal  affection,  and  cachexias  generally.  It 
occurs  also  without  previous  dropsy  in  cerebral  diseases,  acute  pulmonary 
congestion,  and  angina  pectoris.  General  oedema  of  the  uninvolved 
portions  of  the  lungs  may  occur  in  the  stadium  ultimum  of  croupous 
pneumonia. 

2.  Collateral  (Edema. — Local  (Edema  of  the  Lungs. — This  condition  is 
the  outcome  of  the  collateral  fluxion  in  the  pulmonary  tissue  bordering  on 
pneumonias,  infarcts,  active  foci  of  tuberculous  inflammation,  or  new 
growths.  The  cut  surface  exudes  a  bloody  serum.  The  entire  lung  is  not 
involved  and  the  opposite  lung  may  wholly  escape.  This  constitutes  the 
form  known  as  inflammatory  oedema. 

Symptoms. — Pulmonary  oedema  may  develop  gradually  or  with  great 
suddenness.  The  symptoms  of  the  pre-existing  malady  are  aggravated. 
Progressive  dyspnoea,  cough,  copious,  frothy,  thin,  fluid  sputum  which,  in 
the  case  of  collateral  oedema,  is  often  bloody,  characterize  the  condition 
(see  Part  III,  page  458).  As  it  progresses  cyanosis  and  the  stupor  and 
convulsive  tremblings  which  indicate  the  action  of  carbon  dioxide  upon 
the  n.ervous  system  occur.  Fever  does  not  usually  accompany  stasis 
oedema,  but  in  inflammatory  oedema  there  may  be  a  rise  in  temperature. 

Physical  Signs.  —  The  percussion  resonance  is  usually  somewhat 
impaired  over  the  bases  posteriorly  and  has  the  tympanitic  quality.  In 
very  abundant  serous  transudation  there  may  be  dulness.  Upon  auscul- 
tation the  respiratory  murmur  is  enfeebled,  and  over  the  whole  extent 
of  the  involved  lung  tissue  are  heard  moist  bronchial  subcrepitant  and 
crepitant  rales.  Vesiculobronchial  or  pure  bronchial  breathing  may  be 
heard  in  hmited  areas  at  the  bases  in  intense  oedema,  and  corresponds  to 
the  areas  of  dulness. 


CIRCULATORY  DERANGEMENTS.  1063 

Diagnosis. — Direct. — The  diagnosis  of  general  oedema  of  the  lungs 
rests  upon  the  occurrence  of  the  above  described  symptoms  in  cases  of 
oedematous  or  cachectic  disease,  cerebral  disease  or  injury,  angina  pectoris, 
and  impairment  of  the  power  of  the  left  ventricle,  especially  when  the 
power  of  the  right  heart  is  fairly  well  maintained.  Collateral  oedema  may 
be  at  least  provisionally  diagnosticated  when,  in  pneumonia  or  other 
inflammatory  conditions,  infarct,  active  circumscribed  tuberculosis,  or 
new  growths,  the  symptoms  are  aggravated,  the  temperature  rises,  many 
moist  rales  are  heard  in  the  adjacent  lung,  and  there  is  an  abundant  thin, 
blood-stained  sputum.  In  rare  instances  acute  oedema  of  the  lungs  follows 
the  withdrawal  of  a  pleural  effusion  by  aspiration.  The  sputum  is  copious 
and  has  the  characters  above  described.  It  is  the  result  of  the  sudden 
removal  of  pressure  upon  the  pulmonary  vessels.  Even  more  rare  is  the 
perforation  of  the  lung  by  a  serous  pleural  effusion.  There  are  coarse 
rales  usually  confined  to  the  affected  side,  and  an  abundant  expectoration 
presenting  the  characters  of  the  sputum  in  oedema  but  with  a  larger 
albumin  content. 

Prognosis.  —  General  oedema  of  the  lungs  is  frequently  one  of  the 
manifestations  of  dissolution.  There  are,  however,  cases  that  recover 
under  proper  treatment.  The  outlook  is  at  the  best  uncertain.  Collateral 
oedema  may  mark  an  unfavorable  turn  in  an  acute  illness  or,  as  is  fre- 
quently the  case,  subside  under  energetic  management  and  be  the  point  of 
departure  for  lasting  improvement. 

(c)  Pulmonary  Hemorrhage. — There  are  two  forms.  In  the  first 
the  blood  escapes  into  the  bronchi  and  is  expectorated — bronchopulmonary 
hemorrhage;  in  the  second  the  blood  is  effused  into  the  tissue  of  the  lungs 
and  air-cells — pulmonary  apoplexy,  hemorrhagic  infarct. 

1.  Bronchopulmonary  Hemorrhage. — Bronchorrhagia;  Hoemoptysis.  (See 
Part  III,  page  458.) 

2.  Pulmonary  Apoplexy. — Pneumorrhagia;  Infarct. — Anatomically  two 
conditions  are  encountered:    diffuse  infiltration  and  hemorrhagic  infarct. 

Diffuse  Hemorrhagic  Infiltration  of  the  Lungs. — The  lung  tissue  and 
air-cells  are  densely  and  uniformly  infiltrated  with  extravasated  blood. 
The  cut  surface  presents  a  smooth,  somewhat  gelatinous  appearance  and 
a  blackish  color.  The  condition  is  rare.  It  occurs  more  frequently  in  the 
hemorrhagic  fevers,  less  often  in  sepsis  and  acute  cerebral  disease.  The 
symptoms  are  dyspnoea,  cyanosis,  bloody  sputum,  blackish  in  color,  and 
the  nervous  phenomena  of  collapse.  Resonance  is  impaired.  This  form 
of  hemorrhage  is  of  no  great  diagnostic  importance,  since  it  constitutes 
the  terminal  event  in  an  otherwise  fatal  malady. 

Hemorrhagic  Infarct. — The  extravasation  of  blood  is  due  to  the  arrest  of 
circulation  in  a  branch  of  the  pulmonary  artery  by  an  embolus  or  thrombus. 
The  anatomical  condition  and  the  symptoms  differ  greatly  according  to 
the  location  of  the  occlusion.  If  it  occiirs  in  the  trunk  or  a  main  branch 
of  the  pulmonary  artery,  the  whole  or  a  large  part  of  the  blood  is  i)revented 
from  entering  the  pulmonary  circuit,  and  there  is  dilatation  of  the  right 
heart,  a  small,  thready,  arterial  pulse,  intense  dyspnoea,  cyanosis,  and 
death  from  apna^a — pulmonary  apoplexy.  As  the  clinical  manifestations 
from  cardiac  paralysis  are  the  same  the  diagnosis  remains  an  uncertain  one. 


1064  MEDICAL  DIAGNOSIS. 

When  the  obstruction  takes  place  in  a  smaller  branch  of  the  pulmo- 
nary artery  infarction  usually  occurs.  These  lesions  are  commonly  at  the 
periphery  of  the  lung,  and  wedge-shaped,  with  the  base  resting  upon  the 
pleura,  which  is  inflamed.  Exceptionally  they  are  located  within  the 
tissue  of  the  lung  and  they  are  then  irregularly  oblong.  Recent  infarcts 
present  the  appearance  of  a  blood-clot  in  the  pulmonary  tissue.  The 
air-cells  and  their  walls  and  the  capillaries  are  packed  with  red  blood- 
corpuscles.  Infarcts  are  commonly  multiple,  exceptionally  single.  They 
vary  in  size  from  a  pigeon's  egg  upward  and  may  occupy  a  large  portion 
of  a  lobe.  In  the  arterial  branch  of  supply  may  commonly  be  fovmd  the 
embolus  or  thrombus  in  the  neighborhood  of  the  apex.  These  obstructions, 
notwithstanding  the  fact  that  the  pulmonary  arteries  are  terminal,  do  not 
always  cause  infarction,  owing  to  the  width  and  free  anastomosis  of  the 
capillaries  and  the  ability  of  the  bronchial  vessels  to  maintain  the  circula- 
tion. The  changes  in  the  infarct  are  similar  to  those  in  blood-clots  in  other 
situations.  The  color  becomes  reddish-brown;  the  tissues  contract,  and 
are  finally  converted  into  a  puckered,  pigmented,  fibroid  nodule.  The 
source  of  the  embolus  is  to  be  sought  in  the  right  heart  or  peripheral  venous 
system.  The  white  thrombi  which  form  in  the  right  auricular  appendix,, 
the  vegetations  which  develop  upon  the  tricuspid  leaflets  in  the  rare  cases- 
of  right-sided  endocarditis,  fibrin  formations  among  the  columnar  carnese 
may  be  swept  by  the  venous  blood  stream  into  the  ramification  of  the  pul- 
monary arter}^  and  become  lodged.  Any  condition  which  tends  to  weaken 
the  action  of  the  right  ventricle  predisposes  to  this  accident.  Among 
these  are  valvular  disease,  especially  mitral  affections  and  myocardial 
degenerations.  These  emboli  are  not  usually  septic.  Emboli  from  inflam- 
matory or  suppurating  foci  in  various  regions  are  infected  and  cause  not 
a  simple  infarct  but  a  metastatic  abscess.  When  the  general  condition 
is  septic,  numerous  small  suppurating  foci  develop  in  the  lung — pycemic 
abscesses.  These  cannot  always  be  recognized  during  life.  When,  however, 
a  more  extensive  portion  of  the  lung  undergoes  septic  infarction  pulmonary 
abscess  results. 

Symptoms.  —  The  symptoms  are  neither  constant  nor  distinctive. 
An  initial  chill  may  occur.  It  is,  however,  never  so  severe  or  prolonged  as 
the  ordinary  chill  of  croupous  pneumonia.  Cyanosis,  increased  respira- 
tory frequency,  and  dyspnoea  at  once  develop.  These  symptoms  vary 
in  proportion  to  the  number,  and  especially  the  size,  of  the  infarctions. 
They  may  be  slight  or  altogether  absent.  There  is  cough  and  the  sputurp 
contains  blood  (see  Part  III,  page  459). 

Physical  Signs.  —  There  is  circumscribed  dulness,  more  commonly 
in  the  lower  lobes,  especially  on  the  right  side,  with  bronchial  breathing 
and  high-pitched  small  mucous  rales.  Pleural  friction  over  a  limited 
area  may  very  often  be  demonstrated. 

Diagnosis.  ^ — Direct.  —  The  diagnosis  cannot  always  be  made  with 
certainty.  The  sudden  occurrence  of  the  above  rational  symptoms  and 
physical  signs  in  the  course  of  chronic  disease  of  the  heart,  or  thrombosis 
of  a  crural  or  other  vein,  or  some  distant  inflammatory  or  suppurative 
process  warrants  a  provisional  diagnosis. 


CIRCULATORY  DERANGEMENTS.  1065 

Differential. — Croupous  Pneumonia. — There  is  a  superficial  resem- 
blance in  some  of  the  cases;  but  the  situation  and  outlme  of  the  consolida- 
tion, the  character  of  the  sputum  in  which  the  blood  or  haemoglobin  is 
more  intimately  mixed  than  in  infarction,  and  the  results  of  the  laboratory- 
examination  of  the  sputum,  which  contains  pneumococci,  are  distinctive. 
HcEmoptysis  in  Mitral  Disease,  especially  Mitral  Stenosis. — The  occurrence 
of  blood  spitting,  usually  in  small  amounts  and  extending  over  a  period 
of  days  or  weeks,  may  suggest  infarction.  The  differential  diagnosis  in 
the  absence  of  physical  signs  or  marked  pulmonary  symptoms  is  impos- 
sible. The  blood  may  be  due  to  engorgement  of  the  pulmonary  vessels. 
Its  recurrence  after  exertion  and  at  long  intervals  is  in  favor  of  the  latter 
view.  Malignant  Disease  of  the  Lung. — Blood  spitting  and  signs  of  con- 
solidation are  present  in  both  conditions.  Pain,  wasting,  localizing  physical 
signs,  which  gradually  include  more  territory,  cachexia,  the  presence  of 
new  growths  elsewhere,  and  in  particular  of  pigmented  nsevi  or  warts, 
with  secondary  nodules  in  the  skin  or  subcutaneous  tissues,  implication 
of  the  lymph-nodes,  or  a  history  of  the  removal  of  a  malignant  growth, 
justify  a  provisional,  and  in  well-marked  cases  a  positive,  diagnosis  of 
cancer  or  sarcoma  of  the  lung. 

Air  Embolism;  Fat  Embolism. — An  embolus  is  any  body  transported 
by  the  circulating  blood  and  capable,  when  arrested  by  the  narrowness 
of  the  vessel,  of  obstructing  the  circulation.  Emboli  are  usually  too  large 
to  pass  through  the  capillaries.  They  may  be  composed  of  fibrin  masses, 
fragments  of  thrombi,  vegetations  or  calcareous  particles  from  endocardial 
vegetations,  or  fragments  of  neoplasms,  which  have  penetrated  the  wall 
of  a  vessel.  They  may  be  infected  or  non-infected.  There  are  two  sub- 
stances, differing  from  ordinary  emboli  in  not  consisting  of  solid  bodies, 
which  may  give  rise  to  urgent  or  fatal  consequences  when  arrested  in  the 
capillaries  of  the  pulmonary  circulation;   these  are  air  and  fat. 

Etiology. — Air  embolism  occurs  under  certain  circumstances  when 
a  vein  is  lacerated.  Fat  or  oil  embolism  may  follow  fracture  or  injury  to 
a  bone,  with  escape  of  marrow  into  the  tissues,  or  extensive  laceration  of 
adipose  tissue,  or  its  rapid  breaking  down  in  suppurative  processes. 

Symptoms. — The  symptoms  of  air  embolism  are  urgent  or  even  fatal 
in  cases  in  which  the  quantity  of  air  is  sufficient  to  form  large  numbers  of 
bubbles  which  cannot  pass  the  pulmonary  capillaries — an  embolic  shower. 
They  consist  of  an  extreme  degree  of  air  hunger,  loss  of  consciousness, 
convulsions,  and  collapse,  and  usually  prove  fatal  in  a  brief  period,  some- 
times instantly.  In  rare  cases,  however,  these  most  alarming  manifesta- 
tions improve  in  consequence  of  the  rapid  absorption  of  the  air.  and  prompt 
recovery  takes  place — a  fortunate  event  not  seen  Avhen  multiple  embolism, 
the  embolic  shower,  is  due  to  solid  emboli.  When  the  air  bubble  entering 
the  vein  is  small  or  the  air  enters  slowly  the  symptoms  are  commonly  less 
urgent.  No  symptoms  attend  the  presence  of  the  most  minute  air  bubbles 
which,  having  passed  the  wider  pulmonary  capillaries,  are  arrested  in  the 
capillaries  of  other  organs. 

Since  the  fat  globules  obstruct  only  the  finest  vessels  in  the  lungs 
and  only  gradually  enter  the  circulation,  the  sudden  pulmonary  symptoms 
seen  in  air  embolism  rarely  present  themselves.     As  a  rule  no  symptoms 


1066  MEDICAL  DIAGNOSIS. 

occur  until  some  hours  or  days  have  elapsed  from  the  time  of  the  injury. 
Severe  dyspnoea,  oedema  of  the  lungs,  great  depression,  and  coma  may 
occur.  As  the  fat  emboli  have  no  tendency  to  cause  blood  coagulation 
or  thrombosis,  they  are  gradually  forced  on  under  the  pressure  of  the 
blood  stream,  or  undergo  resorption,  and  recovery  takes  place.  The  fat 
particles  which  pass  the  lungs  may  reach  the  cerebral  capillaries  or  be 
arrested  in  the  renal  glomeruli.  In  the  latter  case  they  may  be  voided  in 
the  urine.    Death  is  uncommon  in  fat  embolism. 

ii.   Diseases  Characterized  by  Changes  in  the  Vesicular 
Structure  of  the  Lungs. 

(a)  PULMONARY  EMPHYSEMA. 

Vesicular  Emphysema;  Substantive  Emphysema;  Pseudohypertrophic 

Emphysema. 

Definition. — A  chronic  disease  of  the  lungs,  in  which  the  infundibula 
and  vesicles  are  dilated  and  their  walls  atrophied. 

This  is  a  v/ell-defined  clinical  affection,  and  characterized  by  enlarge- 
ment of  the  lungs,  changes  in  the  contour  of  the  chest,  incomplete  aeration 
of  the  blood,  and  varying  degrees  of  dyspnoea,  especially  upon  exertion. 
It  is  to  be  distinguished  from  acute  vesicular  emphysema,  compensatory 
emphysema,  and  interstitial  and  atrophic  forms. 

Etiology. — Heredity  constitutes  an  important  predisposing  influence. 
The  disease  is  frequently  encountered  in  successive  generations  or  in  several 
members  of  a  family,  and  is  not  uncommon  in  childhood.  It  has  been 
ascribed  to  congenital  defects  in  the  development  of  the  elastic  fibres. 
Long-continued  habitual  intra-alveolar  pressure,  acting  upon  a  congenitally 
defective  alveolar  structure,  causes  distention  which  tends  to  become  per- 
manent. The  hyperinflation  of  the  lungs  which  occurs  in  the  paroxysms  of 
whooping-cough  and  asthma  is  often  the  starting-point  of  emphysema. 
Repeated  attacks  of  bronchitis  or  chronic  bronchitis  are  often  present.  It 
is  common  also  in  players  upon  wind  instruments,  glass-blowers,  and 
those  whose  work  demands  heavy  lifting  or  prolonged  muscular  strain. 
The  tension  under  these  circumstances  is  expiratory.  In  violent  attacks  of 
cough  and  in  straining,  the  glottis  is  closed  and  the  intrathoracic  tension 
greatly  heightened.  The  parts  of  the  lungs  least  supported  by  the  chest 
wall,  namely,  the  apices  and  anterior  and  inferior  margins,  show  the  most 
developed  lesions  of  emphysema. 

Anatomically  the  primary  changes  are  in  the  lungs;  the  secondary 
changes  in  the  wall  of  the  thorax. 

The  lungs  are  voluminous,  their  margins  meeting  in  the  anterior 
mediastinum  and  extending  downward  to  the  extent  of  two  fingers' 
breadth  or  more.  The  diaphragm  is  correspondingly  displaced  in  a  down- 
ward direction.  They  have  lost  their  normal  contractilitj^  and  do  not 
retract  when  the  costal  pleura  is  incised  nor  when  withdrawn  from  the 
chest  and  laid  upon  the  table.  At  the  apices  and  borders  there  are  seen 
beneath  the  pleura  greatly  distended  air-vesicles,  varying  in  diameter  from 


PULMONARY  EMPHYSEMA.  1067 

1  to  3  mm.,  and  sometimes  attaining  the  size  of  a  pigeon's  egg.  There 
is  marked  diminution  in  the  pigment  usually  found  in  the  subpleural 
lymph-spaces.  The  atrophy  of  the  distended  vesicular  walls  leads  to  loss 
of  their  pumping  function  and  permanent  pressure  upon  the  capillaries, 
and  this  to  diminution  in  the  intervesicular  vascular  suppl3\  The  infun- 
dibula  are  dilated,  but  bronchiectasis  is  not  very  common.  The  chambers 
of  the  right  heart  are  dilated  and  hypertrophied.  The  pulmonary  artery 
is  in  some  instances  dilated  and  atheromatous. 

The  chest  permanently  assumes  the  inspiratory  form  and  the  costal 
cartilages  progressively  undergo  calcification  and  lose  their  elasticity. 

Symptoms.  —  The  derangement  of  function  is  twofold.  First,  the 
residual  air  is  greatly  increased  and  the  tidal  air  correspondingly  decreased 
in  volume,  and  second,  the  pulmonary  circulation  is  diminished.  If  these 
facts  are  borne  in  mind  the  significance  of  the  symptoms  is  obvious.  The 
lesions  are  gradually  developed  and  it  is  only  after  they  have  made  some 
progress  that  the  characteristic  symptoms  and  signs  occur.  At  first  there 
is  merely  dyspnoea  and  faint  lividity  upon  exertion,  and  the  chest  merely 
looks  full  with  the  inspiratory  contour.  When  the  disease  is  fully  developed 
the  following  symptoms  are  present:  Dyspnoea. — The  elasticity  of  the 
vesicular  structure  being  to  a  great  extent  impaired,  expiration  is  pro- 
longed and  difficult.  The  dyspnoea  is  chiefly  expiratory.  The  loss  of  resili- 
ency in  the  costal  cartilages,  the  permanent  maximum  distention  of  the 
thorax,  and  the  restricted  play  of  the  diaphragm  render  inspiration  also 
difficult,  even  with  the  aid  of  the  auxiliary  muscles  of  respiration.  The 
dyspnoea  may  be  felt  upon  slight  exertion  or  it  may  be  continuous.  It 
is  increased  upon  the  occurrence  of  the  exacerbations  of  bronchitis,  to 
which  the  patient  suffering  from  emphysema  is  so  liable.  The  breathing 
is  puffy  and  wheezy.  Asthmatic  Attacks. — The  dyspnoea  under  certain 
circumstances,  and  especially  after  ''taking  cold,"  often  assumes  a  paroxys- 
mal intensity,  differing  in  no  respect  from  true  spasmodic  asthma.  Cough 
is  a  common  symptom.  It  is  due  to  the  associated  bronchitis.  It  is  com- 
monly wheezy  and  feebly  explosive,  and  without  much  expectoration. 
It  is  usually  less  troublesome  in  warm,  dry  weather,  and  constitutes  the 
recurrent  winter  cough  of  many  elderly  persons.  Cyanosis. — The  patients 
are  frequently  able  to  go  about  with  lividity  of  high  grade.  This  symptom 
is  variable  and  may  amount  merely  to  a  certain  blueness  of  the  lips  and 
finger-nails  while  the  patient  is  at  rest. 

Intermittent  Cervical  Hernia  of  the  Lung  of  Spontaneous  Origin. — 
C.  B.  Farr  has  reported  a  case  of  this  kind  and  collected  seven  other 
instances  from  the  literature.  As  a  rule  the  condition  accompanied 
chronic  bronchitis  with  emphysema.  It  was  unilateral  in  five  cases 
and  bilateral  in  three.  These  protrusions  are  of  the  form  and  size  of  a 
pear,  with  the  base  below  and  the  apex  extending  upward.  They 
are  not  present  upon  quiet  breathing  but  prominent  during  cough  and 
are  the  seat  of  a  faint  rustling  murmur.  They  are  resonant  on  percus- 
sion and  may  be  reduced  by  gentle  taxis.  In  several  of  the  cases  a 
hernial  ring  could  be  felt.  They  are  to  be  differentiated  from  enlarge- 
ments of  the  sinuses  of  the  jugular  veins,  abscesses,  and  an  empyema 
which  presents  in  the  neck. 


1068  MEDICAL  DIAGNOSIS. 

Physical  Signs.— Inspection. — In  advanced  cases  the  deformity  of 
the  chest  is  typical.  It  is  barrel-shaped  (see  p.  64).  The  elevation  of  the 
sternum  and  ribs  gives  the  neck  a  shortened  appearance.  The  respiratory 
movements  appear  forcible,  but  the  thorax  does  not  expand.  Many 
dilated  superficial  venules  are  seen  along  the  line  of  attachment  of  the 
diaphragm.  The  cardiac  impulse  is  not  visible.  Epigastric  pulsation 
and  dilated  cervical  veins,  sometimes  pulsating,  are  signs  of  a  dilated  and 
overdistended  right  heart.  The  deformity  of  the  chest  is  less  marked  in 
those  cases  in  which  emphysema  has  commenced  in  advanced  life  at  a 
period  when  the  cartilages  have  already  become  calcified.  Palpation. — 
The  lack  of  respiratory  excursus  is  very  obvious  upon  palpation.  The 
vocal  fremitus  is  enfeebled.  The  impulse  of  the  heart  cannot  be  located. 
Ttiere  is  pulsation  over  the  lower  sternal  and  epigastric  regions.  Mensura- 
tion.— The  restricted  expansion  of  the  chest  is  confirmed  by  careful  measure- 
ment, and  the  rounded  contour  by  the  cyrtometer.  Percussion. — The  reso- 
nance is  of  vesiculotympanitic  quality,  especially  sonorous  over  the  lateral 
and  posterior  regions.  The  percussion  sound  has  been  compared  with  that 
eHcited  upon  tapping  a  bandbox — Schachtelton.  More  important  than  the 
quahty  of  the  percussion  sound  are  the  borders  of  the  expanded  lungs  which 
it  marks.  They  are  extended  in  every  direction  and  may  reach  in  front 
to  the  eighth  rib  and  below  it,  behind  to  the  level  of  the  twelfth  dorsal  or 
even  the  second  lumbar  vertebra.  The  cardiac  dulness  may  be  completely 
obliterated.  The  hver  and  splenic  dulness  are  much  lowered.  Auscultation. 
— The  vesicular  murmur  is  greatly  enfeebled.  Its  very  faintness  is  sug- 
gestive. The  expiratory  element  is  not  often  audible.  Instead  of  it,  how- 
ever, there  are  many  sibilant  and  wheezy  rales.  The  sounds  of  the  heart 
are  faint  and  distant,  the  pulmonary  second  sound  is  often  accentuated, 
and  in  advanced  cases  a  tricuspid  regurgitant  murmur  may  be  heard. 

The  effect  of  the  lesions  of  emphysema  upon  the  circulation  is  to 
obstruct  the  pulmonary  circuit;  to  dilate  and  enfeeble  the  right  ventricle; 
to  diminish  the  arterial  blood;  and  to  increase  the  accumulation  of  venous 
blood.  The  enfeeblement  of  the  right  heart  is,  however,  delayed  by  com- 
pensatory hypertrophy  by  which  the  circulatory  faults  are  postponed. 
Ultimately,  however,  compensation  fails  and  the  results  of  venous  engorge- 
ment become  manifest.  These  are  persistent  cyanosis,  pulsation  in  the 
veins  of  the  neck,  hepatic  enlargement,  diminished  secretion  of  albuminous 
urino,  oedema,  anasarca  and  effusions  into  the  great  serous  sacs,  and 
gastric  and  intestinal  catarrh.  When  these  conditions  are  present  there 
is  almost  always  a  compHcating  catarrhal  bronchitis,  manifest  by  the 
ordinary  symptoms  of  cough  and  expectoration,  the  latter  being  usually 
mucoid  and  viscid,  sometimes  purulent.  The  presence  of  blood  is  not 
common  and  suggests  either  a  compHcating  tuberculosis  or  pulmonary 
infarct.    The  general  nutrition  is  impaired. 

Diagnosis. — Direct. — In  well-developed  cases  the  condition  may 
be  at  once  recognized  by  the  contour  and  diminished  mobility  of  the  chest, 
the  dyspnoea  and  cyanotic  lips,  the  spare  frame,  and  a  facies  which  is 
very  suggestive  to  those  who  have  observed  many  cases.  The  physical 
signs,  and  especially  the  displaced  boundaries  of  the  lungs  as  determined 
by  percussion,  are  confirmatory. 


PULMONARY  EMPHYSEMA.  1069 

Differential.  —  Acute  Vesicular  Emphysema;  Acute  Over-inflation 
of  the  Lungs. — During  the  paroxysm  of  bronchial  asthma  and  pertussis, 
and  in  bronchitis  of  the  smaller  tubes,  the  lungs  are  frequently  much 
distended.  The  chest  maintains  the  inspiratory  form,  and  upon  a  single 
examination  the  condition  might  be  confounded  with  emphysema.  The 
anamnesis  is  important.  The  borders  of  the  lung  are  enlarged,  but  not 
beyond  the  limits  of  normal  full-held  inspiration,  and  in  the  course  of  a 
little  time  after  the  termination  of  the  primary  disease  they  regain  their 
normal  position  upon  inspiration  and  expiration.  In  congenital  weakness 
of  the  lung  tissue  such  attacks  may  become  the  point  of  departure  for 
true  emphysema.  A  similar  condition  occurs  in  cases  of  cardiac  dyspnoea 
and  angina  pectoris.  The  lungs  are  distended,  their  borders  extended, 
and  the  expiration  is  prolonged  and  accompanied  by  wheezing  rales. 
Compensatory  Emphyserna;  Vicarious  Emphysema. — When  local  lesions 
in  the  lung  or  pleura  interfere  with  expansion  upon  inspiration,  the  unaf- 
fected tissue  takes  upon  itself  increased  functional  activity — vicarious 
respiration.  This  change  may  involve  parts  adjacent  to  the  lesion,  an  adjoin- 
ing lobe,  or  the  opposite  lung.  It  occurs  in  bronchopneumonia  and  around 
tuberculous  foci  and  cicatrices,  the  air-cells  of  the  unaffected  lobules  under- 
going a  vicarious  distention;  in  pulmonary  cirrhosis,  the  unaffected  lung 
undergoing  vicarious  enlargement,  and  to  a  less  extent  in  pleural  adhesions 
and  effusions  and  in  pneumothorax.  This  process,  at  first  truly  compen- 
satory and  physiological,  becomes  after  a  time  pathological.  The  vesicular 
walls  and  capillaries  undergo  atrophy;  a  circumscribed  or  partial  emphy- 
sema comes  to  pass.  In  bronchopneumonia  or  pulmonary  tuberculosis 
with  scattered  lobular  lesions  the  distention  of  the  adjacent  air-cells  masks 
the  dulness  and  may  render  the  diagnosis  obscure;  in  retracted  and  cir- 
rhotic conditions  of  one  lung,  such  as  follow  the  resorption  of  the  pleural 
effusion,  the  borders  of  the  opposite  lung  are  much  distended  and  may 
be  followed  by  careful  percussion,  not  only  in  their  inferior  extent,  but 
also  over  the  area  of  superficial  cardiac  dulness  and  beyond  the  median 
line  toward'  the  contracted  side.  Atrophic  Emphysema;  Atrophy  of  the 
Lungs;  Senile  Emphysema. — This  is  a  purely  senile  change  and  is  occasion- 
ally encountered  in  wizened  old  people  with  small,  narrow  chests  which 
are  permanently  in  the  expiratory  form.  The  alveolar  walls  and  inter- 
alveolar  capillaries  are  extensively  atrophied,  and  the  alveoli  in  places 
converted  into  series  of  large  communicating  cells.  The  lungs  themselves 
are  small  and  the  thorax  conforms  to  the  changes  in  the  contained  organs. 
It  is  flattened,  the  shoulders  droop,  the  costal  angle  is  acute,  the  neck 
appears  elongated.  The  diaphragm  is  high.  The  right  heart  does  not 
show  dilatation  and  hypertrophy  as  in  large-lunged  emphysema,  because 
it  also  undergoes  a  corresponding  senile  involution.  The  respiratory 
muscles  are  atrophic.  Interstitial  Emphysema.  —  Small  bubbles  of  air 
find  their  way  into  the  interlobular  and  subpleural  tissues.  Their  access 
is  by  way  of  tracheotomy  or  other  surgical  or  accidental  wounds  of  the 
neck  or  throat;  less  frequently  through  rupture  of  the  alveolar  walls  by 
violent  coughing,  contusions  of  the  chest,  or  ulceration.  When  the  opening 
is  near  the  root  of  the  lung  air  may  pass  to  the  mediastinal  connective 
tissue.     The  condition  is  rare.     Mediastinal  emphysema  may  be  diagnosti- 


1070  MEDICAL  DIAGNOSIS. 

cated  when  the  causal  factors  are  present  together  with  crepitating  sub- 
cutaneous emphysema  of  the  neck  or  chest,  absence  of  cardiac  dulness 
and  impulse,  obliteration  of  the  sternal  ends  of  the  intercostal  spaces, 
and  upon  auscultation  a  fine  crepitus  synchronous  with  the  action  of  the 
heart.  The  veins  of  the  neck  are  distended.  Subpleural  and  interlobular 
emphysema  not  extending  to  the  mediastinum  does  not  usually  present 
positive  diagnostic  phenomena.  Rupture  of  an  air  bleb  in  subpleural 
emphysema  may  cause  pneumothorax. 

Prognosis. — Substantive  emphysema  is  incurable,  but  much  can  be 
done  to  relieve  the  sufferings  of  the  patient  and  to  prolong  his  life.  Treat- 
ment of  the  bronchitis,  a  favorable  climate,  and  attention  to  the  state  of 
the  heart  are  important.  Death  usually  occurs  in  consequence  of  some 
intercurrent  disease,  as  pneumonia  or  bronchopneumonia. 

(b)  PULMONARY    ATELECTASIS. 

Collapse  of  the  Lung. 

Definition. — An  airless  condition  of  lobules  or  parts  of  the  lung,  the 

vesicles  being  in  a  state  of  collapse  and  not  occupied  by  fluid  or  solid  exudate 
or  other  pathological  products.    It  is  congenital  or  acquired. 

Congenital  Atelectasis. — The  lung  is  airless  at  birth,  or  remains 
only  partially  expanded  in  consequence  of  deficient  inspiratory  efforts  or 
obstruction  of  the  respiratory  passages  by  meconium  or  mucus.  The 
respiration  is  feeble,  ultimately  gasping,  shallow  and  rapid,  the  lower 
part  of  the  thorax  and  the  epigastrium  are  retracted  during  inspiration, 
there  is  universal  deep,  bluish-black  cyanosis,  together  with  muscular 
twitchings  or  general  shivering  convulsions. 

Acquired  Atelectasis.  —  This  is  a  secondary  anatomical  lesion. 
It  is  caused  in  two  ways:  (a)  by  obstruction  of  small  bronchi  by  mucus 
or  swelling  of  the  mucosa — as  in  bronchopneumonia,  the  intra-alveolar 
air  undergoing  resorption  by  the  capillaries  and  the  vesicles  collapsing 
by  virtue  of  the  elasticity  of  their  walls;  or  (b)  by  pressure  upon  the 
lung  such  as  occurs  in  pleural  or  pericardial  effusions,  pneumothorax  and 
pneumopericardium,  tumors  of  the  lungs  or  pleura,  mediastinal  tumors 
or  massive  enlargement  of  the  heart,  scoliosis,  and  abdominal  disorders 
which  restrict  the  movements  of  the  diaphragm,  including  persistent 
meteorism,  large  ascites,  and  visceral  and  other  tumors.  Diffuse  atelectasis 
may  arise  in  paretic  conditions  involving  the  muscles  of  respiration. 

Symptoms. — The  clinical  phenomena  vary  according  to  the  extent  of 
lung  tissue  involved.  In  slight  cases  they  are  not  distinctive.  There  may 
be  moderate  dyspnoea,  cyanosis,  a  vesiculotympanitic  percussion  sound, 
and  enfeebled  vesicular  murmur.  When  extensive  atelectasis  is  present, 
especially  if  superficial,  there  are  signs  of  consolidation,  namely,  dulness, 
increased  vocal  fremitus,  bronchial  respiration,  and  bronchophony.  If 
there  are  in  the  affected  region  lobules  which  are  incompletely  collapsed, 
the  percussion  sound  has  the  tympanitic  quality  and  there  is  persistent 
fine  crepitus.  The  clinical  picture  is  usually,  however,  dominated  by  the 
symptoms  of  the  primary  affection.  A  condition  showing  the  above  symp- 
tom-complex which  is  transitory,  that  is,  which  passes  off  in  the  course  of 
twenty-four  hours,  is  from  this  very  fact  almost  sure  to  be  due  to  atelectasis. 


BRONCHOPNEUMONIA.  1071 

(c)    BRONCHOPNEUMONIA^ 

Lobular  Pneumonia;    Catarrhal  Pneumonia;   So-called  Capillary  Bronchitis. 

Definition. — Inflammation  of  capillary  or  terminal  bronchi  and  the 
air-vesicles  which  constitute  the  corresponding  pulmonary  lobules.  There 
are  several  forms,  all  of  which  are  caused  by  bacterial  invasion  of  the  lungs. 
The  disease  may  be  primary  or  secondary  and  is  characterized  clinically 
by  symptoms  of  infection  and  interference  with  the  respiratory  function. 

Etiology. — Predisposing  Influences. — Bronchopneumonia  is  com- 
mon at  the  extremes  of  life.  In  children  the  relatively  small  size  of  the 
bronchi,  their  more  abundant  vascular  supply,  and  the  more  rapid  and 
exuberant  growth  of  the  epithelium  of  the  bronchial  mucosa  constitute 
predisposing  factors  of  great  importance;  while  in  the  aged  tissue  relaxa- 
tion, tendencies  to  passive  congestion,  and  diminished  reflex  excitability 
on  the  part  of  the  bronchial  mucous  membrane  act  in  the  same  way.  Bron- 
chopneumonia is  more  prevalent  in  the  winter  and  spring  than  at  other 
seasons  of  the  year.  It  is  more  common  among  the  poorer  classes.  In 
the  great  majority  of  the  cases  bronchopneumonia  occurs  as  a  secondary 
or  intercurrent  process.  There  are  two  principal  groups  of  cases:  1.  Those 
in  which  it  arises  in  the  course  of  simple  bronchitis  or  an  acute  infectious 
disease  in  which  bronchitis  forms  part  of  the  symptom-complex,  as  measles, 
pertussis,  diphtheria,  scarlet  fever,  influenza,  and  less  frequently  the 
variolous  diseases,  erysipelas,  and  enteric  fever.  It  is  a  common  complica- 
tion of  the  acute  intestinal  diseases  of  infancy.  Bronchopneumonia  is  a 
grave  complication  in  all  these  affections  and  constitutes  the  cause  of 
death  in  the  majority  of  fatal  cases.  Its  frequency  corresponds  closely 
to  their  epidemic  prevalence.  It  is  far  less  common  in  the  acute  febrile 
diseases  of  middle  life.  In  the  aged  it  is  a  common  complication  and  fre- 
quently forms  the  terminal  event  in  various  acute  and  chronic  diseases. 
The  consolidating  lesions  of  pulmonary  tuberculosis  are  due  to  chronic 
localized  tuberculous  bronchopneumonia.  2.  Aspiration  or  deglutition 
pneumonia.  In  the  stupor  of  the  low  fevers  and  in  comatose  states  of  all 
kinds  the  reflex  excitability  of  the  larynx  is  lowered,  and  the  secretions  of 
the  mouth,  minute  portions  of  drink,  and  particles  of  food  during  the  act 
of  swallowing  are  drawn  into  the  trachea  and  bronchi.  In  this  situation 
they  set  up  an  active  bronchitis  which  by  extension  rapidly  involves  the 
smaller  bronchi  and  gives  rise  to  an  intense  bronchopneumonia.  This 
accident  is  very  common  after  operations  upon  the  throat,  nose,  larynx, 
and  trachea.  Most  cases  of  ether  pneumonia  arise  in  this  way.  The  infect- 
ing material  may  come  from  within  the  chest  itself;  severe  bronchopneu- 
monia not  rarely  follows  haemoptysis  and  occasionally  the  aspiration  of  the 
contents  of  a  bronchiectatic  cavity,  or  pus  from  an  empyema  which  has 
found  its  way  into  the  lung  by  way  of  a  bronchopulmonary  fistula  is  fol- 
lowed by  this  disease.  The  extension  of  tuberculosis  from  one  part  of  a  lung 
to  another,  or  to  the  opposite  lung,  is  due  in  some  instances  to  aspiration. 

Exciting  Cause. — Various  micro-organisms  are  associated  w'ith  the 
lesions  of  bronchopneumonia.  In  the  primary  form  which  attacks  young 
children  in  previous  health  the  common  organism  is  the  pneumococcus, 


1072  MEDICAL  DIAGNOSIS. 

which  may  be  found  in  pure  culture.  In  the  secondary  forms  the  strepto- 
coccus is  the  common  infecting  agent,  but  mixed  infections  are  usual.  The 
organisms  present  are  the  Bacillus  pneumoniae  of  Friedlander,  Streptococcus 
pyogenes,  Staphylococcus  albus  et  aureus.  The  Klebs-Loffler  bacillus 
is  frequently  found  in  the  bronchopneumonia  of  diphtheria,  and  Pfeiffer's 
bacillus  in  influenza  pneumonias. 

The  lesions  consist  in  interstitial  inflammation  of  the  bronchi  and 
alveolar  walls.  The  small  bronchi  are  plugged  with  exudate  composed  of 
leucocytes  and  swollen  epithelium;  their  walls  are  swollen,  infiltrated 
with  cells,  and  traversed  by  distended  capillaries,  and  there  is  dense  peri- 
bronchial infiltration.  The  vesicles  are  filled  with  leucocytes  and  swollen 
epithelium,  and  rarely  show  the  dense  accumulations  of  red  corpuscles 
and  the  fibrillated  fibrin  seen  in  croupous  pneumonia. 

The  pathological  unit  is  the  inflamed  pulmonary  lobule.  Hence  the 
descriptive  term  lobular  pneumonia.  According  to  the  distribution  of 
the  lesions  three  anatomical  forms  exist:  1.  There  is  more  or  less  intense 
bronchitis  extending  to  the  finer  tubes,  without  the  gross  evidences  of 
lobular  consolidation,  but  with  the  microscopic  findings  of  inflammation. 
This  form  is  bilateral.  2.  The  foci  of  inflammation  are  scattered  through- 
out the  lung  tissue,  with  lobular  collapse  and  infiltrated  lobules  felt  as  hard 
nodules.  These  patches  of  bronchopneumonia  are  sometimes  isolated 
with  strands  of  congested  or  uninflamed  tissue  intervening  and  areas  of 
collateral  emphysema,  and  sometimes  massed  in  groups  of  considerable 
size.  This  form  is  also  bilateral.  3.  The  greater  part  of  a  lobe  is  often 
involved — the  pseudolobar  form  of  bronchopneumonia.  Even  in  this 
form  the  consolidation  is  not  uniform  as  in  croupous  pneumonia,  but 
there  are  more  or  less  extensive  tracts  of  deeply  congested  but  still  crepitant 
tissue  scattered  among  the  inflamed  lobules. 

The  terminations  are  in  resolution,  suppuration  or  gangrene,  or  fibro- 
sis. In  the  tuberculous  forms,  which  are  very  common  in  previously  ap- 
parently healthy  children,  bronchopneumonia  terminates  in  caseation  or 
chronic  fibroid  changes.  Such  cases  often  follow  measles,  pertussis,  or 
diphtheria  and  may  be  the  result  of  the  lighting  up  of  a  latent  tuberculosis 
or  of  tuberculous  infection  at  the  time. 

Symptoms. — The  onset  of  the  primary  form  is  abrupt.  It  is  marked 
by  convulsions  and  sudden  rise  of  temperature.  Cerebral  symptoms  are 
frequent  and  often  intense.  The  defervescence  may  be  critical.  These 
cases,  which  run  a  course  analogous  to  that  of  croupous  pneumonia  and 
present  similar  symptoms  and  localized  physical  signs,  when  they  terminate 
fatally  often  show  pseudolobar  consolidation  and  the  pneumococcus  in 
the  lesions. 

The  secondary  forms  are  preceded  bj^  the  signs  of  a  bronchitis  extend- 
ing to  the  smaller  tubes.  The  disease  develops  gradually  without  chill 
or  convulsion.  The  I'ever  is  of  variable  intensity— 102°-104°  F.  (39°-40°  C.) 
— and  does  not  conform  to  type,  being  irregularly  remittent.  The  skin  is 
hot  and  dry.  There  is  cough,  which  is  hard,  dry,  and  distressing.  The 
respiration  frequency  may  reach  60  to  80  per  minute,  and  cyanosis  soon 
appears.  Other  evidences  of  deficient  oxygenation  of  the  blood  are  fre- 
quent, small,  thready  pulse,  stupor,  restlessness,  and  occasional  convulsive 


BRONCHOPNEUMONIA. 


1073 


tremor.  The  cough  becomes  less  urgent,  the  child  no  longer  struggles 
for  air,  the  face  becomes  suffused  and  loses  its  anxious  expression,  and 
death  occurs  from  cardiac  paralysis.     Sputum  (see  Part  III,  page  457). 

Physical  Signs. — Upon  inspection  there  are  early  signs  of  obstruction 
in  the  terminal  bronchi,  inspiratory  retraction  of  the  intercostal  spaces 
and  lower  sternal  and  epigastric  regions,  rapid,  shallow,  jerky  respiration, 
and  cyanosis  of  the  lips  and  finger-tips.  Percussion. — Death  may  occur 
before  signs  of  consolidation  develop.  There  may  be  merely  vesiculo- 
tympanitic resonance.  If  consolidation  is  present  impaired  resonance, 
sometimes  actual  dulness,  is  found  at  the  bases  in  scattered  areas.     To 


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Fig.  316. — Bronchopneumonia  in  a  man  aged  seventy-six. 


elicit  it  in  the  latter  case  demands  very  careful  light  percussion.  Com- 
pensatory emphysema  may  mask  small  areas  of  dulness.  Auscultation 
in  the  early  stages  reveals  only  the  signs  of  the  extension  of  the  bronchitis 
to  the  finer  tubes,  namely,  many  diffuse  small  mucous  and  some  crepitant 
rales.  These  are  usually  more  intense  and  numerous  at  the  bases  posteri- 
orly. Vesiculobronchial  and,  here  and  there,  pure  bronchial  respiration 
may  be  heard  over  the  patches  of  dulness.  Failure  of  the  right  heart  is 
followed  by  pulmonary  oedema,  which  is  usually  the  forerunner  of  the 
death  agony. 

Clinical  Varieties.  —  1.  Primary  Form.  —  It    is  a  question  whether 
many  of  these  cases  are  not  in  truth  irregular "  forms  of  croupous  pneu- 
monia— pneumococcus  pneumonia.     The  primary  form  is  rare  in  adults. 
68 


1074 


MEDICAL  DIAGNOSIS. 


2.  Masked  Forms. — The  actual  condition  may  in  infants  be  masked  by 
cerebral  symptoms  such  as  also  occur  in  croupous  pneumonia  at  this 
period  of  life,  namely,  convulsions,  drowsiness,  retraction  of  the  muscles 
of  the  back  of  the  neck,  and  stupor;  or  by  gastro-intestinal  symptoms., 
such  as  nausea,  vomiting,  and  looseness  of  the  bowels.  3.  Suffocative 
Catarrh. — The  overwhelming  cases  were  so  designated  by  the  earlier 
writers.  The  ordinary  acute  cases  of  this  group,  fatal  in  the  course  of 
two  or  three  days,  are  most  appropriately  described  under  this  term. 
4.  Secondary  Forms. — Mild    secondary    bronchopneumonia    may    follow 


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Fig.   318.  —  Fatal  bronchopneumonia. 
Man  aged  seventy-six. 


severe  forms  of  bronchitis,  both  in  children  and  adults.  This  form  assumes 
great  importance  in  diagnosis,  since  it  may  be  merely  a  simple  pathological 
condition,  on  the  one  hand,  or  an  insidiously  developing  tuberculous  bron- 
chopneumonia, upon  the  other.  5.  Ether  Pneumonia;  Postoterative 
Pneumonia. — This  form  of  bronchopneumonia  usualty  is  pseudolobar  and 
presents  close  resemblances  to  croupous  pneumonia.  The  anaesthesia  bron- 
chitis which  precedes  the  pneumonic  symptoms,  the  low  temperature 
range,  the  absence  of  bloody  sputum,  and  the  course  of  the  attack  are 
significant.     In  a  majority  of  the  cases  it  is  an  inhalation  pneumonia. 

Course  and  Duration.  —  Bronchopneumonia  is  not  a  self-limited 
disease.  The  primary  cases,  which  suggest  croupous  pneumonia,  run  a 
short  course  and  frequently  terminate  by  crisis.     The  secondary  cases 


CHRONIC  INTERSTITIAL  PNEUMONIA.  1075 

are  often  prolonged  and  the  defervescence  is  by  lysis.  Fatal  cases  in  chil- 
dren often  come  to  an  end  in  from  3  to  5  days.  The  duration  of  favorable 
cases  is  from  1  to  4  or  5  weeks.  Recovery  may  still  take  place  after  an 
illness  of  8  or  10  weeks.     In  protracted  cases  tuberculosis  is  to  be  feared. 

Diagnosis.  —  Direct.  —  A  positive  diagnosis  cannot  be  made  unless 
the  signs  of  consolidation  are  present.  Circumscribed  areas  of  relative 
dulness,  usually  bilateral  with  vesiculotympanitic  resonance  interspersed, 
together  with  high-pitched,  small  mucous  and  crepitant  rales,  bronchial 
breathing,  bronchophony,  and  increased  vocal  fremitus  are  diagnostic 
in  the  primary  as  well  as  in  the  secondary  forms.  In  cases  in  which  the 
lesions  are  massed  in  a  single  lobe,  careful  physical  examination  will  almost 
always  show  a  focus  of  consolidation  upon  the  opposite  side.  The  signs 
of  consolidation  are  often  absent,  especially  early  in  the  attack.  The 
diagnosis  is  even  then  probable  if  in  bronchitis  the  temperature  rises  to 
104°  F.  (40°  C),  the  cough  becomes  short,  harassing,  and  painful,  the 
respiration  and  pulse-frequency  become  high,  cyanosis  develops,  and 
diffuse,  high-pitched  fine  rales  are  heard. 

Differential. — Croupous  Pneumonia  (see  page  728).  Acute  Miliary 
Tuberculosis  (see  page  790).  Acute  Tuberculous  Bronchopneumonia  (see 
page  804).  Atelectasis. — The  dulness  and  rales  of  this  condition  are  modi- 
fied and  sometimes  even  disappear  upon  change  of  posture.  Fever  is  not 
an  essential  concomitant.  If  present  it  is  usually  due  to  an  associated 
bronchitis.  Meningitis. — In  infants  marked  cerebral  symptoms  sometimes 
occur,  and  the  condition  closely  simulates  meningitis.  The  differential 
diagnosis  between  tuberculous  meningitis  and  bronchopneumonia  with 
cerebral  symptoms  can  in  some  cases  only  be  made  by  time. 

Prognosis. — The  outlook  is  much  more  favorable  in  the  primary  than 
in  the  secondary  forms.  It  is  greatly  influenced  by  the  age  of  the  patient. 
Within  the  first  year  almost  every  case  dies;  until  the  fifth  year  from  30  to 
50  per  cent. ;  in  the  aged  the  prognosis  is  ominous.  Pale,  fat,  flabby  children 
do  not  bear  the  disease  well.  Aspiration  pneumonia  is  a  very  fatal  disease, 
especially  that  form  which  follows  operations  upon  the  mouth  and  throat. 

iii.  Diseases  of  the  Lungs  Characterized  by  Interstitial 

Inflammation. 

(a)  CHRONIC  INTERSTITIAL  PNEUMONIA. 

Cirrhosis  of  the  Lung. 

Definition. — Chronic  inflammation  of  the  lung  with  increase  of  the 
interstitial  tissue  and  decrease  in  the  vesicular  tissue,  with  general  indura- 
tion and  contraction.  There  are  two  forms,  the  local  or  circumscribed, 
and  the  diffuse,  involving  the  greater  part  of  one  or  both  lungs. 

1.  Local  Pulmonary  Fibrosis. — This  condition  is  very  common. 
It  occurs  as  a  secondary  process  in  inflammatory  diseases  of  the  lung,  as 
bronchitis,  croupous  pneumonia,  and  bronchopneumonia.  It  constitutes 
an  important  feature  in  the  complex  lesions  of  tuberculosis  and  the  chief 
final  local  process  in  obsolescent  or  cured  tuberculous  disease.     It  is  the 


1076  MEDICAL  DIAGNOSIS. 

termination  of  pulmonary  atelectasis  prolonged  through  the  stages  of  com- 
pression and  carnification  until  the  tissue  has  become  organized  and  expan- 
sion is  no  longer  possible.  Hence  it  is  a  feature  of  the  lung  tissue  adjacent 
to  aneurisms,  tumors,  abscesses,  hydatids,  and  gummata.  It  is  especially 
important  as  the  outcome  of  neglected  pleural  effusion,  because  by  the 
early  withdrawal  of  the  exudate  the  pressure  atelectasis  may  be  relieved 
and  subsequent  fibroid  changes  minimized.  The  clinical  phenomena  of 
local  fibroid  changes  are  subordinate  to  those  of  the  primary  disease  which 
it  accompanies.  Retraction  of  the  supra-  or  infraclavicular  spaces,  or  cir- 
cumscribed retraction  elsewhere,  is  suggestive.  Nevertheless  the  diagnosis 
must  often  be  provisional  rather  than  positive.  The  chief  importance  of 
the  condition  arises  from  its  often  constituting  the  point  of  departure  for 
fibroid  changes  involving  the  entire  lung. 

2.  Diffuse  Pulmonary  Fibrosis. — To  a  certain  extent  the  etiological 
factors  are  the  same  as  in  the  localized  form.  Thus  the  fibroid  changes 
in  chronic  bronchitis  and  emphysema,  and  associated  with  bronchiecta- 
sis, are  usually  diffuse.  When  the  condition  follows  pressure  atelectasis 
it  may  be  diffuse  when  the  greater  part  of  a  lobe  or  lung  is  compromised. 
Other  conditions  which  may  be  followed  by  chronic  interstitial  pneumonia 
are  the  irritation  of  a  foreign  body  long  retained  in  a  bronchus,  chronic 
bronchopneumonia,  in  rare  instances  unresolved  croupous  pneumonia, 
pleurisy,  the  connective-tissue  overgrowth  invading  the  lung  from  a  chronic 
fibrinous  pleural  exudate — the  pleurogenous  form  of  chronic  interstitial 
pneumonia — and  syphilis. 

Two  forms  are  recognized,  (a)  Lobar  Interstitial  Pneumonia. — The 
disease  is  unilateral.  The  entire  lung  is  usually  involved.  It  frequently 
appears  as  a  small,  dense,  airless  mass  of  tissue  lying  along  the  spine.  It 
is  densely  indurated,  showing  upon  section  a  compact,  grayish,  fibroid 
tissue  traversed  by  the  bronchi  and  blood-vessels.  In  the  pleurogenous 
form  the  lung  is  bound  to  the  wall  of  the  thorax  by  dense,  thick,  pleural 
adhesions.  When  the  process  has  been  intrapulmonary  from  the  beginning 
the  pleural  adhesions  may  be  of  only  moderate  thickness.  Bronchiectasis 
is  common  and  often  very  extensive.  In  tuberculous  cases  vomicse  and 
caseating  foci  are  present  and  the  opposite  lung  shows  evidences  of  tubercle. 
The  right  heart  is  hypertrophied,  and  atheroma  and  local  arteriosclerosis 
are  frequently  encountered.  The  heart  is  displaced  toward  the  affected 
side.  The  opposite  lung  is  emphysematous — vicarious  emphysema — and 
its  border  extends  beyond  the  median  line  toward  the  affected  side, 
(b)  Disseminated  Interstitial  Pneumonia.  —  The  condition  is  bilateral. 
There  are  circumscribed  areas  of  fibrosis  separated  by  lung  tissue  more  or 
less  emphysematous — collateral  vicarious  emphysema.  These  fibroid  islets 
are  deeply  situated  in  the  lung  tissue  and  more  frequently  in  the  lower 
lobes.     They  surround  bronchiectatic  dilatations. 

Symptoms. — Fever  when  present  is  due  to  an  acute  associated  process, 
or  to  tuberculosis.  There  are  cough,  dyspnoea  upon  exertion,  and  expecto- 
ration, which  may  show  the  special  characteristics  of  the  sputum  of  bron- 
chiectasis. Haemoptysis  is  fairly  common,  especially  in  the  tuberculous 
cases.  The  affection  is  the  very  type  of  a  chronic  disease  but  the  adapta- 
tions are  remarkable.     The  general  health  is  often  remarkably  good  when 


CHRONIC  INTERSTITIAL  PNEUMONIA.  1077 

the  extent  and  nature  of  .the  lesions  are  considered,  and  the  patients  are 
capable  of  conducting  their  affairs. 

Physical  Signs. — Inspection. — The  deformity  of  the  chest  in  well- 
developed  cases  is  conspicuous  both  in  the  unilateral  and  bilateral  types 
of  the  affection,  though  in  the  latter  retraction  is  more  or  less  modified 
by  compensatory  emphysema.  In  the  unilateral  variety  the  affected  side 
of  the  thorax  is  retracted  and  immobile.  The  ribs  approach  each  other 
so  that  the  intercostal  spaces  are  obliterated,  or  the  ribs  may  overlap.  The 
shoulder  droops  and  there  is  lateral  curvature  of  the  spine,  the  concavity 
in  the  dorsal  region  being  toward  the  affected  side.  The  respiratory 
muscles  and  those  of  the  shoulder  and  arm  are  wasted.  The  semicircum- 
ference  of  the  affected  side  is  much  diminished  and  remains  uninfluenced 
by  respiratory  effort.  The  heart  is  strongly  displaced  toward  the  affected 
side,  being  drawn  over  by  the  contracting  lung.  The  changes  in  the  cardiac 
phenomena  are  much  more  apparent  when  the  left  lung  is  involved.  Under 
these  circumstances  there  may  be  an  extensive  area  of  pulsation  in  the 
second,  third,  and  fourth  interspaces  to  the  left  of  the  sternal  border.  When 
the  right  lung  is  affected  the  cardiac  impulse  may  be  wholly  obliterated 
by  the  extending  median  border  of  the  emphysematous  left  lung.  The 
unaffected  side  is  in  strong  contrast  with  its  large  size,  wide  intercostal 
spaces,  and  free  respiratory  excursus.  Palpation. — If  the  bronchi  are 
unobstructed  the  vocal  fremitus  is  increased  over  the  affected  side.  There 
is  usually  epigastric  pulsation  transmitted  from  the  right  heart.  Cardiac 
pulsation  is  well  felt  in  the  second,  third,  and  fourth  interspaces  in  left- 
sided  fibrosis,  and  in  some  cases  there  is  a  short  diastolic  thrill  to  the  left 
of  the  pulmonary  area.  Percussion. — Dulness  is  usually  marked  and 
may  be  extreme  at  the  apex  and  base.  When  the  bronchi  are  extensively 
dilated  the  percussion  sound  has  the  tympanitic  quality.  This  may  be 
especially  marked  in  the  axillary  region.  Over  the  opposite  lung  there  is 
hyperresonance.  Upon  linear  percussion  the  anterior  border  of  the  unaf- 
fected lung  is  found  to  be  displaced  as  far  as,  or  even  beyond,  the  sternal 
border  on  the  affected  side,  and  its  lower  border  displaced  downward, 
while  the  lower  border  of  the  affected  lung  and  the  related  organ,  i.e., 
liver  or  spleen,  are  displaced  upward  and  show  no  respiratory  movement. 
Auscultation. — There  is  more  or  less  widely  extended  bronchial  respira- 
tion. At  the  apex  the  quality  may  be  cavernous  or  amphoric;  at  the  base 
feeble  and  distant.  In  some  cases  small  mucous  rales  are  heard.  There 
is  bronchophony  and,  if  bronchial  dilatation  extends  to  the  periphery  of 
the  lung,  whispering  pectoriloquy  may  be  heard.  The  pulmonary  second 
sound  is  accentuated  and  endocardial  murmurs  frequently  appear  toward 
the  close  of  the  disease  as  dilatation  and  failure  of  the  right  heart  come  on. 

Diagnosis. — In  the  disseminated  form  the  diagnosis  may  be  obscure. 
The  symptoms  and  signs  may  be  simply  those  of  bronchiectasis.  In  the 
unilateral  form  the  diagnosis  is  unattended  with  difficulty.  The  underlying 
condition  cannot,  however,  always  be  determined.  The  resemblance  to 
fibroid  phthisis  is  often  very  close.  Signs  of  disease  in  the  opposite  lung, 
especially  at  the  apex,  fever,  haemoptysis,  and  foci  of  moist  rales  are  in 
favor  of  a  diagnosis  of  tuberculosis.  Tubercle  bacilli  in  the  sputum  are 
conclusive. 


1078  MEDICAL  DIAGNOSIS. 

Prognosis.  —  The  outlook  as  regards  life  is  favorable;  as  regards 
recovery  hopeless.  The  patients  live  many  years  and  often  have  no  great 
inconvenience  except  from  cough,  expectoration,  and  dyspnoea  upon  exer- 
tion. The  powers  of  resistance  are  diminished  and  they  readily  succumb 
to  intercurrent  disease.  Otherwise  death  is  commonly  due  to  progressive 
failure  of  the  right  heart  or  amyloid  disease. 

(b)  PNEUMONOCONIOSIS. 

Definition. — Disseminated  fibrosis  of  the  lungs  caused  by  the  habitual 
inhalation  of  a  dust-laden  atmosphere  in  various  occupations. 

Etiology.  —  Pneumonoconiosis  is  the  very  type  of  an  occupation 
disease.  Several  varieties  are  described,  according  to  the  character  of 
the  work  and  the  nature  of  the  dust  inhaled:  aidhracosis  or  coal  miners' 
disease;  siderosis,  the  form  caused  by  inhaling  metallic  dust,  especially 
iron  oxide,  and  brass  and  bronze  particles;  chalicosis,  due  to  mineral 
dusts,  as  stonecutters'  consumption  or  the  grinders'  rot  of  the  workers  in 
cutlery.  Similar  affections  occur  in  workers  in  flax  and  cotton  and  in 
grain  shovellers. 

The  condition  of  the  lungs  in  advanced  cases  of  the  disease  caused  by 
different  substances  is  practically  the  same.  The  interstitial  inflammation 
starts  from  the  peribronchial  lymph-nodes  in  which  the  dust  particles 
excite  proliferation  of  connective  tissue,  and  in  the  early  stages  of  the 
process,  esi3ecially  in  anthracosis,  is  confined  to  these  tissues.  There  is  an 
associated  chronic  bronchitis  to  which  many  of  the  symptoms  are  due. 
Bronchiectasis  is  common  and  in  a  majority  of  the  cases  the  clinical  picture 
is  that  of  a  chronic  bronchitis  with  emphysema.  In  anthracosis  there  is 
a  carbon-laden  black  spit.  In  advanced  cases  softening  occurs  in  the 
indurated  nodules,  and  small  cavities  are  formed  which  in  some  cases 
suppurate  and  discharge  a  purulent  fluid  by  way  of  the  bronchi.  Notwith- 
standing the  prevalence  of  anthracosis  among  coal  miners  tuberculous 
phthisis  is  comparatively  rare. 

Symptoms. — The  disease  does  not  show  itself  until  after  long  exposure 
to  the  dust.  There  are  the  general  signs  of  failing  health,  with  cough, 
expectoration,  often  abundant,  dyspnoea,  and  wheezing,  especially  upon 
exertion.  The  mucopurulent  sputum  in  anthracosis  is  blackish.  It  is 
popularly  known  as  ''black  spit."  That  of  the  other  forms  is  light  or 
grayish  in  color,  without  gross  characteristics.  In  chalicosis  glittering 
crystalloid  particles  of  silicious  material  may  be  seen.  Under  the  micro- 
scope the  dust  particles  are  seen  in  the  alveolar  epithelium.  Tuberculosis 
may  form  the  terminal  condition. 

Diagnosis. — The  direct  diagnosis  is  not  as  a  rule  difficult.  The  anam- 
nesis, the  gradual  development  of  the  affection  after  years  of  exposure, 
the  symptoms  of  chronic  bronchitis  with  emphysema  and  bronchiectasis, 
the  mucopurulent  sputum  with  the  special  characteristics  mentioned, 
and  the  absence  of  tubercle  bacilli  are  all  of  diagnostic  importance. 

Prognosis. — The  outlook  is  favorable  if  the  condition  is  recognized 
early  and  the  patient  can  change  his  work.  Otherwise  the  cases  run  a 
progressive  though  very  chronic  course. 


PULMONARY  ABSCESS.  1079 

iv.  Diseases  of  the  Lungs  due  to  Suppuration  and 

Necrosis. 

(a)  PULMONARY   ABSCESS. 

Definition.  —  Localized  collections  of  pus  in  cavities  formed  by  the 
disintegration  of  lung  tissue. 

Etiology.  —  Pulmonary  abscess  is  a  secondary  process  due  to  the 
intense  action  of  various  pyogenic  organisms,  among  which  streptococci 
and  staphylococci  are  the  most  common.  It  may  occur  under  the 
following   conditions: 

1.  Acute  Inflammation. — Suppuration  may  follow  croupous  pneu- 
monia. It  occurs  in  two  forms:  first,  the  purulent  infiltration  which  con- 
stitutes an  advanced  stage  of  gray  hepatization,  and  second,  the  much 
more  rare  condition  of  actual  abscess  cavity.  The  latter  are  usually  small, 
multiple,  with  shreddy  walls,  and  frequently  contain  necrotic  tissue. 
They  tend  by  fusion  to  form  larger  abscesses.  Purulent  infiltration  and 
abscess  are  sometimes  present  in  the  same  lung.  Abscess  is  more  common 
in  bronchopneumonia,  especially  the  form  known  as  aspiration  or  degluti- 
tion pneumonia.  In  the  low  fevers  and  stuporous  and  comatose  conditions, 
after  wounds  of  the  neck  and  operations  upon  the  nose,  throat,  and  mouth, 
and  suppurative  diseases  of  these  parts,  an  intense  acute  bronchitis  fre- 
quently arises,  which  by  extension  involves  the  distant  tubules  and  causes 
purulent  bronchopneumonia.  Multiple  abscesses,  mostly  minute  but 
frequently  attaining  the  size  of  an  orange,  may  result.  A  similar  condition 
may  follow  the  inflammation  caused  by  a  foreign  body  lodged  in  a  bronchus. 
Pulmonary  abscess  is  a  relatively  common  sequel  of  epidemic  influenza. 
2.  Traumatism. — Perforation  of  the  lung  from  without,  as  in  stab  or 
gunshot  wounds,  laceration  of  the  lung  by  a  fractured  rib,  and  analogous 
accidents,  may  cause  pulmonary  abscess.  3.  Perforation  from  Within. — 
Sudden  invasion  of  the  lung  by  purulent  or  otherwise  infected  substances 
from  adjacent  organs  is  a  common  cause  of  abscess.  Cancer  of  the  oesopha- 
gus, abscess  of  the  liver,  a  suppurating  hydatid  cyst,  or  the  aspiration  of 
the  pus  in  empyema  suddenly  rupturing  into  the  lung  may  cause  abscess. 
4.  Infective  Emboli. — Metastatic  abscesses  in  the  lung  are  common 
in  septic — pyemic — states.  The  purulent  foci  are  multiple,  mostly  sub- 
pleural,  and  at  first  wedge-shaped.  They  are  commonly  small,  but  occa- 
sionally extensive  purulent  infection  occurs.  The  related  pleura  is  inflamed 
and  covered  with  a  thick,  greenish  lymph.  Occasionally  softening  and 
perforation  are  followed  by  pneumothorax.  5.  Tuberculous  Abscesses. 
— Circumscribed  local  suppurative  processes  enter  largely  into  the  com- 
plex lesions  of  pulmonary  tuberculosis,  especially  in  the  later  course  of 
the  disease.  They  are  associated  with  caseation  and  cavity  formation, 
and  give  rise  to  important  and  significant  symptoms  and  physical  signs. 

Symptoms. — As  in  other  suppurative  processes  there  are  irregular 
chills  and  fever.  In  pneumonia  the  general  symptoms  are  aggravated, 
the  sputum  becomes  purulent,  and  the  signs  of  a  cavity  can  sometimes  be 
demonstrated.  In  pytemia  the  local  symptoms  of  pulmonary  abscess  are 
obscured  by  the  general  symptoms  of  sepsis,  and  the  condition  is  usually 


1080  MEDICAL  DIAGNOSIS. 

overlooked.  Aside  from  the  presence  of  pus  in  large  amounts  the  sputum 
presents  characters  of  diagnostic  importance  (see  Part  III,  page  457). 

Physical  Signs.^The  signs  of  a  cavity  which  empties  itself  under 
the  stress  of  violent  paroxysms  of  cough,  and  again  refills,  may  be  elicited 
upon  physical  examination  when  the  abscess  is  of  sufficient  size  and  situ- 
ated in  the  periphery  of  the  lung.  In  small  abscesses  the  signs  are  often 
wholly  inconclusive. 

Diagnosis. — Direct. — When  the  above  symptoms  and  signs  are  pres- 
ent, especially  when  the  etiological  factors  essential  to  diagnosis  can  be 
established  and  purulent  sputum  containing  elastic  fibres  and  the  other 
characters  named  accompanies  the  cough,  the  diagnosis  is  positive.  In 
many  cases,  however,  it  is  at  best  provisional,,  and  not  rarely  abscess 
in  the  lungs  not  suspected  during  life  is  found  upon  the  post-mortem  table. 

Differential. — Collections  of  Pus  Perforating  into  the  Lung. — Accu- 
mulations that  may  break  into  the  lung  occur  in  empyema,  subphrenic 
abscess,  hepatic  abscess,  suppurating  hydatid  cyst,  in  spinal  caries,  and 
other  suppurative  processes  in  adjacent  viscera.  The  differential  diag- 
nosis rests  upon  the  presence  of  symptoms  and  signs  significant  of  such 
pathological  conditions,  and  especially  upon  the  absence  of  the  elastic 
fibres  from  the  expectorated  pus.  Bronchiectasis. — The  etiological  factors 
are  different.  Both  are  secondary  affections,  but  bronchiectasis  is  a  chronic, 
pulmonary  abscess  an  acute,  affection.  The  cough  is  more  urgent  and  less 
constant  in  bronchiectasis,  and  the  sputum  more  foul  and  does  not  as  a  rule 
contain  elastic  fibres,  which,  when  present,  are  less  abundant  than  in 
abscess.  Pulmonary  Cavities  in  Tuberculosis. — Etiological  considerations 
are  important.  The  slow  development  of  phthisical  cavities,  their  antecedent 
■and  concomitant  phenomena,  the  characters  of  the  sputum,  and  the  pres- 
ence of  tubercle  bacilli  are  of  positive  diagnostic  significance.  Pulmonary 
Gangrene. — The  sputum  in  gangrene  of  the  lung  has  an  extremely  intense, 
putrid  odor  not  often  present  in  the  purulent  expectoration  of  pulmonary 
abscess,  and  contains  shreds  of  decomposing  lung  tissue,  which  can  be 
readily  detected  when  it  is  spread  out  upon  a  glass  plate.  These  shreds 
frequently  present  the  structure  of  the  pulmonary  alveoli. 

(b)  GANGRENE  OF  THE  LUNG. 

Definition. — Decomposition  of  lung  tissue  caused  by  the  action  of  the 
bacteria  of  putrefaction.     It  may  be  diffuse  or  circumscribed. 

Etiology. — Sphacelus  of  the  lung  occurs  as  an  anatomical  condition 
under  a  variety  of  circumstances.  Impaired  vitality  of  the  tissues  from 
general  or  local  causes  is  a  necessary  predisposing  factor.  The  subjects 
are  commonly  greatly  debilitated  by  long-continued  chronic  or  grave 
acute  disease.  Severe  general  disturbances  of  nutrition,  such  as  are  caused 
by  prolonged  infections  or  disease  of  the  bones,  or  arise  in  malignant 
disease  or  diabetes  mellitus,  constitute  predisposing  influences  of  impor- 
tance. Equally  important  are  bronchiectasis,  especially  that  form  of  bron- 
chiectasis which  occurs  as  the  result  of  the  pressure  of  a  tumor  or  aneurism, 
tuberculous  cavities  and  putrid  bronchitis,  since  the  putrid  contents  of 
the  cavities  or  bronchi  often  cause  secondary  gangrene  when  aspirated 


GANGRENE  OF  THE  LUNG.  1081 

into  the  adjacent  tissues.  Among  the  acute  diseases  in  which  gangrene 
of  the  lung  occurs  are  croupous  pneumonia,  particular!}-  when  it  affects 
debilitated  or  diabetic  persons;  aspiration  bronchopneumonia,  whether 
the  infectious  material  be  derived  from  the  nose  or  throat  of  the 
patient,  or  from  some  focus  of  disease  adjacent  to  the  lung,  as  cancer  of 
the  oesophagus,  abscess  of  the  hver,  or  empyema;  emboHsm  of  the  pul- 
monary artery,  especially  when  the  embolus  is  infected,  as  in  pyaemia  or 
necrosis  of  the  bones,  and  in  enteric  fever  thrombosis  of  one  of  the  principal 
branches  of  the  pulmonary  artery.  No  satisfactory  explanation  of  the 
occasional  occurrence  of  gangrene  under  these  circumstances,  when  it 
remains  absent  in  the  majority  of  similar  cases,  has  been  advanced. 

1.  Diffuse  Pulmonary  Gangrene. — This  form  is  very  rare.  It  has 
been  observed  after  croupous  pneumonia  and  in  the  most  intense  cases  of 
aspiration  pneumonia.  It  may  also  occur  after  the  occlusion  of  a  large  branch 
of  the  pulmonary  artery  by  an  embolus  or  thrombus.  A  large  portion  or 
the  whole  of  a  lobe  may  undergo  putrefaction  in  the  course  of  a  day  or  two. 

2.  The  Circumscribed  Form. — The  gangrenous  portions  of  lung  are 
surrounded  by  an  intensely  congested  and  oedematous  border  of  tissue. 
The  lesions  may  be  single  or  multiple.  They  are  more  commonly  situated 
in  the  lower  lobes  than  the  upper  and  in  the  peripheral  than  in  the  central 
parts  of  the  lung.  The  greenish-black  gangrenous  tissue  rapidly  softens, 
with  the  form^ation  of  an  irregular  cavity  with  shreddy  walls  and  an 
abundant,  horribly  offensive  fluid. 

Symptoms. — The  expectoration  is  profuse,  thin,  and  green  or  brownish 
in  color.  Its  odor  is  exceedingly  fetid,  disgusting,  and  penetrating.  In  some 
instances  it  is  mawkishly  sweet.  It  is  not  only  present  upon  the  breath  but 
also  pervades  the  atmosphere  of  the  patient's  room  (see  Part  III,  p.  457). 
The  symptoms  of  the  primary  affection  and  constitutional  debility  usually 
precede  the  characteristic  phenomena  of  gangrene  of  the  lung.  There  is 
commonly  a  mioderate  fever  associated  with  rapid  pulse  and  great  general 
depression.     Hemorrhage  is  not  uncommon  and  may  prove  fatal. 

Physical  Signs. — The  signs  in  the  diffuse  form  are  those  of  infiltration, 
impaired  resonance,  with  the  tympanitic  quality,  and  vesiculobronchial 
or  bronchial  respiration.  In  the  circumscribed  form  the  signs  of  a  cavity 
predominate.  Very  often  in  limited  gangrene  the  signs  may  elude  detection. 
Severe  bronchitis  is  common. 

Diagnosis. — Direct. — The  sputum  and  the  odor  of  the  breath  are  char- 
acteristic.   The  presence  of  shreds  of  gangrenous  alveolar  tissue  is  conclusive. 

Differential. — From  putrid  bronchitis  and  bronchiectasis  gangrene 
of  the  lung  cannot  always  be  differentiated,  except  by  the  presence  of 
lung  tissue  in  the  sputum,  and  when  this  is  found  in  old  standing  cases 
it  constitutes  positive  evidence  of  secondary  gangrene. 

Prognosis. — Pulmonary  gangrene  is  almost  always  a  terminal  event. 
The  patient  sinks  rapidly  and  dies  from  exhaustion.  When  the  gangrenous 
area  can  be  localized,  and  the  condition  of  the  patient  is  favorable,  a  surgical 
operation  may  be  the  means  of  saving  life.  In  rare  cases  of  circumscrilied 
gangrene  encapsulation  has  taken  place,  and  still  more  rarely  recovery 
has  occurred  after  the  expectoration  of  pieces  of  gangrenous  lung  of 
considerable  size. 


1082  MEDICAL  DIAGNOSIS. 

V.  New  Growths  in  the  Lungs. 

Neoplasms  in  the  lungs  are  usually  malignant.  They  are  primary 
or  secondary.     The  former  are  rare;    the  latter  comparatively  common. 

1.  Primary  Tumors. — Carcinoma  is  the  usual  form.  Much  more 
rare  are  primary  sarcoma  and  endothelioma.  The  growth  usually  invades 
one  lung  and  forms  a  large  mass,  which  may  ultimately  break  down  and 
give  rise  to  a  cavity.  Diffuse  cancerous  infiltration  may  simulate  tuber- 
culous bronchopneumonia.  Diffuse  miliary  infiltration  has  been  described 
— carcinosis  'pulmonum  miliaris. 

2.  Secondary  New  Grow^ths. — Every  variety  of  malignant  growth 
may  by  metastasis  invade  the  lungs.  In  comparatively  rare  instances 
the  secondary  growth  may  be  solitary,  and  chiefly  involves  the  pleura. 
Usually  they  are  multiple  and  occupy  both  lungs.  Large  tracts  of  pul- 
monary tissue  may  be  densely  invaded.  The  primary  tumor  is  usually 
mammary,  in  the  gastro-intestinal  or  genito-urinary  tract,  or  in  the  bone. 
It  may  be  epithehoma,  scirrhus,  colloid,  sarcoma,  enchondroma,  or  osteoma. 
In  melanosarcoma  the  primary  growth  may  have  its  starting-point  in  a 
pigmented  mole.  In  Hodgldn's  disease  the  growth  may  perforate  the 
sternum  and  widely  involve  the  lungs,  or  it  may  reach  the  lungs  by  way 
of  the  tracheal  and  bronchial  lymph-nodes.  In  cancerous  disease  there 
is  commonly  secondary  implication  of  the  tracheal  and  bronchial  glands, 
and  less  often  of  the  cervical  chains.  Other  superficial  glands,  includ- 
ing the  inguinal,  may  be  enlarged.  Pleurisy  is  common.  It  may  be 
cancerous  or  serofibrinous.  Frequently  both  conditions  are  present. 
Not  rarely  the  effusion  is  hemorrhagic. 

Etiology. — New  growths  in  the  lungs  occur  with  gi^eatest  frequency 
in  middle  life.  Males  suffer  more  commonly  from  primary  mahgnant 
disease  of  the  lungs  and  pleura;   women  from  the  secondary  form. 

Symptoms. — The  clinical  picture  is  not  well  defined,  especially  in  the 
primary  form.  It  sometimes  suggests  chronic  pneumonia,  sometimes  a 
mediastinal  tumor  or  thoracic  aneurism,  or  again  there  may  be  nothing 
to  suggest  an  affection  of  the  lungs.  Pain  is  usually  present  when  the 
pleura  is  affected.  It  may  be  substernal.  Cough  is  not  constant.  It  is 
frequently  aggravated  in  certain  postures  and  may  be  dry  and  attended 
wdth  pain.  There  is  in  many  cases  a  jelly-like  bloody  sputum  which  is 
highly  suggestive,  though  it  may  occur  in  other  conditions.  Dyspnoea 
upon  exertion  is  a  sj^mptom  of  large  growths  or  extensive  infiltration,  and 
may  be  parox5^smal.  Pleural  effusion,  often  found  upon  aspiration  to  be 
hemorrhagic,  may  develop.  The  lymph-nodes  of  the  axilla  or  above  the 
inner  end  of  the  clavicle  are  frequently  enlarged.  There  is  progressive 
wasting  and  cachexia,  and  toward  the  end  irregular  fever  of  remittent 
type.  Pressure  symptoms  are  common.  These  consist  of  distention  of 
the  large  veins,  with  cyanosis  of  the  face  and  one  or  both  arms,  enlarged 
and  tortuous  veins  over  the  upper  part  of  the  chest,  distressing  dyspnoea 
or  stridor  from  compression  of  the  trachea  or  large  bronchi,  brassy  cough, 
and  aphonia  fi-om  pressure  upon  recurrent  laryngeal  nerves.  In  large 
unilateral  tumors  the  heart  is  displaced  toward  the  opposite  side  and  the 
diaphragm  depressed. 


DISEASES  OF  THE  MEDIASTIXOI.  1083 

Physical  Signs. — The  signs  may  be  due  to  the  tumor  itself  or  to  an 
accompanying  pleural  effusion.  In  the  latter  case  the  affected  side  is 
enlarged,  the  intercostal  depressions  obliterated,  the  respiratory  move- 
ment restricted.  The  vocal  fremitus  is  diminished.  Upon  percussion  and 
auscultation  the  signs  are  modified  by  the  presence  of  fluid  and  its  amount, 
which  is  not  usually  great.  Even  when  it  is  considerable,  the  tumor  affects 
its  distribution  and  upper  lines.  There  is  dulness  which  may  be  complete 
at  the  base.  The  breath  sounds  are  feeble  and  distant.  There  may  be 
well-characterized  bronchial  breathing. 

Diagnosis. — Direct. — In  primary  cases  the  diagnosis  may  be  difficult 
or  impossible.  Important  criteria  are  strictly  unilateral  phenomena, 
irregular  character  and  distribution  of  the  physical  signs,  dark,  jelly-like, 
mucoid,  bloody  expectoration,  tendency  to  cachexia,  and  implication  of 
superficial  lymph-nodes.  If  carcinomatous  tissue  elements  are  found  in 
the  sputum  or  the  growth  perforates  the  chest  wall — ver}^  rare  events — 
the  diagnosis  is  positive.  The  X-ray  examination  is  important.  In  a 
case  of  single  large  growth  in  the  lower  lobe  of  the  right  lung,  with 
multiple  pigmented  cutaneous  lesions,  occurring  in  a  man  aged  sixty-four, 
the  results  of  physical  examination  were  fully  confirmed.  In  the  secondary 
form  a  probable  diagnosis  may  be  made  with  some  confidence  when  the 
above  described  pulmonary  symptoms  arise  in  the  course  of  several  months 
after  the  recognition  of  a  primary  malignant  tumor,  as  of  the  breast,  womb, 
stomach,  or  bowel,  with  or  without  operation. 

Differential. — The  recognition  of  a  mediastinal  new  growth  or  an 
aneurism  of  the  aorta,  in  contradistinction  from  new  growths  in  the  lungs, 
may  involve  serious  diagnostic  difficulties. 

Prognosis.— The  course  of  malignant  growths  in  the  lungs  is  lethal, 
the  end  occurring  within  a  year  or  two,  and  not  rarely  within  a  few  months 
after  the  appearance  of  the  symptoms. 

V.  DISEASES  OF  THE  MEDIASTINUM. 

Enlarged  lymphatic  glands,  suppurative  h'mphadenitis,  abscess,  inter- 
stitial emphysema,  chronic  indurative  mediastinitis,  and  new  growths  are 
to  be  considered. 

1.  Enlargement  of  the  lymphatic  glands  m  the  mediastinum  accom- 
panies inflammation  of  the  bronchi,  bronchopneumonia  and  the  specific 
infections,  croupous  pneumonia,  measles,  pertussis,  and  tuberculosis.  This 
constant  anatomical  change  does  not  commonly  attain  sufficient  dimensions 
to  cause  definite  symptoms  or  physical  signs;  exceptionally  pressure  upon 
the  trachea  may  cause  a  paroxysmal,  brassy  cough,  and  dulness  over  the 
manubrium  sterni,  in  the  upper  part  of  the  interscapular  region,  or  a  modi- 
fication of  the  sound  upon  direct  percussion  over  the  upper  dorsal  spines. 

2.  Suppurative  Lymphadenitis. — Suppuration  may  occur  in  the  tra- 
cheal or  bronchial  lymphatic  glands  as  the  result  of  ordinary  inflammation. 
More  commonly  it  is  of  tuberculous  origin.  The  symptoms  are  obscure. 
Perforation  into  a  bronchus,  the  oesophagus,  or  the  aorta  may  occur.  In 
other  cases  the  fluid  contents  of  the  glandular  abscess  are  absorbed,  lime 
salts  are  deposited,  and  the  condition  becomes  one  of  anatomical  rather 
than   clinical  interest. 


1084  MEDICAL  DIAGNOSIS. 

3.  Mediastinal  Abscess.- — The  abscess  cavity  usually  occupies  the 
anterior  mediastinum.  The  condition  may  be  acute  or  chronic.  The 
acute  cases  are  due  to  traumatism  or  occur  in  connection  with  the  acute 
febrile  infections;  the  chronic  cases  are  as  a  rule  tuberculous.  Males  are 
more  commonly  affected.  The  pus  shows  a  disposition  to  burrow  and 
may  find  its  way  through  an  intercostal  space,  into  the  abdomen,  may 
rupture  into  the  trachea  or  oesophagus,  or  may  perforate  the  sternum. 

Symptoms. — Substernal  pain  is  constant.  In  the  acute  cases  it  is 
severe  and  throbbing,  and  accompanied  with  chills,  fever,  and  sweating. 
Large  abscesses  may  give  rise  to  pressure  symptoms  and  dyspnoea.  There 
may  be  resorption  of  the  fluid  and  inspissation. 

Physical  Signs. — A  fluctuating  tumor  may  appear  in  the  episternal 
space  or  at  the  sternal  border.  In  the  latter  situation  it  may  suggest 
empyema  necessitatis.  Pulsating  synchronously  with  the  heart  it  may 
simulate  a  pulsating  empyema  or  an  aneurism.  From  pulsating  empyema 
it  may  be  distinguished  by  the  absence  of  the  signs  of  pleural  effusion; 
from  aneurism  by  absence  of  murmur,  of  diastolic  shock,  and  of  the  expan- 
sile character  in  the  pulsation.  Exploratory  puncture  with  a  fine  needle 
may  be  performed. 

4.  Emphysema. — The  escape  of  air  into  the  connective-tissue  spaces 
of  the  mediastinum  is  an  occasional  event  after  traumatism  or  surgical 
operations  upon  the  neck,  as  tracheotomy,  and  in  pertussis.  It  may  be 
associated  with  pneumothorax.  There  are  no  special  symptoms.  Crack- 
ling rales  having  the  rhythm  of  the  heart  are  heard  over  the  sternal  region. 
If  the  air  finds  its  way  into  the  subcutaneous  tissue  of  the  neck  the  crepitus 
may  be  recognized  upon  kneading  the  tissues  lightly  with  the  finger-tips. 
Etiological  factors  are  important. 

5.  Indurative  Mediastinitis.— Adherent  pericardium  wdth  chronic  pro- 
liferative mediastinitis  is  a  rare  condition.  The  heart  is  greatly  enlarged. 
Its  action  is  hampered  by  the  extensive  adhesions  to  the  adjacent  parts; 
its  signs  obscured  by  the  greatly  thickened  fibrous  tissue  of  the  mediasti- 
num. Friction  sounds  may  sometimes  be  heard  along  the  sternal  borders. 
The  nutrition  of  the  heart  muscle  ultimately  fails,  and  dyspnoea,  cyanosis, 
and  anasarca  develop. 

6.  Mediastinal  New  Growths. — The  common  varieties  are  carcinoma 
and  sarcoma.  Dermoid  cysts,  hydatid  cysts,  and  lymphomata,  fibromata, 
lipomata,  enchondromata,  and  gummata  are  of  comparatively  infrequent 
occurrence.  The  tumor  may  have  its  origin  in  the  thymus,  the  lymph- 
glands,  or  the  pleura  or  lung.  Tumors  of  the  anterior  mediastinum  originate 
from  the  remnants  of  the  thymus  of  the  connective  tissue;  those  of  the 
middle  and  posterior  mediastinum  from  the  h^mph-nodes.  Primary 
tumors  are  more  commonly  sarcoma  than  carcinoma.  Among  personal 
predisposing  influences  age  and  sex  are  important.  Mediastinal  tumor 
most  frequently  develops  in  the  fifth  decade  of  life  and  in  men. 

Symptoms. — The  important  manifestations  of  a  tumor  developing 
in  or  encroaching  upon  the  mediastinal  spaces  are  displacement  and  pres- 
sure symptoms.  These  symptoms  relate  to  the  heart,  great  vessels  and 
nerves,  the  trachea,  bronchi,  lungs,  and  pleurae,  and  the  oesophagus.  The 
symptoms  depend  upon  the  size  of  the  new  growth,  and  its  immediate 


DISEASES  OF  THE  MEDIASTINUM.  1085 

location.  .  A  small  tumor  may  not  be  the  occasion  of  any  derangement 
of  function.  On  the  other  hand,  as  the  growth  increases,  remarkable  adap- 
tations take  place,  and  life  may  be  maintained  despite  great  compression 
and  dislocation  of  the  heart  and  lung.  The  pressure  of  the  tumor  exerted 
upon  the  wall  of  the  heart  interferes  with  diastole  and  diminishes  the 
volume  of  blood  thrown  into  the  aorta  with  the  ventricular  systole.  The 
pulse  is  therefore  small  and  frequent.  The  dislocation  of  the  organ  is 
backward  or  downward  in  tumors  of  the  anterior  mediastinum,  with  dis- 
placement of  the  apex  beat  to  the  left.  The  liver  or  spleen  is  also  dis- 
placed downward  by  large  mediastinal  tumors.  There  may  be  cardiac 
dyspnoea  from  pressure.  The  presence  of  the  tumor  interferes  with  respira- 
tion and  produces  of  itself  a  slight  degree  of  cyanosis,  which  is  increased 
by  pressure  upon  large  venous  trunks.  When  the  intrathoracic  portion 
of  the  inferior  vena  cava  is  affected,  venous  distention  and  cedema  of  the 
abdomen  and  lower  extremities  result;  when  the  superior  vena  cava  is 
compromised,  swelling  and  oedema  in  the  face  and  both  upper  extremities 
may  occur,  together  with  signs  of  interference  with  the  cerebral  circula- 
tion, such  as  headache,  vertigo,  and  ringing  in  the  ears.  A  collateral  venous 
circulation  may  be  established  in  either  case  with  great  distention  of  the 
superficial  veins  of  the  abdomen  or  thorax.  Pressure  upon  and  obstruction 
of  the  right  or  left  innominate  vein  is  more  common.  This  hinderance  to 
the  return  of  the  venous  blood  manifests  itself  by  oedema  of  the  face  and 
arm  of  the  corresponding  side,  and  enlargement  of  the  superficial  veins  of 
the  thorax.  The  arterial  trunks  yield  less  readily  to  the  presence  of  the 
tumor  than  the  veins.  When  the  pressure  becomes  so  great  as  to  interfere 
with  the  lumen  of  the  subclavian  or  innominate,  the  pulse  upon  the  affected 
side  is  enfeebled.  Pressure  upon  the  recurrent  laryngeal  nerves  causes 
dyspnoea,  aphonia,  and  the  severe,  brassy,  paroxj^smal  cough  often  present. 
The  laryngoscope  should  be  used.  Pressure  upon  the  phrenic  may  cause 
hiccough  and  shallow  respiration;  upon  the  vagus  asthmatic  attacks  and 
dysphagia  in  the  absence  of  direct  pressure  upon  the  oesophagus,  and 
bradycardia  or  tachycardia.  Implication  of  the  sympathetic  may  cause 
dilatation  or  contraction  of  the  pupil  upon  the  affected  side — inequality 
of  the  pupils.  Dyspnoea  is  an  early  and  constant  symptom.  It  is  due  to 
various  factors,  as  pressure  upon  the  heart,  the  recurrent  laryngeal  nerves, 
the  trachea,  the  lungs  themselves,  or  the  presence  of  a  pleural  effusion.  It 
is  often  slight  when  the  patient  is  quiet,  but  severe  and  distressing  upon 
exertion.  The  mechanical  compression  of  considerable  portions  of  a  lung 
manifests  itself  in  dyspnoea  of  inspiratory  type  with  slow  and  deep  respira- 
tory movements.  In  extreme  conditions  of  pressure  there  is  orthopnoea. 
When  the  pressure  is  unilateral  there  may  be  inspiratory  depression  of 
the  intercostal  spaces.  Areas  of  fibrinous  pleurisy  are  attended  with  local 
pains  and  friction  sounds.  Compression  of  the  oesophagus  renders  the 
act  of  swallowing  difficult  or  in  extreme  cases  impossible. 

Physical  Signs.  —  Insj)ection.  —  Orthopnea,  cedema,  and  cyanosis  of 
the  face,  arm,  and  upper  part  of  the  chest,  and  varicose  enlargement  of  the 
superficial  mammary  and  epigastric  veins  are  often  seen.  But  in  many 
cases  these  signs  are  absent.  In  old  cases  there  may  be  clubbing  of  the 
finger-tips  and  incurvation  of  the  nails.     There  may  be  bulging  of  the 


1086  MEDICAL  DIAGNOSIS. 

sternum.  The  new  growth  may  even  erode  the  bone  or  perforate  the  chest 
wall  at  the  sternal  border.  The  impulse  of  the  heart  may  be  displaced  tO' 
the  left  and  downward.  Respiratory  derangements  are  conspicuous.  In 
some  cases  inspiratory  retraction  of  the  soft  parts  of  one  side  denotes 
unilateral  compression  of  a  main  bronchus  or  the  large  part  of  the  lung. 
Diminished  respiratory  excursus  upon  one  side  may  be  a  sign  of  pleural 
effusion.  Palpation. — Vocal  fremitus  is  absent  over  the  tumor  and  over 
pleural  effusions.  If  the  tumor  pulsates  it  lacks  the  forcible,  expansile 
impulse  of  an  aneurism.  Percussion. — Dulness  of  a  high  grade  and  in- 
creased resistance  are  present  over  the  tumor.  The  borders  of  the  area 
of  dulness  are  irregular,  and  do  not  correspond  to  the  outline  of  the  heart 
or  of  the  margin  of  an  infiltrated  lung.  The  dull  area  is  continuous  with 
the  dulness  of  a  pleural  effusion  when  the  latter  is  present  and  its  persist- 
ence after  the  withdrawal  of  the  fluid  is  of  diagnostic  significance.  Auscul- 
tation.— The  respiratory  murmur  retains  its  vesicular  qualitj^,  in  the  main, 
but  is  enfeebled.  At  the  borders  of  the  tumor  it  may,  owing  to  pressure 
atelectasis,  have  the  bronchial  quality.  Stridor  is  the  sign  of  compression . 
of  the  trachea  or  a  main  bronchus. 

Diagnosis. — Direct. — An  area  of  dulness  in  the  sternal  region,  with 
irregular  and  advancing  borders,  bulging  of  the  breast-bone,  dyspnoea  of 
inspiratory  type,  absence  of  respiratory  murmur,  displacement  of  the  heart 
and  of  the  liver  or  spleen,  signs  of  obstruction  of  the  venous  circulation, 
of  pressure  upon  the  vagi,  the  sympathetic,  the  phrenic,  and  the  recurrent 
laryngeal  nerves,  the  trachea,  bronchi,  or  the  lung  itself,  and  dysphagia 
constitute  a  symptom-complex  upon  which  the  diagnosis  of  mediastinal 
tumor  may  be  confidently  made.  The  association  of  a  number  of  them 
justifies  a  provisional  diagnosis.  When,  however,  to  several  of  these  signs 
are  added  the  presence  of  enlarged  superficial  lymph-nodes  and  the  visible 
and  palpable  evidences  of  a  tumor  perforating  the  sternum  or  the  chest 
wall  at  the  borders  of  the  sternum,  or  advancing  into  the  episternal  notch, 
the  diagnosis  becomes  positive. 

Differential. — Obscure  pressure  symptoms  may  arise  in  consequence 
of  the  presence  of  a  small  mediastinal  tumor,  tuberculous  tracheal  or  bron- 
chial glands,  gummata  or  syphilitic  cicatrices,  or  a  small  aneurism.  The 
differential  diagnosis  of  these  conditions  cannot  be  made  nor  can  a  positive 
diagnosis  of  mediastinal  tumor  be  reached  until  abnormal  dulness  associated 
with  distinct  evidences  of  intrathoracic  pressure  appear.  With  reference  to 
the  differential  diagnosis,  pericardial  and  pleural  effusions,  malignant 
disease  of  the  pleura,  and  aneurism  of  the  aorta  demand  special  considera- 
tion. Pericardial  Effusion. — Fluid  pericardial  and  pleural  exudates  pro- 
gressively displace  the  organs  contained  in  the  mediastinum;  mediastinal 
new  growths  compress  them.  A  fiat  percussion  sound  is  the  sign  of  both 
conditions;  but  the  area  of  flatness  in  uncomplicated  effusion  into  the 
serous  sacs  has  definite  and  regular  outlines,  whereas  in  mediastinal  tumor 
its  borders  are  irregular  and  anomalous.  In  pericardial  effusion  the  apex 
beat  may  be  faintly  palpable  within  the  dull  area  and  more  distinct  when 
the  patient  bends  forward.  In  this  attitude  the  dulness  is  also  slightly 
increased  in  its  transverse  diameter.  In  mediastinal  tumor,  on  the  other 
hand,  the  cardiac  impulse  is  at  the  left  border  of  the  dull  area,  which  is 


DISEASES  OF  THE  MEDIASTINUM.  1087 

not  affected  by  change  of  posture.  In  cases  in  which  the  tumor  extends 
between  the  apex  of  the  heart  and  the  wall  of  the  chest  no  impulse  can  be 
detected.  Pleural  Effusion. — This  condition  is  frequently  associated  with 
mediastinal  tumor.  Under  these  circumstances  the  physical  signs  are 
anomalous.  The  persistence  of  dulness  of  irregular  outline  and  compres- 
sion symptoms  after  the  withdrawal  of  the  fluid  are  significant.  Dyspnoea 
upon  exertion,  and  dislocation  of  adjacent  organs,  unilateral  prominence 
of  the  chest  wall  with  diminished  respiratory  excursus  upon  the  same 
side,  point  to  pleural  effusion.  In  tumor  the  vocal  fremitus  is  more  com- 
monly preserved,  signs  of  pressure  upon  the  recurrent  are  more  frequent 
and  more  marked,  and  dysphagia  is  often  present.  An  exploratory  punc- 
ture will  at  once  clear  up  any  uncertainty.  Malignant  Disease  of  the  Pleura. 
— More  obscure  is  the  differential  diagnosis  when  this  condition  is  pres- 
ent, especially  if  the  new  growth  takes  origin  from  the  costal  pleura  and 
has  attained  considerable  size.  These  tumors  cause  local  bulging  of  the 
chest  wall,  dulness  of  irregular  outline,  effusion  into  the  pleural  sac,  and 
compression  of  the  lung,  large  venous  trunks,  and  the  oesophagus,  and  they 
may  invade  the  mediastinal  spaces.  In  the  latter  case  they  constitute  a 
variety  of  mediastinal  tumors.  Aneurism  of  the  Thoracic  Aorta. — The 
differential  diagnosis  between  mediastinal  tumor  and  aneurism  may  be 
very  difficult,  especially  in  areas  in  which  the  outline  of  the  aneurism  is 
irregular  and  the  sac  more  or  less  occupied  by  firm  clot.  The  symptoms 
of  both  are  due  to  pressure,  and  the  effects  of  pressure  are  practicall}^  the 
same,  whether  it  be  exerted  by  a  solid  tumor  or  one  distended  with  blood. 
The  following  data  are  in  favor  of  mediastinal  tumor:  marked  cyanosis, 
venous  engorgement,  and  the  enlarged  superficial  veins  of  collateral  circu- 
lation; right-sided  oedema  of  the  face  and  arm;  absence  of  diastolic  shock; 
absence  of  tracheal  tugging;  relatively  short  duration;  if  pulsation  be 
present,  it  is  limited  in  extent,  especially  in  large  tumors,  and  not  expan- 
sile in  character;  if  murmurs  be  present,  they  are  usually  systolic  only; 
enlargement  of  the  lymph-nodes  and  a  firm  nodular,  rather  than  an 
elastic,  mass  palpable  at  the  sternal  notch.  The  following  render  the 
diagnosis  of  aneurism  probable;  absence  of  oedema  and  cyanosis,  and  the 
absence  of  enlarged  superficial  veins  upon  the  thorax  and  abdomen;  the 
presence  of  diastolic  shock  and  tracheal  tugging;  prolonged  duration; 
expansile,  heaving,  and  forcible  pulsation,  either  in  areas  in  which  the 
tumor  lies  in  relation  with  the  chest  wall  or  has  perforated  the  sternum; 
double  murmurs,  inequality  of  the  radial  pulses,  and  severe  boring  pain 
radiating  to  the  back,  arms,  and  neck.  Loud  murmurs  heard  over  a  con- 
siderable area  are  common  in  aneurism,  but  murmurs  may  be  wholly 
absent,  whereas  in  mediastinal  tumor  murmurs  are  only  occasionally  heard. 

Examination  by  the  X-rays  yields  conclusive  results  when  the  shadow 
.shows  in  any  part  the  rounded  expansile  pulsation  of  an  aneurismal  sac. 
Rest  in  bed,  a  limited  diet,  the  restriction  of  fluid,  and  the  administration 
of  potassium  iodide  may  be  followed  by  relief  of  pain  in  aneurism. 

Diagnosis  of  the  Location  of  Mediastinal  Tumors. — Developing  in  the 
anterior  mediastinum,  new  growths  push  forward  and  sometimes  erode  the 
sternum.  They  may  frequently  be  felt  in  the  suprasternal  notch.  The 
symptoms    indicate    compression  of    venous    trunks.     D5'spna'a  is   often 


10S8  MEDICAL  DIAGNOSIS. 

urgent,  and  the  lymphatic  glands  of  the  neck  are  often  enlarged.  When  the 
growth  occupies  the  middle  and  posterior  mediastinum  the  physical  signs 
may  be  obscure.  Pressure  is  especially  exerted  upon  the  oesophagus  and 
the  recurrent  laryngeal  nerves.  Dysphagia,  urgent  dyspnaa,  and  a  brassy, 
laryngeal  cough  occur.  In  tumors  springing  from  the  pleura  or  lung 
symptoms  of  pressure  upon  the  blood-vessels,  nerves,  and  gullet  are  less 
marked;  signs  indicating  compression  of  the  lung  itself  more  prominent. 
A  complicating  pleural  effusion  is  common.  There  is  a  tendency  to  rapid, 
emaciation  and  cachexia. 

Diagnosis  of  the  Character  of  Mediastinal  Tumors. — The  most  com- 
mon forms  are  carcinoma  and  sarcoma,  the  former  developing  as  a 
rule  later  in  life  than  the  latter,  but  there  are  many  exceptions  to  this 
statement.  Rapidity  of  growth,  metastatic  tumors,  glandular  enlargement, 
loss  of  weight,  anaemia,  cachexia,  subnormal  temperature,  and  cutaneous 
pigmentation  point  to  carcinoma.  In  sarcoma  the  weight  and  the  appear- 
ance of  fair  nutrition  may  be  long  maintained. 

Prognosis. — Acute  enlargement  of  the  tracheal  and  bronchial  Ij^mphatic 
glands  usually  subsides  with  the  pulmonary  disease  of  which  it  is  a  feature. 
Suppurating  glands  may  rupture  into  contiguous  structures  or  undergo 
retrogressive  changes,  with  resorption  of  the  fluid  and  deposition  of  lime 
salts.  Tuberculous  glands  remain  enlarged,  with  the  tendency  to  caseation 
and  softening.  Abscess  is  a  serious  affection,  but  a  fair  proportion  of  the 
cases  are  amenable  to  surgical  treatment.  Chronic  proliferative  medias- 
tinitis  is  a  progressive  disease  tending  to  destroy  life  by  impairing  the 
function  of  the  heart.  The  conditions  under  which  mediastinal  emphysema 
occur  are  usually  of  grave  prognostic  import.  Finally,  mediastinal  tumors 
are  in  a  large  proportion  of  the  cases  malignant  and  without  hope. 

VI.  DISEASES  OF  THE  PLEURA, 
i.  Pleurisy. 

Definition. — Inflammation  of  the  pleura.  The  cases  may  be  grouped 
according  to  various  principles  of  classification.  Etiologically  primary 
and  secondary  forms  may  be  recognized,  but  this  distinction  cannot  always 
be  made  at  the  bedside;  clinically  the  disease  may  run  an  acute  or  chronic 
course,  but  forms  characterized  by  similar  features  differ  greatly  in  intensity 
and  duration.  The  anatomical  division  into  dry  or  plastic  pleurisy  and 
pleurisy  with  effusion  is  most  convenient  for  descriptive  purposes. 

(a)  Fibrinous  or  Plastic  Pleurisy. 

Pleuritis  Sicca. 

Acute  Dry  Pleurisy. — The  pleural  membrane  is  the  seat  of  a  fibrinous 
exudate  of  varying  thickness,  arranged  in  a  single  layer  or  in  superimposed 
strata.  This  form  of  pleurisy  apparently  occurs  in  some  instances  as  a 
primary  disease  after  exposure  to  cold  or  contusion  of  the  chest.  It  is 
far  more  frequent  as  a  secondary  affection  in  acute  and  chronic  diseases  of 
the  lung  when  the  lesions  extend  to  the  pleura.     It  is  an  almost  constant 


PLEURISY.  1089 

accompaniment  of  croupous  pneumonia  and  very  common  in  broncho- 
pneumonia. Pulmonary  infarct,  abscess,  gangrene,  and  malignant  disease 
cause  inflammation  of  the  pleura  when  they  extend  to  the  periphery  of 
the  lung.  Dry  pleurisy  is  a  constant  accompaniment  of  chronic  pulmonary 
tuberculosis,  alike  when  the  primary  infection  involves  the  lung  or  the 
pleura  itself. 

Symptoms. — The  subjective  symptoms  of  pleural  irritation  are  pres- 
ent, namely,  the  pain  known  as  stitch  in  the  side,  and  dry  cough.  Fever 
of  moderate  intensity  is  usually  also  present.  The  pain  is  usually 
referred  to  the  region  of  the  nipple  or  the  axilla.  In  diaphragmatic 
pleurisy  the  pain  is  often  referred  to  the  abdomen,  especially  in  children. 
It  is  increased  upon  deep  breathing.  The  respiratory  movement  is  there- 
fore consciously  or  unconsciously  somewhat  restricted,  and  the  patient 
presses  his  hand  upon  the  affected  side  when  he  coughs.  Cough  is 
sometimes   absent. 

Physical  Signs. — Inspection. — The  respirator}'  movement  is  somewhat 
limited  upon  the  affected  side.  Palpation. — A  distinct  friction  fremitus 
may  very  often  be  felt.  This  sign  is  due  to  roughening  of  the  opposed 
pleural  surfaces.  Percussion. — There  is  no  change  in  the  sound,  but  upon 
linear  percussion  a  limited  inspiratory  descent  of  the  lower  border  of  the 
Jung  upon  the  affected  side  may  be  made  out.  Auscultation.- — A  pleural 
friction  rub,  the  almost  constant  and  always  distinct  sign  of  dry  pleurisy, 
is  heard.  When  the  plastic  exudate  affects  the  pleura  in  the  neighborhood 
of  the  heart  the  friction  sounds  occur,  not  only  synchronousl}^  with  the 
respiratory  movements,  but  also  with  the  cardiac  revolution — pleuropcri- 
cardial  friction.  In  miliary  tuberculosis  involving  the  pleura  a  fine,  widely 
diffused  friction  sound  may  be  heard. 

Diagnosis.  —  Direct.  —  The  friction  sound  is  of  positive  diagnostic 
significance.  When  it  is  not  heard  the  diagnosis  of  fibrinous  pleuris)''  can- 
not be  affirmed.  Pain  in  the  side,  increased  upon  cough  and  deep  breath- 
ing, occurs  in  other  conditions.  Even  when  the  friction  sound  is  present, 
"we  cannot  in  every  case  be  sure  that  the  pleurisy  of  which  it  is  the  sign  is 
not  associated  with  pneumonia,  or  the  forerunner  of  pleural  effusion.  Time 
is  therefore  in  certain  cases  essential  to  the  diagnosis. 

Differential. — Pleurodynia. — Myalgia  of  the  intercostal  muscles  of 
one  side,  intensified  by  cough  and  deep  breathing,  and  by  pressure 
often  over  a  circumscribed  area,  may  be  mistaken  for  dry  pleurisy. 
It  is  more  common  upon  the  left  side.  The  absence  of  friction  sounds 
and  the  constitutional  condition  under  which  myalgias  arise  render  the 
differential  diagnosis  an  easy  matter.  Intercostal  Neuralgia. — The  pain 
is  limited  to  the  course  of  nerve-trunks  and  is  paroxysmal.  There  are 
tender  points.  The  disease  is  common  in  neurotic  and  hysterical  women. 
It  is  a  chronic  affection.  Friction  sounds  do  not  occur.  Neuritis  of  Inter- 
costal Nerves. — Whether  associated  with  herpes  zoster,  spinal  caries,  or 
disease  of  the  cord,  or  due  to  the  pressure  of  a  tumor  or  aneurism,  this 
painful  affection  of  the  chest  is  sometimes  mistaken  for  pleurisy.  The 
one  essential  diagnostic  point  is  the  presence  or  absence  of  friction  sounds. 
Causal  factors  are  important,  and  the  distribution  of  the  pain  along 
nerve-trunks  with  points  douloureux  is  significant. 
69 


1090  MEDICAL  DIAGNOSIS. 

Prognosis. — The  outlook  is  mostly  favorable.  In  the  primary  form, 
after  a  few  days  adhesions  take  place,  the  friction  murmur  disappears, 
and  the  pain  ceases.    The  secondary  forms  often  run  the  same  course. 

Chronic  Dry  Pleurisy. — There  are  three  forms:  primitive  dr}^  pleurisy, 
that  form  which  follows  the  resorption  or  withdrawal  of  pleural  effusions, 
and  tuberculous  dry  pleurisy. 

1.  Primitive  Dry  Pleurisy. — This  variety  may  develop  insidiously 
without  marked  symptoms,  and  be  first  recognized  by  the  accidental  dis- 
covery of  the  friction  fremitus,  or  it  may,  as  is  commonly  the  case,  be  the 
outcome  of  the  acute  disease.  Limited  or  general  pleural  adhesions  take 
place.  The  respiratory  function  is  but  little  affected.  With  general  bilat- 
eral adhesions  the  respiratory  play  of  the  chest  is  restricted.  Percussion 
is  normal.  The  excursus  of  the  lower  border  of  resonance  is  dimin- 
ished and  the  lessened  movements  of  the  diaphragm  are  confirmed  by 
Litten's  sign.  This  form  of  pleurisy  may  result  in  remarkable  thickening 
and  connective-tissue  proliferation  within  the  lung,  with  contraction  and 
induration — 'pulmonary  cirrhosis. 

2.  Adhesive  Pleurisy  Following  the  Removal  op  Exudates. — 
Upon  resorption  of  an  effusion,  or  its  removal  by  aspiration  or  otherwise, 
the  pleural  surfaces  unite  and  the  fibrinous  material  becomes  organized. 
This  process  is  most  marked  at  the  base  of  the  chest  and  gives  rise  to  a 
characteristic  deformity,  in  which  there  is  flattening,  with  narrowing  of 
the  intercostal  spaces  and  overlapping  of  the  ribs,  deficient  expansion, 
enfeebled  respiratory  murmur,  and  dulness.  The  pathological  change  is 
largely  due  to  prolonged  pressure  atelectasis,  a  fact  of  great  importance 
as  bearing  upon  the  prompt  removal  of  pleural  effusions.  The  condition 
follows  serofibrinous  pleurisy,  empj^ema,  and  traumatism  of  the  chest, 
especially  gunshot  and  stab  wounds.  It  is  of  every  grade,  from  the  slight 
retraction  of  the  chest  wall  following  a  rapidly  removed  serofibrinous 
effusion,  relieved  by  respiratory  gymnastics,  particularly  in  young  persons, 
to  the  gross  and  disfiguring  deformity  which  is  seen  after  neglected  effusions 
of  all  kinds,  especially  old  empyemata,  and  is  associated  with  a  permanently 
compressed,  airless,  fibroid  and  bronchiectatic  lung. 

3.  Tuberculous  Dry  Pleurisy.  —  The  course  of  tuberculous  dry 
pleurisy  is  from  the  onset  essentially  chronic  and  characterized  by  great 
thickening,  together  with  implication  of  the  connective-tissue  framework 
of  the  limg.  It  may  involve  both  sides  and  usually  begins  at  an  apex. 
Proliferating  pericarditis  or  peritonitis  may  be  also  present. 

Flushing  or  sweating  of  one  cheek  and  dilatation  of  a  pupil  may 
occur  when  the  pleural  thickening  implicates  the  upper  thoracic  ganglion. 

The  differential  diagnosis  l^etween  a  circumscribed  pleural  effusion 
and  great  pleural  thickening  is  in  many  cases  extremely  difficult,  a  fact 
not  surprising  in  view  of  the  physical  condition  and  the  occasional  pres- 
ence of  small  collections  of  residual  fluid  in  the  thickened  pleura.  Dulness, 
even  flatness,  feeble  respiratory  sounds,  diminished  vocal  resonance,  and 
absent  vocal  fremitus  occur  in  both  conditions.  The  use  of  the  aspirator 
will  usually  at  once  determine  the  diagnosis. 


PLEURISY.  1091 

(b)  Pleurisy  with  Effusion. 

Pleuritis  Exudativa. 

Definition. — Inflammation  of  the  pleura  in  which  fluid  exudate  is 
associated  with  the  fibrin. 

Pleural  inflammation  is  due  to  microbic  infection.  The  organisms 
present  in  the  exudate  are,  with  greatest  frequency,  the  tubercle  bacillus, 
the  pneumococcus,  and  the  streptococcus;  far  less  commonly  the  staphy- 
lococcus, Bacterium  coli  commune,  Friedlander's  bacillus,  the  bacillus  of 
Eberth,  and  the  Klebs-Loffler  bacillus.  Mixed  infections  occur.  Accord- 
ing to  the  character  of  the  effusion  the  following  forms  are  recognized: 
serofibrinous,  purulent,  hemorrhagic,  and  chyliform. 

SEROFIBRINOUS  PLEURISY. 

This  term  is  not  used  to  designate  those  cases  in  which  small  quanti- 
ties of  serum  are  entangled  in  the  meshes  of  a  loose  plastic  exudate,  but 
to  describe  considerable  collections  of  fluid  which,  unless  prevented  by 
adhesions,  accumulate  under  the  influence  of  gravity  in  the  dependent 
parts  of  the  pleural  sac. 

Etiology. — Predisposing  Influences. — The  cases  may  be  divided 
into  idiopathic  and  secondary.  Idiopathic  or  primary  pleurisy  often 
quickly  follows  a  wetting  or  chill  in  an  apparently  healthy  person.  The 
majority  of  the  cases  are,  however,  tuberculous.  Serofibrinous  pleurisy 
may  follow  injury  to  the  chest.  With  reference  to  personal  predisposition, 
hospital  statistics  show  a  greater  liability  on  the  part  of  males — 5  to  1 — 
and  in  middle  life,  especially  between  40  and  50.  The  disease  occurs, 
however,  at  all  ages.  Secondary  pleurisy  occurs  not  only  in  connection 
with  tuberculous  disease  of  the  lung,  or  tuberculous  lesions  in  distant 
parts  of  the  body,  but  also  in  croupous  pneumonia  and  bronchopneumonia, 
malignant  disease  of  the  pleura  or  lung,  pericarditis,  rheumatic  fever, 
enteric  fever,  diseases  of  the  liver,  and  chronic  nephritis. 

Exciting  Causes.  —  Exposure  to  cold  and  damp  and  traumatism 
lower  local  tissue  resistance  to  pathogenic  micro-organisms. 

Morbid  Anatomy.  —  The  serous  and  fibrinous  exudates  are  present 
in  varying  proportions.  Fibrin  may  be  scanty,  or  form  thick,  shaggy 
layers  upon  the  pulmonary  and  costal  pleurae  and  curd-like  masses  or 
flocculi  which  float  in  the  serum  and  collect  in  the  most  dependent  part 
of  the  pleural  sac.  The  fluid  is  clear  or  slightly  turbid,  according  to  the 
relative  abundance  of  cells  and  fibrin  masses  which  it  contains.  It  is 
of  a  pale  citron  or  lemon  color,  but  may  be  darker.  It  coagulates  on  boil- 
ing, but  sometimes  on  standing  undergoes  spontaneous  coagulation.  Chemi- 
cally it  resembles  blood-serum.  It  may  show  the  presence  of  cholesterin, 
uric  acid,  or  sugar.  Microscopically  there  are  seen  leucocj^tes,  endothelial 
cells,  fibrin  shreds,  and  erythrocytes.  The  fluid,  according  to  its  volume, 
exerts  prevSsure  upon  the  lungs  and  adjacent  organs.  In  small  effusions 
the  lower  lobe  is  compressed  and  partially  atelectic;  in  large  effusions  the 
entire  lung  may  be  reduced  to  a  flat,  airless,  carnified  mass  lying  against 


1092  MEDICAL  DIAGNOSIS. 

the  spine.  In  large  effusions  the  mediastinum  and  heart  are  displaced 
toward  the  opposite  side,  the  diaphragm  is  depressed,  and  with  it  the 
liver  or  spleen,  as  the  case  may  be. 

Symptoms. — Serofibrinous  pleurisy  may  begin  insidiously  or  with 
acute  symptoms.  The  former  mode  of  onset  is  more  common  in  children 
and  aged  persons  and  in  the  secondary  forms  which  develop  in  acute  or 
chronic  disease.  The  chief  symptoms  are  shortness  of  breath  on  exertion 
and  rapid  anaemia.  The  latter  may  be  preceded  by  prodromes,  or  a  chill 
with  fever  and  pleural  pain  may  suddenly  occur.  If  relatively  mild  these 
symptoms  suggest  acute  plastic  pleurisy;  if  severe,  croupous  pneumonia. 
The  pain  is  severe,  lancinating,  and  aggravated  by  deep  breathing.  It  is 
referred  to  the  nipple  or  axillary  region;  sometimes,  probably  when  the 
diaphragmatic  pleura  is  involved,  to  the  umbilical  region  or  the  hypo- 
chondriac region  of  the  affected  side,  suggesting  gastralgia,  gastric  ulcer, 
or  an  acute  inflammatory  infradiaphragmatic  inflammation,  as  cholecys- 
titis or  appendicitis.  In  rare  cases  the  pain  is  located  in  the  lumbar  region. 
The  temperature  rises  gradually  rather  than  rapidly  and  attains  an  aver- 
age of  102°-103°  F.  (39°-39.5°  C).  The  fever  is  atypical  and  irregular 
and  of  varying  duration.  Surface  observations  show  in  the  early  course 
of  the  disease  a  slightly  higher  elevation  upon  the  affected  side.  Cough 
as  a  rule  is  present.  It  is  accompanied  by  scanty,  mucous  expectoration. 
When  this  contains  blood,  a  larval  pneumonia  is  to  be  suspected.  Dyspnoea 
is  at  first  due  to  the  fever  and  pain;  later  to  circumscription  of  the  respiratory 
surface  in  consequence  of  the  compression  of  the  lung.  The  more  rapidly 
the  fluid  accumulates  the  more  urgent  the  shortness  of  breath.  A  large 
effusion  if  slowly  formed  may  cause  little  or  no  dyspnosa  so  long  as  the 
patient  lies  quietly  in  bed.  A  moderate  leucocytosis — 12,000  to  15,000 — 
is  present  during  the  febrile  period.  In  a  small  proportion  of  the  cases  the 
leucocytes  are  below  normal. 

Physical  Signs. — Inspection. — The  patient  prefers  to  lie  upon  his 
back  slightly  propped  up  on  pillows  or  upon  the  affected  side.  In  large 
effusions  the  contour  of  the  affected  side  appears  to  be  abnormally  full, 
and  the  chest  may  show  upon  measurement,  due  allowance  being  made 
for  the  normal  disparity,  an  increase  of  2  or  3  cm.  in  the  semicircumference. 
The  intercostal  furrows  are  absent.  The  immobility  of  the  affected  side 
is  often  in  striking  contrast  to  the  movement  of  the  sound  side,  which  is 
exaggerated  by  vicarious  function.  In  right-sided  effusion  the  apex  of 
the  heart  may  be  displaced  to  the  fourth  interspace  beyond  the  mammiDary 
Ime,  or  even  as  far  as  the  left  anterior  axillary  line;  in  left  effusions  the 
apex  may  lie  behind  the  sternum  and  no  impulse  be  seen;  or  there  may 
be  a  visible  impulse  in  the  third  or  fourth  interspaces  as  far  to  the  right 
as  the  nipple  line.  Palpation. — The  signs  obtained  upon  inspection  are 
confirmed  by  the  sense  of  touch.  The  vocal  fremitus  is  diminished  or 
absent.  In  children  the  fremitus  attendant  upon  crying  is  sometimes 
transmitted  along  the  chest  wall  to  the  affected  side.  It  ma}'  be  present 
in  circumscribed  areas  over  large  effusions  when  there  are  locaUiied  old 
pleural  adhesions.  Fluctuation  is  not  a  sign  of  simple  serofibrinous 
pleurisy,  and  oedema  of  the  chest  wall  scarcely  ever  occurs.  Mensura- 
tion.— The  difference  in  the  contour  between  the  sides  as  determined  by 


PLEURISY. 


1093 


the  cyrtometer  is  very  striking.  There  is  an  increase  in  the  anteroposterior 
diameter,  together  with  an  increase  in  the  semicircumference.  The 
difference  in  respiratory  expansion  may  be  accurately  measured  by  the 
saddle-tape.  Percussion. — The  percussion  sound  over  the  effusion  is 
flat,  and  the  percussing  finger  perceives  an  absence  of  elasticity  which  is 
very  suggestive.  Above  the  level  of  the  fluid,  Skodaic  resonance — the  sign 
of  relaxation  of  vital  intrapulmonary  tension — may  be  elicited  in  front 
and  to  a  less  degree  behind.  The  upper  line  of  flatness  is  not  horizontal, 
but  rises  in  a  curve  resembling  the  italic  letter  /S,  starting  at  its  lowest 
point  from  the  spine  and  rising  to  the  axilla,  from  which  it  descends  obliquely 
in  a  straight  line  to  the  sternum.  This  line,  known  as  "  Ettis's  line  of  flat- 
ness," has  been  estabhshed  by  abundant  clinical  and  experimental  studies. 
It  is  much  modified  when  the  patient  has  been  confined  to  bed  during  the 
accumulation  of  the  fiuid,  when  there  are  lesions  in  the  lung  which  modify 
its  shape  and  consistence,  and  when  the  compression  of  the  lung  is  inter- 


FiG.  319. — Ellis's  curve;    moderate  pleural 
effusion;   patient  in  upright  posture. 


Fig.  320. — Anterior  line  of  flatness. 


fered  with  by  pleural  adhesions.  It  is  effaced  when  the  fluid  rises  above 
the  third  rib.  The  flat  percussion  sound  on  the  right  side  is  continuous 
with  that  of  the  liver,  from  which  it  cannot  be  discriminated;  on  the  left 
in  the  mammillary  line  it  extends  to  Traube's  semiliinar  space,  the  convex 
upper  border  of  which  becomes  gradually  flattened  as  the  fluid  increases. 
The  rising  and  falling  of  the  upper  line  of  dulness,  as  the  effusion  increases 
or  undergoes  resorption,  may  be  demonstrated  by  careful,  light  percussion 
and  markings  upon  the  skin  at  intervals  of  two  or  three  days.  In  moderate 
effusions  in  which  the  lung  is  not  confined  by  adhesions  movable  dulness 
may  be  demonstrated  by  marking  the  upper  line  of  dulness  in  the  anterior 
surface  while  the  patient  is  in  the  erect  or  sitting  posture,  and  again  after 
some  time  spent  in  the  dorsal  decubitus.  Massive  effusions  reach  the 
clavicle  and  even  extend  to  the  sternal  border  of  the  opposite  side.  The 
downward  dislocation  of  the  liver  or  spleen  may  be  demonstrated  by 
linear  percussion,  which  enables  us  to  demonstrate  the  lower  borders  of 
these  organs  respectively.  The  liver  is  depressed  in  very  lai-ge  left  effu- 
sions by  reason  of  the  dislocation  of  the  heart  toward  the  right,  the  crowd- 
ing of  the  lung  in  the  right  pleural  cavity,  and  the  general  depression 
of  the  diaphragm. 


1094 


MEDICAL  DIAGNOSIS. 


Normal  Paravertebral  Triangles  of  Relative  Dulness. — Upon  percussion 
over  the  spine  from  above  downward,  the  resonance  is  progressively  dimin- 
ished in  the  lower  thoracic  region.  This  impairment  of  resonance  also 
extends  laterally  in  such  a  m.anner  as  to  form  on  each  side  of  the  lower 
thoracic  spine  a  narrow  triangle  of  relative  dulness,  the  base  of  which 
corresponds  to  the  lower  limit  of  normal  pulmonary  resonance. 

Koranyi's  (Grocco's)  Sign;  Abnormal  Paravertebral  Triangles  of  Dul- 
ness. — These  triangles  appear  upon  the  sound  side  in  pleural  effusion,  and 
may  differ  from  the  normal  triangles  only  in  respect  of  the  degree  of  dul- 
ness. More  commonly  they  differ  also  in  extent.  The  procedure  is  as 
follows:  (1)  The  borders  of  the  effusion  are  determined  by  percussion. 
(2)  The  base  of  the  lung  upon  the  sound  side  is  ascertained  by  percussing 
from  above  downward.  (3)  The  degree  of  resonance  over  the  spinous 
processes  is  learned  by  percussion  also  from  above  downward,  and  the 
point  at  which  relative  dulness  begins  is  noted.     This  commonly  is  at  the 


Fig.  321. — Normal  paravertebral  triangles. 


Fig.  322. — Right  pleural  effusion  with  triangle 
of  dense  paravertebral  dulness  on  left  side. 


level  of  impaired  resonance,  or  slightly  above  the  level  of  flatness  on  the 
side  of  the  effusion.  (4)  Percussion  upon  the  sound  side  in  a  direction 
toward  the  spine  in  serial  horizontal  lines  from  above  downward  reveals 
a  paravertebral  right-angled  triangle  of  dulness,  the  vertical  side  of  which 
corresponds  to  the  spine  and  rises  to  or  slightly  above  the  level  of  the 
effusion  on  the  opposite  side,  the  base  to  the  lower  border  of  the  lung, 
while  the  hypothenuse  extends  from  the  apex  to  the  outer  and  lowest 
point  of  dulness.  The  base  line  varies  with  the  volume  of  the  effusion  and 
may  reach  6  or  10  cm.  in  length.  The  triangle  is  usually  larger  in  right-  than 
in  left-sided  effusions.  The  respiratory  murmur,  vocal  resonance,  and 
vocal  fremitus  are  enfeebled  over  this  area  of  dulness.  The  phenomenon 
occurs  alike  in  hydrothorax  and  in  serofibrinous  and  purulent  effusions. 
The  base  line  is  longer  in  purulent  than  in  serous  effusions.  The  triangle 
in  free  effusions  disappears  upon  change  from  the  upright  to  the  recumbent 
posture.  The  explanation  of  the  paravertebral  triangles  of  dulness  is  not 
clear.  It  is  probable  that  under  normal  conditions  the  vibrations  of  the 
lung  tissue  are  to  some  extent  inhibited  by  the  bodies  of  the  vertebras 
against  which  it  rests,  and  that  an  effusion  upon  the  opposite  side  acts  as 
a  "mute"  or  damper  and  still  further  interferes  with  the  vibrations  of 
the  lung  in  the  costovertebral  recess  of  the  sound  side. 


PLEURISY.  1095 

Auscultation. — In  the  beginning  of  the  attack  friction  sounds 
having  the  quality  and  situation  of  the  friction  signs  in  acute  fibrinous 
pleurisy  are  heard.  When  the  case  has  been  under  observation  from  the 
beginning,  the  rapid  replacement  of  this  sign  by  flatness  is  of  the  highest 
diagnostic  significance.  As  the  fluid  undergoes  resorption  and  the  pleural 
surfaces  once  more  come  in  contact,  friction  soimds  are  again  heard.  At 
this  period  they  are  grating  or  creaking,  or  fine  and  moist,  like  the  crepitus 
of  pneumonia,  and  are  heard  just  above  the  level  of  flatness.  As  expansion 
of  compressed  vesicular  tissue  accompanies  the  process  of  resorption, 
there  are  crepitant  rales  to  be  heard.  As  the  fluid  accumulates,  the  respira- 
tory murmur  becomes  at  first  feeble  and  distant.  Later,  while  retaining 
its  distant  quality  it  assumes  the  bronchial  character  and  may  be  amphoric. 
Cavernous  respiration  associated  with  rales,  especially  in  children,  may 
suggest  a  cavity.  Over  large  effusions  the  respiratory  sounds  may  be 
wholly  absent.  Above  the  level  of  the  fluid  the  respiration  is  vesiculo- 
bronchial or  bronchial.  The  vocal  resonance  is  usually  diminished  or 
absent.  In  rare  instances  there  is  bronchophony,  ^gophony  is  sometimes 
heard  in  the  scapular  region  in  medium-sized  effusions.  The  whispered 
voice  is  better  transmitted  through  a  serous  than  a  purulent  effusion — 
Bacelli's  sign. 

The  Heart. — The  diastole  is  restricted  by  pressure.  The  sounds  are 
therefore  usually  less  distinct  than  normal.  There  is  a  diminished  flow 
of  blood  into  the  arteries,  which  causes  small  pulse  and  a  tendency  to 
cyanosis  and  oliguria.  Murmurs  are  not  uncommon  in  the  displaced  heart, 
and  a  pleuropericardial  friction  may  be  detected  in  many  cases. 

Clinical  Course  of  Serofibrinous  Pleurisy. — The  cases  may  be  grouped 
according  to  the  amount  of  fluid,  which  varies  up  to  4  litres.  Less 
than  500  c.c.  cannot  be  satisfactorily  demonstrated  in  an  adult.  There 
are  many  cases  in  which  the  effusion  does  not  exceed  this  amount  and 
manifests  itself  by  limited  dulness  at  the  base  of  the  chest  and  immobility 
of  the  lower  border  of  pulmonary  resonance.  Spontaneous  arrest  of  the 
process  occurs  and  resorption  begins — slight  effusion.  In  another  group 
the  fluid  reaches  to  the  level  of  the  fourth  rib  in  front  and  resorption  is 
more  tardy — moderate  effusion.  Again  the  upper  line  of  flatness  may  reach 
the  second  rib — large  effusion;  and  finally  there  are  cases  in  which  the 
outpour  of  the  serous  exudate  appears  to  be  limited  only  by  the  capacity 
of  the  pleural  sac,  and  the  whole  side  is  distended  and  flat,  the  signs  of 
fluid  reaching  to  the  clavicle  and  beyond  the  opposite  sternal  border — 
massive  effusion. 

In  slight  effusions  the  fever  subsides,  the  cough  ceases,  and  recovery 
takes  place  in  the  course  of  a  week  or  ten  days.  Some  impairment  of 
resonance  with  feeble  respiratory  sounds  usually  persists  for  a  longer 
period.  In  moderate  and  large  effusions  the  tendency  is  to  spontaneous 
resorption,  but  the  process  is  slow  and  permanent  damage  to  the  lung 
results  from  prolonged  pressure  atelectasis.  In  this  group  there  is  commonly, 
but  by  no  means  invariably,  a  gradual  subsidence  of  fever.  The  exceptional 
cases  in  which  fever  persists  impair  the  usefulness  of  this  symptom  in  the 
differential  diagnosis  between  serofibrinous  and  purulent  pleurisies.  Mas- 
sive effusions  when  the  intrapleural  pressure  is  extreme  are  usually  attended 


1096  MEDICAL  DIAGNOSIS. 

with  distressing  pressure  symptoms.  In  cases  in  which  the  accumulation 
of  fluid  has  been  slow,  the  patient  may  experience  merely  a  sense  of  weight 
and  oppression,  with  shortness  of  breath  upon  exertion.  Large  effusions 
arrest  the  pumping  function  of  the  thoracic  organs,  and  thereby  diminish 
the  outflow  of  arterial  blood  from,  and  the  inflow  of  venous  blood  to,  the 
heart,  and  the  movement  of  the  lymph.  They  show  little  or  no  tendency 
to  undergo  resorption.  Serofibrinous  effusions  in  very  rare  instances 
have  perforated  the  lung  or  the  chest  wall.  In  massive  effusions  with 
great  dislocation  of  the  heart  there  is  danger  of  sudden  death,  an  accident 
attributed  to  various  causes,  as  heart-clot,  embolism  of  the  pulmonary 
artery,  paralysis  of  the  heart  muscle,  and  twists  or  kinking  of  the  great 
vessels.  The  last  of  these  explanations  is  purely  hypothetical.  Sudden 
oedema  of  the  functionating  lung  occurs  when  death  is  not  immediate. 

PURULENT  PLEURISY:    EMPYEMA. 

This  designation  is  applied  to  those  cases  of  pleural  inflammation 
characterized  by  the  formation  of  pus.  When  pus  finds  its  way  into  the 
pleural  sac  by  perforation  from  neighboring  structures  the  condition  is 
known  as  pyothorax. 

Etiology.  —  Predisposing  Influences.  —  Empyema  is  mostly  a 
secondary  affection.  It  occurs  as  a  sequel  to  the  infectious  febrile  diseases, 
especially  scarlet  fever,  and  is  common  after  croupous  pneumonia  and 
bronchopneumonia  and  in  connection  with  abscess  and  gangrene  of  the 
lung.  It  constitutes  a  rare  complication  of  pulmonary  tuberculosis,  occur- 
ring in  tuberculous  bronchopneumonia  and  less  frequently  in  consequence 
of  pleural  infection  from  a  caseating  lesion  or  a  subpleural  tuberculous 
abscess.  Direct  infection  from  without  may  also  occur,  as  in  fracture  of 
a  rib  or  a  penetrating  wound  of  the  chest.  It  occurs  at  every  age  and  is 
common  in  young  infants,  in  whom  a  false  diagnosis  of  pneumonia  is 
frequently  made. 

Exciting  Cause. — The  usual  organisms  in  their  order  of  frequency 
are  the  pneumococcus,  the  ordinary  pyogenic  bacteria,  and  the  tubercle 
bacillus.  The  influenza  bacillus  and  the  Bacterium  coli  communis  have 
been  found  in  rare  instances.  Empyema  is  not  a  stage  in  the  course  of 
serofibrinous  pleurisy.  The  conversion  of  the  serous  into  the  purulent 
effusion  is  unusual.  In  very  rare  instances  serofibrinous  effusions  have 
been  infected  in  aspiration. 

Morbid  Anatomy. — The  lung  is  compressed  to  an  airless  mass.  The 
pleural  surfaces  are  thickened,  and  are  the  seat  of  a  grayish-white  granular 
exudate.  Upon  the  costal  layer  may  be  seen  superficial  erosions  and  some- 
times the  openings  of  fistulous  tracts.  The  fluid  has  the  gross  and  micro- 
scopical characters  of  ordinary  pus,  varying  from  a  thin  to  a  thick  or 
creamy  consistence.  Its  odor  is  sometimes  sweetish,  but  in  many  cases, 
especially  those  following  wounds  or  associated  with  gangrene,  it  is 
horribly  fetid. 

Symptoms. — An  abrupt  onset  with  acute  symptoms  is  rare.  The 
common  beginning  is  insidious,  with  an  intensification  of  the  symptoms 
of  the  primary  affection.     Cough  is  neither  frequent  nor  urgent;    there  is 


PLEURISY.  1097 

little  or  no  expectoration,  and  dyspnoea,  except  m  large  effusions,  is  present 
only  upon  exertion.  The  symptoms  of  sepsis,  as  pallor,  chilliness,  irregular 
fever,  and  more  or  less  profuse  sweating,  are  very  common,  especially  in 
children.  There  is  a  high  leucocytosis,  40,000  or  more  per  cubic  millimetre. 
Physical  Signs. — The  signs  elicited  upon  physical  examination  are 
the  same  as  in  serofibrinous  pleurisy,  with  the  following  superadded: 
marked  bulging  of  the  affected  side  with  obliteration,  even  prominence, 
of  the  intercostal  spaces  in  the  lower  segment  of  the  chest,  especially  in 
children.  In  many  cases  oedema  and  cyanotic  discoloration  of  the  lower 
part  of  the  chest  with  dilatation  of  the  venules.  Whispering  pectoriloquy 
is  not  heard  over  the  effusion — Bacelli's  sign.  Distinct  bronchial  breath- 
ing, transmitted  along  the  chest  wall,  is  often  heard  over  the  effusion  in 
young  children,  a  sign  which  may  lead  to  a  false  diagnosis  of  pneumonia. 
Displacement  phenomena,  affecting  the  heart,  liver,  and  spleen,  are 
more  pronounced  than  in  serofibrinous  effusion,  a  fact  attributed  to  the 
greater  weight  of  the  fluid,  but  probably  due  to  the  greater  impairment 
in  the  tonicity  of  the  tissues  from  the  imbibition  of  toxin  laden  fluids. 

VARIETIES  OF  PURULENT    PLEURISY. 

Empyema  Necessitatis. — The  pus  by  erosion  of  the  costal  pleura 
finds  its  way  through  an  intercostal  space  and  forms  a  subcutaneous, 
fluctuating  tumor.  This  tumor  may  appear  at  various  parts  of  the  chest, 
but  is  usually  situated  anteriorly  from  the  third  to  the  sixth  interspace. 
After  a  time  if  left  to  itself  it  opens,  and  an  oblique  fistulous  communica- 
tion with  the  pleural  cavity  is  established,  which  continues  to  discharge 
pus  for  an  indefinite  time.  When  near  the  heart  the  tumor  may  pulsate. 
It  is  usually  hemispherical  and  diminished  in  size  upon  full  inspiration. 

Pulsating  Pleural  Effusion. — The  pulsation  is  synchronous  with  the 
cardiac  revolution,  and  may  be  intrapleural  and  manifest  in  the  lower 
intercostal  space,  in  the  anterolateral  aspect  of  the  chest,  or  show  itself 
merely  in  an  empyema  necessitatis.  The  pulsation  occurs  in  old  cases, 
almost  always  upon  the  left  side,  and  with  one  exception  among  the 
reported  cases  the  effusion  has  been  purulent.  Various  explanations  have 
been  advanced,  none  of  which  has  met  with  general  acceptance. 

Encysted  or  Circumscribed  Pleural  Effusion. — The  effusion  is  limited 
by  pleural  adhesions.  The  encysted  fluid  may  vary  in  amount  and  suggest 
abscess  of  the  lung,  or  two  or  more  loculi  may  communicate  with  each 
other  by  narrow  openings.  It  is  sometimes  serofibrinous  but  usually  pur- 
ulent. These  collections  may  be  situated  between  the  pulmonary  and 
costal  pleura,  especially  in  the  posterolateral  region  of  the  chest  between 
the  base  of  the  lung  and  the  diaphragm,  or  they  may  be  interlobar. 

HEMORRHAGIC    PLEURISY. 

The  exudate  is  mixed  with  blood.  The  condition  is  to  be  distinguished 
from  ha3mothorax,  which  arises  in  the  absence  of  pleural  inflammation 
when  blood  escapes  into  the  pleural  sac  from  traumatism,  the  rupture  of 
an  aneurism,  or  the  compression  of  thoracic  veins  by  a  new  growth. 


1098  MEDICAL  DIAGNOSIS. 

Etiology.  —  Hemorrhagic  effusion  is  of  comparatively  infrequent 
occurrence.  It  is  encountered  in  pleurisy  under  the  following  conditions: 
in  the  malignant  and  hemorrhagic  forms  of  the  acute  febrile  infections; 
in  visceral  diseases  associated  with  extensive  vascular  changes,  as  chronic 
nephritis  and  cirrhosis  of  the  liver;  in  tuberculous  disease,  both  miliary 
tuberculosis  of  the  pleura  and  the  more  chronic  pleural  tuberculosis  which 
accompanies  chronic  ulcerative  phthisis;  in  primary  and  secondary  malig- 
nant disease  of  the  pleura, — carcinoma  and  sarcoma, — very  rarely  in 
so-called  idiopathic  or  primary  serofibrinous  pleurisy,  in  which,  however, 
red  corpuscles  are  always  to  some  extent  present. 

CHYLIFORM  PLEURAL  EFFUSIONS:    HYDROPS  ADIPOSUS. 

The  exudate  has  a  milky  appearance  due  to  the  fatty  metamorphosis 
of  endothelial  and  other  cellular  elements.  The  condition  is  not  to  be  con- 
founded with  chylous  effusion  which  it  closely  resembles.  The  fact  is  not 
to  be  overlooked  that  a  mixture  of  chyliform  exudates  and  chylous 
transudates  may  be  present — as  in  a  case  recently  under  my  care. 

Etiology. — Chyliform  effusions  owe  their  peculiar  appearance  to,  (a) 
the  presence  of  cells  that  have  undergone  fatty  degeneration,  as  in  car- 
cinoma of  the  pleura,  tubercular  pleurisy,  non-tuberculous  exudate,  pleurisy 
and  abscess  of  the  lung,  and  (b)  to  abnormal  fat  in  the  blood — lipsemia. 

Diagnosis. — The  nature  of  the  effusion  cannot  be  suspected  during 
life  unless  it  is  withdrawn  by  aspiration.  The  fluid  is  yellow,  whey-like, 
and  cheesy.  Upon  standing  there  collects  upon  the  surface  a  cream-like 
layer,  showing  under  the  microscope  small  globules,  mostly  in  the  form 
of  collections  of  highly  refractive  granules  with  large  indistinct  nuclei. 
In  the  underlying  fluid  are  leucocytes  and  larger  cellular  elements  which, 
in  consequence  of  differences  in  the  amount  of  fat,  show  all  possible  tran- 
sitional forms.  (Compare  this  description  with  that  of  chylous  effusion, 
p.  1103.)  Pseudochylous  effusions  have  been  ascribed  to  the  presence  of 
lecithin,  and  Edsall  has  described  a  non-fatty  pleural  effusion  in  which 
the  opacity  was  due  to  altered  globulins. 

The  Diagnosis  of  Pleurisy  with  Effusion. — Direct. — The  diagnosis 
rests  upon  the  physical  signs.  In  large  effusions  the  physical  examination 
yields  conclusive  results.  The  signs  may  be  divided  into  primary,  or  those 
dependent  upon  the  presence  of  the  fluid  per  se,  and  secondary,  or  those 
due  to  the  pressure  of  the  fluid  upon  adjacent  organs — displacement  signs. 
Among  the  more  important  of  the  primary  signs  are  restricted  respiratory 
movement,  flat  percussion,  absence  of  vocal  fremitus,  feeble  and  distant 
breath  sounds,  and  diminished  or  absent  vocal  resonance.  The  important 
secondary  signs  are  displacement  of  the  heart  toward  the  opposite  side, 
as  shown  by  a  visible  or  palpable  impulse,  or,  in  its  absence,  by  the  point 
of  maximum  intensity  of  the  first  sound;  downward  dislocation  and  immo- 
bility of  the  liver  when  the  pleural  effusion  is  right-sided;  flattening  of 
the  convex  upper  border  of  Traube's  semilunar  space;  and  displacement 
of  the  spleen  when  the  effusion  is  left-sided.  Linear  percussion  shows 
restriction  or  absence  of  movement  of  the  borders  of  the  lung  on  the  affected 
side,    and    inspection    increased — vicarious — respiratory    movement    upon 


PLEURISY.  1099 

the  opposite  side.  Difficulties  arise  in  moderate  effusions.  Here  the 
primary  symptoms  are  usually  characteristic  but  the  valuable  aid  afforded 
by  displacement  phenomena  is  lacking.  The  methods  of  physical  diagnosis 
must  be  employed  with  great  nicety  in  doubtful  cases.  The  >S-shaped 
upper  line  of  dulness,  movable  dulness  when  present,  linear  percussion, 
flatness  below  and  Skodaic  resonance  above  the  border  line,  absent  or 
enfeebled  breath  sounds,  and  absent  or  enfeebled  vocal  resonance  and 
vocal  fremitus  are  significant.  When  several  or  all  of  these  signs  are  present 
the  diagnosis  of  effusion  can  be  made  with  some  confidence.  In  small 
effusions  the  diagnostic  problem  becomes  more  difficult  and  more  inter- 
esting. The  same  signs  are  present,  but  to  recognize  them  demands  the 
highest  skill.  Finally,  we  have  the  aspirator  needle  which  can  be  used 
in  any  case  of  doubt.  There  are  several  reasons  why  the  aspirator  should 
be  used  in  exploratory  puncture  rather  than  the  hypodermic  syringe. 
The  needles  are  longer  and  of  larger  calibre,  an  important  matter  in  en- 
cysted effusions  or  where  there  is  thick  pus;  when  the  exudate  is  sero- 
fibrinous the  exploratory  puncture  becomes  at  once  a  therapeutic  pro- 
cedure and  a  single  operation  takes  the  place  of  two,  and  when  pus  is 
present  the  ocular  demonstration  prepares  the  patient  for  the  necessary 
later  surgical  operation  of  drainage. 

The  apparatus  and  spot  selected  must  be  sterilized,  according  to  sur- 
gical requirements,  directly  before  the  operation.  The  needle  should  be 
introduced  at  a  level  in  which  the  ordinary  signs  of  effusion,  as  dulness, 
absent  or  enfeebled  respiration,  and  absent  or  diminished  fremitus,  are 
well  defined.  As  a  rule,  in  ordinary  effusions  the  sixth  or  seventh  inter- 
space in  the  midaxillary  line,  or  a  spot  just  below  the  angle  of  the  scapula, 
may  be  chosen.  If  the  puncture  is  made  too  low  the  needle  simply  pene- 
trates the  costodiaphragmatic  reflexion  of  the  pleura  and  may  enter  the 
liver;  if  too  high  it  will  be  inserted  into  the  compressed  lung  above  the 
level  of  the  effusion.  The  point  selected  for  an  exploratory  puncture  in  a 
circumscribed  lesion  will  be  determined  by  the  physical  signs.  It  is  an 
imperative  rule  to  test  the  instrument  with  sterile  water  immediately 
before  it  is  used. 

Differential. — It  is  in  the  atypical  cases  that  special  difficulties  arise. 

Croupous  Pneumonia. — The  general  rule  that  increased  vocal  fremitus 
occurs  in  pneumonic  consolidation  and  diminished  or  absent  vocal  fremitus 
in  effusion  is  subject  to  exceptions.  In  consolidation  a  plug  or  mass  of 
tough  mucus  may  obstruct  a  main  bronchus  and  arrest  the  vibrations, 
while  in  effusion  they  may  be  distinctly  transmitted  along  bands  of  old 
pleural  adhesions,  or  in  children  from  the  opposite  side  along  the  elastic 
walls  of  the  chest.  The  occurrence  of  bronchophony  and  bronchial  res- 
piration in  certain  cases  add  to  the  difficulty.  The  following  points  are 
to  be  considered: 

(1)  In  pleurisy,  onset  with  moderate  fever  and  no  rigor;  at  most 
chilliness  or  slight  chill;  (2)  dulness  increasing  to  flatness  at  the  base  and 
posteriorly,  and  extending  upward  and  forward;  a  peculiar  sensation 
of  inelasticity  to  the  percussing  finger;  (3)  vocal  fremitus,  enfeebled  or 
abolished  in  the  great  majority  of  cases;  (4)  bronchial  respiration,  if  heard 
at  all,  at  the  upper  level  of  dulness  or  in  patches;    usually  distant  and 


1100  MEDICAL  DIAGNOSIS. 

faint;  (5)  bronchophony  not  intense,  segophony  common  in  the  scapular 
region;  (6)  friction  sounds  when  the  case  is  seen  early  and  at  the  upper 
border  of  dulness  upon  resorption  of  the  fluid,  when  crepitus  may  be  pres- 
ent; (7)  in  large  effusions  displacement  signs;  (8)  sputum,  mucoid 
when  present,  very  rarely  blood-tinged ;  (9)  fever  of  irregular  remittent  type. 

In  pneumonia,  (1)  onset  abrupt  with  chill,  often  prolonged  and  severe; 
(2)  dulness  rather  than  flatness,  coextensive  with  the  borders  of  a  lobe  or 
lobes;  (3)  vocah  fremitus,  marked  and  corresponding  to  the  dulness,  and 
especially  when,  if  feeble  or  absent,  it  reappears  after  cough  and  the 
expectoration  of  tough  mucoid  sputum;  (4)  bronchial  breathing  most 
marked  over  area  of  greatest  dulness  and  often  whiffing  or  snoring  in 
character;  (5)  bronchophony  marked;  segophony  rare;  (6)  crepitant  rales, 
high-pitched  and  in  ''showers  of  crackles"  diffused  over  an  area  of  dul- 
ness and  disappearing  when  bronchial  breathing  becomes  intense;  (7)  dis- 
placement phenomena  absent;  (8)  rusty  or  prune-juice  sputum  the  rule; 
(9)  high  temperature  of  typical  range,  self-limited  course,  and  critical 
defervescence.  Pleurisy  with  effusion  is  frequently  associated  with  croup- 
ous pneumonia  and  bronchopneumonia. 

Pericardial  Effusion. — When  large  this  condition  may  simulate  left- 
sided  pleural  effusion.  The  outline  of  the  area  of  dulness  anteriorly,  its 
convexity  to  the  right  of  the  sternum,  Skodaic  resonance  at  the  base  and 
in  the  axillary  region,  absence  of  cardiac  impulse  on  the  right,  and  a  degree 
of  dyspnoea  and  cardiac  feebleness  not  seen  in  moderate  pleural  effusions 
are  of  diagnostic  importance. 

Hydrothorax. — When  unilateral,  this  condition  cannot  always  be  differ- 
entiated from  serofibrinous  pleurisy  by  the  ordinary  methods  of  physical 
examination.  It  occurs  in  heart  disease  with  great  enlargement  or  dilatation. 
The  diagnosis  rests  upon  concomitant  conditions  and  character  of  the  fluid. 

Intrathoracic  Tumors. — New  growths  of  the  lung,  pleura,  and  medias- 
tinum may  be  mistaken  for  pleural  effusion.  The  situation  of  the  dulness 
and  its  irregular  outline,  the  signs  of  marked  compression  of  the  large 
venous  trunks,  important  nerves,  and  hollow  organs,  as  the  trachea,  bronchi, 
and  oesophagus,  indications  of  malignant  disease  in  other  parts  of  the  body, 
and  enlargement  of  superficial  lymph-nodes  should  prevent  this  error. 
Intrathoracic  tumors  are  very  often  complicated  by  pleural  effusion. 

Aneurism. — Pulsating  empyema  necessitatis  may  suggest  aortic  aneu- 
rism. The  location  of  the  tumor,  usually  at  the  base  of  the  chest,  the 
absence  of  murmurs,  diastolic  shock,  and  tracheal  tugging,  and  the  fact  that 
on  deep  inspiration  the  tumor  diminishes  in  size  and  tension  are  against 
the  diagnosis  of  aneurism.     A  fine  exploratory  needle  may  be  introduced. 

Extrapleural  Abscess. — This  rare  condition  is  to  be  differentiated  from 
pleural  effusion  by  the  absence  of  the  signs  of  compression  of  the  lungs  and 
the  displacement  of  adjacent  organs.  When  such  an  abscess  is  opened  pneu- 
mothorax does  not  occur  and  a  probe  does  not  enter  the  pleural  cavity. 

Subphrenic  Abscess. — This  condition  may  suggest  a  moderate  pleural 
effusion,  from  which  it  may  be  differentiated  by  the  persistence  of  the 
respiratory  movement  of  the  lower  border  of  the  lung,  the  presence  of 
food  particles  in  the  aspirated  fluid  when  the  condition  is  due  to  gastric 
ulcer,  perihepatic  friction,  and  the  absence  of  pneumothorax  upon  puncture. 


PLEURISY.  1101 

Tumors  of  the  Liver. — Abscess,  hydatid  cyst,  and  carcinoma  in  the 
right  lobe  of  the  liver  may  displace  the  diai3hragm  upward,  compress  the 
lung,  and  cause  dulness  and  feeble  respiratory  murmur.  If  large  they  may 
also  dislocate  the  cardiac  impulse  slightly  to  the  left.  The  diagnosis  of 
hepatic  enlargement  rests  upon  the  retention  of  the  respiratory  movement 
of  the  lower  border  of  the  lung,  friction  sounds  over  the  area  of  dulness, 
and  demonstrable  convexity  of  the  upper  line  of  dulness.  Exploratory 
puncture  may  be  performed. 

Perforation  of  the  diaphragm  may,  when  adhesions  to  the  liver  have 
taken  place,  cause  a  condition  not  to  be  differentiated  clinically  from 
hepatic  abscess,  unless  the  case  has  been  observed  from  its  onset,  or 
pus  which  is  characteristic  of  hepatic  abscess  is  expectorated  or  obtained 
by  operation. 

The  Diagnosis  of  the  Character  of  the  Effusion. — This  may  be  readily 
settled  by  the  use  of  the  aspirator  needle.  With  this  means  at  our  dis- 
posal the  clinical  symptoms,  which  are  somewhat  uncertain,  assume  sec- 
ondary importance.  A  serofibrinous  effusion  is  suggested  by  comparatively 
mild  onset,  the  absence  of  the  evidence  of  previous  disease,  the  transmission 
of  the  whispered  voice,  and  in  general  a  mild  course  characterized  merely 
by  malnutrition,  anaemia,  and  dyspnoea  upon  exertion.  That  the  effusion 
is  purulent  is  rendered  probable  by  the  presence  of  pneumonia,  influenza, 
sepsis  or  phthisis,  irregular  chills,  high  fever  and  copious  sweating,  non- 
transmission  of  the  whispered  voice,  oedema  and  cyanosis  of  the  lower 
portion  of  the  affected  side,  and  a  high  leucocytosis.  But  pus  may  be 
present  in  default  of  several  of  these  symptoms,  on  the  one  hand,  and,  on 
the  other,  severe  septic  phenomena  may  accompany  a  moderate,  even  a 
small  circumscribed  serous  effusion.  Hemorrhagic  and  chyliform  fluids 
can  be  recognized  only  when  withdrawn. 

The  Diagnosis  of  the  Pathological  Process. — The  examination  of  the 
fluid  is  of  great  service  both  as  regards  diagnosis  and  prognosis.  A  major- 
ity of  serofibrinous  effusions  are  of  tuberculous  origin.  Tuberculous  foci 
may  or  may  not  be  present  in  the  lungs.  The  methods  of  examination 
comprise  cytodiagnosis,  which  may  be  employed  at  the  bedside,  and  animal 
inoculation,  microscopy,  and  culture  methods,  which  are  available  only  in 
the  laboratory.  Lymphocytes  generally  predominate  in  tuberculous 
effusions;  a  polynuclear  leucocyte  preponderance  suggests  acute  infection, 
and  a  large  number  of  endothelial  cells  is  found  in  mechanical  effusion  or 
transudate.  Inoculation  methods,  with  small  amounts  of  the  fluid,  as 
usually  practiced  are  negative,  but  when  larger  quantities,  as  15  c.c,  are 
used,  the  result  has  confirmed  the  clinical  and  pathological  findings  in 
regard  to  the  preponderance  of  tuberculous  cases  in  serofibrinous  effusions. 
If  actual  fragments  of  cancerous  tissue  are  present  the  diagnosis  is 
positive.  Bacteria  are  present  in  small  numbers  in  clear  exudates.  In 
purulent  exudates  they  are  present  in  great  numbers,  sometimes  a  single 
variety,  sometimes  several  varieties.  Streptococci  are  most  commonly 
present.  The  infection  may  be  direct  from  the  lung,  as  in  broncho- 
pneumonia or  streptococcus  pneumonia,  or  from  distant  foci.  Less  com- 
mon is  pneumococcus  infection,  which  is  usually  secondar}^,  exceptionally 
primary. 


1102  MEDICAL  DIAGNOSIS. 

The  Prognostic  Value  of  the  Bacteriological  Examination  of  the 
Fluid. — A  sterile  fluid  usually  may  be  regarded  as  of  tuberculous  origin. 
The  presence  of  the  pneumococcus  is  relatively  favorable,  since  the  cases 
generally  run  a  satisfactory  course  and  recovery  may  take  place  after  a 
single  aspiration.  Streptococcus  pleurisy  is  the  most  unfavorable  of  all 
forms.  It  is  frequently  associated  with  general  septicaemia  and  leads  up 
to  the  fatal  issue.     The  mixed  infections  are  of  unfavorable  import. 

The  Prognosis  of  Purulent  Pleural  Effusions. — Empyema  is  an  essen- 
tially chronic  disease.  If  neglected  the  outlook  as  to  recovery  is  extremely 
unfavorable,  and  when  spontaneous  recovery  occurs  it  is  only  partial. 
Early  and  efficient  drainage  is  followed  by  a  large  proportion  of  satisfactory 
recoveries.  The  most  unfavorable  cases  are  those  which  arise  in  the  course 
of  general  streptococcus  infection.  Untreated  cases  may  terminate:  1. 
In  small  empyemata,  by  gradual  resorption  of  the  fluid  and  the  deposition 
of  lime  salts.  2.  By  the  discharge  of  the  pus  through  the  lung,  more  com- 
monly after  the  establishment  of  a  bronchopulmonary  fistula,  very  rarely 
by  soakage  without  the  formation  of  a  demonstrable  fistula.  In  the  former 
case  pneumothorax  almost  always  occurs,  in  the  latter  probably  never. 
If  sudden  rupture  occurs  life  may  be  destroyed  by  suffocation.  3.  By 
the  perforation  of  the  costal  or  diaphragmatic  pleura  and  the  formation 
of  empyema  necessitatis  which,  though  usually  in  the  anterior  surface  of 
the  chest,  may  be  at  any  point,  including  the  lumbar  region  and  the  iliac 
fossa,  where  it  simulates  a  lumbar  or  psoas  abscess.  Under  these  circum- 
stances there  is  usually  permanent  atelectasis  of  the  lung  with  fibroid 
changes,  great  pleural  thickening,  and  contraction  and  deformity  of  the 
chest.  A  fair  degree  of  health  may  be  maintained  for  a  varying  period, 
but  if  the  patient  survive  there  is  clubbing  of  the  finger-tips,  amyloid  dis- 
ease develops,  and  ultimately  tuberculosis  in  a  large  proportion  of  the  cases. 

Morbid  States  Characterized   by  the   Transudation   of 

Serum  or  Chyle,  or  the  Eruption  of  Pus,  Blood,  or 

Air  Into  the  Pleural  Sac. 

(a)    HYDROTHORAX. 

Definition. — The  accumulation  of  simple  non-inflammatory  fluid  in 
the  pleural  cavities.  It  occurs  as  a  secondary  affection  in  many  diseases, 
chiefly  those  attended  by  dropsy. 

Etiology. — The  primary  disease  may  involve  the  kidneys,  the  heart, 
or  the  blood.  There  is  usually  more  or  less  anasarca,  exceptionally  merely 
slight  oedema  of  the  feet.  Hydrothorax  is  in  many  cases  the  precursor 
of  death.  In  disease  of  the  kidneys  it  is  commonly  bilateral,  the  effusion 
being  greater  on  one  side,  usually  the  right.  In  chronic  valvular  disease 
with  hypertrophy  and  dilatation,  the  effusion  is  always  more  marked 
and  sometimes  solely  upon  the  right  side,  and  it  promptly  returns 
after  repeated  aspiration.  The  right-sided  hydrothorax  of  cardiac  dis- 
ease has  been  ascribed  to  pressure  upon  the  azygos  veins,  but  it  is  prob- 
ably due  to  the  larger  space  in  the  left  thorax  occupied  by  the  enlarged 
heart.     Extensive  old  pleural  adhesions  may  prevent  accumulation  upon 


PYOTHORAX.  1103 

one  side.  The  pleural  membranes  are  not  the  seat  of  a  fibrinous  exudate, 
being  smooth  and  glistening.  The  fluid  is  clear  and  free  from  fibrin  floc- 
culi.  It  is  usually  moderate  in  amount.  The  symptoms  are  dyspnoea, 
often  amounting  to  orthopncsa,  and  an  aggravation  of  those  due  to  the 
primary  disease.     The  physical  signs  are  those  of  pleural  effusion. 

Diagnosis. — The  condition  may  be  differentiated  from  serofibrinous 
pleurisy  by  the  nature  of  the  primary  disease,  the  absence  of  fever,  of 
displacement  symptoms,  of  friction  sounds,  and  the  relatively  prompt 
change  in  the  line  of  dulness  with  change  of  posture. 

^)  CHYLOUS  PLEURAL  EFFUSION— HYDROPS  CHYLOSUS. 

Definition. — An  accumulation  of  chyle  from  the  thoracic  duct  or  the 
lacteals  by  transudation  or  direct  discharge  into  the  pleural  sac. 

Etiology. — The  special  causes  of  chylous  effusion  into  the  pleural 
sac  are,  (a)  conditions  leading  to  an  escape  of  chyle,  as  external  violence, 
disease  or  occlusion  of  the  chyliferous  vessels,  carcinoma  of  the  pleura, 
occlusion  of  the  left  subclavian  vein,  compression  of  the  duct  by  a  tumor, 
malignant  lymphoma,  disease  of  lymphatic  vessels,  sclerosis,  lymphan- 
giectasis,  and  filariasis,  and  (b)  the  discharge  of  a  chylous  ascites  into  the 
pleural  cavity  by  way  of  the  lymph  spaces. 

Symptoms. — The  symptoms  and  physical  signs  do  not  differ  in  any 
particular  from  those  of  a  pleural  effusion. 

Diagnosis. — There  are  no  means  by  which  the  nature  of  the  fluid  can' 
be  determined  intra  viiam  except  by  the  withdrawal  of  a  portion  of  it. 
In  many  of  the  reported  cases  its  presence  was  first  recognized  at  the 
autopsy.  The  fluid  bears  the  closest  resemblance  to  milk,  is  literally  milk- 
like. It  is  opaque  white  in  color,  with  a  faint  yellowish  or  creamy  shade, 
slightly  alkaline,  and  of  a  specific  gravity  of  about  1,017.  Microscopically 
there  are  seen  great  numbers  of  minute,  dust-like  granules  in  active,  molec- 
ular movement,  a  few  larger  fatty  bodies  scattered  separately  or  in  groups, 
a  few  leucocytes,  larger  cells  containing  distinct,  highly  refracted  granules, 
and  a  very  few  erythrocytes.  Shaken  with  ether  in  a  test-tube  after  the 
addition  of  a  few  drops  of  potassium  hydroxide,  the  fluid  becomes  trans- 
parent and  almost  colorless.  Upon  the  addition  of  osmic  acid  it  becomes 
black  in  color.  The  morphological  elements  are  almost  exclusively  leuco- 
cytes and,  in  great  preponderance,  lymphocytes.  The  fluid  is  sterile.  The 
foregoing  characters  serve  to  distinguish  chylous  effusion — transudates — 
from  chyliform  effusions — exudates  (see  p.  1098).  The  presence  of  grape- 
sugar  is  without  diagnostic  importance,  since  the  fact  has  recently  been 
established  that  this  substance  may  frequently  be  demonstrated  in  ordinary 
serous  transudates  and  exudates,  and  may  therefore  be  expected  in 
chyliform  exudates. 

(c)   PYOTHORAX. 

The  sudden  rupture  of  a  hepatic,  subphrenic,  mediastinal,  or  pul- 
monary abscess  into  the  pleural  sac  may  take  place.  This  accident  is 
usually  prevented  by  more  or  less  extensive  pleural  adhesions.  When  it 
occurs,   general  infection   of    the    pleura   immediately  follows    with    the 


1104  MEDICAL  DIAGNOSIS 

conversion  of  pyothorax  into  purulent  pleurisy.  Communication  with 
the  bronchi  or  with  a  subplirenic  pneumothorax  will  give  rise  to  the 
association  of  air  with  the  pus — pyopneumothorax. 

(d)  H/CMOTHORAX. 

Hemorrhage  into  the  pleural  cavity  results  from  trauma,  the  rupture 
of  an  aneurism,  the  pressure  of  a  tumor  upon  the  thoracic  veins,  and  in 
rare  instances  from  pulmonary  gangrene.  The  sudden  manifestation  of  the 
symptoms  of  internal  hemorrhage,  pallor,  collapse,  small,  thready  pulse, 
coupled  with  the  physical  signs  of  pleural  effusion  justify  a  provisional 
diagnosis.  The  withdrawal  of  blood  upon  exploratory  puncture  renders 
the  diagnosis  positive. 

(e)   PNEUMOTHORAX. 

Hydropneumothorax;    Hcemopneumothorax;  Pyopneumothorax. 

Definition. — Air  in  the  pleural  cavity.  This  condition  is  extremely 
rare.  Infection  of  the  pleura  takes  place  in  almost  every  instance,  and 
in  the  course  of  a  short  time  the  air  is  associated  with  fluid — hydropneumo- 
thorax, hcemopneumothorax,  or  pyopneumothorax. 

There  exists  in  the  normal  pleural  cavity  a  negative  pressure,  by 
reason  of  which  the  lung  fills  the  chest  in  a  state  of  vital  tension.  When, 
'through  any  communication  with  the  external  atmosphere,  the  tension 
is  relieved,  the  distended  lung  collapses  to  the  limits  of  its  inherent  elas- 
ticity, and  a  volume  of  air,  equivalent  to  the  differences  in  the  mass  of  the 
lung  under  normal  distention  and  under  balanced  intrapulmonary  and 
intrapleural  pressure,  enters  the  pleural  sac — pneumothorax.  This  balance 
is,  however,  maintained  only  in  the  case  of  the  communication  remaining 
freely  open  as  in  some  external  wounds  or  perforation  through  consolidated 
lung  tissue.  Under  other  circumstances  a  valvular  action  is  established, 
particularly  in  the  perforation  through  the  lung,  and  the  intrapleural 
pressure  gradually  becomes  positive.  While  the  balance  is  maintained, 
the  mediastinum  is  drawn  toward  the  opposite  side,  and  the  diaphragm 
somewhat  depressed;  when  the  pressure  becomes  positive,  displacement 
phenomena  become  more  marked,  the  mediastinum  is  pushed  further  to- 
ward the  sound  side,  and  the  diaphragm  pushed  downward. 

Etiology.  —  Pneumothorax  is  caused  by:  1.  Perforating  wounds 
of  the  pleura:  (a)  through  the  chest  wall,  as  in  the  case  of  stabs  and  gun- 
shot injuries,  aspiration  and  other  surgical  operations;  (b)  internal  trauma, 
as  when  sharp  or  pointed  foreign  bodies  are  swallowed,  or  an  emphy- 
sematous lung  or  one  tied  down  by  local  adhesions  is  torn  in  violent 
efforts  at  lifting  or  in  paroxysms  of  cough.  The  accident  may  even  occur 
in  the  absence  of  straining.  The  air  may  gradually  undergo  resorption. 
More  commonly  pleurisy  with  effusion  follows.  2.  Perforation  of  the 
pleura  by  ulceration  or  necrosis:  (a)  from  without,  as  in  (i)  diseases  of  the 
lung:  (a)  tuberculosis,  by  far  the  most  common  cause,  the  perforating 
lesion  being  the  softening  of  a  caseous  mass  or  the  rupture  of  a  rapidly 
forming  cavity  before  limiting  pleural  adhesions  have  taken  place.     (^) 


PNEUMOTHORAX. 


1105 


Necrosis  of  lung  tissue  in  septic  conditions,  as  septic  bronchopneumonia, 
gangrene,  and  very  rarely  infarctions.  (ii)  Malignant  disease  of  the 
oesophagus.  (iii)  Infradiaphragmatic  lesions,  as  (a)  subphrenic  abscess, 
(/?)  abscess  of  the  liver,  (;-)  malignant  disease  of  the  stomach  or  colon, 
(b)  From  within,  as  in  empyema,  with  the  formation  of  a  bronchopul- 
monary or  pleurobronchial  fistula.  3.  As  the  result  of  the  development 
in  pleural  exudates  of  the  gas-producing  bacillus — B.  aerogenes  cap- 
sulatus  of  Welch. 

In  rare  cases  pneumothorax  is  double,  and  recurrent  cases  have  been 
reported.      The  condition  is  common  in  adults,  exceptional  in  children. 

riorbid  Anatomy. — The  air  space  is  usually  large,  the  lung  compressed 
and  carnified,  the  pleura  inflamed,  and  serous  or  purulent  effusion  present. 
The  confined  air  may  escape  through  a 
cannula    with    a   whistling   sound    and 
force  enough  to  blow  out  a  candle. 

Symptoms. — The  occurrence  of 
pneumothorax  is  usually  attended  by 
sudden  pain  in  the  side,  distressing 
shortness  of  breath,  slight  cyanosis,  and 
feeble  pulse.  In  old  tuberculous  cases 
it  may  occur  insidiously. 

Physical  Signs.— The  results  of 
physical  examination  are  characteris- 
tic. Inspection.- — The  affected  side  is 
enlarged,  the  intercostal  spaces  bulge, 
and  the  respiratory  excursus  is  greatly 
diminished.  The  impulse  of  the  heart 
is  displaced  toward  the  opposite  side, 
absent  or  greatly  diminished.  Percussion. — The  signs  depend  upon 
the  degree  of  intrapleural  tension  and  the  amount  of  fluid  present. 
When  tension  is  moderate  the  physical  conditions  necessary  to  the  pro- 
duction of  tympanitic  resonance  are  present,  and  as  these  conditions  vary 
the  quality  of  tympany  changes  from  clear,  high-pitched  hyperresonance 
to  the  flat,  woodeny  tympany  of  Skodaic  resonance.  When  tension  is 
extreme  the  physical  conditions  underlying  tympany  no  longer  exist, 
and  the  percussion  sound  is  muffled  and  dull — a  fact  of  great  importance 
in  diagnosis.  There  is  flatness  at  the  base  due  to  effused  fluid,  its  upper 
horizontal  line  indicating  the  height  to  which  the  effusion  rises  and  chang- 
ing with  change  of  ■posture—movable  dulness.  Auscultation. — The  breath 
sounds  are  feeble  and  distant  and  have  the  amphoric  quality.  They  are 
in  strong  contrast  with  the  loud  puerile  vesicular  murmur  of  the  sound 
side.  The  voice  has  also  a  peculiar,  amphoric  quality.  The  ringing  musical 
rale  known  as  metallic  tinkling  or  gutta  cadens  is  heard  upon  deep  breathing 
or  coughing.  The  coin  test  is  also  present  and  of  positive  diagnostic  value. 
Finally,  the  swash  of  the  free  fluid  within  the  pleural  cavity  upon  energetic 
sudden  changes  of  the  patient's  body — Hippocr-atic  succussion—may  often 
be  heard  at  a  distance,  or  even  by  the  patient  himself.  In  that  form  of 
pneumothorax  in  which  there  is  free  communication  with  a  bronchus 
through  consolidated  lung,  the  bulging  of  the  intercostal  spaces  and  dis- 

70 


Fig.  323. — Horizontal  line  of  surface  of 
effusion  in  pyopneumothorax;  patient  in  the 
upright  position.  This  line  shifts  with  change 
of  posture. 


Palpation. — Vocal   fremitus  is 


1106  MEDICAL  DIAGNOSIS. 

placement  signs  are  less  marked,  coarse,  gurgling  rales  are  observed  at 
times,  and  there  is  the  occasional  expectoration  of  a  thin,  purulent  fluid. 
In  rare  instances  of  left-sidea  pneumothorax  the  heart  sounds  may  have  a. 
metallic  echoing  quality. 

Diagnosis. — Direct. — The  signs  are  characteristic  and  the  diagnosis^ 
even  when  in  consequence  of  old  adhesions  the  air  space  is  limited,  may 
be  made  with  confidence. 

Differential. — The  following  conditions  may  give  rise  to  uncer- 
tainty: Cirrhosis  of  the  Left  Lung. — The  high  position  of  the  diaphragm 
with  a  dilated  stomach  yields  tympany  in  the  lower  part  of  the  left  chesty 
amphoric  sounds,  and  sometimes  gastric  succussion.  The  various  sounds 
are  little  influenced  by  respiration.  Percussion  when  the  stomach  is  filled 
with  fluid  and  the  fact  that  the  impulse  of  the  heart  is  displaced  toward 
the  left  are  conclusive.  Diaphragmatic  Hernia.  —  This  condition  when 
congenital  may  be  misleading.  After  a  crushing  accident  the  metallic 
sounds  are  related  to  peristaltic  rather  than  respiratory  movements,  and 
the  difficulty  in  passing  the  tube  at  the  cardiac  orifice,  owing  to  the  dis- 
location of  the  stomach,  is  suggestive.  Pyopneumothorax  Suhphrenicus 
of  Leyden. — The  anamnesis  is  important — symptoms  of  gastric  or  duodenal 
ulcer,  chronic  intestinal  disease,  hepatic  or  splenic  abscess  usually  precede 
this  condition.  Cough  and  sputum  are  not  commonly  present;  the  heart 
is  slightlj"  displaced,  the  liver  much  lowered.  The  lower  border  of  the  lung 
rises  and  falls,  as  shown  by  percussion  and  auscultation,  upon  deep  res- 
piratory efforts,  and  movable  dulness  cannot  be  made  out.  Large  Intra- 
pulmonary  Cavities. — Two  conditions  are  to  be  considered:  first,  the 
breaking  down  of  the  greater  part  of  a  lung — a  very  rare  event — in  which 
the  physical  arrangement  closely  resembles  ordinary  pneumothorax; 
and  second,  the  cavities  resulting  from  pulmonary  abscess,  gangrene,  or 
bronchiectasis,  or  the  ordinary  cavities  of  phthisis,  which  may  simulate 
circumscribed  pneumothorax,  which  is  likewise  of  extremely  rare  occur- 
rence. In  the  first  of  these  conditions  the  amphoric  quality  of  the  respir- 
atory and  voice  sounds  may  be  intense,  but  the  succussion  splash,  the  coin 
sound,  and  displacement  phenomena  are  absent.  In  extremely  rare  cases, 
however,  coin  percussion  may  yield  the  bell-like  resonance  over  a  cavity. 
Smaller  cavities  may  be  differentiated  from  circumscribed  pneumothorax 
by  the  presence  or  increase  of  the  vocal  fremitus,  absence  of  chest  disten- 
tion, sinking  of  the  intercostal  spaces  over  the  cavity,  and  changes  in  the 
physical  signs,  upon  percussion  and  auscultation,  after  severe  cough  with 
copious  expectoration.  The  location  of  the  cavity  is  without  diagnostic 
importance-,  since  sacculated  pneumothorax  may  occur  at  the  apex,  while 
the  cavities  following  abscess  and  gangrene  are  usually  in  the  lower  lobe, 
those  of  bronchiectasis  may  occupy  any  portion  of  the  lung,  and  those  of 
phthisis,  while  usually  apical,  are  sometimes  situated  at  the  base. 

Prognosis. — Spontaneous  pneumothorax,  occurring  upon  effort  in 
a  person  suffering  from  emphysema  or  with  local  pleural  adhesion,  fre- 
quently terminates  in  recovery  with  resorption  of  the  air.  The  traumatic 
and  surgical  cases  also  do  well.  There  is  a  group  of  tuberculous  cases  in 
which  the  occurrence  of  pneumothorax  appears  to  arrest  the  progress  of 
the  disease.     There  are  chronic  cases  of   open  pneumothorax,  the  fistula 


ANOMALIES  OF  THE  KIDNEYS.  1107 

.being  either  pleurobronchial  or  external,  which  last  for  years,  the  patients 
being  able  to  go  about  and  attend  to  their  affairs.  In  pneumothorax 
acutissimus  death  may  take  place  within  an  hour  or  in  the  course  of  the 
first  day,  though  the  catastrophe  may  be  averted  by  the  use  of  the  trocar 
and  cannula.  As  a  rule,  the  cases  occurring  in  tuberculosis  die  in  a  few 
days  or  weeks. 

Masked  Pneumothorax. — This  term  has  been  applied  to  cases  in  which 
the  symptoms  of  pneumothorax,  namely,  intense  pleural  pain,  dyspnoea, 
pressure  phenomena,  and  displacement  of  the  mediastinal  organs  and 
diaphragm,  have  suddenly  occurred  in  the  course  of  advanced  tuberculosis 
in  the  absence  of  the  usual  signs  of  pneumothorax  upon  auscultation  and 
percussion.  In  the  course  of  some  days  these  signs  gradually  appear,  and 
a  circumscribed  pneumothorax  may  be  demonstrated.  They  are  at  first 
obscured  by  the  deep  situation  of  the  collection  of  extrapulmonary  air, 
which  has  escaped  by  way  of  an  opening  into  the  mediastinum,  an  inter- 
lobar space,  or  a  space  between  the  base  of  the  lung  and  the  diaphragm, 
and  is  retained  by  previously  formed  pleural  adhesions.  Deep-seated  cir- 
cumscribed pneumothorax  is  sometimes  encountered  post  mortem  in  cases 
in  which  neither  the  signs  nor  symptoms  have  been  observed  during  life. 


XL 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  KIDNEYS. 

I.  ANATOMICAL  ANOMALIES  OF  THE  KIDNEYS. 

The  kidneys  may  be  displaced,  with  or  without  deformity;  the  displace- 
ment may  be  congenital  or  acquired.  They  may  vary  in  number:  con- 
genital absence  of  one  or  both  kidneys,  supernumerary  kidneys,  atrophy 
of  one  kidney.  They  may  be  anomalous  in  form:  general  departures 
from  type,  as  lobulation;  hypertrophy  of  one  or  both  organs,  and  fusion 
— horse-shoe  kidney,  sigmoid  kidney, 
disk-shaped  kidney.  Finally,  there 
may  be  variations  in  the  blood- 
vessels, pelvis,    and   ureters. 

Of  these  abnormal  conditions 
the  hypertrophied  kidney  can  be 
diagnosticated  only  when  the  affected 
organ  is  movable  and  is  recognized 
upon  palpation  through  the  abdom- 
inal wall;  the  horse-shoe  kidney  only 
when  it  has  descended  to  a  position 

,  ,,  c     ,  1  Fig. 324. — "  Horse-shoe  "kidnev — German  Ho.spital. 

just   above  the   promontory   oi   the 

sacrum  and  can  be  felt  through  thin  abdominal  walls  as  a  prevertebral 
tumor  with  a  non-expansile  pulsation  communicated  from  the  underlying 
aorta,  upon  which  it  in  part  rests;  a  single  kidney  may  be  suspected  when 
tympanitic  percussion  resonance  is  constantly  elicited  in  one  lumbar 
region  and  no  movable  kidney  is  palpable,  or  when,  after  an  attack  of 


1108  MEDICAL  DIAGNOSIS. 

renal  colic  w'th  impaction,  complete  anuria  and  ultimately  fatal  ursemia 
occur.  In  rare  cases  the  impaction  of  a  calculus  upon  one  side  may  be 
followed  by  anuria  when  both  kidneys  are  present.  Other  anomalies 
cannot  be  recognized  during  life. 

II.  MOVABLE  KIDNEY. 

Ren  Mohilis;  Palpable  Kidney;  Floating  or  Wandering  Kidney;  Nephroptosis. 

Etiology. — The  condition  may  be  congenital,  the  kidney  being  sur- 
rounded by  peritoneum  which  forms  a  mesonephron.  Far  more  commonly 
it  is  acquired.  It  is  probable  that  congenital  defects  in  the  mechanism  of 
attachment  are  at  fault  in  all  cases.  Wasting  of  the  perirenal  fat  is  a  factor. 
Movable  kidney  has  been  observed  at  all  ages,  but  is  most  usual  in  middle 
life.  It  is  more  common  in  women  than  men  in  the  proportion  of  7  to  1 — 
a  fact  attributed  to  compression  of  the  base  of  the  chest  by  the  corset 
and  the  change  in  the  position  of  the  uterus  and  the  relaxation  of  the 
abdominal  wall  after  repeated  child-bearing.  It  occurs,  however,  in 
women  who  have  never  borne  children.  It  is  mostly  unilateral,  several 
times  as  often  on  the  right  side  as  on  the  left,  and  occasionally  double. 
The  greater  frequency  on  the  right  side  is  attributed  to  the  relation  of  the 
right  kidney  to  the  liver  and  the  respiratory  movement  communicated  to 
it  by  the  latter  organ.  In  the  anamnesis  there  is  sometimes  an  antecedent 
history  of  injury  or  strain.  The  kidney  undergoes  dislocation  together 
with  the  other  abdominal  viscera  in  Glenard's  disease — enteroptosis. 

Symptoms. — In  a  large  proportion  of  the  cases  there  are  no  definite 
or  characteristic  symptoms.  Neurasthenic  and  gastro-intestinal  symptoms 
are  common.  Constipation  is  frequent  and  fecal  obstruction  may  occur. 
Dragging  pains  in  the  lumbar  region,  especially  upon  prolonged  standing, 
are  observed.  Neuralgic  pains  in  the  abdomen  occur.  The  tumor,  which  is 
often  accidentally  discovered  by  the  patient,  is  not  tender  upon  gentle 
pressure,  but  when  firmly  compressed  there  is  a  dull,  sickening  pain.  Dietl's 
Crises. — In  some  cases  of  floating  kidney  there  are  paroxysmal  attacks, 
characterized  by  abdominal  pain,  nausea,  and  vomiting,  with  chills,  fever, 
and  collapse.  These  attacks  have  been  mistaken  for  renal  colic,  acute 
intestinal  disease,  and  appendicitis,  but  the  kidney  may  be  felt  and  is 
tender,  swollen,  and  less  freely  movable  than  usual.  The  urine  during  the 
attack  may  contain  uric  acid  or  calcium  oxalates  in  excess,  and  inter- 
mittent hsematuria  may  occur.  These  paroxysms  have  been  ascribed  to 
torsion  of  the  renal  vessels.  Intermittent  hydronephrosis  sometimes  occurs. 
The  nervous  symptoms  of  movable  kidney  are  important.  In  women 
hysterical  manifestations,  in  men  hypochondriasis  are  common.  Such 
patients  are  very  susceptible  to  suggestion,  and  their  sufferings  are  often 
much  increased  when  the  diagnosis  is  communicated  to  them.  In  other 
cases  a  plain  statement  of  the  cause  of  the  trouble  is  followed  by  relief. 

Physical  Examination. — The  patient  should  be  placed  upon  his  back, 
with  the  abdominal  muscles  relaxed.  In  well-marked  cases  the  tumor  is 
plainly  visible  and  palpable  in  the  erect  posture.  Ordinarily,  upon  bimanual 
palpation  in  the  dorsal  decubitus,  one  hand  being  placed  in  the  lumbar 


MOVABLE  KIDNEY.  1109 

region,  the  other  in  the  hypochondrium,  with  gentle  manipulation  during 
full  respiratory  movements,  the  kidney,  if  movable,  may  be  recognized  by 
the  fingers  upon  the  abdomen  as  an  oval,  smooth  mass.  By  this  manoeuvre 
various  degrees  of  mobility  may  be  determined.  (1)  Palpable  Kidney. — 
The  lower  end  of  the  organ  may  be  felt  upon  deep  palpation  just  below 
the  edge  of  the  ribs  in  the  nipple  line — a  condition  of  little  or  no  clinical 
import.  (2)  Movable  Kidney. — Upon  deep  inspiration  the  fingers  upon 
the  abdomen  may,  if  there  is  little  abdominal  fat,  be  pressed  over  the  upper 
end  of  the  kidney,  which  can  be  thus  fixed  for  the  time  but  has  no  wider 
excursion — a  degree  of  dislocation  the  importance  of  which  is  frequently 
overrated.  (3)  Floating  or  Wandering  Kidney. — The  organ  may ^  be 
felt  as  an  oval,  smooth,  solid  tumor,  having  the  size  and  contour  of  the 
kidney.  In  some  instances  the  hilum  and  pulsating  renal  artery  can  be 
recognized.  This  tumor  is  freely  movable,  and  sometimes  lies  just  above 
Poupart's  ligament,  or  may  by  gentle  pressure  be  displaced  to  the  median 
line  or  beyond  it.  In  different  postures  the  wandering  kidney  changes  its 
position,  falling  forward  in  the  knee-elbow  position,  and  away  from  the 
abdominal  wall  in  the  dorsal  decubitus,  when  it  is  often  possible  to  slip  it 
upward  into  its  normal  place.  To  this  degree  of  displacement  belong  the 
more  distressing  symptoms  of  ren  mobilis.  Dilatation  and  downward  dis- 
placement of  the  stomach  can  be  demonstrated  in  a  large  proportion  of 
the  cases,  especially  in  women. 

Diagnosis. — Direct. — A  positive  diagnosis  can  usually  be  made  in 
palpable  and  movable  kidney  by  the  position  of  the  smooth,  rounded, 
firm  tumor,  which  descends  with  deep  inspiration  and  can  be  made  to  dis- 
appear by  pressure  upward  and  backward,  particularly  when,  as  sometimes 
happens  upon  repeated  examination,  flattening  or  tympanitic  resonance  is 
found  in  the  renal  region  ujDon  the  same  side.  Floating  kidney  rarely 
presents  difficulty  in  diagnosis. 

Differential. — Tumor  of  the  Gall-bladder. — The  mass  presents  at 
the  border  of  the  ribs,  has  the  respiratory  movement  of  the  liver,  cannot 
be  grasped  from  above,  and  when  forced  backward  immediately  returns 
to  its  former  position.  Its  movement  is  less  extensive  than  in  floating 
kidney  and  is,  roughly  speaking,  in  the  arc  of  a  circle  having  its  centre  in 
the  normal  position  of  the  gall-bladder.  Furthermore,  in  tumors  of  the 
gall-bladder  the  upper  margin  reaches  and  is  continuous  with  the  Uver. 
Other  tumors  of  the  liver  and  tumors  of  the  bowel  are  fixed  and  do  not 
present  the  characteristic  contour  of  the  kidney.  Movable  Spleen. — Any 
doubt  as  to  whether  a  movable  tumor  upon  the  left  side  is  the  kidney  or 
spleen  is  at  once  settled  by  the  shape  of  the  tumor  and  the  presence  or 
absence  of  the  normal  area  of  dulness  in  the  splenic  region.  Tumor  of  the 
Pylorus. — Carcinoma  in  this  region  may  be  freely  movable.  Under  such 
circumstances  the  shape  of  the  tumor,  its  relation  to  the  stomach,  filled 
and  emptied  by  means  of  the  stomach  tube,  dulness  in  both  renal  regions, 
and  the  prominence  of  gastric  symptoms  arc  of  diagnostic  value.  Ovarian 
Cysts. — The  facts  that  the  tumor  arises  from  the  pelvis,  that  its  outline  is 
round  or  globular,  that  it  is  elastic  rather  than  firm,  and  that  it  cannot  be 
made  to  disappear  into  the  normal  position  of  the  kidney,  readily  settle 
any  doubt  as  to  the  differential  diagnosis. 


1110  MEDICAL  DIAGNOSIS. 

Prognosis. — The  outlook  as  to  permanent  fixation  is  less  hopeful  than 
as  to  reUef  by  the  adjustments  that  follow  'mprovement  in  the  general  health. 
Nephropexy  and  nephrorrhaphy,  with  and  without  decapsulation,  have  many 
successes  and  many  failures  to  their  credit.  Relief  in  many  cases  may  be 
obtained   by  a  suitable  belt  and  pad  and  treatment  of  the  neurasthenia. 

III.  CIRCULATORY  DERANGEMENTS. 

Theoretically  anaemia  and  congestion  occur. 

(a)  Renal  Anaemia. — ^The  oncometric  observations  of  Mendelsohn 
indicate  that  the  kidneys  are  small  and  bloodless  in  acute  fever.  This 
investigator  holds  that  the  scant}^,  high-colored  urine  of  febrile  states  is 
due  to  anaemia.  Clinicians  have  generally  attributed  it  to  renal  conges- 
tion.    No  positive  diagnosis  of  anaemia  of  the  kidneys  can  be  made. 

(b)  Congestion  of  the  Kidneys. — Active  Congestion. — Etiology. — 
Certain  drugs,  as  the  terebinthinates  and  cantharides,  when  taken  in  over- 
doses, are  accredited  with  causing  congestion  of  the  kidnej^s.  Exposure 
to  damp  and  cold,  various  poisons  and  irritants  have  the  same  effect. 
Active  hyperaemia  is  characteristic  of  the  onset  of  acute  nephritis,  from 
which  it  cannot  be  clinically  differentiated.  Post  mortem  the  kidney  is 
large,  dark,  and  soft,  and  upon  section  drips  blood.  The  condition  is  typical 
in  postscarlatinal  nephritis.  The  urine  is  scanty,  densely  albuminous, 
and  contains  red  blood-corpuscles  and  tube-casts. 

Passive  Congestion. — Etiology. — The  hyperaemia  is  mechanical.  It 
results  from  the  transference  of  blood-pressure  from  the  arterial  to  the 
venous  side  of  the  circulation,  which  occurs  in  cardiac  disease  and  emphy- 
sema, and  locally  from  pressure  upon  the  renal  veins  by  the  pregnant 
uterus,  abdominal  tumors,  and  large  ascites.  The  condition  found  post 
mortem  is  known  as  cyanotic  induration,  and  is  a  form  of  chronic  diffuse 
nephritis.  The  urine  is  diminished,  dark  red  in  color,  of  high  specific 
gravity,  and  contains  albumin  in  moderate  amount,  with  hyaline  tube- 
casts.  A  few  red  blood-corpuscles  may  be  present  in  the  sediment.  The 
line  between  congestion  and  nephritis  cannot  always  be  drawn  at  tlie  bed- 
side. Hyaline  casts  only,  moderate  albumin,  isolated  red  corpuscles,  total 
absence  of  uraemic  symptoms,  cynosis  rather  than  pallor,  and  iirprove- 
ment  upon  the  administration  of  digitalis  suggest,  in  a  heart  case,  the 
diagnosis  of  congestion  rather  than  nephritis.  Prognosis. — The  causal 
conditions  in  chronic  hyperaemia  of  the  kidneys  are  such  as  to  render  the 
prognosis  unfavorable.     Congestion  tends  to  pass  into  nephritis. 

(c)  Hemorrhagic  Infarct  of  the  Kidney. — Etiology. — Embolism  of 
renal  arteries  occurs  in  valvular  disease,  endarteritis,  and  traumatism 
involving  the  renal  artery.  Symptoms. — Sudden  pain  in  the  region  of  the 
kidney  upon  one  side,  with  corresponding  tenderness  upon  pressure,  and 
haematuria  constitute  the  symptoms  in  well-marked  cases.  These  sj^mp- 
toms  are  all  transient,  the  pain  and  tenderness  subsiding  in  the  course  of 
a  day  or  two,  the  blood  disappearing  from  the  urine  in  three  or  fovr  days, 
and  the  albumin  a  short  time  later.  In  the  majority  of  instances  in  which 
infarcts  are  found  post  mortem  no  clinical  symptoms  have  been  noted. 
Diagnosis. — Hemorrhagic  infarct  of  the  kidney  cannot,  as  a  rule,  be  diag- 


URiEMIA. 


1111 


nosticated  during  life.  When  the  above  symptoms  occur  in  a  patient  in 
whom  the  etiological  facte  rs  are  present,  or  in  whom  embolic  processes 
elsewhere  can  be  demonstrated,  the  diagnosis  is  positive.  Prognosis. — 
The  outlook  is  that  of  the  underlying  morbid  condition.  Old  infarcts  of 
the  kidneys  are  often  found  in  post-mortem  examinations. 


c. 

r-42<> 


IV.  UREMIA. 

Definition. — A  toxaemia  developing  in  the  course  of  acute  or  chronic 
nephritis  and  other  conditions  characterized  by  deficient  urinary  secre- 
tion or  complete  anuria,  and  manifested  by  irregularly  associated  nervous 
and  gastro-intestinal  symptoms. 

Various  hypotheses  have  been  advanced  regarding  the  pathology  of 
uraemia,  among  which  the  following  are  important:  1.  That  it  is  due  to 
the  accumulation  of  excrementitious  substances  normally  eliminated  by 
the  kidneys,  especially  urea,  salts,  and  nitrogenous  bodies.  2.  That  it  is 
caused  by  toxins  evolved  in  the  course  of  abnormal  tissue  metabolism, 
of  the  nature  of  which  nothing  positive  is  known.  Uraemia  has  been 
attributed  to  derangements  of  a  hypo- 
thetical internal  secretion  of  the  kidney. 
3.  That  the  nervous  symptoms  are 
largely  due  to   local  cerebral  oedema. 

Symptoms. — Uraemia  may  be  of 
•every  grade  of  intensity  and  of  the  most 
variable  duration.  Latent,  acute,  and 
chronic  forms  are  therefore  described. 

The  Latent  Form. — This  form 
has  been  especially  studied  in  cases  of 
complete  anuria.  The  patient  may 
suffer  very  little  inconvenience.  Pre- 
hminary  headache  and  the  alternation 
■of  convulsions  and  coma  seen  in  acute 
uraemia  are  often  absent.  The  mind 
remains  clear,  the  pupils  are  contracted, 
muscular  twitchings  and  vomiting 
•occur.     The  temperature  is  subnormal. 

The  Acute  Form. — The  onset  is 
preceded  by  headache,  mental  con- 
fusion, dulness,  and  drowsiness.  The 
attack  begins  abruptly  with  vomit- 
ing and  diarrhoea,  or  convulsions  alter- 
nating with  or  followed  by  coma, 
or  coma  may  develop  in  the  absence 
of  convulsions.  Such  an  attack  very 
often  occurs  in  persons  in  whom  no 
previous  indications  of  nephritis  have  been  observed.  Fever  of  irregular 
type  is  frequently  present,  and  may  be,  in  acute  nephritis,  a  manifes- 
tation of  the  underlying  disease  or  symptomatic  of  some  complication,  as 
an  intercurrent  inflammatory  or  infectious  process,  itself  the  cause  of  the 
uraemia,  or  the  fever  may  be  part  of  the  uraemic  symptom-complex. 


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f    3.Q 

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y 

Fig.  325. — Chronic  parenchymatovis  nephritis. 
Ursemia;   convulsions;   recoverj'. 


1112  MEDICAL  DIAGNOSIS. 

The  Chronic  Form. — The  patient  may  go  about  and  in  a  way  attend 
to  his  affairs,  He  suffers,  however,  from  headache,  vertigo,  confusion, 
drowsiness,  and  pruritus,  and  very  often  has  transient  muscular  twitch- 
ings.  Dyspnoea,  which  may  be  continuous  or  paroxysmal,  and  is  fre- 
quently nocturnal  only,  is  a  common  symptom  in  chronic  ursemia.  It  is 
often  regarded  as  asthma.  The  respi^tion  is  sometimes  Cheyne-Stokes 
in  type.  Itching,  numbness,  and  cramps  in  the  calves  of  the  legs  also  occur. 
Local  palsies,  hemiplegias,  and  monoplegias  occur,  and  are  frequently  tran- 
sient. The  psychoses  of  chronic  ursemia  are  important.  They  very  often 
occur  in  persons  not  known  to  have  nephritis.  Mania  and  delusional  insanity 
are  common.  Delusions  of  persecution,  suicidal  tendencies,  and  melancholia 
occur.  The  alienist  may  be  in  doubt  whether  an  insane  person  has  nephritis, 
or  a  patient  suffering  from  nephritis  has  an  uraemic  psychosis — an  uncertainty 
which  emphasizes  the  artificial  character  of  nosological  classifications. 

The  convulsions  of  uraemia  may  occur  abruptly  or  after  a  spell  of  head- 
ache and  restlessness.  They  closely  resemble  the  epileptic  seizure,  though 
the  epileptic  cry  is  said  not  to  occur.  The  repetition  of  the  general  convul- 
sion with  unconsciousness  in  the  intervals  may  suggest  "  status  epilepticus." 
Jacksonian  epilepsy  may  occur.  The  temperature  sinks  as  a  rule  after  the 
attack.  Uraemic  amaurosis  may  occur  after  a  convulsive  attack,  or  in 
the  absence  of  convulsions.  It  may  pass  off  in  the  course  of  a  few  days. 
The  ophthalmoscopic  findings  are  negative.  Uraemic  deafness  of  the  same 
fleeting  character  has  also  been  obser-ved. 

Persons  suffering  from  chronic  uraemia  frequently  have  no  appetite 
and  a  foul  tongue  and  breath.  The  stomatitis  sometimes  present  has  no 
special  characters. 

In  grave  cases  of  acute  uraemia  a  frost-like  efflorescence  of  urea  has 
sometimes  been  observed  upon  the  skin.  Acute  inflammations  of  the 
serous  membranes,  endocarditis,  pericarditis,  pleurisy,  peritonitis,  and, 
much  more  rarely,  meningitis  occur  as  terminal  events  in  patients  suffer- 
ing from  conditions  in  which  chronic  ursemia  has  developed. 

Diagnosis. — Direct. — The  diagnosis  of  ursemia  depends  upon  the 
association  of  nephritis  and  nervous  symptoms  of  more  or  less  irregular 
character  and  combination.  In  cases  of  anuria  from  any  cause  a  direct 
diagnosis  is  justified.  In  other  cases  an  examination  of  the  urine  yields 
definite  data.  The  nervous  symptoms  are  often  such  that  a  diagnosis  by 
exclusion  becomes  necessary.  The  copious  vomitus  in  some  cases  may 
have  the  odor  of  ammonia,  since  the  urea  in  the  gastric  contents  may 
have  undergone  the  change  into  ammonium  carbonate.  The  determina- 
tion of  the  urea  output  in  the  urine  cannot  be  relied  upon  as  indicating 
the  approach  of  ursemic  symptoms. 

The  diagnosis  of  the  latent  uraemia  of  Roberts  rests  upon  the  asso- 
ciation of  certain  of  the  milder  symptoms  of  the  condition  with  more  or 
less  complete  anuria.  In  acute  fully  developed  ursemia  with  vomiting, 
convulsions,  coma,  amaurosis,  and  stertorous  or  Cheyne-Stokes  respiration, 
the  symptom-complex  is  so  characteristic  that  errors  in  diagnosis  seldom 
occur.  If  some  of  these  symptoms  suddenly  develop  as  the  result  of  intoxi- 
cations or  severe  infectious  processes,  in  persons  not  suffering  from 
nephritis,  the  presence  of  albumin  in  relatively  small  amounts  and  hyaline 


UREMIA.  1113 

casts  only,  without  red  blood-corpuscles  or  other  tube-casts,  particularly 
if  the  specific  gravity  of  the  urine  be  not  abnormally  low,  is  of  diagnostic 
value.  Nor  is  it  always  easy  to  recognize  the  nausea,  vomiting,  and  diar- 
rhoea of  the  gastro-intestinal  form  as  ursemic.  Chronic  ursemia  is  even 
more  difficult  of  recognition.  Asthma-like  attacks  with  shortness  of 
breath,  especially  at  night,  may  lead  to  an  incorrect  diagnosis  in  cases  in 
which  the  nervous  symptoms  are  slight  and  ill-defined.  The  acute  attack 
very  often  occurs  in  the  course  of  the  chronic  condition.  The  pupils  are 
inconstant.  They  may  be  dilated  or  normal.  The  j)resence  of  albuminuric 
retinitis  may  be  of  positive  diagnostic  significance. 

Differential. — 1.  Cerebral  Disease. — (a)  The  ursemic  attack,  with 
sudden  loss  of  consciousness,  and  hemiplegia,  especially  when  these  symp- 
toms are  associated  with  convulsions,  may  present  the  clinical  picture  of 
apoplexy  from  cerebral  hemorrhage  or  thrombosis.  In  favor  of  the  latter 
diagnosis  are  the  abruptness  of  the  onset,  the  completeness  of  the  loss  of 
power,  conjugate  deviation,  and  persistence  of  the  symptoms.  It  is  char- 
acteristic of  the  nervous  symptoms  of  ursemia  that  they  are  incomplete 
and  transitory,  (b)  Meningitis. — Sudden  coma  following  headache  and 
vomiting,  without  localizing  phenomena  but  attended  by  albuminuria, 
may  present  great  difficulties  in  diagnosis.  The  results  of  spinal  puncture 
are  important  Stiffness  of  the  neck,  paralysis  of  cerebral  nerves,  retrac- 
tion of  the  abdomen,  and  Kernig's  sign  occur  in  meningitis,  (c)  Tumors. — 
The  symptoms  of  coarse  lesions  of  the  brain  may  suggest  ursemia.  Jack- 
sonian  and  general  convulsions,  vomiting,  headache,  vertigo,  and  hemi- 
plegia and  monoplegia  occur  in  both  conditions.  But  in  anatomical  lesions 
the  symptoms  are  chronic  and  usually  though  not  always  progressive, 
while  in  ursemia  characterized  by  such  symptoms  the  attack  is  sudden 
and  frequently  transitory.  2.  Severe  Infections. — There  are  cases  of 
ursemia  in  which  stupor,  a  dry  tongue,  rapid,  feeble  pulse,  muscular  twitch- 
ing, and  fever  persist  for  weeks,  and  the  appearance  of  the  patient  suggests 
an  acute  specific  disease  with  secondary  infection.  These  cases  may  re- 
semble: (a)  Enteric  Fever. — The  differentiation  from  ursemia  depends 
upon  the  presence  of  a  pulse  relatively  slow,  as  compared  with  the  rise 
of  temperature,  splenic  tumor,  rose  rash,  a  temperature  range  conforming 
to  type,  and  a  positive  Widal  reaction,  (b)  Miliary  Tuberculosis. — The 
pulmonary  symptoms  and  signs,  the  signs  of  an  associated  pleurisy  or 
pericarditis,  and  choroidal  tubercles  when  present  suffice  to  establish  the 
true  nature  of  the  affection,  (c)  Septic  Conditions. — Local  necrotic  proc- 
esses, multiple  foci  of  inflammation,  irregular  chills,  fever  and  sweating, 
embolic  phenomena  are  diagnostic.  3.  Intoxications. — Ursemic  coma 
may  be  mistaken  for  poisoning  by  alcohol  or  opium.  The  anamnesis  is 
important.  In  all  cases  the  urine  must  be  drawn  and  examined.  The  cir- 
cumstances in  which  the  patient  is  found  and  the  odor  of  the  breath  may 
be  suggestive,  (a)  Alcohol. — The  temperature  is  subnormal,  the  pupils 
usually  dilated,  the  coma  often  incomplete;  if  it  alternates  with  delirium 
the  latter  is  of  peculiar  type  and  attended  with  tremor,  (b)  Opium. — 
Contracted  pupils,  slow  pulse  and  respiration,  profound  stupor  from 
which  the  patient  cannot  be  roused  favor  the  diagnosis  of  opium  poisoning 
rather  than  ursemia. 


1114  MEDICAL  DIAGNOSIS. 

Prognosis. — As  ursemia  is  a  secondary  toxsemia  the  prognosis  depends 
upon  that  of  the  primary  disease.  Latent  ursemia  dependent  upon  anuria 
may  disappear  when  the  flow  of  urine  is  re-established.  The  urtemia  of 
acute  nephritis  disappears  with  recovery  from  the  renal  condition;  that 
of  the  chronic  forms  may  be  transient  and  recurrent.  A  patient  in  the 
Pennsylvania  Hospital  was  unconscious  for  several  days,  with  convulsions 
alternating  with  coma,  but  recovered  and  lived  four  or  five  years,  working 
as  a  laborer.  Sudden  ursemic  coma  is  common  in  chronic  interstitial  nephri- 
tis, and  may  be  the  first  indication  of  renal  disease.     It  is  frequently  fatal. 

V.  INFLAMMATION  OF  THE  KIDNEYS. 

The  inflammations  of  the  kidneys  comprised  under  the  general  term 
Bright's  disease  cannot  be  satisfactorily  classified,  either  from  the  clinical 
or  the  pathological  stand  point.  Still  less  can  the  clinical  varieties  be 
c'osely  coordinated  with  the  post-mortem  findings.  Clinically  the  cases 
may  be  grouped  as  acute  and  chronic;  anatomically  they  are  all  diffuse; 
that  is  to  say,  epithelial,  vascular,  and  intertubular  tissues  are  involved, 
but,  since  the  changes  in  these  structures  vary  in  degree,  parenchymatous, 
glomerular,  and  interstitial  forms  are  recognized,  according  as  one  or  the 
other  of  these  groups  of  tissues  is  particularly  affected. 

(a)  Acute  Nephritis. 

Acute  Parenchymatous  Nephritis;    Acute  Bright's  Disease. 

Definition. — Acute  diffuse  inflammation  of  the  kidneys,  caused  by 
the  action  of  cold,  poisons,  or  the  toxins  of  the  infectious  diseases,  and 
characterized  by  scanty  urine  containing  albumin,  blood-corpuscles,  and 
tube-casts,  a  tendenc}^  to  dropsy,  and  evidences  of  toxsemia. 

Etiology. — Exposure  to  cold  and  wet  is  very  often  followed  in  the 
course  of  a  day  or  two  by  the  evidences  of  acute  nephritis.  Trench  diggers 
and  other  laborers  in  low  wet  places  are  especially  liable.  It  is  common 
after  the  exposure  incident  to  a  debauch.  Certain  drugs,  as  cantharides, 
internally  administered  or  externally  applied,  turpentine,  balsam  of  Peru, 
potassium  chlorate,  naphthol,  and  certain  acids,  as  sulphuric  acid,  salicylic 
acid,  and  phenol,  in  excessive  doses  are  sometimes  followed  by  this  form 
of  nephritis.  The  nephritis  which  frequently  follows  scarlet  fever  is  typical. 
Less  common  and  usually  less  intense  is  the  acute  nephritis  associated 
with  pneumonia,  enteric  fever,  influenza,  and  diphtheria.  The  acute 
nephritis  of  yellow  fever  and  cholera  is  of  severe  type.  Nephritis  may  occur 
in  association  with  variola,  varicella,  meningitis,  syphilis,  septic  condi- 
tions, purpura,  and  angina  tonsillaris.  The  acute  nephritis  of  pregnancy 
is  probably  caused  by  toxins  of  unknown  nature,  and  the  remarkable  form 
which  occurs  after  extensive  burns  and  other  cutaneous  lesions  probably 
belongs  to  this  group. 

Symptoms. — The  general  symptoms  after  exposure  to  cold  and  wet 
usually  develop  suddenlj^;  after  poisoning  and  the  infections,  gradually. 
The  onset  in  children  may  be  attended  with  convulsions;    in  adults,  by  a 


NEPHRITIS.  1115 

chill  or  chilliness.  -  Much  more  common  are  such  initial  symptoms  as  pain 
in  the  back,  nausea,  vomiting,  and  headache.  PaLor,  puffiness  about  the 
eyes,  and  oedema  of  the  ankles  are  very  often  the  first  symptoms  to  call 
attention  to  the  kidneys.  Fever  is  not  constant.  It  is  more  common  in 
children  than  adults.  The  temperature  may  reach  102°- 103°  F.  (38.9°-39.5° 
C).     Its  range  does  not  conform  to  type. 

The  urinary  changes  are  characteristic.  The  quantity  is  at  first  greatly 
diminished.  Anuria  may  occur.  Usually  a  few  ounces — 100  to  200  c.c. — 
are  secreted  in  twenty-four  hours.  The  specific  gravity  is  high — 1.020  to 
1.030.  Later,  when  the  secretion  is  re-establ  shed,  the  specific  gravity  falls 
to  normal  or  below  it.  The  percentage  of  urea  is  high,  but  the  total  quan- 
tity is  greatly  reduced.  Owing  to  the  excess  of  solids  the  urine  is  not 
transparent.  It  varies  in  color  from  a  mere  smokiness  to  the  dense,  opaque 
brown  of  porter.  These  changes  are  due  to  the  presence  of  blood,  but  the 
urine  is  never  bright  red.  Upon  standing  an  abundant,  dark,  coarse  sedi- 
ment is  precipitated,  which  consists  of  red  blood-corpuscles,  epithehum 
from  the  urinary  tract,  uric  acid  and  other  crystals,  and  hyaline,  granular, 
blood,  and  epithelial  tube-casts.  Albumin  is  abundant  and  upon  testing 
precipitates  in  coarse,  curdy  flakes.  Upon  the  application  of  heat  the  urine 
may  solidify  in  the  test-tube.  The  foregoing  urinary  changes  are  of  highest 
grade  in  the  beginning  of  the  attack.  They  are  to  some  extent  a  measure 
of  the  severity  of  the  disease  and  they  gradually  lessen  as  improvement 
occurs  in  favorable  cases. 

Dropsy,  though  exceptionally  absent,  is  a  frequent  and  important 
symptom.  It  varies  from  mere  puffiness  about  the  eyelids  to  a  general 
anasarca  with  effusion  into  the  serous  sacs.  It  is  a  peculiarity  of  the  dropsy 
oi  acute  nephritis  that  it  is  irregular  in  its  distribution  and  does  not  always 
gravitate  according  to  the  posture  of  the  patient.  The  degree  of  oedema  is 
greater  after  colds,  in  pregnancy,  and  after  scarlatina  than  after  the  other 
infections.  In  the  nephritis  of  diphtheria  there  may  be  little  or  none.  There 
are  cases  of  post-scarlatinal  nephritis  in  which  effusion  into  the  serous 
cavities  occurs  with  scanty  subcutaneous  oedema.  Pulmonary  oedema 
and  oedema  of  the  glottis  may  occur.  Anaemia  is  an  early  and  marked 
condition.  Epistaxis  is  common  and  symptomatic  purpura  not  infre- 
quent. The  pulse  tension  may  be  increased  and  the  aortic  second  sound 
accentuated.  Acute  dilatation  of  the  heart  may  occur.  Albuminuric 
retinitis  is  comparatively  infrequent,  though  retinal  hemorrhages  are 
occasionally  encountered. 

Ursemic  symptoms,  among  which  we  include  the  preliminary  anorexia, 
dulness,  and  headache,  and  the  initial  nausea  and  vomiting,  are  almost 
constant.  When  to  these  minor  symptoms  caused  by  the  retention  of 
excrementitious  substances  are  added  convulsions  and  coma,  the  condi- 
tion of  acute  uraemia  is  fully  established.  This  may  occur  at  any  period 
in  the  course  of  the  attack. 

Diagnosis. — Direct. — The  general  symptoms  are  variable  and  by  no 
means  characteristic.  Pallor,  with  slight  puffiness  of  the  ankles  or  eyelids, 
may  be  present  in  the  absence  of  subjective  sensations  of  impaired  health; 
or  the  symptoms  of  the  causal  affection  may  mask  those  of  the  nephritis. 
This  is  apt  to  be  the  case  in  pregnancy.    It  is  therefore  imperative  that  the 


1116  MEDICAL  DIAGNOSIS. 

urine  be  examined  at  intervals  of  two  or  three  weeks  as  a  matter  ot  routme 
during  gestation.  The  cHnical  picture  of  acute  nephritis  in  the  acute 
cases  following  cold,  or  occurring  after  scarlatina,  is  such  as  to  justify 
a  positive  diagnosis.  In  the  insidiously  developing  cases  the  conditions 
may  be  less  obvious.  The  urinary  findings  as  given  above  are  of  diagnostic 
significance.  The  presence  of  blood-corpuscles  with  blood  and  epithelial 
casts  is  characteristic. 

Differential. — 1.  Febrile  or  toxic  albuminuria  cannot  in  all  cases 
be  distinctly  differentiated  from  an  infectious  nephritis.  In  favor  of  the 
former  is  the  absence  of  special  symptoms,  pallor,  slight  oedema,  or  uraemic 
phenomena,  and  certain  characters  of  the  urine,  namely,  albuminuria  of 
hghter  degree  and  transitorj^  duration,  lower  specific  gravity  and  larger 
quantity  of  the  urine,  and  the  absence  of  blood-corpuscles  and  blood  and 
epithelial  casts. 

2.  Intercurrent  acute  nephritis  in  the  course  of  chronic  nephritis.  This 
condition  is  by  no  means  infrequent.  The  acute  attack  has  the  clinical 
phenomena  of  the  primary  affection  and  is  often  regarded  as  primary. 
Attention  to  the  anamnesis,  which  shows  antecedent  poor  health,  charac- 
terized by  weakness  and  lassitude,  headache,  gastric  derangements, 
pallor,  and  slight  or  transitory  oedema,  and  usually  the  absence  of  any 
recent  definite  causal  factor,  may  explain  the  occurrence  of  acute  dropsy 
with  toxic  phenomena.  The  urinary  changes  are  less  sharply  defined 
than  in  the  primary  cases,  and  a  tense  pulse  with  cardiac  hypertrophy  and 
accentuated  aortic  second  sound,  and  particularly  albuminuric  retinitis, 
render  the  diagnosis  of  coexistent  chronic  nephritis  certain, 

3.  Glomerular  Nephritis. — The  attempt  to  differentiate  cases  in  which 
vascular  changes  are  primar.y  and  severe,  while  the  epithelium  and  inter- 
tubular  tissues  are  affected  to  a  less  degree,  constitutes  an  extreme  refine- 
ment of  diagnosis.  This  condition  is  present  in  post-scarlatinal  nephritis, 
a  variety  characterized  by  anuria,  extreme  dropsy,  and  acute  uraemic 
symptoms.  The  absence  of  epithelial  casts  might  under  such  circumstances 
have  some  degree  of  diagnostic  significance. 

Prognosis. — The  outlook  depends  more  upon  the  course  than  upon 
the  immediate  condition  of  the  patient.  It  is  more  unfavorable  in  post- 
scarlatinal and  puerperal  nephritis  than  in  other  forms.  Acute  nephritis 
following  cold  is  less  dangerous.  That  which  follows  the  various  infections 
other  than  scarlet  fever,  is  usually  of  milder  type.  Complete  and  rapid 
recovery  may  follow  the  intense  forms  associated  with  3^ellow  fever  and 
cholera.  The  death-rate  in  infancy  is  not  lower  than  33  per  cent.  The 
prognosis  as  to  entire  recovery  is  uncertain.  Acute  nephritis  is  very  often 
the  point  of  departure  for  the  chronic  form.  Even  with  apparent  recovery 
there  remains  an  especial  liabihty  to  attacks  later  in  life.  At  the  onset 
neither  the  dropsy,  the  amount  of  urine,  nor  the  proportion  of  albumin 
which  it  contains  justifies  a  positive  prognosis.  Urgent  uraemic  symp- 
toms are  always  alarming.  In  the  gravest  acute  nephritis  dropsy  may 
be  absent.  Complete  anuria  lasting  for  a  day  or  two  may  occur  in  cases 
terminating  favorably,  and  dense  albuminuria  often  gradually  disappears. 
Low  arterial  tension,  intense  anaemia,  persistence  of  dropsy,  effusion  into 
the  serous  sacs,  continuing  albuminuria  of  high  grade,  and  chronic  uraemic 


NEPHRITIS.  1117 

symptoms  are  of  unfavorable  prognostic  import.  Cases  thus  characterized 
are  Hable  to  an  acute  fatal  exacerbation,  or  escaping  that;  to  a  chronic 
course.  The  absence  of  these  conditions  is  favorable.  Recovery  may  be 
practically  complete  in  four  or  six  weeks.  In  other  cases  a  favorable 
termination  may  occur  at  the  end  of  several  months. 

(b)  Chronic  Nephritis. 

Chronic  Bright's  Disease. 

Anatomically  two  principal  forms  are  encountered,  namely,  chronic 
parenchymatous  nephritis  and  chronic  interstitial  nephritis,  and  these  respec- 
tively manifest  themselves  by  a  more  or  less  well-defined  symptom-complex. 

1.  CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Chronic  Desquamative  Nephritis;    Chronic  Tubal  Nephritis. 

Definition. — Chronic  diffuse  inflammation  of  the  kidneys,  occurring 
as  a  sequel  of  acute  nephritis  or  developing  insidiously,  and  characterized 
by  albuminous  urine  of  high  specific  gravity,  containing  tube-casts. 

Etiology. — This  form  of  nephritis  frequently  follows  the  acute  variety 
and  is  due  to  the  same  causes.  In  many  cases  it  insidiously  develops  after 
an  acute  attack  in  the  course  of  a  chronic  infection.  It  is  common  in 
persons  who  have  suffered  from  repeated  attacks  of  malarial  fever,  and  in 
chronic  alcoholism.  It  is  met  with  at  all  ages,  but  is  especially  common 
in  early  adult  life,  and  in  children  as  a  sequel  of  scarlatinal  nephritis. 
In  adult  life  it  is  more  frequent  in  males  than  females. 

The  kidneys  may  show  the  changes  which  constitute  the  large  white 
kidney,  the  small  white  or  pale  granular  kidney,  or  the  kidney  of  chronic 
hemorrhagic  nephritis.  Whether  the  pale  granular  kidney  is  a  condition 
consecutive  to  the  large  white  kidney,  or  an  independent  pathological 
process  from  the  beginning,  is  not  positively  known.  These  two  conditions 
cannot  be  differentiated  clinically  either  by  the  symptoms  or  by  the  com- 
position and  contents  of  the  urine.  A  protracted  course,  with  the  symp- 
toms and  urinary  changes  of  parenchymatous  nephritis  passing  by  degrees 
into  those  suggestive  of  the  chronic  interstitial  form,  would  support  the 
opinion  that  the  small  white  kidney  may  be  a  later  stage  of  the  large 
white   kidney. 

Symptoms.  —  When  consecutive  to  the  acute  form,  chronic  paren- 
chymatous nephritis  presents  similar,  though  less  urgent,  symptoms.  A 
majority  of  the  patients,  after  a  period  of  failing  health  with  ill-defined 
symptoms,  become  pallid  and  puffy  about  the  eyelids  and  ankles,  or  the 
albumin  and  casts  are  discovered  upon  routine  examination  of  the  urine. 

The  urine,  especially  in  the  earlier  course  of  the  disease,  is  diminished 
in  quantity,  averaging  in  the  adult  750  to  1000  c.c.  in  the  course  of  twent)'- 
four  hours.  With  increasing  dropsy  the  output  usually  diminishes,  to  again 
increase  as  the  dropsical  effusion  undergoes  resorption.  It  is  dirty  yellow 
in  color  and  turbid  from  the  presence  of  urates.    Upon  standing  it  precipi- 


1118  MEDICAL  DIAGNOSIS. 

tates  a  sediment,  which  reveals  upon  examination  leucocytes,  often  red 
blood-corpuscles,  epithehum  from  the  urinary  passages,  and  many  tube- 
casts,  hyahne,  granular,  fatty,  and  epithelial.  Albumin  is  usually  abundant,, 
showing  a  relative  decrease  during  repose  and  an  increase  after  exercise. 
It  varies  in  amount  from  .5  to  2  per  cent.  The  specific  gravity  is  above 
normal,  varying  from  L025  to  1.035.  As  the  case  progresses,  the  average 
daily  quantity  of  urine  augments,  while  the  average  daily  amount  of 
albumin  excreted  declines,  and  the  specific  gravity  falls.  The  daily 
amount  of  urea  fluctuates,  but  the  average  is  below  the  normal.  The 
presence  of  blood  in  considerable  quantities  is  suggestive  of  chronic 
hemorrhagic    nephritis. 

The  tendency  to  dropsy  is  characteristic  of  this  form  of  nephritis. 
The  eyelids  and  ankles  early  in  the  disease,  the  subcutaneous  tissues 
generally  later,  and  toward  the  close  the  serous  sacs  become  the  seat  of 
dropsical  effusions.  The  loose  tissues  of  the  genitalia  in  both  sexes,  and 
dependent  parts  in  general,  become  in  advanced  cases  highly  distended  and 
oedematous.  Ursemic  symptoms,  especially  headache  and  drowsiness,  are 
common.  Gastro-intestinal  symptoms,  anorexia,  nausea,  vomiting,  and  diar- 
rhoea belong  to  this  group.  Convulsions  may  occur  as  the  end  approaches. 
Albuminuric  retinitis  is  not  common  early  in  the  disease.  Hypertrophy 
of  the  heart  is  of  less  frequent  occurrence  and  less  marked  than  in 
the  chronic  interstitial  form.  The  longer  the  duration  of  the  disease  the 
greater  the  tendency  to  cardiac  enlargement.  The  pulse  tension  is  usually 
increased,  the  aortic  second  sound  accentuated,  and  some  degree  of  arterio- 
sclerosis gradually  develops.  In  chronic  parenchymatous  nephritis  there  is 
a  peculiar  tendency  to  bronchitis,  pneumonia,  pleurisy,  and  pericarditis. 

Diagnosis.  —  Direct.  —  The  recognition  of  this  form  of  nephritis 
depends  upon  the  association  of  the  above-described  urinary  changes,  the 
tendency  to  dropsy,  and  mild  ursemic  symptoms,  as  headache,  drowsiness, 
loss  of  appetite,  and  nausea.  In  mild  cases  the  diagnosis  must  rest  upon 
the  condition  of  the  urine.  The  facies,  which  exhibits  marked  pallor,  a 
dull,  pasty  complexion,  and  puffy  eyelids,  is  suggestive. 

Prognosis. — The  prognosis  is  grave,  both  as  to  life  and  as  to  recovery. 
A  limited  proportion  of  cases  under  very  strict  and  judicious  management, 
especially  among  children,  recover  in  the  course  of  a  year  or  two.  The 
greater  number  have  already,  when  the  diagnosis  is  made,  entered  upon 
a  life  of  chronic  invalidism.  The  scene  closes  with  increasing  and 
unmanageable  dropsy,  acute  ursemic  symptoms,  or  intercurrent  acute 
inflammation,  usually  of  the  pleurae  or  pericardium. 


2.  CHRONIC  INTERSTITIAL  NEPHRITIS. 

Contracted  or  Granular  Kidney;   Sclerosis  of  the  Kidney;   Gouty  Kidney. 

Definition. — Chronic  diffuse  inflammation  of  the  kidneys,  associated 
with  overgrowth  of  intertubular  connective  tissue,  and  characterized  by 
insidious  development,  increased  urine  of  low  specific  gravity,  albuminuria, 
which  is  usually  slight  and  often  intermittent,  arteriosclerosis,  and  little 
tendency  to  dropsy. 


NEPHRITIS.  1119 

Anatomically,  there  is  marked  increase  in  the  connective  tissue,  with 
degeneration  of  the  parenchymatous  structures.  The  process  is  essentially 
atrophic,  the  atrophy  probably  beginning  in  the  glomerules  and  tubules, 
and  being  followed  by  increase  in  the  connective  tissue.  Three  forms  are 
described:  (a)  The  pale  granular  kidney,  to  which  reference  has  already 
been  made — secondary  atrophic  kidney;  (b)  the  contracted  kidney,  occurring 
as  an  independent  affection — primary  atrophic  kidney;  and  (c)  sclerosis  of 
the  kidneys,  developing  in  connection  with  cardiovascular  disease — arterio- 
sclerotic atrophy  of  the  kidney. 

Etiology.  —  The  pale  granular  kidney  probably  constitutes  a  later 
stage  of  the  large  white  kidney,  in  which  atrophic  changes  in  the  secreting 
structures  have  been  followed  by  connective-tissue  overgrowth.  The  pri- 
mary contracted  kidney  is  the  result  of  a  gradual  degenerative  process. 
Many  of  the  cases  occur  in  the  absence  of  discoverable  cause  and  may  be 
due  to  premature  senile  involution.  Hereditary  influences,  early  arterio- 
sclerosis, syphilis,  and  gout  are  causal  factors.  Chronic  intoxications, 
especially  alcohol  and  lead,  play  an  important  part  in  the  etiology  of 
sclerosis  of  the  kidney.  Habitual  excesses  at  table,  especially  the  eating 
of  large  quantities  of  meat,  are  particularly  injurious.  The  arteriosclerotic 
form  is  associated  with  cardiac  hypertrophy  and  sclerosis  of  the  arterial 
walls.  It  is  common  in  active,  energetic  men,  who  work  hard  and  eat 
and  drink  too  much.  Habitual  anxiety  and  worry,  and  inability  to  endure 
the  stress  of  life  favor  the  development  of  the  vascular  changes  of  which 
contracted  kidney  is  the  outcome.  This  form  of  renal  disease  is  much  more 
common  after  forty  than  in  early  life,  and  in  men  than  in  women.  In  this 
country  arteriosclerosis  develops  at  an  earlier  age  among  the  Slav  immi- 
grants than  in  persons  of  other  nationalities. 

Symptoms. — The  changes  in  the  kidneys  are  insidious  and  frequently 
reach  an  advanced  stage  before  they  cause  symptoms  that  attract  atten- 
tion. Acute  ursemic  symptoms  frequently  constitute  the  first  marked 
i^anifestations  of  the  disease.  The  earlier  symptoms,  headache,  frequent 
micturition,  and  digestive  disorders  are  often  disregarded  by  the  patient. 
More  commonly  the  general  health  becomes  gradually  impaired.  The 
patient  is  weak  and  breathless  upon  exertion.  He  rises  frequently  to 
pass  urine,  suffers  from  habitual  headache,  and  complains  of  nausea  and 
occasional  vomiting. 

The  composition  of  the  urine  varies  to  some  extent  according  to  the 
variety  of  the  renal  atrophy.  In  the  secondary  form  the  quantity  of  the 
urine  is  less  and  the  amount  of  albumin  greater  than  in  the  primary  form. 
The  specific  gravity  is  more  nearly  normal,  that  is,  higher.  There  are 
various  kinds  of  casts  and  a  few  red  blood-corpuscles  in  the  sediment. 
The  tendency  to  dropsy  is  more  marked.  In  the  primary  form  the  quantity 
of  urine  is  much  increased  above  normal  and  frequently  reaches  as  much 
as  four  litres.  This  polyuria  is  the  cause  of  an  abnormal  thirst.  The 
color  is  pale  yellow,  the  transparency  clear,  and  the  specific  gravity  low — 
1.005  to  1.012.  A  scanty  sediment  is  deposited,  in  which  are  found  a  few- 
hyaline  and  granular  tube-casts,  granular  epithelial  cells,  leucocytes,  and 
rarely  red  blood-corpuscles.  The  amount  of  albumin  is  small,  especially 
after  repose.     It  increases  during  attacks  of  intercurrent  disease  or  with 


1120  MEDICAL  DIAGNOSIS. 

cardiac  weakness,  when  the  quantity  of  urine  is  diminished.  It  is  char- 
acteristic of  this  form  of  nephritis  that  there  are  often  albumin-free  periods, 
especially  in  the  early  part  of  the  day.  The  casts  in  some  instances  disap- 
pear even  while  the  urine  remains  albuminous.  The  urinary  solids  are 
decreased,  especially  urea.  Temporarily  the  urea  may  reach  normal, 
and  uric  acid,  phosphoric  acid,  the  chlorides,  and  ammonia  may  approach 
normal.  In  the  arteriosclerotic  form  polj'uria  is  less  common,  the  color 
of  the  urine  is  normal,  the  albumin  is  more  abundant  and  more  constant, 
and  there  are  hyaline  and  granular  casts,  which  may  at  times  disappear. 

Dropsy,  so  long  as  the  power  of  the  hypertrophied  heart  and  the 
polyuria  are  maintained,  is  absent  or  scanty.  Pretibial  oedema  msij  be 
noted,  or  slight  puffiness  of  the  ankles.  The  heart  is  hypertrophied,  the 
left  ventricle  being  first  affected.  The  apex  is  displaced  to  the  left  and 
downward.  The  impulse  is  forcible  and  sometimes  heaving.  The  aortic 
second  sound  is  accentuated.  There  may  be  reduplication  of  the  first  sound, 
or  an  apex  systolic  murmur  transmitted  to  the  axilla.  Toward  the  close 
the  hypertrophy  fails  and  the  signs  of  dilatation  are  pronounced,  together 
with  lessened  urine,  increased  albumin,  and  mounting  dropsy.  The  pulse 
is  hard  and  tense.  The  superficial  arterial  walls  are  thickened  and  incom- 
pressible. The  radials  can  be  rolled  with  the  finger  like  a  wh  p-cord  upon 
the  underlying  bone.  The  temporals  are  prominent  and  tortuous.  There 
is  early  and  persistent  increase  of  blood-pressure.  Epistaxis  is  common 
and  may  be  troublesome.  Hemorrhages  into  the  skin  occur.  Headache  is 
a  very  common  symptom.  The  symptoms  in  advanced  cases  are  mostly 
due  to  the  cardiovascular  conditions,  or  to  uremia.  To  the  former  group 
are  to  be  referred  sudden  oedema  of  the  glottis  or  lungs,  pleural  effusion, 
and  some  cases  of  cardiac  d3^spnoea.  This  symptom  may  resemble  asthma 
and  is  often  troublesome  at  night.  Cerebral  hemorrhage  is  not  uncommon. 
Fully  40  per  cent,  of  the  cases  of  apoplexy  occur  in  persons  suffering  from 
contracted  kidneys.  To  ursemia,  either  in  its  chronic  or  acute  forms,  must 
be  referred  certain  of  the  cases  of  nocturnal  dyspnoea — so-called  renal 
asthma,  Cheyne-Stokes  respiration,  nausea,  vomiting,  which  is  often  uncon- 
trollable, and  diarrhoea.  The  complexion  is  usually  pallid  and  muddy. 
Sweating  is  uncommon.  The  urea  "frost"  may  be  deposited  after  free 
perspiration.  Pruritus  and  eczema  are  common.  Muscular  cramps  occur, 
especially  on  waking  in  the  morning.  Albuminuric  retinitis  occurs  more 
frequently  than  in  any  other  form  of  nephritis.  Visual  troubles,  in  a 
large  proportion  of  the  cases,  lead  to  the  discovery  of  the  actual  condition. 
Sudden  blindness  without  ophthalmoscopic  findings — uraemic  amaurosis — 
is  sometimes  observed.  Hemorrhages  beneath  the  conjunctivae  or  into  the 
eyelids  occur.  Tinnitus  aurium  or  cerebri,  vertigo,  and  nervous  deafness 
are  encountered. 

Persons  subject  to  chronic  interstitial  nephritis  are  peculiarly  hable 
to  severe  intercurrent  diseases.  Bronchitis  and  pneumonia  are  common. 
Inflammatory  affections  of  the  serous  membranes,  as  acute  pleurisy  and 
pericarditis,  occur. 

Diagnosis. — The  early  stages  of  chronic  interstitial  nephritis  present 
no  characteristic  clinical  phenomena.  The  anatomical  condition  may  be 
advanced  in  cases  unattended  by  evidences  of  ill  health  prior  to  the  occur- 


PYELITIS.  1121 

rence  of  the  acute  disease  which  has  been  the  cause  of  death.  The  asso- 
-ciation  of  cardiac  hypertrophy,  sclerotic  arteries,  high  pulse  tension, 
accentuated  aortic  second  sound,  with  copious  urine  of  low  specific  gravity 
containing  an  inconstant  trace  of  albumin  and  a  few  hyaline  and  granular 
casts,  justifies  a  positive  diagnosis.  The  urine  should  be  repeatedly  exam- 
ined, specimens  being  taken  at  night  and  in  the  morning.  The  condition 
is  often  discovered  accidentally  in  examination  for  life  insurance,  and 
sometimes  overlooked  under  the  same  circumstances. 

The  diagnosis  of  small  granular  kidney  cannot  be  positively  made 
from  the  symptoms  and  urinary  composition.  It  is  rendered  probable  by 
a  previous  history  of  acute  or  chronic  parenchymatous  nephritis.  Nor 
can  the  arteriosclerotic  form  be  distinguished  from  the  other  varieties 
with  certainty.  The  diagnosis  becomes  probable  when  the  patient  is  past 
forty  and  has  marked  cardiac  hypertrophy,  hardened  arteries,  increased 
pulse  tension,  and  ursemic  symptoms,  and  particularly  when  the  progress 
of  the  case  is  comparatively  rapid. 

Prognosis. — The  outlook  as  regards  recovery  is  hopeless.  The  disease 
is  incurable.  As  regards  prolongation  of  life  and  a  fair  degree  of  health, 
the  prognosis  is  not  altogether  without  encouragement.  Many  of  the  cases, 
under  careful  management  and  with  a  self-denying  and  regular  manner  of 
living,  make  slow  progress  and  continue  for  years  without  passing  into 
invalidism.  The  symptoms  of  chronic  uraemia  are  danger  signals;  those  of 
acute  uraemia  heralds  of  catastrophe.  The  signs  of  cardiac  failure  are 
usually  the  beginning  of  the  end. 

VI.  PYELITIS. 

Definition. — Inflammation  of  the  pelvis  of  the  kidney,  due  to  direct 
bacterial  infection  by  way  of  the  blood  or  the  ureters  and  lymphatics. 

When  the  inflammation  extends  to  the  substance  of  the  kidney  the 
condition  is  designated  pyelonephritis;  when  the  entire  organ  is  involved, 
pyonephrosis  or  renal  abscess;  the  form  due  to  tuberculosis  is  known  as 
nephrophthisis. 

Etiology.  —  Under  ordinary  conditions  the  kidneys  are  capable  of 
eliminating,  without  damage  to  themselves,  the  pathogenic  organisms 
reaching  them  by  way  of  the  blood  stream  or  ureters  and  lymph  channels 
in  constitutional  or  local  infection.  When,  however,  their  resistance  to 
pathogenic  influences  is  diminished  by  such  general  causes  as  prolonged 
malnutrition,  anaemia,  cold,  or  over-exertion,  or  by  local  conditions,  as 
congestion,  nephritis,  pressure  upon  the  kidney  or  ureter,  twisting  of  the 
ureter  in  displacement  or  operation,  infection  occurs.  Whether  this  takes 
place  from  the  side  of  the  blood  current  or  from  the  urinary  tract,  the  pelvis 
of  the  kidney  is  first  affected — pyelitis.  The  colon  bacillus,  Bacillus  pro- 
teus,  streptococcus,  and  staphylococcus  albus  have  been  found  in  pure 
cultures.  The  tubercle  bacillus  is  the  cause  of  a  special  form  of  pyelitis. 
That  form  which  occurs  in  gonorrhosa  is  caused  not  by  the  gonococcus 
but  by  associated  pyogenic  organisms. 

Morbid  Anatomy. — Pyelitis  may  be  catarrhal  or  suppurative.  The 
tuberculous  form  begins  locally,  the  kidney  gradually  becoming  infil- 
71 


1122  MEDICAL  DIAGNOSIS. 

trated  with  tubercle  which  undergoes  caseation  and  softening,  with  ultimate 
transformation  into  cretaceous  masses  from  the  resorption  of  fluid  ele- 
ments and  the  deposition  of  lime  salts.  It  is  associated  with  tuberculosis 
of  the  ureters,  bladder,  and  prostate  and  testicles,  or  the  ovaries  or  Fallo- 
pian tubes — urogenital  tuberculosis.  Pyelitis  due  to  local  causes  usually 
affects  one  kidney;  that  caused  by  general  conditions  may  involve  one 
or  both;  the  form  consecutive  to  cystitis,  following  enlarged  prostate, 
stricture,  catheter  infection,  and  surgical  operation,  is  bilateral  and 
extends  to  the  kidney  substance.  The  acute  supj^urative  pyelonephritis 
which  follows  operations  is  known  as  surgical  kidney. 

Symptoms. — The  pyelitis  which  accompanies  the  acute  infections 
usually  causes  no  symptoms  by  which  it  can  be  recognized  during  life. 
There  may  be  pain  in  the  back  and  deep  tenderness  over  the  affected 
kidney.  The  urine  is  albuminous,  turbid,  sometimes  acid,  sometimes 
alkaline,  and  contains  a  few  pus-cells,  transitional  epithelial  cells,  and  red 
blood-corpuscles,  rarely  tube-casts.  Recurrent  attacks  occur  in  which, 
after  an  interval  during  which  the  patient  has  had  clear  urine  and  no 
special  symptoms,  the  urine  suddenly  becomes  turbid  and  smoky,  and 
contains  albumin  and  pus-cells,  the  change  being  accompanied  by  pain 
in  the  lumbar  region,  chills,  fever,  and  profuse  sweating. 

In  chronic  pyelitis  the  pus  in  the  urine  varies  in  amount  and  may  at 
times  wholly  disappear — a  phenomenon  due  to  the  blocking  of  the  ureter 
when  one  kidney  only  is  affected,  and  associated  in  some  cases  with  the 
signs  of  a  tumor  in  the  renal  region.  In  acute  pyelonephritis  shreds  of 
renal  tissue  are  sometimes  present,  together  with  tube-casts  which  may 
be  composed  of  pus-cells  or  bacteria.  The  urine  is  usually  increased 
in  amount  and  contains  albumin  in  proportion  to  the  pus  and  blood 
present.  Its  reaction  varies,  being  usually  alkaline,  but  sometimes  acid, 
according  to  the  infecting  bacterium.  It  is  commonly  acid  in  the  clear 
intervals  when  the  pyuria  is  intermittent,  and  alkaline  when  there  is  an 
associated  cystitis. 

Paroxysmal  fever,  intermittent  in  type  and  associated  with  chills 
and  sweating,  is  very  common.  The  attacks  are  sometimes  ague-like  and 
recur  with  a  periodicity  so  regular  that  they  closely  simulate  malaria. 
After  a  time  the  chills  cease  and  the  fever  assumes  the  hectic  type.  Chronic 
pyelitis  is  usually  accompanied  by  emaciation,  anaemia,  and  progressive 
impairment  of  health.  Sepsis  with  secondary  abscess  formation  may 
develop — septicopysemia.  The  symptoms  in  some  cases  suggest  enteric 
fever,  but  the  diagnostic  clinical  and  laboratory  criteria  of  that  disease 
are  wholly  lacking.  There  is  a  considerable  group  of  cases  familiar  to 
practitioners  in  which,  with  intermittent  or  persistent  pyuria,  fairly  good 
general  health  is  maintained.  A  knowledge  of  this  fact  is  important  in 
connection  with  surgical  considerations.  Dryness  of  the  mouth,  vomiting, 
profound  asthenia,  and  drowsiness  passing  into  coma,  with  dyspnoea — a 
condition  suggestive  of  diabetic  coma — sometimes  constitute  a  terminal 
symptom-complex.  At  one  time  attributed  to  intoxication  by  ammoniacal 
products  of  decomposing  urine,  this  condition  has  been  regarded  as  an 
ammoniaemia.  It  is  probably  due  to  intoxication  products  of  decomposing 
urine  or  pus,  or  specific  bacterial  toxins.     It  differs  from  uraemia  in  the 


PERINEPHRIC  ABSCESS.  1123 

absence  of  convulsions  and  retinitis.  Paraplegia,  variously  ascribed  to 
myelitis,  peripheral  neuritis,  or  reflex  causes,  is  not  uncommon. 

The  local  swelling  in  the  renal  region  varies  in  size  from  time  to  time. 
It  may  attain  large  size  and  give  rise  to  signs  of  fluctuation  in  pyonephrosis 
— abscess  of  the  kidney. 

Diagnosis. — Direct. — The  constant  or  intermittent  presence  of  pus 
and  blood  in  the  urine,  the  occurrence  of  renal  tissue,  the  absence  of  tube- 
casts,  a  tumor  in  the  renal  region  inconstant  in  size  or  showing  deep  fluctua- 
tion in  the  absence  of  oedema,  one-sided  lumbar  pain  and  tenderness,  and 
chills,  fever,  sweating,  wasting,  and  anaemia  justify  a  positive  diagnosis. 
In  the  absence  of  several  of  these  clinical  phenomena  a  provisional  diagnosis 
may  be  made. 

Differential. — Tuberculous  pyelonephritis  may  be  diagnosticated 
when,  with  the  above  symptoms,  tubercle  bacilli  are  present  in  the  puru- 
lent urine.  In  doubtful  cases  laboratory  methods  must  be  employed, 
especially  the  inoculation  of  guinea-pigs.  Evidences  of  tuberculous  disease 
in  the  urinary  passages  or  genital  organs  are  of  diagnostic  importance. 
The  discrimination  between  pyelitis  and  pyelonephritis  cannot  always  be 
made  with  precision.  The  presence  of  minute  bits  of  renal  tissue  in  the 
urine  or  a  tender  tumor  in  the  region  of  the  kidney  would  point  to  the 
latter  condition.  A  deep  fluctuating  tumor  points  to  renal  abscess. 
Abscess  within  the  capsule  of  the  kidney  is  to  be  distinguished  from 
perirenal  abscess  by  the  more  circumscribed  outline  of  the  tumor,  the 
absence  of  oedema,  and  the  anamnesis,  but  the  differential  diagnosis  is 
sometimes  impracticable. 

Cystitis  and  pyelitis  are  frequently  associated.  The  polyuria,  inter- 
mitting pyuria  when  present,  the  pain,  tenderness,  and  tumor  mass  in 
one  lumbar  region,  and  the  absence  of  frequent  micturition  and  vesical 
tenesmus  are  in  favor  of  the  latter  affection.  The  anamnesis  is  important. 
The  cystoscope  and  catheterization  of  the  ureters  may  be  employed  in 
doubtful  cases. 

Prognosis. — The  cases  associated  with  the  acute  febrile  infections 
usually  recover  with  the  convalescence  from  the  primary  disease.  The 
tuberculous  form,  when  the  kidney  only  is  infected,  may  terminate  in 
recovery,  with  cretaceous  masses  replacing  more  or  less  renal  tissue.  In 
abscess  the  outlook  is  unfavorable.  Amyloid  disease,  fatal  sepsis,  or 
peritonitis  from  perforation  may  occur.  The  diagnosis  assumes  importance 
in  view  of  the  possibility  of  relief  by  surgery. 


VII.  PERINEPHRIC  ABSCESS. 

Paranephritis;   Perirenal  Abscess. 

Definition.  —  Suppurative  inflammation  of  the  connective  tissue 
surrounding  the  kidney. 

Etiology. — Perinephric  abscess  may  follow  blows  and  injuries,  the 
acute  febrile  infections,  especially  in  children,  inflammation  of  the  kidney 
or  ureter,  perforation  of  the  appendix  or  bowel,  or  result  from  a  perforating 
empyema  or  spinal  caries. 


1124  MEDICAL  DIAGNOSIS. 

Morbid  Anatomy.  —  The  pus  cavity  is  usually  extensive,  and  the 
adjacent  tissues  cedematous.  The  accumulation  is  usually  posterior,  but 
may  be  anterior,  to  the  kidney.  It  shows  a  strong  tendency  to  burrow, 
and  may  perforate  into  the  pleura,  the  bowel,  the  peritoneum,  the  bladder, 
or  vagina,  or  follow  the  direction  of  gravitating  spinal  pus  along  the  sheath 
of  the  psoas  muscle  or  the  iliac  fascia,  or  finally  the  abscess  if  left  to  itself 
may  burst  externally. 

Symptoms. — Pain  in  the  region  of  the  kidney,  aggravated  by  pres- 
sure, or  referred  to  the  hip-joint,  or  inside  of  the  thigh,  and  associated 
with  retraction  of  the  testicle,  a  limping  gait,  flexed  thigh,  stooping  posture, 
and  rigid  spine,  deep  induration  and  oedema,  and  a  tumor  mass  upon 
palpation  between  the  last  rib  and  the  crest  of  the  ilium,  normal  urine 
unless  the  primary  pus  depot  is  within  the  capsule  of  the  kidney,  and  the 
constitutional  evidences  of  pus  make  up  the  clinical  picture. 

Diagnosis. — The  direct  diagnosis  is  justified  by  the  above  associa- 
tion of  symptoms.  Pus-free  urine,  and  oedema  overlying  the  tumor,  and 
deep  fluctuation  are  significant.  It  is  not  always  possible  to  determine 
whether  the  infection  comes  from  the  kidney  or  some  source  outside  of  it. 
Here  the  history  is  important. 

Differential.  —  The  pain  and  attitude  may  closely  simulate  hip- 
joint  disease;  but  the  essential  symptoms  are  wanting,  and  the  tumor 
and  oedema  in  the  region  of  the  kidney  are  conclusive.  When  the  abscess 
points  in  the  inguinal  region  spinal  caries  must  be  excluded. 


VIII.  NEPHROLITHIASIS. 

Renal  Calculus;   Renal  Infarct. 

Definition. — A  condition  characterized  by  the  presence  in  the  substance 
or  pelvis  of  the  kidney,  or  in  the  ureter,  of  concretions  formed  by  the  depo- 
sition of  certain  of  the  constituents  of  the  urine  normally  held  in  solution. 

Renal  Infarct. — The  deposition  of  urinary  salts  in  the  substance  of 
the  kidneys  occurs  under  the  following  circumstances:  In  the  new-born  in 
the  shape  of  uric  acid  crystalline  masses  in  the  tubules,  and  especially  at 
the  apices  of  the  pyramids— wWc  acid  infarcts;  in  chronic  gout,  sodium 
and  ammonium  urate  in  whitish  linear  deposits,  chiefly  in  the  pyramids — 
sodium  urate  infarcts;  and  dense  white  linear  deposits  of  calcium  phosphate 
or  carbonate  in  the  pyramids,  chiefly  in  aged  persons — calcareous  infarcts. 

Renal  Calculus. — The  concretions  which  form  in  the  pelvis  and 
calices  constitute,  according  to  their  size,  sand,  gravel,  or  stone.  Renal 
sand  consists  of  gritty  particles  of  a  size  not  too  large  to  traverse  the  urinary 
passages  without  arrest.  These  minute  calculi  are  frequently  voided  in  the 
urine  in  considerable  quantities  at  intervals  for  j^ears,  without  causing 
symptoms.  They  form  a  characteristic  coarse  urinary  sediment.  The 
term  gravel  is  applied  to  larger  concretions,  ranging  in  size  from  a  canary 
seed  to  a  pea,  usually  multiple,  sometimes  single,  round  and  smooth,  or 
irregular  and  rough,  which  form  in  the  pelvis  and  calices,  and  passing  into 
the  ureter  cause  renal  colic.  Kidney  stones,  dendritic  or  coral  calculi,  are 
larger  concretions,  which  attain  dimensions  in  the  pelvis  which  prevent 


NEPHROLITHIASIS.  1125 

their  entering  the  ureter.  Gradually  increasing  in  size,  they  often  form 
remarkable  branching  casts  or  moulds  of  the  pelvis  and  calices.  Ureteral 
Calculi. — The  orifice  of  the  ureter  may  be  blocked  by  a  large  calculus, 
formed  in  the  pelvis  of  the  kidney,  or  a  calculus  may  be  arrested  at  any 
point  in  its  course  from  the  kidney  to  the  bladder. 

Chemical  Composition  of  Renal  Calculi. — These  concretions  do  not 
represent  mere  precipitations  of  crystallizable  or  other  solid  constituents  of 
the  urine.  They  are  composed  in  the  first  place  of  mixtures  of  various  sub- 
stances of  this  kind,  arranged  irregularly  or  in  concentric  layers,  and  in  the 
second  place  they  contain  various  proteid  substances  present  as  the  result 
of  inflammatory  irritation  of  the  tissues  with  which  they  are  in  contact, 
and  finally  bacteria  are  frequently  found  in  the  somewhat  irregularly  dif- 
ferentiated central  nucleus.  The  principal  varieties  consist  of:  Uric  Acid 
and  Urates. — This  is  the  common  form  and  constitutes  renal  sand,  small 
single  calculi,  and  the  large  branching  kidney  stones.  They  are  of  a  yel- 
lowish or  brownish-red  color,  smooth  or  slightly  irregular  surface,  and 
dense  consistence.  The  large  stones  are  composed  of  concentric  strata 
and  are  ver}^  hard.  They  consist  of  uric  acid  and  urates  in  varying  pro- 
portions. In  urinary  sand  the  crystalline  particles  may  consist  of  uric 
acid  alone;  in  children  calculi  composed  of  urates  occur.  Calcium  Oxalate. 
— Mulberry  calculi  are  of  a  brownish  or  black  color,  rough  and  mammil- 
lated  or  pointed  surface,  and  very  hard.  They  are  composed  of  oxalate 
of  lime  and  uric  acid,  the  former  predominating.  Calcium  Phosphate 
and  Ammoniomagnesium  Phosphate. — Phosphatic  calculi  are  composed  of 
these  salts,  together  with  small  quantities  of  calcium  carbonate.  They  are 
of  a  whitish  or  pale  fawn  color,  crystalline  or  chalk-like  surface,  and  light 
consistence.  They  are  sometimes  friable.  They  are  common,  and  the 
substances  of  which  they  are  composed  are  deposited  as  an  outer  layer 
upon  uric  acid  or  oxalate  calculi.  Cystin,  Xanthin,  and  Indigo. — Calculi 
chiefly  composed  of  these  substances  are  occasionally  met  with. 

Immediate  Effects  upon  the  Kidney. — In  many  cases  the  kidney 
manifests  a  remarkable  tolerance  for  the  slowly  forming  calculus.  Single 
or  multiple  stones  may  be  found  post  mortem  without  lesions  of  the  kid- 
ney or  a  history  of  renal  symptoms.  Urinary  sand  or  small  round  uric  acid 
calculi  are  often  passed  at  intervals  by  persons  otherwise  in  good  health. 
Large  dendritic  calculi  cause  induration  and  atrophy  of  the  kidney  substance. 
When  infection  takes  place,  calculous  pyelitis  and  pyonephrosis  result. 

Etiology. — The  subjects  of  uric  acid  and  calcium  oxalate  crystals  are 
usually  adults  of  good  constitution,  active,  and  given  to  the  pleasures  of 
the  table.  Many  of  them  are  gouty.  The  urine  is  highly  acid  and  contains 
uric  acid  in  excess.  Phosphatic  calculi  are  met  with  in  anaemic  persons  in 
poor  health,  often  women  with  alkaline,  sedimentary  urine.  In  general, 
renal  calculus  is  much  more  common  in  men  than  in  women;  in  infancy 
and  late  adult  life  than  in  the  middle  periods.  Dyspepsia,  migraine,  and  a 
sedentary  life  are  predisposing  influences. 

Symptoms. — Nephrolithiasis  may  be  latent.  Persons  pass  renal  sand 
occasionally  without  local  or  general  derangement  of  health.  Sometimes 
a  large  dendritic  calculus  is  unattended  by  symptoms.  As  a  rule  two  sets 
of  definite  symptoms  occur. 


1126  MEDICAL  DIAGNOSIS. 

1.  SYMPTOMS  OF  Stone  in  the  Kidney. — These  are:  (a)  Pain,  which 
may  be  dull  and  continuous,  or  paroxysmal.  It  is  usually  referred  to  the 
lumbar  region  of  the  affected  side,  and  sometimes  radiates  to  the  scrotum 
or  glans  penis.  It  may  extend  to  the  opposite  side  of  the  back.  It  may  be 
aggravated  by  a  misstep  or  sudden  jarring  of  the  body.  Nephralgia  is 
common  in  movable  kidney,  and  occurs  in  the  absence  of  renal  calculus, 
(b)  Hcematuria. — Microscopic  blood  in  the  urine  is  very  common.  The 
amount  of  blood  may  cause  smokiness,  or,  exceptionally,  give  a  bright  red 
tinge  to  the  urine.  Haematuria  may  be  continuous,  or  it  may  recur  at 
intervals,  coming  on  spontaneously  or  after  exertion,  and  ceasing  upon 
rest.  Bleeding  is  more  common  when  the  calculus  is  lodged  in  the  ureter 
than  when  it  remains  in  the  pelvis  of  the  kidney,  (c)  Pyuria. — Pus  in  the 
urine  is  the  indication  of  calculous  pyelitis,  which  may  exist  for  a  long 
time  without  causing  serious  symptoms,  or  may  result  in  pyelonephritis 
or  renal  abscess,  (d)  Septic  Phenoviena. — There  are  cases  in  which 
paroxysms  of  intense  pain,  with  chills,  high  fever, — 104°  to  106°  F.  (40°- 
41.1°  C), — and  sweating  occur  at  varying  but  irregular  intervals.  The 
urine  becomes  turbid  and  contains  blood  and  transitional  epithelium,  but 
remains  free  from  pus.  These  attacks,  often  regarded  as  malaria,  are  more 
like  hepatic  fever.  Their  recognition  depends  upon  the  positive  evidence 
of  nephrolithiasis  and  negative  signs  as  regards  malaria,  i.e.,  absence  of 
blood  parasites  and  failure  of  quinine.  When  calculus  is  established, 
irregular  chills,  fever  and  sweating,  anaemia,  wasting,  pyuria,  and  smoky 
urine  are  commonly  present. 

2.  Symptoms  of  Renal  Colic. — The  attack  begins  with  dull  pain  in 
the  renal  region,  which  presently  extends  to  the  flank  and  toward  the 
groin.  This  pain  is  continuous  with  excruciating  exacerbations  and  points 
of  focal  intensity  in  the  glans  penis  and  testicle,  which  is  retracted.  It  is 
accompanied  by  a  most  urgent  continuous  vesical  tenesmus  and  desire  to 
pass  water,  which  is  without  result  beyond  a  few  drops  of  bloody  urine, 
the  voidance  of  which  is  attended  with  distressing  scalding  sensations. 
Rectal  tenesmus  and  intense  nausea  and  vomiting  frequently  add  to  the 
distress  of  the  patient.  Restlessness,  anxiet}^  pallor,  shivering,  cold 
sweats,  feeble  pulse,  and  other  collapse  symptoms  are  usuallv  also  present. 
Fever  may  occur,  101°- 103°  F.  (38.3°-39.5°  C).  The  'attack  ceases 
abruptly,  with  sensations  of  relief  as  the  calculus  jjasses  into  the  bladder 
or  returns  into  the  pelvis  of  the  kidney.  Its  duration  varies  from 
about  an  hour  to  a  day  or  more.  In  the  longer  attacks  there  are 
periods  of  remission. 

During  the  attacks  an  acute  hydronephrosis  develops  upon  the  afTected 
side,  which  is  relieved  upon  the  escape  of  the  calculus  into  the  bladder 
with  the  discharge  of  a  large  quantity  of  urine.  A  large  amount  of  clear 
urine  may  be  discharged  from  the  sound  kidney  during  the  course  of  the 
attack.  Renal  colic  does  not  always  terminate  in  complete  relief.  The 
calculus  may  become  impacted  in  the  ureter  and  cause  hydronephrosis 
and  haematuria;  in  extremely  rare  cases  it  may  rupture  into  the  peritoneal 
cavity  or  the  intestine,  or  may  form  an  abscess  and  perforate  the  skin. 
Again,  anuria  may  occur  under  the  following  circumstances:  with  a  nor- 
mal kidney  on  the  opposite  side,  from  functional  arrest,  in  consequence  of 


HYDRONEPHROSIS.  1127 

nervous  irritation;  with  a  previously  diseased  kidney  from  the  same  cause; 
with  a  single  kidney.    These  conditions  are  rare. 

Death  occurs  from  uraemia,  as  a  rule  within  ten  or  twelve  days  after 
complete  anuria  has  set  in,  exceptionally  not  for  two  or  three  weeks. 

Diagnosis. — Direct. — Other  forms  of  paroxysmal  pain  may  be  mis- 
taken for  renal  colic,  but  the  seat  of  the  pain,  its  definite  extension  toward 
the  groin,  with  local  intensification  in  the  testicle  and  glans,  together  with 
hematuria,  are  characteristic.  When  direct  evidence  of  the  existence  of 
a  calculus,  as  previous  attacks  with  the  passage  of  one,  or  the  voidance  of 
one  subsequent  to  the  attack,  can  be  secured,  the  diagnosis  becomes  cer- 
tain. The  recognition  of  a  calculus  in  the  pelvis  of  the  kidney  or  in  the 
ureter,  or  the  grating  of  several  calculi  upon  palpation,  has  been  mentioned, 
but  I  have  no  personal  knowledge  of  such  signs. 

Differential.- — Similar  paroxysms  of  colicky  pain  are  attributed  to 
accumulation  of  renal  sand,  uric  acid,  or  oxalates  in  the  pelvis  of  the  kidney. 
Dietl's  crises,  the  nephritic  crises  of  tabes,  and  clots  of  blood  in  renal 
hemorrhage,  such  as  occur  in  cancer,  may  closely  simulate  renal  colic. 
Biliary  colic  and  intestinal  colic  rarely  give  rise  to  uncertainty.  The  dif- 
ferential diagnosis  must  be  reached  by  a  careful  study  of  the  individual 
case.    A  diagnosis  by  exclusion  may  be  necessary. 

The  diagnosis  of  nephrolithiasis  depends  upon  the  foregoing  symp- 
toms, the  occurrence  of  renal  colic,  and  the  shadows  cast  by  the  Rontgen 
rays.  This  means  of  diagnosis  is  imperatively  required  in  order  to  deter- 
mine the  presence  and  position  of  calculi,  and  whether  they  exist  in  one  or 
both  kidneys  in  connection  with  the  considerations  of  surgical  intervention. 

The  differential  diagnosis  between  renal  and  vesical  calculus  may 
sometimes  be  in  doubt.  In  the  lattei"  the  pain  is  usually  bilateral,  more 
common  at  the  neck  of  the  bladder.  The  tenesmus  is  continuous,  with 
frequent  micturition,  and  the  sound  will  detect  the  presence  of  the  stone. 

Prognosis. — Many  cases  are  recurrent.  There  is  the  ultimate  danger 
of  calculous  pyelitis.  The  more  serious  accidents  of  renal  colic  and  actual 
obstruction  are  rare.     Many  lives  have  been  saved  by  surgical  procedures. 

IX.  HYDRONEPHROSIS. 

Definition. — A  collection  of  urinary  fluid  in  the  pelvis  and  calyx  of 
the  kidney  due  to  obstruction  of  the  ureter,  forming  a  cyst  by  the  disten- 
tion and  atrophy  of  the  organ. 

Etiology. — Hydronephrosis  may  be  congenital  owing  to  develop- 
mental defects,  and  may  be  of  sufficient  size  to  interfere  wdth  parturition. 
Much  more  commonly  it  is  acquired.  The  obstruction  may  be  in  the  ure- 
thra or  in  the  bladder.  In  suddenly  developing  polyuria  the  normal  ureter 
may  be  incapable  of  carrying  off  the  excess  of  urine,  and  an  acute  hydro- 
nephrosis result.  The  ui-oter  may  be  occluded  by  calculus,  stricture  follow- 
ing ulcer,  or  torsion  or  kinking  in  movable  kidney.  It  may  be  blocked  b}^ 
neoplasms,  particularly  tubercle  or  cancer.  Compression  from  without, 
by  cicatricial  adhesions  or  bands,  or  by  abdominal  or  pelvic  tumors,  is  a 
more  common  cause.  Bilateral  hydronephrosis  may  result  from  the  impli- 
cation of  both  ureters  by  any  of  the  lesions  just  named.     When,  however, 


1128  MEDICAL  DIAGNOSIS. 

the  obstruction  is  in  the  bladder,  the  hydronephrosis  is  almost  always 
double.  The  common  conditions  are  cancer,-  which  may  involve  only  one 
ureteral  orifice,  habitual  urinary  distention  of  the  bladder  in  prostatic 
hypertrophy  or  stricture,  and  the  extreme  thickening  and  contraction  of 
the  bladder  wall  which  accompanies  these  conditions. 

The  fluid  accumulates,  causing  distention  of  the  ureter  above  the 
obstruction,  but  especially  of  the  pelvis  of  the  kidney.  Pyelitis  may  occur, 
but  usually  the  kidney  substance  undergoes  a  simple,  progressive  atrophy, 
forming  in  extreme  cases  a  large  cyst,  upon  the  inner  surface  of  which 
traces  of  renal  tissue  may  be  found.  As  the  secretion  of  urine  diminishes 
mucus  and  serum  accumulate  until  the  cyst  contains  a  pale  yellow  or 
straw-colored  fluid,  holding  in  solution  traces  of  the  urinary  solids  and 
frequently  a  little  albumin.  There  may  be  turbidity  from  the  presence  of 
pus.  The  cyst  thus  formed  njay  attain  an  enormous  size  and  simulate 
ascites.  Cardiac  hypertrophy  is  frequently  associated  with  hydronephrosis. 
Exceptionally  complete  occlusion  of  the  ureter  is  followed  by  atrophy  of 
the  kidney  without  dilatation. 

Symptoms. — The  urinary  conditions  are  by  no  means  constant.  In 
one-sided  hydronephrosis  with  complete  occlusion,  the  urine  from  the 
vicariously  acting  opposite  kidney  may  be  normal  in  quantity  and  com- 
position. When  the  condition  is  bilateral,  oliguria  and,  ultimatelj^,  com- 
plete anuria  result  and  death  occurs  with  ursemic  symptoms.  Intermittent 
hydronephrosis  arises  when  a  valve-like  obstruction  yields  to  the  pres- 
sure of  the  accumulated  fluid,  or  the  twisted  or  kinked  ureter  is  restored 
to  its  natural  condition.  Under  these  circumstances  there  is  a  sudden  large 
discharge  of  clear  urinary  fluid  with  the  subsidence  of  the  tumor.  When 
the  obstruction  recurs  the  cystic  tumor  reappears,  to  vanish  again  when 
the  obstruction  is  relieved — flush-tank  symptom.  Intermittent  hydro- 
nephrosis may  continue  for  years.  It  is  unilateral,  commonly  associated 
with  movable  kidney,  and  usually  occurs  in  women.  In  cases  in  which 
pyelitis  exists  the  urine  may  be  normal  when  the  tumor  is  forming  and 
turbid  from  the  presence  of  mucus,  pus,  or  blood  as  the  tumor  subsides. 

Physical  Signs. — When  the  tumor  attains  sufficient  size  it  may  be 
recognized  upon  palpation  or  inspection.  If  unilateral  and  of  moderate 
size,  it  occupies  the  renal  region;  when  large  it  may  simulate  ovarian  or 
other  cysts;  an  enormous  hydronephrosis  may  be  mistaken  for  peritoneal 
effusion.  It  may  also  simulate  solid  tumors  of  the  kidney  or  enlarged 
retroperitoneal  glands.  The  physical  signs  of  hydronephrosis  and  a  large 
renal  abscess  are  the  same.  The  latter  is,  however,  usually  attended  by 
septic  phenomena.  They  consist  of  dulness  in  the  renal  region  with  deep 
fluctuation.  When  the  tumor  presents  anteriorly,  the  ascending  colon  on 
the  right  side,  the  descending  colon  on  the  left,  usually  yields  an  oblique 
band  of  tympany. 

Diagnosis. — Direct. — Hydronephrosis  can  only  be  recognized  when 
it  gives  rise  to  a  fluctuating  tumor.  Even  then  it  is  readily  confounded 
with  other  cysts.  The  greatest  difficulties  arise  when  the  condition  involves 
a  displaced  kidney;  the  least,  in  the  intermittent  form.  The  relation  of 
the  tympanitic  colon  to  the  tumor  is  important.  The  sac  may  be  aspi- 
rated.    The  fluid  obtained  is  of  low  specific  gravity,  commonly  clear,  and 


CYSTS  OF  THE  KIDNEY.  1129 

contains  urea  and  urinary  salts,  and  transitional  epithelium.  In  very  old 
cases  with  extreme  atrophy  of  the  kidney  substance,  the  fluid  may  contain 
nothing  characteristic. 

Differential. — Ovarian  Cysts. — Large  hydronephrosis  is  frequently 
mistaken  for  an  ovarian  tumor.  The  latter  may  be  differentiated  by  its 
mobility,  except  in  the  case  of  hydronephrosis  involving  a  floating  kidney. 
Hydronephrosis  has  its  starting-point  in  the  renal  region,  whereas  ovarian 
tumors  spring  from  the  pelvis,  as  can  be  determined  by  bimanual 
examination  externally,  or  with  the  fingers  of  one  hand  in  the  vagina, 
later  in  the  rectum,  and  the  other  hand  upon  the  abdomen.  By  this  mode 
of  examination  the  relation  of  the  uterine  appendages  and  the  presence 
or  absence  of  a  pedicle  can  be  determined.  In  ovarian  disease  disturbances 
of  function — for  example,  amenorrhoea — are  not  constant,  just  as  in  hydro- 
nephrosis the  condition  of  the  urine  varies  in  different  cases.  Renal  Cysts. 
— The  differentiation  is  mostly  impossible.  In  the  new-born  cystic  kidneys 
and  hydronephrosis  may  present  the  same  signs.  When  the  abdominal 
wall  is  congenitally  defective  the  dilated  bladder  and  ureters  may  be 
readily  observed.  Echinococcus  cysts  of  the  kidney  may  be  suspected  if 
daughter  cysts  or  hooklets  are  found  in  the  urine  or  in  non-albuminous 
fluid  obtained  by  exploratory  puncture.  But  a  positive  diagnosis  of 
echinococcus  cyst  of  the  kidney  can  only  be  made  when  it  is  possible  to 
exclude  such  a  condition  perforating  into  the  urinary  passages.  The 
hydatid  thrill  is  by  no  means  constant.  Mesenteric  Cysts. — These  tumors 
vary  in  size  from  the  closed  fist  to  a  cocoanut  and  are  commonly  situated 
in  the  lower  right  quadrant  of  the  abdomen.  They  are  freely  movable, 
of  oval  contour,  smooth  surface,  elastic,  and  fluctuating.  Paroxysms  of 
pain  and  vomiting  are  often  associated  with  their  presence.  Ascites. — 
The  differential  diagnosis  may  be  difficult  in  bilateral  hydronephrosis. 
Movable  dulness  upon  change  of  position,  the  absence  of  tympany  in  the 
flanks,  and  the  character  of  the  fluid  in  peritoneal  effusion  are  important. 

Prognosis. — Unilateral  hydronephrosis  when  quiescent  constitutes  a 
benign  tumor,  but  the  prognosis  must  in  all  cases  be  guarded.  The  con- 
dition acquires  importance  by  progressive  increase  in  size,  the  danger  of 
rupture  into  the  peritoneum  or  lung,  pyonephrosis,  and  the  possibility  of 
the  blocking  of  the  other  ureter,  with  anuiia  followed  by  urasmia.  The 
fluid  may  discharge  by  way  of  the  ureter  and  never  reaccumulate.  Inter- 
mittent hydronephrosis  may  cause  little  inconvenience  and  finally  undergo 
spontaneous  cure.  When  double,  the  condition  is  far  more  serious,  and 
the  outlook  depends  upon  the  possibility  of  relieving  the  condition  which 
causes  the  obstruction — urethral  stricture,  prostatic  enlargement,  tumor- 
pressure.    The  cases  due  to  malignant  disease  are  without  hope. 

X.  CYSTS  OF  THE  KIDNEY. 

The  multiple  small  cysts  due  to  obstruction  of  uriniferous  tubules  in 
chronic  nephritis,  and  larger  solitary  cysts  sometimes  seen  post  mortem 
in  kidneys  otherwise  normal,  do  not  cause  symptoms  or  signs  by  which 
they  can  be  recognized  during  life.  Rare  forms  are.  combined  cystic  disease 
of  the  liver  and  kidneys,  and  paranephric  cysts.     Of  greater  importance 


1130 


MEDICAL  DIAGNOSIS. 


clinically  are:  Congenital  Cystic  Kidneys. — The  organs  arc  enormously 
enlarged  and  consist  of  a  mass  of  round  or  oblong  cysts,  varying  in  diame- 
ter from  0.5  to  3  centimetres,  with  kidney  tissue  sufficient  to  discharge 
the  renal  function  distributed  in  the  interspaces.  The  fluid  contained  in 
these  cysts  varies  in  color  from  clear  to  opaque  reddish  or  black,  and  in 
consistence  from  limpid  to  colloid.  It  contains  albumin  and  other  pro- 
teids,  cholesterin  plates,  crystals  of  hsematoidin  and  ammoniomagnesium 
phosphate,  and  fat  droplets. 

Etiology. — Cystic  kidneys  occur  in  the  foetus  and  may  be  the  cause 
of   dystocia.      They   are   regarded   as   developmental   defects.      They  are 


Fig.  326. — Congenital  cystic  kidneys. — German  Hospital. 


sometimes  associated  with  hydrocephalus,  defects  of  the  bladder,  and 
malformations  of  the  extremities.  The  cystic  condition  increases  with 
age  and  is  encountered  in  young  adults,  the  tumors  often  attaining  great 
size.  The  condition  is  usually  bilateral,  though  unilateral  cases  have  been 
observed.     The  condition  has  been  noted  in  several  members  of  a  family. 

Symptoms. — The  urine  is  abundant,  of  low  specific  gravity,  and 
contains  albumin  in  small  amounts  and  hyaline  and  granular  casts.  Re- 
current hsematuria  may  be  noted.  There  is  pallor,  a  muddy  skin,  and 
not  rarely  diffuse  cutaneous  pigmentation. 

Physical  Signs. — The  physical  examination  reveals  the  evidences  of 
cardiovascular  disease — enlargement  of  the  heart,  accentuated  aortic  sec- 
ond sound,  hardening  of  the  arteries — and  the  signs  of  double  tumor  in 
the  renal  region  extending  forward,  elastic  but  non-fluctuating,  and,  when 


TUMORS  OF  THE  KIDNEY.  1131 

distinctly  palpable  through  the  belly  walls,  irregularly  nodular.  I  have 
observed  these  signs  in  a  unilateral  case  in  which  the  diagnosis  was 
confirmed  by  operation. 

The  symptoms,  urinary  conditions,  and  general  physical  signs  are 
those  of  chronic  nephritis;    the  local  signs,  those  of  renal  tumors. 

The  diagnosis  rests  upon  the  association  of  the  foregoing  symptoms 
and  signs.  The  recognition  of  the  condition  derives  its  importance  from 
the  fact  that,  as  a  rule,  to  which  there  are  very  few  exceptions,  surgical 
intervention  is  positively  contraindicated. 

Prognosis. — The  outlook  is  not  favorable.  Death  results  in  many 
cases  before  or  directly  after  birth.  If  the  patient  survive  infancy,  death 
occurs  before  thirty  from  cardiovascular  changes  or  uraemia. 

XI.  TUMORS  OF  THE  KIDNEY. 

Solid  tumors  of  the  kidney  are  benign  and  malignant.  Benign  tumors 
comprise  fibroma,  lipoma,  myxoma,  angioma,  gumma,  and  adenoma. 
They  do  not  give  rise  to  symptoms  referable  to  the  kidneys,  nor  do  they, 
as  a  rule,  attain  such  a  size  as  to  respond  to  the  methods  of  physical  exam- 
ination— inspection,  palpation.  They  are,  however,  of  anatomical  rather 
than  clinical  interest. 

Malignant  neoplasms — carcinoma,  sarcoma — are  primary  or  second- 
ary. The}'  are  accompanied  by  distinct  symptoms,  both  general  and 
urinary,  and  frequentl}^  grow  to  a  large  size. 

Renal  carcinoma  is  a  rare  lesion  and  when  small  may  not  reveal  its 
presence  during  life.  Larger  cancers  cause  conspicuous  abdominal  tumors, 
usually  immovable  upon  deep  respiration  or  palpation,  occupying  the 
upper  quadrants  of  the  abdomen  in  relation  with  the  liver  or  spleen, 
obliquely  traversed  by  the  ascending  or  descending  colon  as  the  case  may 
be,  and  of  an  irregular  surface  and  consistence. 

Sarcoma  of  the  kidney  is  much  more  common.  It  constitutes  a 
frequent  form  of  abdominal  tumor  among  children,  especially  the  primary 
variety.  The  growth  reaches  a  large  size  and  may  greatly  distend  the 
abdomen.  It  is  almost  always  unilateral  and  presents  objective  characters 
similar  to  those  of  carcinoma,  save  that  it  is  commonly  less  nodular  and 
softer,  in  some  cases  even  fluctuating  over  extensive  or  limited  areas. 

Hypernephroma,  which  may  develop  from  suprarenal  tissue  excep- 
tionally upon  the  kidney,  as  a  rule  within  its  substance,  is  a  very  common 
form  of  renal  tumor.  This  neoplasm  may  be  found  upon  post-mortem 
examination  as  small  tumors  within  the  cortex,  or  it  may  form  large  tumors 
having  the  characters  of  malignant  growths  of  the  kidneys  in  general. 
Metastases  occur. 

Symptoms  of  Malignant  Tumors  of  the  Kidney. — Pain,  usually  of  a 
dull,  dragging  character  and  referred  to  the  flank  upon  the  affected 
side,  is  common.  It  may  radiate  to  the  thigh  or  extend  to  the  pleura. 
There  are  large  growths  in  which  pain  does  not  occur.  Emaciation  is 
commonly  progressive  and  rapid,  and  a  high  grade  of  cachexia  is  usual. 
There  are  cases,  however,  especially  of  sarcoma,  in  which  the  nutriticm 
and  strength  are  fairly  well  maintained.     Pressure  upon  the  abdominal 


1132 


MEDICAL  DIAGNOSIS. 


veins  may  cause  venous  distention  and  cedema  of  one  or  both  lower 
extremities,  and  ascites.  Pressure  upon  nerve-trunks  may  cause  pain  or 
pressure  neuritis  in  the  distribution  of  the  intercostals  or  the  crural  nerves. 
Metastatic  growths  occur  in  various  organs,  and,  in  particular,  in  the 
lungs.  They  may  occasion  special  symptoms.  If  the  spinal  cord  is 
involved  paraplegia  may  result. 

The  urine  contains  blood  at  some  time  in  the  course  of  a  majority 
of  the  cases.  The  hsematuria  is  intermittent,  the  urine  being  practically 
normal  during  the  intervals.  If  the  growth  involves  the  pelvis  the  urine 
may  be  turbid  and  albuminous.  The  blood  is  sometimes  fluid,  sometimes 
clotted.  It  is  characteristic  of  the  hsematuria  of  mahgnant  disease  of  the 
kidney  that  blood-casts  of  the  ureter,  sometimes  of  the  pelvis  of  the  kid- 
ney, are  occasionally  passed.  The  passage  of  these  clots  is  attended  with 
intense  pain  like  that  of  renal  colic.     In  rare  instances  cancer  elements 

have  been  discovered  in  the  urine. 
Physical  Signs. — If  the  growth  involves 
a  floating  kidney,  the  organ  may  remain 
for  some  time  movable  and  be  found  in 
the  iliac  fossa.  When  the  kidney  is 
affected  in  situ  the  tumor  is  stationary, 
unilateral,  and  develops  from  the  upper 
and  posterior  region  of  the  abdomen. 
Other  attributes  have  been  mentioned. 
Bimanual  palpation  is  important.  The 
relation  of  the  colon  as  indicated  by 
the  tympanitic  percussion  sign  which 
it  yields  is  of  great  value  in  the 
differential    diagnosis. 

Diagnosis. — Direct. — The  diagnosis 
of  malignant  tumor  of  the  kidney  in 
well-developed  cases  maybe  readily  made 
when  all  of  the  above  symptoms  and  signs  enter  into  the  symptom-complex. 
In  proportion  as  several  of  them  are  absent  the  diagnosis  becomes  uncertain. 
The  nature  of  the  neoplasm  cannot  in  all  cases  be  positively  determined. 
Carcinoma  is  more  common  in  adult  life,  attended  with  a  greater  tendency  to 
wasting  and  cachexia,  and  to  haematuria.  Sarcoma  is  far  more  common 
under  ten  years  of  age;  it  frequently  runs  its  course  without  hsematuria,  and 
may  be  attended  with  little  disturbance  of  the  general  health.  If  primarj^ 
or  metastatic  growths  accessible  to  direct  examination  are  present,  the 
determination  of  their  character  settles  any  diagnostic  uncertainty  as  to 
the  nature  of  the  renal  tumor.  The  examination  of  tissue  elements  found 
in  the  urine,  or  obtained  by  exploratory  puncture,  may  yield  conclusive 
results.  The  recent  investigations  of  Kelly  and  others  render  it  probable 
that  a  large  proportion  of  the  cases  described  as  primary  carcinoma  and 
sarcoma  of  the  kidneys  are  hypernephromata. 

Differential. — Tumors  of  the  Pelvic  Organs. — Tumors  of  the  kidney 
are  frequently  mistaken  for  ovarian  tumors.  The  greater  mobility  of  the 
latter,  their  development  from  the  pelvis,  their  relation  to  the  uterus  and 
the   presence   of   a   pedicle   as   determined   by  vaginal   examination,  and 


Fig.  327. — Suprarenal  sarcoma;  metastases  in 
the  skull. — Robert  Hutchinson. 


ANAEMIA.  1133 

derangement  of  sexual  functions,  as  menstruation,  are  significant.  Tlie 
presence  or  absence  of  intermittent  haematuria  is  important.  Tumors  of 
the  uterus  are  less  likely  to  present  diagnostic  difficulties.  Retroperitoneal 
sarcoma — Lobstein's  cancer — may  give  rise  to  diagnostic  uncertainty, 
particularly  in  children.  Both  conditions  form  very  large  tumors.  The 
disease  of  the  lymphatic  glands  is  more  central  and  less  movable.  It  may 
extend  to  the  kidneys.  In  the  advanced  stages  the  diagnosis  cannot 
always   be  made. 

The  careful  application  of  the  methods  of  physical  diagnosis  in  con- 
nection with  the  facts  relative  to  tumors  of  the  kidneys  renders  their 
discrimination  from  tumors  of  the  liver  and  spleen  an  easy  matter. 

Prognosis. — The  outlook  is  unfavorable.  The  extirpation  of  a  small 
growth  has  in  a  low  percentage  of  the  cases  been  followed  by  recovery. 


XII. 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  BLOOD  AND 
DUCTLESS  GLANDS. 

DISEASES  OF  THE  BLOOD. 

I.  ANiEMIA. 

Definition. — A  morbid  condition  of  the  blood  characterized  by  a 
diminution  of  the  erythrocytes  or  the  haemoglobin,  or  of  both. 

i.  General  Considerations. 

Pallor  of  the  skin  and  mucous  membranes  is  in  a  high  degree 
suggestive  of  anaemia.  For  a  positive  diagnosis,  however,  a  systematic 
microscopic  examination  is  essential.  By  this  method  only  can  the  exist- 
ence of  anaemia  in  every  case  be  recognized  and  the  nature  of  the 
anaemia  positively  determined. 

Pseudo-anemia. — There  are  individuals  in  whom  marked  pallor  of 
the  skin  and  mucous  membranes  suggests  anaemia,  but  whose  blood  shows, 
upon  microscopical  examination,  a  normal  number  of  erythrocytes  and  a 
normal  percentage  of  haemoglobin.  Such  persons  usually  owe  their  pallor 
to  one  or  another  of  the  following  conditions:  (1)  hereditary  peculiarities 
of  the  integuments,  among  which  is  an  opaque  but  non-pigmentcd  skin 
deficient  in  capillary  network;  (2)  prolonged  life  in  tropical  regions,  the 
so-called  tropical  anaemia;  (3)  chronic  nephritis,  arteriosclerosis,  certain 
cases  of  cardiac  disease,  neurasthenia,  and  tuberculosis;  (4)  habitual 
indoor  life,  as  in  prisoners, — the  so-called  "prison  pallor," — Avorkers  in 
sweat-shops,  miners,  and  others  whose  occupations  and  circumstances 
deprive  them  of  sunlight  and  fresh  air. 

There  are  transitory  conditions  in  which  pallor  of  the  skin  and  mucous 
surfaces  is  ischaemic  rather  than  anaemic,  as  syncoj)e,  rigor,  chilling  of  the 
surface,  fatigue,  pain,  and  sudden  intense  emotions,  especially  fear.     The 


1134  MEDICAL  DIAGNOSIS. 

volume  of  the  blood  and  its  corpuscular  values  are  unchanged,  but  it 
retires  from  the  surface  and  accumulates  in  the  viscera  and  deeper  tissues 
of  the  body.  The  tidal  blood  flows  and  ebbs,  not  rhj^thmically,  but  under 
the  influences  of  various  physiological  and  pathological  influences. 

Local  An.^mia. — The  distribution  of  the  blood  mass  is  controlled  by 
the  arteries,  which  contract  or  dilate  under  the  influence  of  the  central  or 
peripheral  vasomotor  ganglia.  Hence  afflux  and  deflux,  physiological 
within  limits;  pathological  in  excess.  In  one  territory  congestion;  in 
another  anaemia.  Cerebral  anaemia  with  faintness  or  syncope  results  from 
sudden  dilatation  of  the  mesenteric  vessels,  such  as  is  caused  by  intense 
emotion,  pain,  the  rapid  removal  of  pressure,  as  in  the  abrupt  change  to 
the  upright  posture,  or  a  copious  stool  in  advanced  aortic  incompetence, 
or  the  evacuation  of  a  large  ascites.  Chronic  anaemia  of  the  central  ner- 
vous system  may  be  the  cause  of  many  of  the  vague  symptoms  in  cardiac 
disease  and  enteroptosis.  Local  anaemias  due  to  spasm  of  peripheral 
vessels,  such  as  is  seen  in  Raynaud's  disease,  causing  asphyxia  of  the 
extremities,  may  affect  visceral  vessels,  causing  functional  derangements, 
or  circumscribed  areas  of  brain  tissue,  and  give  rise  to  transitory  palsies, 
aphasia,  or  hemicrania. 

General  Anemia. — The  general  anaemias  are  primary,  essential  or 
cytogenic,  and  secondary  or  symptomatic. 

ii.  Primary  Ansemia. 

The  blood-making  organs  are  at  fault.  The  etiology  is  obscure. 
The  essential  lesions  involve  the  blood  as  a  tissue.  Clinical  phenomena 
manifest  in  other  structures  are  secondary  to  changes  in  the  blood.  This 
group  comprises  chlorosis,  pernicious  anaemia,  and  splenic  anaemia. 

(a)  CHLOROSIS. 

Definition. — Anaemia  of  undetermined  cause,  common  in  females  at  or 
shortly  after  the  age  of  puberty,  and  characterized  by  a  peculiar  greenish- 
yellow  pallor  of  the  skin,  constipation,  breathlessness  upon  exertion,  and 
marked  relative  diminution  of  the  haemoglobin. 

Etiology. — Predisposing  Influences. — Sex  is  paramount.  Chlorosis 
occurs  only  in  females.  The  period  of  onset  corresponds  to  that  of  puberty, 
and  varies  from  about  the  thirteenth  to  the  seventeenth  year.  Earlier 
than  this  period  it  is  uncommon;  later  it  is  due  to  recurrences,  which  are 
sometimes  multiple.  The  disease  may  occur  in  successive  generations, 
and  the  daughters  of  mothers  who  had  suffered  from  chlorosis  are  often 
chlorotic.  Several  girls  in  the  same  family  often  manifest  the  disease. 
The  condition  is  sometimes  associated  with  hypoplasia  of  the  aorta  and 
sexual  organs.  The  disease  occurs  in  every  walk  of  life,  but  is  much  more 
common  among  the  poorer  classes  and  working  girls  in  factory  towns  and 
large  cities.  It  is  not  uncommon  among  domestic  servants.  Among 
farmers'  daughters  it  is  rare.  Lack  of  exercise,  of  fresh  air  and  sunshine, 
and  insufficient  and  improper  food  are  important  predisposing  influences. 
The  subjects  of  the  disease  are  often  lethargic  and  phlegmatic;   sometimes 


ANEMIA.  1135 

emotional  and  nervous.  The  disease  has,  upon  insufficient  grounds,  been 
regarded  as  a  neurosis,  attributed  to  coprtemia  from  constipation  and  to 
the  wearing  of  the  corset. 

The  Exciting  Cause. — The  actual  cause  of  chlorosis  is  unknown. 
It  is  apparently  due  to  a  functional  default  of  the  blood-making  organs — 
defect  of  hsemogenesis — incident  to  the  functional  maturity  of  the 
reproductive  organs. 

Symptoms. — Pallor  is  marked,  and  the  skin  has  a  faint  yellowish- 
green  tinge  to  which  is  clue  the  designation  chlorosis,  or  green  sickness. 
The  conjunctivse  are  faintly  bluish  and  the  mucous  membranes  of  the 
mouth  and  lips  very  pale.  In  some  cases  the  normal  pigmentation  about 
the  folds  of  the  joints  is  slightl}^  intensified.  The  subcutaneous  fat  is 
frequently  increased  and  there  is  an  increased  turgor  of  the  integumentary 
tissues.  There  may  be  actual  oedema  of  the  face  and  ankles.  There  are 
rare  cases  in  which  the  cheeks  have  a  reddish  color,  especially  upon  exer- 
tion or  during  excitement — chlorosis  Jiorida,  chlorosis  rubra.  Gastro- 
intestinal symptoms  are  common  and  often  prominent.  The  appetite  is 
capricious.  The  school-girl's  fondness  for  pickles  and  bits  of  chalk  is 
well  known.  Hyperacidity  is  often  present  and  associated  with  epigastric 
distress.  Dilatation  of  the  stomach,  gastroptosis,  and  movable  right 
kidney  are  frequently  present.  Constipation  is  a  common  and  troublesome 
condition.  Dyspnoea,  palpitation,  and  vertigo  occur  upon  exertion,  as 
in  the  rapid  ascent  of  a  flight  of  stairs.  The  heart  is  frequenth^  dilated  and 
the  apex  displaced  slightly  to  the  left.  A  systolic  murmur  in  the  mitral 
area  may  be  the  sign  of  relative  insufficiency.  Much  more  common  are 
systolic  murmurs  at  the  base,  particularly  in  the  pulmonary  area.  Distinct 
pulsation  in  the  second  left  intercostal  space  is  not  uncommon.  Diastolic 
murmurs  are  infrequent.  A  distinct,  loud,  continuous,  venous  hum  may 
be  heard  over  the  jugular  vein  on  the  right  side — iiun's  murmur,  bruit  de 
diable,  humviing-to'p  murmur.  Pulsation  may  sometimes  be  seen  in  the 
veins  of  the  neck;  less  frequently  in  the  peripheral  veins.  Thrombosis 
may  occur  in  the  cerebral  sinuses  or  in  the  left  femoral  vein.  In  the  latter 
event  there  is  danger  of  pulmonary  infarct.  Slight  enlargement  of  the 
thyroid  body  is  not  uncommon.  It  may  be  associated  with  Joffroy's  sign. 
Amenorrhoea  and  dysmenorrhoea  are  common.  Hysterical  manifestations 
occur  in  a  large  proportion  of  the  cases.  Headache,  coldness  of  the  extrem- 
ities, and  mental  depression  are  prominent  symptoms.  Moderate  rises  of 
temperature  are  occasionally  observed. 

The  Blood. — The  droplet  is  pale  and  flows  freely  from  the  puncture. 
It  is  characterized  by  transparency  and  fluidity  as  contrasted  with  normal 
blood.  The  coagulation  period  is  short  and  the  specific  gravity  decreased. 
The  alkalinity  of  the  blood,  according  to  most  observers,  remains  normal. 
There  is  marked  absolute  decrease  in  the  hemoglobin;  and  a  high  degree  of 
diminution  in  haemoglobin  relative  to  the  reduction  in  the  number  of 
erythrocytes,  as  manifested  by  low  color  indices,  constitutes  a  character- 
istic phenomenon  of  chlorotic  blood.  Microscopically  the  erythrocytes  are 
moderately  decreased,  usually  to  about  4,000,000  per  cubic  millimetre. 
They  may  fall  as  low  as  8,000,000  or  even  2,000,000  in  severe  cases.  There 
is  a  slight  general  diminution  in  their  average  diameter.     Nucleated  forms 


1136  MEDICAL  DIAGNOSIS. 

— normoblasts — are  occasionally  present.  Poikilocytosis  is  common  and 
may  be  marked  in  severe  cases.  Microcytosis  also  occurs  in  the  graver 
cases.  Polychromatophilia  is  rare.  The  leucocytes  are  usually  normal 
or  slightly  increased.  There  is  relative  increase  in  the  number  of  lympho- 
cytes. Small  percentages  of  myeloc5i:es  occur  in  severe  cases.  Eosino- 
philes  are  absent  in  the  majority  of  the  cases. 

Pseudochlorosis. — This  term  has  been  applied  to  a  rare  condition  in 
which  the  characteristic  symptom-complex  is  present,  but  no  marked  change 
in  the  blood  can  be  discovered  upon  ordinary  clinical  examination.  It  has 
been  assumed  that  the  actual  condition  of  the  blood  as  regards  the  relation 
between  the  haemoglobin  and  erythrocytes  is  masked  by  a  diminution  in 
the  volume  of  plasma. 

Diagnosis. — The  direct  diagnosis  of  chlorosis  is  unattended  with 
difficulty.  The  pallor,  the  pearly  or  bluish  conjunctivae,  the  preservation 
of  subcutaneous  fat  occurring  in  a  girl  at  or  shortly  after  puberty  con- 
stitute a  characteristic  clinical  picture.  Headache,  breathlessness  upon 
exertion,  and  gastro-intestinal  sj^mptoms,  especially  constipation,  are  of 
diagnostic  value,  particularly  in  the  absence  of  visceral  disease  attended 
by  anaemia  and  dropsy,  as  disease  of  the  heart,  or  forms  of  nephritis,  or 
chronic  infections,  as  tuberculosis,  sj^philis,  or  malaria.  In  the  majority 
of  cases  the  characters  of  the  blood  differentiate  chlorosis  from  other  forms 
of  anaemia;  but  the  fact  is  not  to  be  overlooked  that  there  are  cases  of 
secondary  anaemia,  particularly  in  the  above-mentioned  organic  and  infec- 
tious diseases,  in  which  changes  in  the  blood  closely  corresponding  to 
those  of  chlorosis  occur. 

Differential  Diagnosis. — Cardiac  Disease. — The  dyspnoea  and  pal- 
pitation upon  exertion  frequently  suggest  valvular  disease  of  the  heart. 
The  anamnesis  is  important.  A  history  of  rheumatic  or  scarlet  fever, 
foUow^ed  by  such  symptoms  becoming  progressively  more  severe;  distinct 
cardiac  enlargement;  murmurs  having  characteristic  points  of  maximum 
intensity,  definite  lines  of  propagation,  and  constant  relations  to  the  rev- 
olution of  the  heart;  the  absence  of  a  venous  hum,  are  in  favor  of  disease 
of  the  heart.  The  sex  and  age  of  the  patient  are  highly  important.  Renal 
Disease. — General  pallor  and  some  degree  of  anasarca,  as  shown  in  puffi- 
ness  of  the  face  and  oedema  of  the  feet,  may  be  suggestive  of  nephritis — a 
diagnosis  at  once  negatived  by  the  absence  of  albumin  and  casts.  The 
possibility  of  transient  albuminuria — albuminuria  of  adolescence — is  to  be 
borne  in  mind.  The  intermittent  nature  of  this  form  of  albuminuria  and 
its  tendenc}^  to  disappear  upon  rest  are  significant.  Tuberculosis. — The 
pallor  of  the  early  stages  of  pulmonary  tuberculosis  in  a  3'oung  girl  may 
simulate  chlorosis.  Cough,  wasting,  positive  physical  signs,  rapid  pulse, 
and  a  slight  rise  of  temperature  recurring  about  the  same  time  every  day, 
increased  by  exercise  and  at  the  time  of  menstruation,  point  to  phthisis. 
The  examination  of  the  blood  is  essential.  The  deficiency  of  the  haemoglobin 
in  chlorosis  may  be  apparent  when  a  drop  of  blood  is  allowed  to  fall  upon 
a  piece  of  white  blotting  paper  or  a  handkerchief,  the  blood  of  a  healthy 
person  being  used  for  contrast.  Malaria. — The  character  of  the  febrile 
paroxysm  and  the  presence  of  malarial  parasites  in  the  blood  are  conclu- 
sive.    Syphilis. — The  rapid  anaemia  and  the  fever  of  secondary  syphilis 


ANiEMIA.  1137 

may  give  rise  to  doubts  as  to  the  diagnosis.  The  macular  syphihde, 
adenopathy  and  mucous  patches  are  diagnostic.  When  a  chlorotic  girl 
contracts  syphilis  the  question  of  diagnosis  becomes  complicated. 

Prognosis.  —  The  prognosis  is  favorable.  The  majority  of  cases 
recover  under  treatment  in  the  course  of  a  few  weeks.  The  tendency ' 
to  repeated  attacks  persists  in  some  cases  for  several  years.  The  influ- 
ence of  pregnancy  and  lactation  in  arresting  this  tendency  is  usually 
positive.  The  administration  of  iron  in  proper  doses  appears  in  a  majority 
of  cases  to  exert  a  specific  curative  influence— a  fact  that  might  be  of 
diagnostic  importance  in  a  doubtful  case. 

(b)   PERNICIOUS  AN/GMIA. 
Idiopathic  or  Progressive  Ancemia. 

Definition. — Severe  anaemia  developing  either  idiopathically  or  in 
the  absence  of  discoverable  adequate  cause,  and  characterized  by  a 
progressively  unfavorable  course,  maintenance  of  body  weight,  and  con- 
stant changes  in  the  blood,  namely,  great  reduction  in  the  number  of 
erythrocytes,  megalocytosis,  microcytosis,  poikilocytosis,  the  presence  of 
erythroblasts,  and  relative  increase  in  haemoglobin. 

Etiology. — Clinically  several  different  groups  of  cases  may  be  recog- 
nized which  present  the  symptoms  of  progressive  pernicious  anaemia,  but 
are  due  to  different  causes.  A  majority  of  the  cases  correspond  to  the 
description  of  Addison,  and  arise  in  the  absence  of  the  usual  causes  of  anae- 
mia. Intense  progressive  anaemia,  presenting  all  the  clinical  features  of 
pernicious  anaemia,  is  occasionally  encountered,  (a)  in  child-bearing  women, 
beginning  either  during  pregnancy  or  after  parturition;  (b)  in  gastro- 
intestinal diseases,  particularly  atrophy  of  the  stomach;  and  (c)  in  certain 
forms  of  intestinal  parasitism,  especially  uncinariasis  and  the  presence  of 
the  Bothriocephalus  latus.  The  blood  picture  seen  in  the  anaemia  which 
follows  certain  cases  of  nitrobenzol  poisoning  is  similar  to  that  of  pernicious 
anaemia.  Cases  have  been  observed  in  every  quarter  of  the  globe.  The 
onset  is  gradual  and  wholly  independent  of  seasonal  influences.  The 
exacerbations  which  follow  remissions  under  treatment  sometimes  occur 
in  the  spring  of  the  year.  The  onset  of  the  disease  is  most  common  in  late 
middle  life.  It  has  been  observed  at  all  ages.  Excluding  the  cases  which 
begin  during  pregnancy  and  lactation,  it  would  appear  that  males  are  much 
more  frequently  affected  than  females.  Rare  cases  have  been  encoun- 
tered in  parents  and  children — a  fact  which  does  not  warrant  the  assump- 
tion that  the  tendency  to  the  disease  is  transmitted  from  the  parent 
to  the  offspring.  Severe  nervous  or  mental  shock  and  prolonged  intense 
depressing  emotions  have  in  many  instances  been  followed  by  the  onset  of 
the  disease.  The  researches  of  William  Hunter  lend  support  to  the  conclu- 
sion that  this  form  of  anaemia  is  due  to  chronic  septic  infection  associated 
with  lesions  of  the  gums  or  mouth,  and  gastric  and  intestinal  sepsis,  which 
lead  to  haemolysis. 

Symptoms. — The  onset  is  insidious,  and  the  symptoms  are  those  of  a 
profound  and  progi'essive  anaemia.     Pallor  of  the  skin  and  visible  mucous 

72 


1138 


MEDICAL  DIAGNOSIS. 


membranes,  languor,  breathlessness  upon  slight  exertion  or  emotional 
excitement,  flabbiness  of  the  tissues  associated  with  remarkable  preser- 
vation of  the  subcutaneous  fat  and  slight  pufliness  about  the  ankles, 
extreme  debility,  make  up  the  clinical  picture.  In  a  majority  of  the  cases 
there  is  irregular  fever  of  moderate  intensity.  Cardiovascular  symptoms 
consist  of  faintness,  dyspnoea  and  palpitation  upon  exertion,  a  full,  soft, 
and  compressible  pulse,  visible  pulsation  of  the  superficially  placed  arteries, 
and  hsemic  murmurs.  The  pulse  not  rarely  resembles  the  water-hammer 
pulse  of  aortic  regurgitation, — Corrigmi's  pulse, — a  resemblance  frequently 
increased  by  the  presence  of  capillar}^  and  a  penetrating  venous  pulsation. 
There  is  a  marked  tendency  to  hemorrhage  from  the  mucous  membranes 

and  into  the  skin.  Retinal  hemor- 
rhages are  common  as  in  other 
grave  anaemias.  Gastro -intestinal 
Sym-ptovis. — The  appetite  fails,  and 
in  advanced  cases  anorexia  is  com- 
plete. The  mouth  is  dry,  the  tongue 
furred,  often  sore,  the  gums  are 
ulcerated,  and  the  breath  is  offen- 
sive. Nausea  and  vomiting  are 
common.  Attacks  of  diarrhoea 
occur  without  apparent  cause.  The 
urine  is  abundant  and  usually  of  low 
specific  gravity;  sometimes  pale, 
sometimes  of  a  deep  sherry  color, 
due  to  the  presence  of  urobilin.  The 
skin  is  blanched,  smooth  and  waxy 
in  appearance.  It  is  commonly 
intensely  pale,  frequent»Iy  of  a  faint 
lemon  color,  especially  marked  upon 
the  hands,  sometimes  subicteroid, 
and  less  commonly  pigmented  as  in 
Addison's  disease.  The  pigment 
may  be  more  or  less  uniformly 
distributed,  or  deposited  in  irregular 
patches.  It  is  sometimes  associated  with  patches  of  vitiligo.  In  some  cases 
the  cutaneous  pigmentation  follows  the  prolonged  administration  of  arsenic. 
Spinal  symptoms  may  be  encountered  as  the  result  of  degeneration 
involving  the  posterior  and  lateral  columns,  and  in  some  cases  extending 
beyond  these  tracts  to  the  anterior  part  of  the  cord.  They  may  appear 
earlier  than  the  blood  changes,  but  more  commonly  not  until  the  disease 
is  well  advanced.  They  consist  of  numbness  and  tingling  in  the  legs  and 
feet,  weakness,  and  in  some  cases  severe  pain.  The  reflexes  are  increased. 
Later  similar  symptoms  may  involve  the  upper  extremities.  There  may 
be  marked  ataxia,  with  disturbance  of  the  functions  of  the  bladder  and 
rectum.  After  a  time  loss  of  sensation  may  occur,  with  flaccidity  and 
abolition  of  the  reflexes. 

The  Blood. — There  is  absolute  diminution  of  the  haemoglobin,  which 
is,  however,  increased  relatively  to  the  number  of  red  cells,  so  that  the 


Fig.    .328. — Piu:meiitation   of  th 
pernicious  anaemia. 


skin  in  a  case  of 
-Packard. 


ANEMIA.  1139 

color  index  is  high.  The  erythrocytes  show  a  great  numerical  decrease, 
often  to  1,000,000,  or  in  terminal  states  to  500,000  per  cubic  millimetre. 
Erythroblasts  are  constant,  the  common  form  being  megaloblastic.  Poikilo- 
cytosis  is  constant  and  marked.  Megalocytes  and  microcytes  occur,  the 
former  being  more  common  and  more  marked.  Polychromatophilia  is 
found  in  many  of  the  erythrocytes,  both  non-nucleated  and  nucleated. 
The  leucocytes  are  usually  decreased,  often  markedly  so.  A  relative 
increase  in  the  lymphocytes  is  common.  Myelocytes  are  usually  present. 
The  eosinophiles  are  almost  always  decreased  in  number  and  frequently 
absent  altogether.  The  number  of  blood-plaques  is  variable.  Blood  crises 
(von  Noorden)  are  characterized  by  the  appearance  in  the  blood  of  large 
numbers  of  nucleated  red  blood-corpuscles,  very  often  in  successive  crops, 
and  are  usually  of  sudden  onset  and  brief  duration,  sometimes  lasting 
but  a  few  hours.  These  crises  are  common  in  severe  anaemia  following 
hemorrhage  and  in  chlorosis,  and  not  rare  in  some  forms  of  leukaemia  and 
in  pernicious  ansemia,  and  are  usually  followed  by  periods  of  temporary 
improvement  in  the  blood  count.  The  blood  crises  of  pernicious  ansemia 
are  more  commonly  of  the  megaloblastic  type  and  are  frequently  followed 
by  the  death  of  the  patient.  When  of  the  normoblastic  type  they  may  be 
followed  by  an  actual  increase  in  the  erythrocytes. 

Aplastic  Anemia. — This  term  has  been  applied  to  a  limited  group  of 
cases  presenting  the  S3"mptoms  of  pernicious  ansemia  but  characterized 
by  atrophy  of  the  erythroblastic  tissue  in  the  bone-marrow.  Clinical 
differences  between  this  variety  and  the  ordinary  form  of  pernicious 
ansemia  are  found  in  its  earlier  occurrence,  a  majority  of  the  cases  having 
occurred  before  the  thirty-fifth  year  of  life;  its  greater  frequency  among 
females  than  males;  its  rapid  course,  unattended  by  remissions  and  usually 
terminating  within  a  period  measured  by  months;  a  greater  tendency  to 
hemorrhage.  Differences  in  the  blood  picture  consist  in  a  lower  color  index 
than  in  the  ordinary  form;  a  marked  increase  in  the  percentage  of  lympho- 
cytes; the  absence,  as  a  rule,  of  erythroblasts;  the  absence  or  comparative 
infrequency  of  poikilocytosis,  anisocytosis  (differences  in  the  size  of  the 
erythrocytes),  polychromatophilia;  and  the  great  diminution  of  the  blood- 
plates.  Pathologically  the  most  constant  and  striking  change  is  manifest 
in  the  marrow  of  the  long  bones,  from  which  the  erythroblastic  tissue  has 
disappeared,  leaving  the  medullary  cavities  filled  with  fat.  That  this 
change  has  occurred  in  all  the  bones  has  not  as  yet  been  demonstrated  in 
any  case.  The  femur  is  used  as  a  standard,  and  if  its  marrow  is  yellow 
and  homogeneous  throughout,  the  form  of  ansemia  may  be  regarded  as 
aplastic.  Diagnosis.— The  direct  diagnosis  cannot  be  made  tJitra  vitam.. 
It  is  rendered  probable  by  the  concurrence  of  the  above  clinical  symp- 
toms and  hsematological  findings,  but  finally  rests  upon  the  post-mortem 
examination  of  the  marrow  of  the  bones. 

Diagnosis. — The  direct  diagnosis  of  pernicious  anaemia  can  only  be 
made  by  a  microscopical  examination  of  the  blood.  In  general  practice 
the  true  nature  of  the  disease  is  not  often  suspected  in  its  earlier  course 
and  rarely  recognized  after  it  has  made  some  progress.  Even  the  blood 
changes  are  not  at  all  times  present  in  every  case  in  the  beginning.  A 
severe  ansemia  insidiously  arising  in  the  absence  of  any  obvious  cause, 


1140  MEDICAL  DIAGNOSIS. 

pursuing  an  unevenly  progressive  course  but  little  influenced  by  treat- 
ment; preservation  of  the  subcutaneous  fat  and  body  weight  to  a  remark- 
able degree;  a  blanched,  smooth,  and  waxy  appearance  of  the  surface, 
which  has  a  faint  lemon-yellow  tint;  extreme  languor  and  breathlessness 
upon  exertion;  a  tendency  to  hemorrhage  into  the  skin  or  from  mucous 
surfaces;  retinal  hemorrhage;  gastric  symptoms;  and  the  occurrence  of 
febrile  paroxysms  of  moderate  intensity  constitute  a  symptom-complex 
which  is  highly  characteristic.  A  blood  picture  showing  the  association  of 
oligocythsemia  of  high  grade,  falling  in  many  cases  below  1,000,000  per 
cubic  millimetre;  erythroblasts  mostly  of  the  megaloblastic  type;  poikilo- 
cytosis;  great  variation  in  the  size  of  the  erythrocytes;  a  high  color  index; 
and  leukopenia  render  the  diagnosis  positive. 

Differential. — 1.  Grave  secondary  ancBmias,  such  as  occur  after 
copious  hemorrhages  (especially  a  prolonged  habitual  blood  loss),  visceral 
cancer  (especially  carcinoma  ventriculi),  and  in  advanced  syphilis,  often 
present  clinical  symptoms  precisely  similar  to  those  of  pernicious  ansemia. 
The  anamnesis  is  important.  As  a  rule,  an  obvious  cause  for  the  anaemia 
may  be  discovered.  There  are,  however,  cases  in  w^hich  malignant  disease 
cannot  be  located,  or  the  history  of  syphilis  is  obscure.  The  actual  patho- 
logical condition  then  rests  upon  the  examination  of  the  blood.  The 
following  points  are  of  diagnostic  importance:  In  secondary  anaemia,  (a) 
the  oligocythsemia  is  less  marked,  the  count  rarely  falling  below  1,000,000 
per  cubic  millimetre;  (b)  the  color  index  is  lower;  (c)  leucocytosis  is  often 
present;  (d)  megalocytosis  does  not  occur.  The  fault  does  not  primarily 
involve  the  haematopoietic  organs.  The  blood  changes  result  from,  and 
are  secondary  to,  constitutional  diseases,  as  certain  of  the  acute  and  chronic 
infections  and  intoxications,  diabetes,  parasitism  and  nutritional  dis- 
orders, local  anatomical  lesions  which  seriously  interfere  with  the  functions 
of  important  viscera,— as  the  heart,  lungs,  the  organs  of  digestion,  or  the 
kidneys, — ^  malignant  disease,  or  to  hemorrhage.  The  anaemia  is  due  to 
deficient  blood  formation — haemogenesis;  excessive  blood  destruction — 
haemolysis;  or  the  association  of  these  two  processes.  Severe  secondary 
anaemia,  when  long  continued,  may  exhaust  the  function  of  the  blood- 
making  organs  in  such  a  manner  as  to  be  converted  into  primary  ana&mia. 
2.  Chlorosis. — There  are  often  clinical  phenomena  present  which  suggest 
pernicious  anaemia,  namely,  preservation  of  subcutaneous  fat,  smooth, 
waxy,  and  faintly  greenish-yellow  tint  of  the  skin,  pallor  of  mucous  sur- 
faces and  pearly  tint  of  sclera,  breathlessness,  and  languor;  but  the  blood 
examination  shows  essential  differences.  The  following  points  are  to  be 
considered:  (a)  In  chlorosis  we  have  to  do  with  a  haemoglobin  rather 
than  a  corpuscular  anaemia;  hence  a  low  color  index,  the  reverse  of  the 
condition  in  pernicious  anaemia;  (b)  there  is  a  general  diminution  in  the 
diameter  of  the  er3^throcytes;  (c)  megaloblasts  may  occasionally  be 
encountered,  but  are  never  present  in  great  numbers — nucleated  red 
corpuscles  when  seen  are  almost  always  normoblasts;  (d)  leukopenia  of 
high  grade  is  not  common;  (e)  myelocytes  may  be  observed  in  small 
numbers  in  both  diseases,  but  are  much  less  common  in  chlorosis.  3. 
Bothriocephahis  Anmnia. — The  therapeutic  test  yields  positive  results. 
Metabolic  products  of  the  intestinal  parasite  have  been  thought  to  possess 


AN.EMIA.  1141 

hsemolytic  properties.  Its  expulsion  may  be  promptly  followed  by  an 
improvement  in  the  general  health  and  the  restoration  of  the  blood  to 
its  normal  condition,  the  megaloblasts  and  oligocythsemia  disappearing 
and  the  color  index  falling  to  the  usual  range  of  health.  4.  Various  Affec- 
tions.— In  the  absence  of  a  blood  examination  the  lemon-yellow  tint  of 
the  skin  may  suggest  jaundice,  from  which  pernicious  anaemia  is  to  be 
differentiated  by  the  pearl}''  sclera,  the  fact  that  bile  pigments  are  not 
present  in  the  urine,  and  the  absence  of  definite  signs  and  symptoms 
indicating  disease  of  the  liver  or  bile  passages;  the  anaemia,  puffiness  of 
the  face,  and  swelling  of  the  ankles  may  simulate  nephritis,  especially  if, 
as  is  sometimes  the  case,  albumin  is  found  in  the  urine,  a  view  not  sus- 
tained by  the  results  of  close  analysis  of  the  urine  and  the  history  of  the 
case;  palpitation,  dyspnoea,  and  the  condition  of  the  arteries  point  to 
cardiac  disease,  but  the  anamnesis  and  physical  signs  lend  little  support 
to  such  a  diagnosis;  finally,  nervous  symptoms,  such  as  numbness  of  the 
legs  and  feet,  less  commonly  of  the  hands,  pain,  sometimes  very  severe, 
impairment  of  station  and  gait,  and  loss  of  the  deep  reflexes  arouse  the 
suspicion  that  the  affection  is  of  spinal  origin,  a  diagnosis  always  obscure 
but  much  influenced  by  the  blood  examination,  since  pernicious  anaemia  has 
not  been  found  to  arise  as  a  secondary  affection  in  spinal  degenerations,  while 
posterolateral  sclerosis  has  been  frequently  observed  in  this  form  of  anaemia. 
Prognosis. — The  course  of  the  disease  is  not,  as  a  rule,  steadily  pro- 
gressive. There  are  periods  of  improvement  followed  by  relapse.  Many 
cases  go  on  in  this  way  for  j^ears.  There  are  cases  which  run  a  very 
rapid  course  and  end  fatally  within  a  few  months.  The  average  duration 
is  about  a  year  or  fifteen  months.  Occasionally  recoveries  have  been 
recorded.  The  following  conditions  are  of  bad  omen:  an  oligocythaemia 
of  less  than  1,000,000  per  cubic  millimetre,  a  high  percentage  of  megalo- 
blasts and  blood  crises  of  megaloblastic  type,  the  inability  to  take  arsenic,, 
tendency  to  hemorrhage,  gastro-intestinal  disturbances,  and,  as  in  almost 
all  grave  chronic  diseases,  the  privations  and  disabilities  incident  to  poverty. 

(c)  SPLENIC  AN/CMIA. 

This  affection  is  considered  under  the  heading  Diagnosis  of  Diseases 
of  the  Spleen. 

iii.   Secondary  or  Symptomatic  Anaemia. 

Under  this  heading  are  included  those  forms  of  anaemia  caused  by 
acute  and  long  repeated  hemorrhages,  certain  intestinal  parasites,  unhy- 
gienic surroundings,  insufficient  food,  prolonged  lactation,  the  metal  poison- 
ings, acute  and  chronic  infections,  acute  and  chronic  visceral  diseases, 
especially  nephritis  and  cardiac  disease,  and  malignant  growths. 

In  moderate  cases  the  freshly  drawn  blood  presents  an  appearance 
nearly  normal,  but  in  cases  of  intense  secondary  anaemia  it  may  look  like 
serum  faintly  tinged  with  crimson.  In  the  latter  case  the  tendency  to 
rouleaux  is  slight.  The  coagulation  period  is  diminished  in  proportion  to 
the  intensity  of  the  anaemia.     The  further  changes  in  the  blood  are  as 


1142 


MEDICAL  DIAGNOSIS. 


follows:  haemoglobin  diminished  to  an  extent  proportionate  to  the  energy 
of  the  cause;  color  index  correspondingly  decreased;  erythrocytes  dimin- 
ished to  a  varying  degree;  nucleated  forms  in  intense  anaemia,  the  normo- 
blastic type  prevailing;  departures  from  normal  in  the  size  and  shape,  and 
polychromatophilia  in  severe  cases;  leucoc}i:osis  commonly  present; 
polynuclear  neutrophiles  relatively  increased;  lymphocytes  decreased; 
lymphocytosis  may  occur  in  severe  and  prolonged  cases;  myelocytes  in 
small  numbers;   blood-plaques  increased. 


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>  EKYTHRQCyTES 


— •  t-tEiMOCL-OBIf>l 


Fig.  329. — Chart  showing  variations  in  the  number  of  erythrocytes  and  in  the  percentage  of  hsemoglobin 
,  in  posthemorrhagic  ansemia  due  to  gastric  ulcer. 

Posthemorrhagic  An.cmia.  —  An  examination  directly  after  the 
blood  loss  may  fail  to  show  diminution  in  the  hsemoglobin  or  corpuscles 
by  reason  of  the  oligsemia.  Fluid  is,  however,  rapidly  taken  from  the 
tissues  into  the  capillaries  so  that  a  condition  of  hydrsemia  ensues  and  the 
decrease  in  hsemoglobin  and  erj^throcj^es  becomes  apparent,  the  minimum 
counts  occurring  some  time  within  the  course  of  a  week.  A  more  or  less 
marked  leucocytosis  commonly  occurs  and  persists  for  about  a  week, 
gradually  declining.  A  gradual  regeneration  of  the  blood  takes  place  in 
uncomplicated  cases  and  is  completed  in  from  three  to  four  weeks,  the 
hsemoglobin  reaching  normal  at  a  later  period  than  the  erythrocj^tes. 


LEUKAEMIA.  1143 

Secondary  anaemia  is  very  common  in  childhood.  It  may  be 
congenital,,  as  in  syphilis  and  other  infections,  or  acquired,  as  in  (a) 
hemorrhages  of  various  kinds,  particularly  from  the  navel,  after  cir- 
cumcision, and  in  the  purpura  group,  or  (b)  from  general  causes,  as 
malnutrition,  improper  hygiene,  syphilis,  rickets,  tuberculosis,  the  fevers, 
sepsis,  gastro-intestinal  and  other  visceral  diseases,  nephritis,  acute 
disease  of  the  heart,  and  malignant  disease. 

II.  LEUKAEMIA. 

Definition. — An  affection  of  undetermined  causation,  characterized 
by  an  enormous  but  fluctuating  increase  in  the  leucocytes,  decided  de- 
crease in  the  erythrocytes  and  haemoglobin,  and  lesions  of  the  spleen, 
lymphatic  glands,  or  bone-marrow. 

Varieties. — Two  well-defined  clinical  varieties  are  recognized:  (1) 
myelogenous  or  splenomedullary  leukaemia,  and  (2)  lymphatic  leukaemia. 
The  splenomedullary  is  much  the  more  common  type.  Combined  forms 
and  variations  are  not  infrequent. 

Etiology. — Predisposing  Influences. — The  disease  has  been  encoun- 
tered at  all  periods  of  life,  from  early  infancy  to  the  seventieth  year. 
It  is  most  common  in  the  third,  fourth,  and  fifth  decades.  Leukaemia  is 
more  common  in  males  than  females  in  the  ratio  of  about  two  to  one. 
Cases  have  been  observed  in  pregnancy,  and  the  disease  not  rarely  develops 
at  the  grand  climacteric.  There  are  instances  in  which  leukaemia  has  been 
observed  in  successive  generations,  and  a  leukaemic  mother  has  borne 
eukaemic  children.  On  the  other  hand,  leukaemic  mothers  have  borne 
non-leukaemic  children,  and  a  woman  showing  no  signs  of  the  disease  has 
borne  a  leukaemic  child.  Leukaemia  occurs  in  all  parts  of  the  world.  It 
is  not  rare  in  the  United  States.  Cases  have  been  observed  in  almost  all 
kinds  of  domestic  animals. 

Exciting  Cause. — The  disease  has  upon  inadequate  grounds  been 
attributed  to  malaria.  It  has  followed  blows  and  grave  bodily  injury. 
The  tendencies  to  hemorrhage  and  to  habitual  nose-bleeding,  which  have 
been  regarded  as  etiological,  are  much  more  probably  early  manifestations 
of  an  affection  the  true  nature  of  which  has  been  revealed  by  a  study  of 
the  blood.    In  point  of  fact  nothing  is  as  yet  known  of  the  actual  cause. 

General  Symptoms. — The  onset  is  insidious  and  ma}'  be  associated 
with  persistent  and  intractable  gastro-intestinal  symptoms.  In  some 
instances  the  patients  present  the  appearance  of  fairly  good  health  until 
the  occurrence  of  grave  symptoms  shortly  before  death.  A  lad  of  sixteen 
was  supposed  to  be  in  his  usual  health  until  the  occurrence  of  hemorrhage 
from  the  stomach,  which  proved  fatal  in  the  course  of  two  daj's.  Such 
cases  are  not  very  uncommon.  Epistaxis  is  a  frequent  symptom.  Pallor, 
palpitation,  and  dyspncea  upon  exertion  are  very  common.  Distention 
of  the  abdomen  due  to  splenic  tumor  and  enlargement  of  the  liver  may 
first  attract  the  attention  of  the  patient.  Tenderness  over  the  sternum 
or  the  long  bones  occurs  in  many  of  the  cases.  Diffuse  enlargement  of  the 
superficial  lymph-nodes,  which  are  generall}'  of  moderate  consistency, 
not  adherent  among  themselves  or  to  the  skin,  and  variable  in  size  from 


1144 


MEDICAL  DIAGNOSIS. 


time  to  time,  is  common  in  tlie  Ij'-mphatic  form.  The  groups  usually 
involved  are  the  cervical,  axillary,  and  inguinal.  These  changes  may  be 
restricted  to  the  mesenteric  and  other  deep  groups  without  demonstrable 
signs  of  enlargement  during  life,  and  there  are  cases  in  which  the  bone- 
marrow  alone  is  involved,  without  enlargement  of  the  spleen  or  lymphatic 
glands.  There  may  be  a  high  degree  of  emaciation  and  anasarca,  or 
effusion  into  the  serous  sacs. 


i.  Myelogenous  or  Splenomedullary  Leuksemia. 

Symptoms. — Gradual  enlargement  of  the  spleen  is  usually  the  most 
conspicuous  clinical  phenomenon.  The  enlarged  organ  extends  downward 
and  to  the  right,  and  may  reach  the  level  of  the  pubic  arch  and  pass  beyond 
the  median  line.  Its  well-defined  border  and  often  the  notch  or  notches 
may  be  distinctly  felt.     It  is  usually  painless,  but  occasionally  both  pain 

and   tenderness   are   present.      Peri- 


'^'^r^w^'^^;m!'~^r^'T^r'~-^w.v^ 


splenic  friction  may,  in  such  cases, 
be  recognized  upon  auscultation  and 
palpation.  Minor  fluctuations  in 
size  may  be  observed:  enlargement 
during  digestion,  and  diminution 
during  fasting  and  after  diarrhoea 
or  free  hemorrhage.  Fluctuations 
of  greater  amplitude  frequently  occur 
as  spontaneous  events  in  the  natural 
history  of  the  disease,  or  in  conse- 
quence of  the  administration  of 
arsenic  or  other  therapeutic  meas- 
ures. Massive  splenic  enlargement 
causes  pressure  symptoms,  among 
which  the  more  common  are  distress 
after  eating  and  constipation. 
G astro-intestinal  symptoms  occur  in 
the  course  of  almost  every  case. 
Nausea  and  vomiting  may  be  early 
and  persistent.  Diarrhoea  is  common. 
Hemorrhage  from  the  bowel  is  not 
common.  It  may  be  due  to  chronic 
dysentery.  Fatal  obstruction  of  the 
bowel  may  be  caused  by  pressure 
of  the  enlarged  spleen  upon  the 
intestine.  Jaundice  is  a  rare  symp- 
tom. Peritonitis  and  ascites  may 
also  be  caused  by  the  pressure  of 
a  massive  spleen.  Symptoms  due 
to  circulatory  derangements  and  the 
changes  in  the  blood  are  prominent.  The  cardiac  impulse  is  displaced 
upward  an  interspace  or  more  by  the  big  spleen;  hsemic  murmurs  may  be 
heard.    The  pulse  is  usually  of  large  volume  and  rapid,  but  soft  and  com- 


FiG.   330. — Splenomedullary     leuksemia 
tended  abdomen  due   to   massive   enlargement  of 
the  spleen. — Jefferson  Hospital. 


LEUKEMIA. 


1145 


pressible.  The  dyspnoea  is  anaemic.  Hemorrhage  is  a  very  common  symp- 
tom. Epistaxis,  bleeding  from  the  gums,  hsematemesis,  purpura,  retinal 
hemorrhage,  and  cerebral  hemorrhage  are  frequent.  Haemoptysis  and 
hsematuria  are  much  less  common.  Fluid  exudates  into  the  serous  sacs 
a,re  usually  hemorrhagic.  (Edema  of  the  feet  and  general  anasarca  are 
terminal  conditions.  As  in  all  the  grave  anaemias,  headache,  vertigo,  and 
syncopal  attacks  are  of  frequent  occurrence.  Leukaemic  retinitis  may  be 
due  to  hemorrhage  or  minute  leukaemic  deposits.  Optic  neuritis  is  rare. 
Deafness  is  common  and  the  syndrome  known  as  Meniere's  disease  has  been 
observed.  With  the  exception  of  a  constant  excess  of  uric  acid  the  urine 
presents  no  characteristic  changes.  Priapism  has  been  frequently  noted. 
It  may  be  an  early  and  persistent  symptom.  Pneumonia  or  pulmonary 
oedema  are  common  terminal  events. 


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Fig.  331. — Chart  showing  variations  in  the  number  of  leucocytes,  erythrocytes,  and  in  the  lisemoglobin 
percentage  in  a  case  of  splenomedullary  leukaemia. 

The  Blood. — The  haemoglobin  is  diminished  not  rarely  as  much  as 
50  per  cent.  The  color  index  is  correspondingly  low.  Exceptionally  the 
color  index  is  high. 

Diminution  in  the  number  of  erythrocytes  is  constant  but  not 
extreme.  Counts  falling  below  2,000,000  are  rare.  Nucleated  erythrocytes 
are  very  numerous,  the  normoblastic  type  being  in  excess.  Megaloblasts 
are  relatively  less  numerous  and  frequently  present  in  atypical  forms. 
Deformities  in  size  and  shape  are  present  in  varying  degrees,  dependent 
upon  the  extent  of  the  haemoglobin  loss  and  cellular  diminution,  together 
with  polychromatophilia  affecting  both  the  nucleated  and  non-nucleated 
erythrocytes. 

The  leucocytes  arc  enormously  increased.  Counts  of  300,000  per 
cubic  millimetre  are  common,  of  500,000  by  no  means  rare,  and  of  1,000,000 
occasional.     When  the  oligocythaemia  is  marked  the  whites  may  nearly 


1146 


MEDICAL  DIAGNOSIS. 


equal  or  even  exceed  the  reds.  The  number  fluctuates  widely  from  time  to 
time  in  the  course  of  the  disease,  and  frequently  undergoes  remarkable 
diminution  under  the  free  administration  of  arsenic.  Wide  diurnal  fluc- 
tuations are  observed  in  some  cases,  the  lower  counts  being  noted  late 
in  the  day.  Extreme  changes  occur  in  certain  cases,  both  in  the  blood 
picture  and  in  the  general  condition,  so  that  periods  arise  in  which  there 

are  neither  symptoms  nor  signs  of  leukaemia 
present.  These  remarkable  remissions 
are  not,  however,  permanent.  Such  rever- 
sions to  the  normal  blood  conditions  accom- 
panied by  involution  of  the  splenic  tumor 
have  frequently  followed  the  therapeutic 
use  of  the  Rontgen  raj's.  Myelocytes  in 
great  numbers  are  present  and  constitute 
at  least  20  per  cent,  of  all  leucocytes,  as 
determined  by  the  differential  count  in  the 
majority  of  the  cases.  The  polynu clear 
neutrophiles  are  much  increased,  but  their 
percentage  is  relatively  low.  Many  of  these 
cells  are  dwarfed  and  deformed.  The  rela- 
tive percentage  of  lymphocytes  is  much 
below  normal.  Eosinophilia  is  almost 
invariably  present.  In  the  majority  of 
cases  mast-cells  are  present  in  consider- 
able numbers  and  the  blood-plaques  are 
much   increased. 


ii.  Lymphatic  Leuksemia. 

Symptoms. — The  general  symptoms 
are  similar  to  those  of  the  myelogenous 
form.  There  is  enlargement  of  the  lymph- 
nodes,  which  may  involve  the  superficial 
or  merely  the  deeper  groups  and  is  usually 
associated  with  more  or  less  marked 
enlargement  of  the  spleen.  In  the  acute 
cases  the  lymph  structures  of  the  mouth, 
tongue,  and  pharynx  may  be  enlarged. 
Enlargement  of  the  thymus  gland  is  some- 
times present  in  this  group  of  cases  and  may  be  the  cause  of  characteristic 
symptoms:    stridulous  respiration  with  dyspnoea,   usually  paroxysmal. 

The  Blood. — Haemoglobin  is  much  diminished  and  the  color  index 
correspondingly  low.  The  erythrocytes  are  reduced  in  number  to  3,000,000 
per  cubic  millimetre  or  lower.  Nucleated  red  cells  are  scanty,  those  of  the 
normoblastic  type  predominating.  Deformities  in  size  and  contour  and  the 
tinctorial  reactions  are  proportionate  to  the  degree  of  degeneration  of 
the  blood— anaemia.  The  leucocytes  are  much  increased  in  number,  but 
not  to  the  extent  often  seen  in  myelogenous  leukaemia,  counts  above 
200,000  being  comparatively  unusual.     The  differential  count  shows  this 


Fig.  .3.32. — Chronic  lymphatic   leukaemia. 
— Jefferson  Hospital. 


LEUKEMIA.  1147 

increase  to  be  largely  due  to  an  excess  of  large  and  small  lymphocytes, 
which  comprise  about  90  per  cent,  of  all  forms.  There  are  numerous  atypi- 
cal forms.  The  relative  proportion  of  polynuclear  neutrophils  is  much 
reduced,  those  cells  not  usually  exceeding  5  or  10  per  cent,  of  all  forms. 
Myelocytes  are  present  in  almost  all  cases,  but  in  very  small  numbers. 
Eosinophiles  are  also  present  in  the  majoritj^  of  the  cases  in  scanty  numbers. 
The  blood-plaques  are  increased. 

Leukanaemia. — Leube  has  used  this  term  to  designate  a  symptom- 
complex  consisting  of  intense  anaemia  with  changes  in  the  form  of  both  the 
erythrocytes  and  leucocytes — conditions  sometimes  described  as  transi- 
tional or  mixed  forms  of  leukaemia  and  pernicious  anaemia.  He  expressly 
reserves  this  term  for  forms  of  blood  disease  in  which  "  both  leucocytes 
and  erythrocytes  are  uniformly  and  decidedly  damaged  in  their  develop- 
ment, and  the  case  can  neither  be  put  in  the  category  of  leukaemia  nor  in 
that  of  pernicious  anaemia."  The  cases  are  of  sudden  onset,  with  signs  sug- 
gestive of  an  acute  infectious  process.  In  some  of  the  cases  there  is  severe 
tonsillar  angina;  in  others  stomatitis,  extreme  pallor,  weakness,  fever, 
hemorrhages,  hyperplasia  of  the  spleen,  and  moderate  enlargement  of  the 
liver.  Enlargement  of  the  lymph-nodes  is  not  constant.  The  course  is 
unfavorable;    the  duration  varies  from  a  few  days  to  several  weeks. 

Chloroma. — The  blood  changes  in  this  rare  affection  are  similar  to 
those  of  lymphatic  leukaemia.  There  is  progressive  diminution  of  the 
haemoglobin  and  erythrocytes,  associated  with  increase  in  the  leucocytes. 
Deformities  in  size  and  shape  in  the  erythrocytes,  and  nucleated  forms, 
chiefly  normoblasts,  show  themselves  as  the  anaemia  becomes  more 
intense.  There  is  marked  lymphocytosis.  The  symptom-complex  consists 
of  progressive  weakness,  pallor,  orbital  pain,  exophthalmus,  deafness,  and 
elastic  swellings  in  the  orbital  and  temporal  regions.  There  is  irregular 
hyperplasia  of  the  bone-marrow  with  subperiosteal  infiltrations  and  tumor- 
like metastases  of  greenish  color — so-called  "  green  cancer."  The  blood 
condition  closely  resembles  acute  lymphatic  leukaemia,  and  chloroma  has 
been  regarded  as  a  malignant  form  of  leukaemia  with  greenish  infiltrations 
and  metastases. 

Diagnosis. — The  direct  diagnosis  can  only  be  made  by  a  micro- 
scopical examination  of  the  blood.  The  disease  is  always  leukaemia  when 
the  proportion  of  leucocytes  to  erythrocytes  is  1  to  15  or  less;  when  the 
leucocyte  count  is  more  than  thirty  times  greater  than  normal  and  when 
at  the  same  time  many  of  the  cells  are  conspicuously  immature — mj^elo- 
cytes,  large  lymphocytes,  and  nucleated  red  corpuscles. 

Even  in  cases  in  which  there  is  a  temporary  return  to  the  normal 
ratio  between  the  leucocytes  and  the  erythrocytes,  immature  forms  very 
rarely  seen  in  normal  blood — erythroblasts  and  myelocytes — are  present 
in  sufficient  numbers  to  warrant  a  provisional  diagnosis  of  leukaemia  in 
the  absence  of  a  previous  knowledge  of  the  conditions  of  the  blood. 

Differential. — The  discrimination  between  myelogenous  and  lym- 
phatic leukaemia  can  only  be  made  by  the  blood  examination.  In  the 
myelogenous  form  the  type  of  the  blood  is  myelocytic,  that  is  to  say, 
myelocytes  are  present  in  enormous  numbers  together  with  an  increase 
in  the  eosinophiles  and  mast-cells;    oligocythaemia  is  moderate,  erythro- 


1148  MEDICAL  DIAGNOSIS. 

blasts  are  numerous,  the  normoblastic  type  predominating.  In  the  lym- 
phatic form  the  blood  type  is  lymphocytic,  namely,  there  is  an  excessive 
increase  in  the  lymphocytes,  myelocytes  being  absent,  or  present  in  very 
scanty  numbers;  there  are  very  few  eosinophiles  or  mast-cells;  oligocy- 
thsemia  is  marked;  and  erythroblasts  are  few  in  number  and  proportionate 
to  the  general  deterioration  of  the  blood. 

The  clinical  manifestations  as  regards  the  spleen  and  superficial 
lymph-nodes  do  not  afford  a  basis  for  the  differential  diagnosis  between 
the  two  forms  of  leukaemia;  but  this  fact  is  without  importance  since  an 
examination  of  the  blood  is  essential  to  the  general  diagnosis. 

Hodgkin's  Disease. — The  enlargements  of  the  lymph-nodes  and  of  the 
spleen  in  this  affection  often  closely  simulate  leukaemia.  The  differential 
diagnosis  rests  upon  the  fact  that  the  blood  is  normal  or  presents  the 
changes  which  occur  in  the  various  forms  of  secondary  anaemia.  Associated 
inflammatory  or  infectious  processes  when  present  may  cause  an  increase 
of   leucocytes  with  the  characters  of  a  polynuclear  neutrophile  leucocytosis. 

Chloroma  may  be  recognized  by  the  exophthalmus,  orbital  pains,  and 
elastic  tumor  formations. 

Splenic  Anceviia.— The  remarkable  size  of  the  splenic  tumor,  absence 
of  enlargement  of  the  superficial  lymph-nodes,  and  a  high  grade  of  anaemia 
with  leukopenia  constitute  positive  differential  criteria.  Banti's  disease, 
the  terminal  stage  of  splenic  anaemia,  is  characterized  by  hypertrophic 
cirrhosis  of  the  liver,  jaundice,  and  ascites. 

The  diagnosis  of  leukaemia  rests  wholly  upon  the  microscopical  exam- 
ination of  the  blood.  Other  conditions  which,  by  reason  of  the  presence  of 
superficial  lymphatic  enlargements  or  splenic  enlargement  associated  with 
more  or  less  pronounced  secondary  anaemia,  resemble  leukaemia  may  be 
at  once  differentiated  by  the  findings  in  the  blood.  It  is  only  necessary 
in  this  connection  to  name  the  splenic  tumor  of  chronic  malarial  infection; 
amyloid  disease;  malignant  growths,  cysts,  and  abscess;  enlargements 
involving  the  left  kidney,  as  hydronephrosis,  cysts,  perinephric  cysts; 
abscess  and  malignant  disease  or  cysts  of  the  pancreas;  and  retroperi- 
toneal sarcoma — all  of  which  present  resemblances  to  splenic  tumor;  and 
the  hyperplasias  of  the  lymphatic  glands  which  occur  in  tuberculosis, 
syphilis,  and  malignant  disease. 

Hasty  conclusions  in  a  suspected  case,  in  which  the  ratio  of  leucocytes 
to  erythrocytes  is  normal,  are  unwarrantable  because  remarkable  falls  in 
the  morbidly  increased  whites  occur,  (a)  in  the  natural  history  of  the 
disease;  (b)  during  or  immediately  after  acute  intercurrent  affections,  as 
influenza,  enteric  fever,  sepsis;  (c)  after  the  administration  of  drugs, — as 
arsenic  and  quinine, — the  injection  of  nuclein,  tuberculin,  and  antidiph- 
theritic  serum,  and  the  use  of  the  X-rays. 

Prognosis.— The  outlook  is  in  a  high  degree  unfavorable.  The  number 
of  permanent  recoveries  reported  is  limited.  Remarkable  and  prolonged 
remissions  occur.  The  influence  of  the  X-rays  upon  the  disease  in  some 
cases  is  to  be  considered.  The  acute  lymphatic  variety  is  peculiarly  malig- 
nant and  often  runs  a  rapid  course.  The  myelogenous  form  sometimes 
extends  over  eight  or  ten  years,  with  remissions,  even  intermissions,  and 
exacerbations.    Progressive  deterioration  of  the  blood,  hemorrhages,  marked 


HODGKIN'S  DISEASE.  1149 

gastro-intestinal  disturbances  (especially  intractable  diarrhoea),  fever,  dropsy, 
and  massive  enlargement  of  the  spleen  are  of  unfavorable  significance. 
Mikulicz's  Disease. — There  is  gradual,  symmetrical,  painless  enlarge- 
ment of  the  lachrymal  glands,  followed  by  similar  changes  in  the  salivary 
glands.  Special  predisposing  influences  are  not  recognized,  though  males 
suffer  more  frequently  than  females  and  in  the  majority  of  the  cases  the 
disease  has  occurred  between  the  twentieth  and  fortieth  years  of  life. 
The  condition  is  generally  regarded  as  an  infection,  but  a  special  patho- 
genic agent  has  not  been  demonstrated.  It  has  been  attributed  to  tuber- 
culous infection,  syphilis,  and  hypothyroidism.  Howard,  whose  recent 
studies  of  the  subject  are  of  great  importance,  regards  the  cases  as  con- 
stituting not  a  simple  morbid  entity  but  a  clinical  syndrome  varying  in 
its  etiology,  form,  and  course,  and  comprising  isolated  and  symmetrical 
disease  of  the  lachrymal  and  salivary  glands  due  to  simple  lymphomata, 
pseudoleuksemia,  leukeemia,  tuberculosis,  and  syphilis.  This  observer 
arranges  the  cases  in  three  groups:  (a)  the  simple  form,  in  which  only 
the  lachrymal  and  salivary  glands  are  involved,  neither  the  adjacent  nor 
distant  lymphatics  being  affected  and  the  blood  picture  remaining  normal 
for  years,  (b)  Pseudoleuksemia.  In  this  group  of  cases  the  clinical  mani- 
festations are  similar  to  the  simple  form  except  that  the  lymphatic  glands, 
either  locally  or  generally,  are  involved.  The  enlargement  is  variable  in 
degree.  Softening  and  caseation  do  not  occur.  The  spleen  may  be 
enlarged.  The  blood  may  be  normal  or  there  may  be  a  moderate  second- 
ary anaemia.  In  other  cases  there  is  a  relative  or  absolute  increase  in  the 
small  lymphocytes,  and  in  some  cases  large  lymphocytes  are  present,  (c) 
Leukaemia.  In  this  group,  in  addition  to  the  enlargement  of  the  lachrymal 
and  salivary  glands  of  both  sides  there  are  the  characteristic  general 
enlargements  of  the  lymphatic  glands  and  a  blood  picture  of  leukaemia  of 
the  lymphatic  type  with  the  usual  clinical  phenomena — progressive  weak- 
ness, irregular  fever,  slight  oedema,  and  tendency  to  hemorrhage. 

III.  HODGKIN'S  DISEASE. 

Pseudoleukcemia. 

Definition. — An  affection  of  undetermined  causation  characterized 
by  successive  enlargement  of  the  lymph-nodes  (those  upon  one  side  of  the 
neck  being  first  involved)  and  of  the  spleen;  the  deposition  of  metastatic 
nodules  in  the  various  viscera,  especially  the  spleen,  liver,  and  lungs;  and 
marked  secondary  anaemia  with  cachexia. 

Etiology. — Predisposing  Influences. — The  disease  usually  appears 
in  childhood,  adolescence,  or  early  adult  life.  It  is  very  rare  after  the  fourth 
decade.  It  is  more  common  in  males  than  in  females  in  about  the  propor- 
tion of  six  to  one.  The  occasional  occurrence  of  cases  in  a  parent  or  child, 
or  among  the  children  of  the  same  family,  about  the  same  time,  suggests 
rather  the  action  of  a  local  cause  or  direct  infection  than  the  hereditary 
or  family  transmission  of  the  disease.  Malaria,  syphilis,  and  tuberculosis 
have  been  regarded  upon  wholly  insufficient  grounds  as  predisposing 
influences. 


1150  MEDICAL  DIAGNOSIS. 

Exciting  Cause. — The  pathogenic  agent  is  wholly  unknown.  The 
disease  has  been  thought  to  be  of  infectious  origin,  but  no  results  have 
followed  bacteriological  studies.  Among  the  chnical  facts  which  support 
this  opinion  are  the  following:  Hodgkin's  disease  has  frequently  followed 
irritative  lesions  of  the  throat  and  upper  air-passages  and  sometimes 
acute  affections  attended  by  inflammatory  irritation  of  the  mucous  mem- 
brane of  those  parts,  as  influenza,  measles,  or  pertussis;  preliminary  disease 
of  the  tonsils;  early  locaUzation  in  the  cervical  glands;  gradual  extension 
from  one  group  of  lymphatic  glands  to  another,  with  recurrence  of  fever;  and 
the  acute  course  of  some  of  the  cases. 

There  are  clinical  resemblances  to  lymphosarcoma,  which  are  not 
borne  out  by  the  results  of  histological  studies  of  the  affected  glands  in  the 
two  diseases,  and  to  glandular  tuberculosis,  which  are  negatived  by  the 
following  facts:  (a)  absence  of  tubercle  bacilli  and  the  failure  of  inoculation 
experiments  in  a  majority  of  cases  studied;  (b)  absence  of  reaction  to  the 
tuberculin  test  in  well-characterized  cases;  and  (c)  specific  histological  char- 
acters in  Hodgkin's  disease.  The  view  that  Hodgkin's  disease  is  a  form  of 
lymphatic  tuberculosis  has  arisen  from  the  fact  that  secondary  tuberculous 
infection  not  infrequently  occurs,  especially  in  the  terminal  stages. 

Morbid  Anatomy. — The  internal  lymph-nodes  are  also  generally 
enlarged — those  of  the  thorax,  the  retroperitoneal,  and  the  abdominal 
glands  in  the  order  named — and  form  large,  firm  masses,  which  give  rise 
to  the  pressure  symptoms  which  constitute  striking  clinical  phenomena 
of  the  disease.  The  veins  are  especially  liable  to  compression.  The  nerve- 
trunks  and  ureters  do  not  always  escape.  The  lymph-nodes  even  when 
greatly  enlarged  are  not  often  adherent,  nor  is  there  a  special  tendency  to 
capsular  infiltration  or  invasion  of  contiguous  structures.  Caseation  and 
necrosis  do  not  occur  in  the  absence  of  secondary  infection.  The  spleen 
and  liver  are  enlarged  and  the  seat  of  scattered  lymphoid  masses. 

Symptoms. — The  most  striking  and  usually  the  earliest  clinical  phe- 
nomenon is  the  enlargement  of  one  or  several  lymph-nodes  at  the  angle  of 
the  jaw.  This  enlargement  is  gradual  and  may  attract  little  attention 
until  several  weeks  have  elapsed.  The  swollen  glands  are  painless  and 
may  be  recognized  upon  palpation  as  separate  and  distinct.  They  are 
not  usually  adherent  to  the  skin.  In  some  cases  they  are  adherent  among 
themselves.  The  peculiar  adenopathy  is  progressive.  The  glands  first 
involved  gradually  increase  in  size,  adjacent  groups  in  the  lower  part  of 
the  neck  presently  become  implicated,  then  those  in  the  axilla,  the  inguinal 
region,  and  sometimes  those  at  the  elbow  and  in  the  popliteal  space.  The 
lesions,  at  first  unilateral,  after  a  time  appear  upon  the  other  side,  but  as 
corresponding  groups  are  not  usually  enlarged  to  the  same  extent,  they  are 
irregularly  symmetrical.  The  enlargement  is,  as  a  rule,  most  marked 
upon  the  side  of  the  neck,  where  the  masses  often  exceed  the  size  of  the 
fist  and  give  rise  to  conspicuous  deformities.  It  is  not  so  great  in  the 
axillary  and  inguinal  regions.  The  enlarged  glands  are  at  first  of  moderate 
consistence  and  ma}''  be  moved  under  the  skin;  later  in  the  course  of  the 
disease  they  become  harder  and  more  or  less  adherent  to  the  subjacent 
tissues.  Tonsillitis,  sometimes  chronic,  frequently  precedes  the  early 
glandular  changes  in  the  neck;  but  this  is  not  always  the  case  and  there 


HODGKIN'S  Dli^EASE. 


1151 


are  instances  in  which  the  lymph-nodes  in  this  region  remain  unaffected 
in  the  presence  of  every  other  feature  of  the  malady.  The  evidences  of 
enlargement  of  the  internal  lymph-nodes  do  not  usually  show  themselves 
until  after  the  changes  in  the  superficial  groups  have  made  considerable 
progress.  In  fact  there  are  rare  cases  of  Hodgkin's  disease  in  which  the 
external  glands  are  not  at  all  or  but  slightly  increased  in  size.  Lymph- 
nodes  of  the  digestive  tract,  namely,  the  tonsils,  the  adenoid  masses  at 
the  base  of  the  tongue  and  in  the 
pharynx,  and  the  solitary  and  agmi- 
nate glands  of  the  intestines,  are 
frequently  implicated  without  giving 
rise  to  marked  symptoms.  The 
spleen  is  usually  enlarged,  but  not 
to  the  extent  often  seen  in  spleno- 
medullary  leukaemia. 

Anaemia  does  not  show  itself 
until  the  malady  has  made  some 
progress.  After  a  time  the  changes 
in  the  blood,  characteristic  of  anaemia 
of  secondary  type,  develop  rapidly  in 
the  acute  cases;  more  gradually  in 
the  chronic  forms  of  the  disease.  At 
a  period  when  the  symptom-complex 
is  fully  established,  the  condition  of 
the  blood  is  as  follows:  haemoglobin 
decreased  to  about  50  per  cent.,  not 
commonly  much  below  this;  color 
index  usually  low;  moderate  erythro- 
cyte reduction,  rarely  below  2,000,000 
per  cubic  centimetre;  nucleated 
forms  rare,  when  present  of  the  nor- 
moblastic type;  leucocytes  normal  or 
slightly  increased,  the  increase  often 
transient;  relative  increase  of  poly- 
nuclear  neutrophiles  or  lymphocytes ; 
no  increase  of  eosinophiles. 

Three  groups  of  symptoms 
may   be   recognized,   namely,   those 

due  to  the  enlarged  glands,  those  due  to  the  luueinia,  and   the  cachexia. 
But   the   symptom -complex   is   not   W(>11    defined. 

(a)  Symptoms  Due  to  Lymphatic  Hyperplasia. — Supcrjicial. — 
External  deformities  and  impairment  of  function,  as  of  inox-cment  and  the 
like.  The  prominence  of  these  symptoms  depends  ui)on  the  location  and 
degree  of  enlargement  of  the  affected  groups  of  glands.  Deep. — Pressure 
symptoms,  consisting  of  cough,  dysphagia,  dyspnoea,  dilatation  of  super- 
ficial veins,  c3'anosis,  local  disturbances  of  circulation,  vaiious  dropsies, 
oedema,  and  effusions  into  the  serous  sacs.  Deraugenu^nts  of  function  due 
to  pressure  doubtless  contribute  to  the  cachexia.  Neuralgias  in  various 
distributions  are  caused  by  pressure  upon  de(^p  or  supei-fieial  nerve-trunks. 


Fir,.  3,3.3. —  Ilodgkin's    dispiise. — Jpfferson  Hospital 


1152  MEDICAL  DIAGNOSIS. 

(b)  Symptoms  Due  to  the  Anemia. — Pallor,  headache,  dyspnoea  in 
some  cases,  asthenia,  anasarca,  hemorrhages,  and  fever.  The  last  symp- 
tom may  occm-  as  a  mild,  irregular  pyrexia  early  in  the  course  of  the  dis- 
ease, the  attacks  often  being  associated  with  sudden  increase  in  the  size 
of  the  affected  glands;  as  an  irregular  ague-like  paroxysmal  fever  when 
the  disease  has  reached  an  advanced  stage;  and  finally  in  the  form  of 
the  '^ chronic  relapsing  fever"  of  Pel,  or  ''recurring  glandular  fever"  of 
Ebstein,  in  which  febrile  periods  of  from  ten  to  fourteen  days'  duration, 
and  either  intermittent  or  remittent  in  type,  alternate  with  irregular 
periods  of  apyrexia  lasting  several  days.  In  view  of  the  frequency  with 
which  intercurrent  and  terminal  infections  occur  in  Hodgkin's  disease, 
the  likelihood  that  these  forms  of  fever  are  not  primarily  symptomatic  of 
the  disease  under  consideration  must  be  considered. 

(c)  The  Cachexia. — The  general  disturbances  of  nutrition  ultimately 
reach  a  high  grade.  Extreme  pallor,  emaciation,  profound  asthenia, 
bronzing  of  the  skin  in  some  of  the  cases,  hemorrhages  into  the  skin  and 
from  various  mucous  surfaces,  together  with  the  tumor  masses  in  the  infe- 
rior carotid  triangle  and  the  occipital  region  and  elsewhere,  constitute  a 
striking  and  most  suggestive  clinical  j)icture. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  association  of  a 
widespread  affection  of  the  lymph-nodes  involving  progressively  super- 
ficial and  deep  chains,  anaemia  of  high  grade  and  secondary  type,  and 
cachexia.  The  researches  of  Reed,  Longcope,  and  others  have  settled  the 
question  as  to  the  specific  nature  of  the  histological  lesions  in  Hodgkin's 
disease  and  the  uncertainties  as  to  its  relationship  with  tuberculosis, 
lymphosarcoma,  and  leukaemia.  The  association  of  the  following  changes 
is  characteristic:  proliferation  of  connective-tissue  stroma  resulting  in 
fibrosis,  and  in  a  majority  of  the  cases  numbers  of  eosinophiles.  These 
facts  fully  justify  the  excision  of  one  or  more  superficial  glands  in  a  doubt- 
ful case  for  histological  examination. 

Differential. — Tuberculosis  adenitis  rarely  develops  after  the  twenty- 
fifth  year.  The  enlargement  frequently  involves  the  glands  of  the  neck 
upon  one  or  both  sides.  Inflammatory  adhesions  between  the  individual 
glands  and  to  the  adjacent  structures,  and  in  particular  to  the  overlying 
skin,  are  the  rule.  There  is  tenderness,  and  a  tendency  to  softening,  sup- 
puration, and  caseation  with  sinus  formation.  The  process  is  sluggish  and 
mostly  limited  to  one  or  two  groups  of  glands,  rarely  extending  to  distant 
regions.  The  signs  of  tuberculous  lesions  in  the  mouth  (especially  in  the 
tonsils),  in  the  skin,  bones,  lungs,  or  other  viscera  are  suggestive.  The 
presence  of  tubercle  bacilli  in  the  excised  glandular  tissue  is  suggestive  of  a 
tuberculous  process,  but  the  coexistence  of  the  two  diseases  is  by  no  means 
rare,  while  the  definite  histological  lesions  of  Hodgkin's  disease  are  distinc- 
tive.    In  afebrile  cases  the  tuberculin  tests  may  be  emplo3^ed. 

Syphilitic  Adenitis. — The  glands  in  direct  relation  to  the  initial  lesion, 
usually  the  inguinal,  are  commonly  first  affected,  the  glands  of  the  neck 
being  primarily  involved  only  when  there  are  buccal  or  labial  lesions. 
The  adenopathy  is  general,  with  an  especial  tendency  to  implication  of 
the  postcervical  and  epitrochlear  glands.  The  enlargement  is  moderate, 
firm,  painless,  and  not  accompanied  by  a  tendency  to  form  adhesions  to 


PURPURA.  1153 

contiguous  structures.  A  history  of  exposure,  the  presence  or  vestigia  of 
an  initial  lesion,  secondary  manifestations,  and  the  effects  of  mercurial 
treatment  are  of  diagnostic  importance. 

Leukcemia  (see  p.  1148). 

Lymphosarcoma. — The  conditions  are  very  often  mistaken  for  each 
other.  In  lymphosarcoma  the  masses  are  of  rapid  growth  and  may  attain 
great  size;  adhesions  among  individual  glands  and  to  adjacent  structures, 
with  inflammatory  changes  attended  by  redness,  tenderness,  and  local 
oedema,  are  common.  Softening  and  fluctuation  suggestive  of  abscess 
formation  are  frequent.  The  cutaneous  veins  are  often  enlarged  and 
tortuous,  pain  is  sometimes  a  prominent  symptom,  and  there  are 
progressive  infiltrations   and   metastases. 

It  is  important  in  the  differential  diagnosis  of  Hodgkin's  disease 
that  this  affection  is  characterized  by  a  progressive  implication  of  suc- 
cessive groups  of  glands,  while  in  those  affections,  with  the  exception  of 
syphilis,  to  which  it  may  sometimes  bear  a  superficial  resemblance,  the 
lesions  are  limited  to  single  glands  or,  at  most,  to  two  or  three  groups  which 
are  anatomically  related  and  become  affected  at  or  about  the  same  time. 

Prognosis. — The  disease  runs  its  course  with  exacerbations  of  varying 
intensity  and  remissions  of  irregular  duration.  Acute  cases  may  end  fatally 
in  two  or  three  months.  Very  chronic  forms  may  last  three  or  four  years. 
The  average  duration  is  about  one  year.  Urgent  pressure  symptoms, 
intense  anaemia,  hemorrhages,  and  early  cachexia  are  of  unfavorable  prog- 
nostic significance.  The  outcome  is  lethal,  but  remarkable  improvement 
in  the  blood  and  other  clinical  phenomena  has  followed  the  use  of  the 
X-rays,  the  early  extirpation  of  the  enlarged  glands,  and  the  administra- 
tion by  the  mouth  and  subcutaneously  of  arsenic  in  the  form  of  Fowler's 
solution,  or  of  sodium  cacodylate. 

IV.  DISEASES  CHARACTERIZED  BY  HEMORRHAGE. 

The  Hemorrhagic  Diathesis;   Morbus  Maculosus. 

The  essential  symptom  is  hemorrhage,  which  may  be  into  the  skin, 
from  the  mucous  surfaces,  subserous,  or  into  the  viscera. 

(a)  Purpura. 

Definition. — An  affection  which  appears  spontaneously,  and  is  char- 
acterized by  hemorrhages  into  the  skin,  mucous  membranes,  and  internal 
organs.  The  following  forms  are  recognized:  (1)  purpura  simplex;  (2) 
purpura  hsemorrhagica  or  morbus  maculosus  Werlhofii;  (3)  purpura  rheu- 
matica  or  peliosis  rheumatica;  (4)  purpura  with  visceral  symptoms;  and 
(5)  symptomatic  purpura.  There  are  those,  as  Litten,  who  regard  these 
as  manifestations  of  the  same  disease,  differing  in  intensity. 

Purpura  always  occurs  as  a  sporadic  affection  and  never,  like  scurvy, 
in  local  outbreaks  or  as  an  endemic  disease,  or  like  the  hemorrhagic  cases 
of  the  infections — variola,  varicella — during  the  course  of  epidemics.  It  is 
not  a  common  disease. 

73 


1154  MEDICAL  DIAGNOSIS. 

Etiology. — Predisposing  Influences. — Females  are  somewhat  more 
disposed  than  males.  The  greatest  liability  is  in  middle  life,  but  neither 
infancy  nor  old  age  escapes.  Purpura  sometimes  has  developed  during 
the  convalescence  from  enteric  fever,  malaria,  scarlet  fever,  and  measles, 
and  in  the  course  of  all  forms  of  nephritis,  especially  the  interstitial  variety. 
Intense  nervous  shock,  such  as  attends  fright,  fever,  or  pain,  has  been 
followed  by  the  occurrence  of  purpura. 

Exciting  Cause. — No  immediate  cause  can  usually  be  discovered. 
The  hypothesis  that  purpura  is  an  infectious  disease  has  not  yet  received 
demonstrable  support.  Unfavorable  conditions  of  life,  damp  and  insalu- 
brious dwellings,  and  chilling  of  the  body  have  been  regarded  upon 
inadequate  grounds  as  etiological  factors. 

1.  Purpura  Simplex. — Symptoms. — Isolated  hemorrhagic  spots  upon 
the  skin  may  constitute  the  only  manifestation  of  the  disease.  They  vary 
from  a  mere  point  in  diameter  to  patches  of  considerable  size.  The  latter 
are  not  common  in  simple  purpura.  Purpuric  spots  are  more  commonly 
and  more  abundantly  distributed  on  the  lower  extremities  than  elsewhere. 
They  are  at  first  bright  red  in  color,  but  rapidly  become  darker,  and  fade, 
leaving  patches  of  brownish  pigmentation  which  gradually  undergo  resorp- 
tion. These  spots  do  not  disappear  upon  pressure  or  when  the  skin 
is  made  tense.  In  some  cases  the  spots  appear  abruptly  and  wholly  with- 
out prodromes,  more  commonly  they  are  preceded  by  symptoms  such  as 
attend  the  initial  stage  of  a  mild  infection,  lassitude,  loss  of  appetite, 
nausea,  and  fever.  The  disease  sometimes  lasts  but  a  day  or  so  and  is 
marked  by  a  single  crop  of  hemorrhages  into  the  skin;  in  other  cases  its 
course  may  extend  over  a  week  or  two  and  be  marked  by  successive  crops 
of  petechiae.  The  spots  are  scattered  over  the  arms,  abdomen,  and  legs. 
They  are  rarely  seen  upon  the  face.  The  course  of  this  variety  of  purpura 
is  favorable.  In  a  few  days,  or  at  most  a  fortnight,  the  spots  have  disap- 
peared and  the  patient  has  regained  his  usual  health.  A  slight  degree  of 
anaemia  and  transient  albuminuria  may  occur  during  convalescence.  It 
is  much  more  common  in  children  than  adults,  and  is  often  associated 
with  diarrhoea  and  slight  rheumatoid  pains  and  swelling  of  the  joints. 
Diagnosis. — The  direct  diagnosis  of  purpura  simplex  may  be  made 
when,  in  the  absence  of  a  primary  antecedent  affection,  the  purpuric  erup- 
tion appears  after  trifling  derangements  of  health  and  disappears  in  the 
course  of  a  few  days  or  at  most  a  week  or  two.  The  differential  diag- 
nosis from  other  forms  of  purpura  depends  upon  the  mildness  of  the 
attack,  its  short  duration,  and  the  absence  of  special  characteristic  mani- 
festations, such  as  copious  hemorrhages  into  the  skin,  hemorrhages  from 
mucous  surfaces,  fever,  joint  affection,  urgent  gastro-intestinal  symptoms. 
tendency  to  recur,  and  so  forth. 

2.  Purpura  Haemorrhagica  ;  Morbus  Maculosus  ;  Werlhof  s  Disease. 
— The  cutaneous  hemorrhages  are  abundant  and  extensive,  and  there  is 
bleeding  from  mucous  surfaces.  This  form  of  purpura  sometimes  attacks 
individuals  in  apparent  health,  but  is  far  more  common  in  delicate  children 
or  adolescents,  especially  girls.  It  may  also  occur  without  prodromes 
and  run  an  afebrile  course.  When  fever  is  present  it  is  of  moderate  inten- 
sity—101°-102°  F.  (38.5°-39°  C).     Gastric  disturbances,  a  mild  rheuma- 


PURPURA.  1155 

toid  affection  of  the  joints,  and  albuminuria  occur  in  many  of  the  cases. 
The  cutaneous  hemorrhages  are  profuse  and  extensive,  and  in  some  in- 
stances extensive  areas  or  even  the  greater  part  of  the  surface  of  the  body 
are  involved,  so  that  the  discolored  space  in  some  portions  of  the  body 
greatly  exceeds  that  of  the  normal  skin.  Frequently,  but  not  always, 
there  is  bleeding  from  mucous  surfaces,  usually  first  in  the  form  of  epistaxis, 
which  is  soon  followed  by  hemorrhage  from  the  buccal  and  gingival 
mucous  surfaces,  hsematuria,  haemoptysis,  and  bleeding  from  the  bowel. 
Under  these  circumstances  profound  anaemia  may  rapidly  develop.  Death 
may  result  from  the  loss  of  blood.  Purpura  Fulminans. — A  malignant 
variety  which  occasionally  occurs  in  children  may  cause  death  in  the  course 
of  twenty-four  or  forty-eight  hours  from  extensive  cutaneous  hemorrhage 
with  or  without  bleeding  from  mucous  surfaces.  The  course  of  the  disease 
is  often  protracted,  with  frequent  relapses,  which  are  apt  to  occur  when 
the  patient  attempts  to  leave  his  bed,  and  leads  to  great  debility  and 
anaemia,  with  vertigo,  cardiac  palpitation,  and  syncopal  attacks.  The 
DIRECT  DIAGNOSIS  of  Werlhof's  disease  depends  upon  the  severity  of  the 
affection,  the  prominence  and  extent  of  the  cutaneous  hemorrhage  and 
bleeding  from  mucous  surfaces. 

It  is  to  be  differentiated  from  purpura  simplex  on  the  one  hand  by 
the  above  criteria,  and  from  purpura  rheumatica  npon  the  other  by  the 
infrequency  and  mildness  of  the  arthritis,  the  absence  of  urticaria  and 
erythema,  the  tendency  to  hemorrhage  from  mucous  surfaces.  From  scurvy 
it  is  to  be  distinguished  by  the  conditions  under  which  the  disease  develops, 
its  more  or  less  abrupt  occurrence  in  an  individual  of  fair  previous  health, 
and  the  absence  of  swelling  of  the  gums;  from  the  malignant  or  hemor- 
rhagic forms  of  the  infectious  diseases  by  the  symptoms  of  the  onset  in 
the  latter,  the  gravity  of  the  attack,  the  first  appearance  of  petechiae  upon 
the  forehead  and  wrists,  their  association  with  abortive  eruptions  or  exten- 
sive suggillations. 

3.  Purpura  Rheumatica  ;  Peliosis  Rheumatica  ;  Schonlein's  Disease, 
— This  hemorrhagic  affection  is  characterized  by  an  eruption  in  which  the 
spots  "never  coalesce,"  a  multiple  arthritis,  and  protracted  course.  It 
occurs  in  young  adults,  chiefly  in  males  and  usually  in  individuals  who 
have  a  delicate,  highly  vascular  skin  and  have  previously  suffered  from 
rheumatism.  It  frequently  begins  with  angina  tonsillaris,  fever  of  moder- 
ate intensity, — 102°  F.  (39°  C), — and  rheumatoid  pains  in  the  joints, 
especially  the  ankles,  knees,  the  joints  of  the  hands,  and  the  shoulders. 
The  affected  joints  are  painful  to  the  touch  and  upon  movement  and  the 
seat  of  endo-  and  periarticular  exudate.  The  eruption  appears  first  upon 
the  lower  extremities  or  over  the  affected  joints.  It  is  frequently  merely 
purpuric,  but  may  show  urticarious  wheals,  erythematous  patches,  or 
infiltrated  areas  suggestive  of  erythema  nodosum.  Vesication  may  occur. 
Local  oedema  occasionally  appears,  especially  about  the  face — febrile 
purpuric  oedema.  The  eruption  tends  to  recur  in  crops  and  may  con- 
tinue to  reappear  for  several  weeks.  The  patients  are  sensitive  to  cold, 
and  fresh  outbreaks  occur  upon  rising  from  bed  or  any  chilling  of  the  sur- 
face. Attacks  at  the  same  season  in  successive  years  have  been  noted. 
The  urine  has  no  special  characters.    It  sometimes  contains  albumin.    The 


1156  MEDICAL  DIAGNOSIS. 

DIRECT  DIAGNOSIS  of  Schoiilein's  disease  rests  upon  the  association  of  a 
well-defined  joint  affection  with  purpura,  which  tends  to  recur  in  crops, 
erythema,  and  local  oedema.  The  joint  affection  is  usually  mild  and  shows 
neither  the  evanescence  characteristic  of  rheumatic  fever  nor  the  persist- 
ence of  gonorrhceal  arthritis.  Differential. — The  existence  of  Schon- 
lein's  disease  as  a  nosological  entity  has  been  much  questioned.  It  has 
been  regarded  as  true  rheumatism,  from  which  it  is  easily  distinguished 
by  the  eruption,  which  tends  to  recur,  and  the  almost  constant  absence  of 
cardiac  lesions;  as  a  form  of  gonorrhceal  arthritis,  a  view  that  cannot 
be  entertained,  since  gonorrhoea,  though  sometimes  present,  is  mostly 
absent;  as  an  intense  form  of  purpura  with  rheumatoid  symptoms,  an 
opinion  which  finds  some  support  in  the  fact  that  mild  multiple  arthritis 
is  not  uncommon  in  the  hemorrhagic  diseases. 

4.  Purpura  and  Visceral  Symptoms ;  Purpura  Abdominalis ; 
Henoch's  Purpura. — The  cutaneous  hemorrhages  are  accompanied  by 
abdominal  symptoms,  vomiting,  diarrhoea,  often  hemorrhagic,  and  colic. 
These  symptoms  occur  in  paroxysms  separated  by  intervals  of  several 
weeks  or  months.  The  disease  is  most  common  in  childhood  and  adoles- 
cence, but  may  occur  in  early  adult  life.  It  is  much  more  common  in  males 
than  females.  It  frequently  attacks  individuals  living  in  poverty  and 
want,  but  is  by  no  means  unknown  among  the  affluent.  There  is  a  varjdng 
period  of  impaired  health  with  headache,  weakness,  and  loss  of  appetite, 
followed  by  subacute  or  acute  arthritis  affecting  one  or  more  joints,  and 
moderate  fever.  Purpura  now  appears,  often  but  not  invariably  upon  the 
legs  and  feet,  but  spreading  to  the  trunks  and  elsewhere,  and  being  par- 
ticularl}^  abundant  in  the  neighborhood  of  the  affected  joints.  The  hem- 
orrhagic eruption  is  associated  in  varying  degree  with  erythema,  patches 
of  oedema,  and  urticaria.  Coincidently  with  the  eruption  the  above  men- 
tioned abdominal  symptoms  appear.  Epistaxis  and  hemorrhage  from 
other  mucous  tracts  occur.  The  colic,  most  intense  about  the  umbilicus, 
is  often  especially  severe  and  protracted;  the  abdomen  is  retracted  and 
tender;  there  is  complete  loss  of  appetite;  retching  is  frequent  and  dis- 
tressing; the  spleen  is  enlarged;  the  pulse  small  and  frequent,  and  in 
many  instances  there  is  alarming  exhaustion.  In  fact  it  is  to  this  variety 
of  purpura  that  the  rapidly  fatal  purpura  fulminans  is  to  be  referred. 
Nephritis  is  of  frequent  occurrence  and  may  persist.  These  symptoms  in 
the  ordinary  cases  undergo  gradual  amelioration,  and  the  infant  enters 
upon  an  apparent  convalescence,  only  to  suffer  from  similar  paroxysms 
at  varying  intervals.  The  duration  is  variable.  The  attack  may  last  for 
several  days,  and  recurrences  may  extend  over  a  period  of  months  or 
even  years.  The  prognosis  in  children  is  favorable — mortality  less  than  5 
per  cent.;   in  adults  less  so — mortality  about  23  per  cent. 

The  direct  diagnosis  of  this  form  of  purpura  rests  upon  the  asso- 
ciation of  purpura  with  erythema  and  urticaria,  visceral  symptoms,  espe- 
cially the  abdominal  crises,  and  nephritis,  the  joint  affection  and  fever, 
and  the  paroxysmal  nature  of  the  recurrent  attacks.  This  affection,  con- 
cerning the  cause  of  which  we  have  no  definite  knowledge,  presents  a 
well-defined  symptom-complex.  The  differential  diagnosis  requires  no 
special  consideration. 


PURPURA.  •  1157 

The  blood  changes  in  the  various  forms  of  purpura  are  similar  and 
without  diagnostic  significance.  They  are  those  of  secondary  anaemia  of 
varying  intensity,  with  leucocytosis.  The  coagulation  time  is  much 
protracted,  in  some  cases  reaching  ten  or  even  fifteen  minutes. 

5.  Symptomatic  Purpura. — Purpura  is  a  symptom,  not  a  disease,  yet 
in  the  foregoing  affections  it  is  a  symptom  of  such  prominence  as  to  justify 
the  older  use  of  the  term  to  designate  a  group  of  diseases  the  etiology  of 
which  is  as  yet  unknown,  and  of  which  cutaneous  hemorrhage  is  the  only 
common  and  constant  phenomenon.  But  purpura  is  also  a  very  common 
symptom  in  many  conditions  and  well-defined  diseases.  This  form  is 
known  as  symptomatic  purpura.  Traumatic. — The  ecchymosis  which 
follows  a  blow  or  contusion  does  not  differ  in  appearance  or  course  from 
similar  cutaneous  hemorrhages  occurring  in  disease.  Mechanical  purpura 
may  result  from  severe  transient  venous  stasis,  as  in  whooping-cough  or 
epilepsy,  or  more  prolonged  interference  with  the  circulation,  as  the  pres- 
sure of  a  splint  or  bandage.  Toxic. — The  venom  of  snakes  causes  rapid 
and  extensive  blood  extravasations  Jaundice,  especially  when  prolonged, 
is  frequently  associated  with  petechise.  Among  the  drug  exanthems  pur- 
pura occupies  an  important  place  and  may  follow  the  administration  of 
copaiba,  ergot,  quinine,  belladonna,  mercury,  and  the  iodides.  There  is 
usually  an  idiosyncrasy.  The  question  as  to  whether  the  cutaneous  hemor- 
rhage is  due  to  the  drug  or  the  disease  for  which  the  drug  has  been  given 
is  always  to  be  considered.  There  is  no  question  as  to  the  significance  of 
a  petechial  rash  in  ergotism  or  the  specific  effect  of  the  iodides  in  causing 
this  symptom  in  certain  cases.  In  the  case  of  the  iodides,  coryza,  angina 
tonsillaris,  erythema,  and  fever  may  accompany  the  purpura.  These 
symptoms  may  quickly  follow  small  doses  of  the  drug.  Infectious.^ 
The  ordinary  rashes  of  typhus  and  cerebrospinal  fever  are  purpuric;  sim- 
ilar lesions  of  the  skin  occur  in  sepsis  and  especially  in  malignant  endo- 
carditis; petechise  and  ecchymoses  characterize  the  malignant  forms  of 
measles,  scarlet  fever,  and  smallpox.  In  that  form  of  variola  known  as 
purpura  variolosa  there  are  petechias  and  most  extensive  suggillations  of 
blood.  Cachectic. — The  terminal  dyscrasia  of  cancer,  chronic  nephritis, 
Hodgkin's  disease,  tuberculosis,  and  other  incurable  wasting  diseases  is 
frequently  accompanied  by  petechial  eruptions,  usually  confined  to  the 
lower  extremities.  A  similar  form  occurs  in  old  age  and  prolonged  want  of 
food,  and  extensive  purpura  is  characteristic  of  scurvy.  Neurotic. — 
Myelopathic  purpura  occasionally  occurs  in  spinal  diseases,  particularly 
forms  of  myelitis,  especially  transverse  myelitis.  The  bleeding  may  be 
associated  with  trophic  disturbances,  erythema,  and  localized  sweating. 
It  occurs  also  in  rai'e  instances  in  tabes  in  the  course  of  the  lightning  pains, 
and  in  association  with  herpes,  oedema,  and  local  sweating.  Purpura  may 
occur  in  the  distribution  of  the  affected  nerve  in  severe  neuralgia.  The 
''stigmata"  or  bleeding  points  of  hysteria,  when  not  artificially  produced 
for  purposes  of  deception,  must  be  referred  to  this  category. 


1158  MEDICAL  DIAGNOSIS. 

(b)  Haemophilia. 

Bleeders'  Disease. 

Definition.  —  A  constitutional  anomaly  mostly  hereditary,  —  vitium 
primce  formationis, — very  rarely  acquired,  which  manifests  itself  by  the 
occurrence  of  uncontrollable  bleeding,  either  spontaneous  or  from  trau- 
matism which  may  be  slight,  and  occasionally  by  hgemarthrosis  sometimes 
followed  by  permanent  deformity. 

Haemophilia  is  a  hereditary  and  congenital  condition;  hemorrhage, 
which  shows  neither  tendency  to  stop  nor  yields  to  treatment,  the  sign  by 
which  it  makes  itself  known.  In  the  absence  of  a  history  and  of  bleeding, 
there  are  no  indications  of  the  constitutional  fault. 

Etiology.  —  Predisposing  Influences.  —  Grandidier  has  described 
hsemophilia  as  the  most  hereditary  of  all  hereditary  diseases.  The  occa- 
sional occurrence  of  fatal  hemorrhage  from  trifling  wounds  has  long  been 
known,  but  the  transmission  of  the  tendency  from  generation  to  genera- 
tion has  been  especially  studied  during  the  last  century.  In  the  well- 
known  Appleton-Swain  family  there  have  been  bleeders  for  nearly  two 
hundred  years.  Grandidier  gives  the  history  of  200  bleeder  families.  In 
some  instances  the  transmission  is  direct  from  the  parents  to  the  children. 
Usually,  however,  the  transmission  follows  a  peculiar  law  of  heredity, 
namely,  that  the  females  transmit  while  the  males  acquire  the  condition. 
Exceptionally  females  also  acquire  it.  From  this  it  follows  that  haemo- 
philia is  much  more  common  in  males  than  in  females.  The  actual  ratio  is 
about  13  to  1.  It  is  the  rule  that  in  a  bleeder  family  a  woman  not  a  bleeder 
transmits  the  condition  to  her  children  without  having  acquired  it  herself, 
a  generation  having  thus  escaped.  Men  who  are  bleeders,  but  whose  wives 
are  not  descendants  of  bleeder  families,  do  not  always  beget  bleeder  chil- 
dren, and  men  who  are  members  of  bleeder  families,  but  themselves  not 
bleeders  and  whose  wives  do  not  belong  to  bleeder  families,  rarely  beget 
bleeder  children.  Certain  lines  in  bleeder  families  thus  tend  to  become  nor- 
mal. It  has  occasionally  happened  that  children  born  to  parents  neither  of 
whom  belong  to  bleeder  families  have  been  bleeders — congenital  hcBmophilia, 
spontaneous  haemophilia.  Haemophilia  is  more  common  in  Germany,  Eng- 
land, and  the  United  States  than  elsewhere.  The  condition  is  usually 
discovered  in  infancy  or  early  childhood.  Social  conditions  are  apparently 
without  influence.  In  some  bleeder  families  a  neuropathic  constitution  has 
been  recognized.  As  a  rule  the  stock  is  fine,  the  families  large,  the  members 
healthy  and  robust  looking,  with  good  skins  and  delicate  complexions. 

The  actual  cause  of  haemophilia  remains  unknown 

Pathogenesis.  —  Various  theories  have  been  advanced.  Among  them 
are  habitual  disproportion  between  the  volume  of  blood  and  the  vessels; 
hydraemic  plethora;  abnormal  composition  of  the  blood;  an  increase  in 
the  red  corpuscles — erythrocythaemia;  fragility  of  the  vessels;  pathogenic 
infection;  and  deficiency  in  the  fibrin  ferment.  None  of  these  have  met 
the  requirements  of  the  condition. 

Symptoms. — The  existence  of  haemophilia  is  usually  discovered  in 
consequence   of  trauma.     The  hemorrhage   cannot   be   controlled,   or  is 


HAEMOPHILIA.  1159 

arrested  with  difficulty  and  onlj-  after  prolonged  effort.  There  are  various 
grades  of  severity,  from  the  mildest  to  the  most  severe  which  terminates 
fatally.  The  hemorrhage  may  be  spontaneous  or  traumatic.  The  trau- 
matism is  often  so  slight  as  to  escape  attention,  as  the  contusion  resulting 
from  a  slight  fall  or  blow,  or  chastisement.  Spontaneous  hemorrhages  are 
sometimes  preceded  by  fulness  in  the  head,  vertigo,  tinnitus,  palpitation, 
and  nausea.  Thej^  may  be  superficial,  as  from  mucous  surfaces,  namely, 
that  of  the  nose,  mouth,  female  genitalia,  urinary  passages;  or  from  the 
lungs,  stomach,  or  intestines,  or  finally  from  cicatrices  or  ulcers  upon  the 
skin.  Interstitial  spontaneous  hemorrhages  are  usually  superficial.  They 
chiefly  occur  in  "the  scalp,  face,  scrotum;  less  frequently  upon  the  extremi- 
ties, and  rarely  upon  the  trunk.  It  is  probable  that  the  majority  of  such 
cases  are  in  point  of  fact  the  result  of  slight  traumatism.  They  consist  of 
petechiae,  ecchymoses,  and  subcutaneous  hsematomata.  The  ordinary 
forms  of  trauma  by  which  haemophilia  is  manifest  in  external  hemorrhage 
comprise  abrasions,  scratches,  cuts,  wounds,  and  surgical  incisions.  The 
bleedings  named  in  the  order  of  frequency  are  from  the  nose,  mouth, 
bowels,  urethra,  vulva,  stomach,  lungs.  Less  frequently  continuous 
bleeding  takes  place  from  areas  of  skin,  especially  upon  the  head  and  the 
scrotum,  the  tongue,  eyelids,  conjunctiva,  finger-tips,  lobe  of  the  ear,  and 
vulva.  Bleeding  from  the  head  is  far  more  common  and  usually  more 
severe  than  from  the  extremities  or  trunk.  Trifling  operations,  as  lancing 
the  gums,  the  extraction  of  a  tooth,  circumcision,  or  venesection,  have  been 
followed  by  fatal  hemorrhage.  Lethal  hemorrhage  has  followed  the  rup- 
ture of  the  hymen  in  coitus.  The  bleeding  usually  is  of  the  type  described 
as  parenchymatous;  there  is  capillary  oozing,  more  or  less  abundant,  from 
every  point  of  the  exposed  surface.  It  is  not  common  to  find  flowing 
vessels  of  an}^  size.  It  is  continuous  and  may  last  for  hours  or  for  many 
days.  After  a  time  syncope  may  occur  and  the  bleeding  cease.  Pro- 
longed bleeding  is  often  followed  by  death.  Epistaxis  may  prove  fatal  in 
twenty-four  or  thirty-six  hours.  The  coagulation  time  of  the  blood  is 
much  retarded.  With  Wright's  instrument  it  has  varied  from  twenty  to 
forty-five  minutes  as  compared  with  three  to  six  minutes  with  normal 
blood.  The  arthropathies  of  haemophilia  are  rheumatoid  in  character. 
They  occur  both  spontaneously  and  after  contusions.  The  knees  and 
elbows  are  most  commonly  affected.  The  onset  is  acute,  with  swelling, 
pain,  redness,  and  slight  fever.  Less  commonly  there  is  haemarthrosis 
without  fever.  Repeated  hemorrhage  into  the  joints  and  muscles  may 
occur  in  the  absence  of  external  or  subcutaneous  bleeding,  and  give  rise 
to  a  false  diagnosis  of  chronic  rheumatism  or  tuberculosis.  The  resulting 
deformities  sometimes  suggest  arthritis  deformans. 

Diagnosis. — Direct. — The  recognition  of  haemophilia  depends  upon 
the  family  history  and  the  occurrence  of  persistent  or  uncontrollable  hem- 
orrhage. Neither  the  family  history  alone,  since  there  are  members  of 
bleeder  families  who  are  not  bleeders,  nor  a  single  unmanageable  bleeding 
from  a  trifling  cause,  since  difficult  local  hemorrhages  are  common  enough 
in  those  who  are  not  hsemophilic,  justifies  a  positive  diagnosis.  The  asso- 
ciation of  an  hereditary  tendency  to  repeated  stubborn  bleeding  from 
slight  injury  with  arthritis  is  highly  suggestive.     Even  heredity  is  absent 


1160  MEDICAL  DIAGNOSIS. 

in  the  spontaneous  or  congenital  cases.  Differential. — Habitual  epis- 
taxis  and  haematuria  are  not  attended  with  the  tendency  to  hemorrhages 
from  slight  wounds  or  cuts.  In  the  hereditary  local  bleedings  from  the 
nose  or  mouthy  associated  with  telangiectasis  of  mucous  membranes,  and 
na?vi,  the  blood  losses  arise  from  definite  lesions,  and  arthropathies  are 
absent.  Purpura  rheumatica  presents  points  of  resemblance  to  haemo- 
philia, especially  in  the  prominence  of  the  arthritis.  There  may  be  more 
than  one  case  in  a  family,  but  the  peculiar  form  of  heredity  seen  in  bleeder 
families  does  not  occur,  and  there  are  multiple  spontaneous  hemorrhages 
rather  than  excessive  bleedings  from  limited  surfaces. 

Prognosis. — The  outlook  is  unfavorable;  many  of  the  cases  die  in 
early  infancy,  a  majority  before  puberty.  The  hsemophilic  tendency 
becomes  less  marked  as  life  advances,  but  the  subjects  rarely  reach  seventy. 
The  prognosis  is  less  favorable  in  boys  than  girls.  Death  does  not  often 
occur  in  a  first  bleeding,  but  it  occasionally  results  from  uncontrollable 
bleeding  after  ritual  circumcision.  Females  who  are  hsemophilic  are  apt 
to  menstruate  early  and  freely,  but  neither  this  function  nor  that  of  par- 
turition is  attended  in  bleeder  families  with  an  especial  tendency  to  danger- 
ous blood  loss.  Any  form  of  hemorrhage  may,  however,  prove  fatal; 
that  which  is  most  frequently  so  being  epistaxis. 

(e)  The  Hemorrhagic  Diseases  of  the  New=born. 

Acute  Fatty  Degeneration  of  the  New=born ;  Buhl's  Disease. — This 
rare  affection  is  characterized  by  fatty  degeneration  of  the  heart,  liver,  and 
kidneys,  and  hemorrhages  in  the  various  organs.  The  chief  symptoms 
are  inanition  and  external  hemorrhages,  of  which  the  more  common  are 
omphalorrhagia,  melsena,  and  hsematemesis.  Bleeding  may  also  take 
place  from  the  mouth,  nose,,  eye,  and  ear.  The  infant  is  soon  in  a  condi- 
tion of  asphyxia,  from  which  resuscitation  is  only  partial,  and  dies  at 
once  or  in  the  course  of  a  week  or  ten  days.  The  skin  is  cyanotic  and 
icteric.  An  anatomical  diagnosis  cannot  be  made  in  the  absence  of  a  micro- 
scopical diagnosis.  It  is  therefore  probable  that  the  condition  is  very  often 
overlooked.  The  differentiation  from  phosphorus  and  arsenic  poisoning, 
in  which  similar  parenchymatous  changes  in  the  viscera  occur,  may  be 
apparent  from  a  study  of  the  circumstances;  from  sepsis,  with  interstitial 
hemorrhages  and  fatty  degeneration,  it  may  be  difficult.  Infection  by 
way  of  the  cord  must  be  excluded.    The  prognosis  is  lethal. 

Infectious  Hsemoglobinuria  of  the  New-born  ;  Epidemic  HaBmoglo- 
binuria;  Winckel's  Disease. — This  obscure  affection  arises  as  an  endemic 
or  epidemic  disease  in  lying-in  hospitals.  It  begins  about  the  fourth  day  of 
hfe  and  is  characterized  by  marked  cyanosis  with  icterus,  hsemoglobinuria, 
somnolence,  and  collapse  without  fever.  Vomiting  and  diarrhoea  are  com- 
mon. The  urine  contains  small  amounts  of  albumin  and  methaemoglobin. 
EpitheHal  granular  and  blood-casts  are  also  present.  It  may  attack  strong, 
well-developed  children.  It  runs  a  rapid  course  and  is  extremely  fatal. 
Death  may  be  preceded  by  convulsions.  The  etiology  is  unknown.  The 
post-mortem  findings  are  in  some  cases  similar  to  those  of  Buhl's  disease. 
The  spleen  is  enlarged.     The  diagnosis  rests  upon  the  occurrence  of  asso- 


ANOMALIES  OF  THE  SPLEEN.  1161 

ciated  cyanosis  and  icterus,  the  sudden  onset  upon  the  fourth  day,  the 
character  of  the  urine,  and  the  endemic  or  epidemic  prevalence  of  the 
affection  in  an  institution.  The  disease  is  to  be  distinguished  from  Buhl's 
disease  by  its  onset  some  days  after  birth  and  the  urinary  conditions,  and 
from  icterus  neonatorum  by  the  severity  of  the  process. 

"  Hemorrhagic  Disease  of  tiie  New=born";  Morbus  Maculosus  Neona- 
torum. —  Townsend  has  made  a  thorough  study  of  a  condition  of  not 
infrequent  occurrence  and  uniform  symptomatology,  which  has  been  de- 
scribed under  the  above  terms.  This  affection  is  self-limited,  attended  with 
moderate  fever,  and  occurs  almost  always  within  the  first  week  of  life. 
Hemorrhage  arises  from  the  mouth,  nose,  bowels,  and  navel.  Petechise 
and  ecchymoses  are  common.  Visceral  hemorrhages  and  bloody  collec- 
tions in  the  serous  sacs  are  found  upon  post-mortem  examination.  The 
children  are  very  anaemic  in  appearance,  but  the  peripheral  blood  may 
show  an  increase  in  haemoglobin  and  erythrocytes.  In  a  case  of  Town- 
send's  the  haemoglobin  was  125  per  cent,  and  the  erythrocytes  6,245,600. 
The  affection  is  of  brief  duration.  The  mortality  is  about  60  per  cent. 
When  recovery  takes  place  it  is  usually  complete  and  permanent.  The 
diagnosis  may  be  based  upon  the  general  character  of  the  disease,  its 
manifestly  infectious  nature,  its  self-limited  course,  and  its  prevalence  in 
institutions.  It  is  to  be  distinguished  from  other  forms  of  disease  of  the 
new-born,  characterized  by  hemorrhage,  which  have  been  described,  and 
especially  from  haemophilia.  A  general  rather  than  a  local  tendency  to 
hemorrhage  is  of  diagnostic  significance.  It  is  probable  that  many  of  the 
cases  described  as  melaena  neonatorum  belong  to  this  category. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

I.  DISEASES  OF  THE  SPLEEN, 
i.  Anatomical  Anomalies. 

Complete  absence  of  the  spleen  occasionally  occurs  in  association  with 
other  developmental  faults.  Much  more  commonly  the  organ  is  rudimen- 
tary. Very  frequently  there  are  accessory  spleens  —  splenunculi  —  the 
supernumerary  spleen  or  spleens  lying  within  the  folds  of  the  gastro- 
splenic  omentum  and  other  processes  of  the  peritoneum  passing  to  the 
spleen.  Abnormal  lobulation  and  departures  from  the  usual  shape  are 
common.  These  abnormalities  are  of  no  clinical  interest.  Entire 
absence  of  the  spleeij  may  be  unattended  by  functional  disturbances. 

In  complete  transpositio  viscerum  the  spleen  occupies  a  position 
upon  the  right  side  corresponding  to  its  normal  position  on  the  left. 
Under  these  circumstances  it  is  sometimes  represented  by  a  number 
of  lienculi  which  may  be  arranged  in  a  cluster  or  loosely  separated. 
Exceptionally  the  transposition  may  involve  only  the  liver  and  spleen. 
Displacement  may  occur  in  the  new-born  downward  as  the  result  of 
abdominal  deformities  or  umbilical  hernia,  upward  in  consequence 
of  congenital  diaphragmatic  hernia.  The^e  displacements  are  of  minor 
clinical  interest. 


1162  MEDICAL  DIAGNOSIS. 

ii.  Movable  Spleen. 

Lien  Mobilis;   Wandering  Spleen. 

This  condition  is  sometimes  the  result  of  congenital  elongation  of  the 
gastrolienal  ligament;  sometimes  of  a  similar  elongation  acquired  through 
mechanical  influences,  such  as  pressure,  blows,  the  succussion  of  violent, 
continuous  coughing,  the  traction  of  peritoneal  adhesions,  and  the  weight 
of  the  enlarged  organ  itself.  Wandering  spleen  is  most  commonly  encoun- 
tered in  women  suffering  from  enteroptosis. 

Symptoms.  —  The  dislocation  is  downward  and  forward,  and  the 
organ  may  reach  a  position  below  the  level  of  the  umbilicus  or  even  pass 
into  the  pelvis,  or  it  may  form  part  of  the  contents  of  a  large  inguinal 
hernial  sac.  It  is,  as  a  rule,  more  or  less  enlarged.  Subjective  symptoms 
may  *be  wholly  absent,  and  the  condition  may  be  accidentally  discovered. 
More  commonly  there  are  sensations  of  weight  and  dragging,  with  diffuse 
dull  pain  in  the  left  flank.  Colic,  constipation,  dysuria,  and  neuralgia 
may  result  from  derangement  of  the  various  structures  upon  which  the 
displaced  and  enlarged  spleen  exerts  traction  or  pressure.  The  obstruc- 
tion to  the  circulation  sometimes  causes  great  distention  of  the  splenic 
vein.  Torsion  of  the  pedicle  may  lead  to  strangulation  with  great  pain, 
tenderness,  and  local  swelling,  followed  by  necrosis  with  local  or  general 
peritonitis. 

Physical  Signs. — The  upper  end  of  the  organ  may  sometimes  be  felt 
below  the  edge  of  the  ribs,  an  important  diagnostic  point  in  the  differen- 
tiation between  an  enlarged  and  a  dislocated  spleen.  Palpation  detects 
the  indented  median,  the  outer  rounded,  and  the  sharp  lower  border. 
The  respiratory  movements  do  not  affect  the  dislocated  spleen  as  they  do 
the  normal  or  merely  enlarged  organ.  The  normal  dulness  in  the  left 
hypochondrium  is  replaced  by  tympany. 

Diagnosis. — The  diagnosis  is  usually  unattended  by  difficulty.  The 
size,  shape,  and  position  of  the  organ,  its  free  mobility,  and  the  absence 
of  dulness  in  the  normal  position  of  the  spleen  serve  to  distinguish  it 
from  the  various  abdominal  or  pelvic  tumors,  which  its  presence  in  an 
abnormal  position  might  suggest. 

iii.  Acute  Splenic  Tumor. 

The  spleen  undergoes  enlargement  in  the  acute  febrile  infections. 
The  degree  of  enlargement  varies  in  different  diseases  and  in  different 
cases  of  the  same  disease.  The  enlargement  is  almost  constant  in  malaria, 
and  so  common  in  enteric  fever  as  to  constitute  a  phenomenon  of  diagnos- 
tic importance,  It  is  also  very  frequent  in  typhus  and  relapsing  fever, 
and  occurs  in  pneumonia,  smallpox  and  the  other  exanthemata,  anthrax 
and  septic  conditions.  Moderate  splenic  enlargement  is  frequently  observed 
in  acute  miliary  tuberculosis,  secondary  syphilis,  and  cerebrospinal  fever. 
It  occurs  also,  but  is  less  common  and  less  marked,  in  various  acute 
catarrhal  inflammatory  conditions  of  the  respiratory  system,  as  coryza, 
tonsillitis,  and  bronchitis. 


SPLENIC  TUMOR.  1163 

Symptoms  are  usually  wholly  absent.  In  exceptional  cases  there  are 
sensations  of  weight  and  .tension  in  the  left  flank,  and  some  discomfort  is 
experienced  when  pressure  is  made  over  the  splenic  region. 

Physical  Signs. — Inspection. — In  rare  instances  in  persons  with  little 
subcutaneous  fat  the  side  may  slightly  bulge  and  the  outline  of  the  lower 
border  of  the  enlarged  viscus  may  be  seen  below  the  margin  of  the  ribs, 
especially  upon  deep  inspiration.  Palpation. — By  this  method  moderate 
degrees  of  splenic  enlargement  may  be  recognized.  The  patient  should  be 
partly  upon  the  right  side,  with  his  knees  and  thighs  moderately  flexed, 
and  his  head  and  shoulders  supported  upon  a  pillow.  The  physician  stand- 
ing to  the  left  of  the  patient  performs  bimanual  palpation,  the  palms  of 
his  right  hand  exerting  pressure  over  the  splenic  area  in  the  posterolateral 
aspect  of  the  chest,  while  the  fingers  of  his  left  hand  are  passed  firmly 
upward  beneath  the  margin  of  the  ribs  in  front,  the  patient  at  the  same 
time  being  directed  to  breathe  slowly  and  deeply  with  an  open  mouth. 
The  spleen  descends  with  each  deep  inspiration  and  if  enlarged  may  be 
readily  felt  by  the  fingers  of  the  left  hand.  When  the  enlargement  is  con- 
siderable, the  notches  in  the  anterior  border  may  be  palpated,  and  in 
very  rare  instances  pulsation  has  been  recognized.  Percussion. — This 
method  of  examination  yields  unsatisfactory  results  in  moderate  degrees 
of  enlargement  and  cannot  be  depended  upon.  Errors  occur  in  gaseous 
distention  of  the  stomach,  meteorism,  fecal  accumulations  in  the  colon, 
and  enlargement  of  the  left  kidney.  When  the  spleen  is  considerably 
enlarged  this  method  is  more  satisfactory.  Very  light  direct  percussion 
with  the  dorsal  surface  of  the  finger-tip  yields  satisfactory  results,  as  does 
auscultatory  percussion.  Auscultation. — Intermittent  and  continuous  soft 
murmurs  have  been  heard  in  the  splenic  area  in  the  malarial  paroxysm 
and  in  relapsing  fever. 

iv.  Chronic  Splenic  Tumor. 

Hypertrophy  of  the  Spleen;   Congestive  Hypertrophy. 

Chronic  enlargement  may  follow  acute  splenic  tumor  and  be  due  to 
the  action  of  infectious  principles.  It  occurs  also  in  chronic  malaria, 
leukaemia,  cirrhosis  of  the  liver,  and  cardiac  affections.  The  organ  may 
be  increased  to  twenty-five  or  thirty  times  its  normal  size.  Its  surface 
is  commonly  smooth  and  there  is  thickening  of  the  capsule. 

Symptoms. — When  the  enlargement  is  of  moderate  size  there  are 
often  no  subjective  symptoms.  When  it  is  considerable,  weight,  dragging, 
and  a  dull  pain  in  the  left  side  are  experienced.  Interference  with  the 
respiratory  play  of  the  diaphragm  may  cause  dyspnoea,  especially  when 
the  patient  lies  upon  his  left  side.  Traction  upon  the  stomach  maj^  lead  to 
loss  of  appetite,  indigestion,  nausea,  and  vomiting.  Cardiac  palpitation, 
oedema  of  the  ankles,  and  colic  occur.  Anaemia  is  often  marked.  Hemor- 
rhages and  especially  ha^moj^tysis  are  occasionally  present. 

Physical  Signs. — The  left  side  of  the  abdomen  and  the  left  hypo- 
chondrium  may  be  distended.  The  visible  and  palpable  tumor  is  popularly 
known  in  malarial  districts  as  "ague  cake."     The  lower  and  anterior  mar- 


1164  MEDICAL  DIAGNOSIS. 

gins  are  often  distinctly  palpable  with  their  characteristic  features,  and 
may,  in  extreme  cases,  reach  to  the  brim  of  the  pelvis  and  to  the  right  of 
the  median  line  respectively.  Upon  auscultation  friction  sounds  may 
sometimes  he  heard.  The  bruits  occasionally  heard  in  acute  splenic  tumor 
are  not  present.  In  cases  of  moderate  enlargement  in  which  there  are  no 
adhesions,  the  spleen  may  be  so  freely  movable  as  to  constitute  one  of  the 
forms  of  movable  spleen. 

Diagnosis.- — Direct. — The  physical  signs  elicited  upon  inspection, 
palpation,  and  percussion,  the  presence  of  dulness  in  the  normal  splenic 
area,  together  with  its  uninterrupted  extension  to  abnormal  limits  down- 
ward and  forward  and  the  well-defined  borders  notched  in  the  anterior 
and  rounded  in  the  inferior  lines,  and  more  or  less  distinct  participation 
of  the  tumor  mass  in  deep  respiratory  movements  of  the  diaphragm  jus- 
tify a  diagnosis  of  hypertrophy  of  the  spleen. 

Differential.  —  The  nature  of  the  enlargement  may  be  obscure. 
In  leukaemia  the  condition  of  the  blood  is  diagnostic.  In  Hodgkin's 
disease  the  history  is  important,  and  the  presence  of  enlarged  superficial 
lymph-nodes,  especially  when  they  form  groups  or  masses  in  the  cervical, 
axillary,  or  inguinal  regions,  is  suggestive.  In  congenital  syphilis  and 
rickets  the  associated  phenomena  are  significant.  In  splenic  abscess^ 
fluctuation  and  fever,  together  with  other  septic  phenomena,  point  to  the 
presence  of  pus.  Echinococcus  cysts  of  the  sjDleen  are  rare  and  may  give 
rise  to  uncertainty.  Rupture  into  the  intestine  or  externally  may  afford 
clinical  evidences  by  which  the  true  condition  may  be  recognized  during 
life,  and  rupture  into  the  peritoneum  may  cause  fulminant  peritonitis, 
but  these  accidents  are  among  the  most  infrequent  of  clinical  occurrences. 
Malignant  disease  of  the  spleen  is  attended  with  grave  disturbances  of  the 
general  health,  cachexia,  and  metastasis. 

Tumors  of  the  kidney  usually  occupy  a  lower  position  and  are  less 
movable.  They  are  crossed  diagonally  by  the  colon  and  often  associated 
with  urinary  symptoms  of  importance.  Nephromata  are  common  in 
early  life,  and  hydronephrosis  and  pyonephrosis  at  all  ages.  A  diagnosis 
of  splenic  hypertrophy  or  abscess  should  never  be  made  until  after  every 
form  of  renal  tumor  has  been  excluded.  A  tumor  of  the  fundus  of  the 
stomach,  of  the  colon,  or  the  omentum  may,  as  a  rule,  be  differentiated 
without  difficulty  from  enlargement  of  the  spleen. 

Moderate  enlargement  is  usually  present  in  movable  spleen.  The 
latter  condition  is  characterized  bj^  the  free  movement  of  the  organ,  its 
contour,  and  by  resonance  in  the  region  of  normal  splenic  dulness. 

Prognosis. — The  outlook  depends  upon  the  cause  of  the  enlargement. 
Congestive  and  malarial  spleens  often  undergo  remarkable  diminution  in 
size.  The  leukaemic  spleen  shows  wide  oscillations  in  volume  in  the  course 
of  the  disease  and  under  treatment.  Enlarged  spleens  may  become  smaller 
during  pregnancy.  The  enlargement  may  exist  for  ^-^ears  without  detri- 
ment to  health. 


SPLENIC  TUMOR.  1165 

V.  Splenic  Tumor  with  Anaemia. 

Primitive  Splenomegaly;    Splenic  Ancemia;    Banti's  Disease. 

Anaemia  is  characteristic  of  many  conditions  in  which  the  spleen  is 
enlarged,  especially  the  primary  anaemias,  as  leukaemia  and  pernicious 
anaemia.  Secondary  anaemia  accompanies  splenic  enlargement  in  Hodg- 
kin's  disease,  chronic  malaria,  and  various  forms  of  hepatic  cirrhosis. 
Idiopathic  splenomegaly  with  secondary  anaemia  occurs  in  a  group  of  cases 
of  which  the  following  types  are  the  most  important: 

(a)  Primitive  Splenomegaly. — Marked  and  persistent  enlargement 
may  occur  without  associated  disease  and  with  but  slight  blood  changes, 
and  give  rise  to  no  symptoms  other  than  those  caused  by  the  pressure  and 
weight  of  the  enlarged  organ. 

(b)  Splenic  Anaemia. — The  spleen  is  very  large.  There  is  marked 
anaemia  of  secondary  type.  Hemorrhages,  particularly  hsematemesis,  are 
common.  Purpura,  melanoderma,  and  oedema  of  the  lower  extremities 
occur.    The  disease  runs  a  very  chronic  course. 

■  (c)  Banti's  Disease. — The  advanced  stages  of  splenic  anaemia  are 
characterized  in  a  sub-group  of  cases  by  secondary  cirrhosis  of  the  liver 
with  subicteroid  discoloration  of  the  skin,  or  actual  jaundice  and  ascites. 
Diagnosis. — The  direct  diagnosis  of  splenic  anaemia  rests  upon  the 
association  of  primitive  splenomegaly  with  secondary  anaemia,  and  the 
absence  of  enlargement  of  the  lymph-nodes. 

The  differential  diagnosis  between  splenic  anaemia  and  pernicious 
anaemia  depends  upon  the  morphological  characters  of  the  blood,  the 
relatively  high  haemoglobin  percentage,  and  small  size  of  the  spleen  in  the 
latter  affection.  Leukaemia  may  be  at  once  differentiated  by  the  blood 
picture,  and  Hodgkin's  disease  by  the  enlargement  of  the  lymph-glands 
and  their  peculiar  massing  in  the  cervical,  axillary,  and  inguinal  regions. 
Banti's  disease  and  hepatic  cirrhosis  present  similar  pictures,  but  in  the 
former  the  splenic  enlargement  is  primary  and  of  long  duration  before  the 
changes  in  the  liver  and  the  resulting  jaundice  and  ascites  make  their 
appearance.    A  history  of  alcoholism  is  of  diagnostic  importance. 

vi.  Splenic  Tumor  with  Polycythsemia  and  Cyanosis. 

Osier  and  others  have  recently  described  a  condition  characterized  by 
cyanosis,  an  increase  in  the  number  of  the  red  blood-corpuscles  to  9,000,000 
or  even  13,000,000  to  the  cmm.,  and  enlargement  of  the  spleen.  Headache, 
giddiness,  and  constipation  are  common  symptoms.  The  cause  of  the 
disease  is  wdiolly  unknown.  It  occurs  in  adults.  The  cyanosis  is  more 
marked  in  cold  than  in  warm  weather.  Urinary  changes,  as  low  specific 
gravity,  a  trace  of  albumin,  and  hyaline  and  granular  casts,  are  common. 
The  condition  is  a  persistent  one.  Such  causes  of  c^^anosis  as  emphysema, 
congenital  and  acquired  heart  disease,  pulmonary  sclerosis,  and  acetanilid 
poisoning  must  be  excluded  in  making  the  diagnosis.  The  polycythsemia 
observed  in  those  who  have  resided  at  high  altitudes  must  also  be 
borne  in  mind. 


1166  MEDICAL  DIAGNOSIS. 

vii.  Splenic  Capsulitis — Perisplenic  Peritonitis. 

Inflammation  of  the  capsule  of  the  spleen  occurs  in  arteriosclerotic 
atrophy  of  the  organ,  and  in  particular  in  the  senile  form,  in  acute  splenitis, 
infarction,  and  abscess.  It  is  met  with  also  in  local  and  general  peritonitis 
and  in  chronic  proliferative  peritonitis.  In  many  cases  the  capsular  peri- 
splenitis results  from  the  extension  of  inflammation  from  neighboring  organs, 
as  the  fundus  of  the  stomach,  the  pancreas,  and  loops  of  intestine,  and 
adhesions  between  these  structures  and  the  spleen  are  found. 

Symptoms.  —  The  clinical  manifestations  are  often  subordinate  to 
those  of  the  associated  disease,  as  in  gastric  ulcer,  pancreatic  disease,  or 
general  peritonitis.  In  other  cases  circumscribed  pain,  tenderness,  and 
swelling  are  associated  with  fever  and  much  general  disturbance  of  health. 

The  prognosis  depends  upon  the  nature  of  the  primary  disease.  Cap- 
sular thickening  and  adhesions  are  frequently  found  upon  post-mortem 
examination  in  cases  in  which  no  history  of  acute  symptoms  has  been 
obtained. 

viii.  Infarct  of  the  Spleen. 

Embolism  of  the  terminal  branches  of  the  splenic  artery  may  occur  in. 
endocarditis,  thrombosis  of  the  left  heart,  and  atheroma  of  the  thoracic 
aorta.  The  infarcts  thus  caused  may  be  single  or  multiple.  They  vary 
greatly  in  size.  They  are  pyramidal  in  shape,  the  apex  presenting  toward 
the  helium  and  the  base  toward  the  periphery  of  the  organ,  the  corresponding 
capsule  being  very  frequently  the  seat  of  a  circumscribed  plastic  inflam- 
mation. The  infarct,  hemorrhagic  at  first,  may  undergo  softening  or  a 
gradual  cicatricial  change  which  results  in  a  contracting  and  pigmented 
scar.      Infected  emboli  undergo  softening  with  abscess  formation. 

Symptoms. — A  chill,  sudden  severe  pain  and  tenderness  in  the  region 
of  the  spleen,  which  at  the  same  time  becomes  enlarged,  sometimes  vomit- 
ing and  collapse  symptoms,  constitute  the  symptom-complex.  When 
these  symptoms  occur  in  endocarditis  or  in  cases  in  which  there  are  signs 
pointing  to  atheroma,  the  diagnosis  of  splenic  infarct  becomes  highly 
probable.  If  there  are  coincident  indications  of  renal  infarct,  such  as 
severe  pain  referred  to  the  loins,  and  hemorrhagic  and  albuminous  urine, 
the  diagnosis  is  positive.  A  friction  sound  may  be  heard.  In  many  cases 
in  which  the  anatomical  diagnosis  is  made  neither  symptoms  nor  the  signs 
of  enlargement  of  the  spleen  were  present  during  hfe. 

ix.  Suppurative  Splenitis — Abscess  of  the  Spleen. 

This  condition  results  from  direct  infection  by  pyogenic  micro-organ- 
isms. There  are  two  forms:  simple  and  embohc.  The  former  may  result 
from  traumatism  or  be  secondary  to  infective  processes  in  adjacent  struc- 
tures or  infection  by  way  of  the  blood.  The  latter  occurs  in  septic  condi- 
tions, the  infected  emboH  being  derived  from  local  suppurative  foci  in 
distant  parts.  The  simple  abscess  is  usually  single.  It  may  vary  in 
size  from  a  cherry  to  the  dimensions  of  the  enlarged  and  overdistended 
spleen,  the  substance  of  which  it  replaces.     Embohc  abscesses  are  small 


DISEASES  OF  THE  THYMUS  GLAND.  1167 

and  numerous,  and  begin  as  infarcts  which  rapidly  undergo  softening  and 
are  converted  into  collections  of  pus. 

Symptoms. — The  symptoms  are  those  of  infarction,  namely,  localized 
pain  and  tenderness,  splenic  enlargement,  and  irregular  fever.  They 
develop  rapidly  in  embolic,  more  gradually  in  simple,  abscess.  There  may 
be  cough  and  dyspnoea  due  to  interference  with  the  movement  of  the 
diaphragm;  gastric  derangement  caused  by  sepsis;  oedema  of  the  lower 
extremities  arising  from  compression  of  the  abdominal  veins. 

Physical  Signs. — The  lower  end  of  the  spleen  may  be  palpated  below 
the  margin  of  the  ribs.  Fluctuation  may  be  elicited.  The  rupture  of  the 
abscess  may  be  followed  by  sudden  pain  and  collapse  symptoms,  and  the 
discharge  of  a  considerable  quantity  of  pus  by  vomiting  or  by  the  bowel, 
or  in  rare  instances  by  way  of  the  bronchi  or  the  urinary  passages. 

Prognosis. — A  great  majority  of  the  cases  die.  Recovery  may  take 
place  by  the  resorption  of  the  fluid  contents  of  a  small  cavity  and  inspissa- 
tion,  or  after  the  evacuation  of  the  pus  spontaneously  or  by  a  surgical 
operation. 

X.  Rupture  of  the  Spleen. 

Spontaneous  rupture  must  be  extremely  rare.  It  is  said  to  occur  in 
connection  with  the  acute  enlargement  of  the  organ  in  enteric  and  malarial 
fevers.  Undue  force  in  palpation  or  some  similar  traumatism  may  be 
suspected.  Rupture  of  the  spleen  has  been  noted  in  childbirth.  Severe 
blows,  contusions,  or  penetrating  wounds  have  caused  rupture  of  the 
normal  spleen.  The  rupture  may  occur  at  the  site  of  an  infarct,  or  an 
abscess  may  give  way.  The  symptoms  denote  sudden  internal  hemorrhage 
associated  with  intense  pain  in  the  splenic  region.  There  may  be  extended 
dulness  in  the  splenic  region  or  in  the  flanks  due  to  collections  of  blood. 
The  abdomen  may  be  swollen  and  the  seat  of  general  distress. 

The  diagnosis  becomes  probable  when,  in  the  presence  of  acute  or 
chronic  enlargement  of  the  spleen,  or  in  the  case  of  direct  violence  to  the 
left  side  of  the  trunk,  sudden  intense  local  pain,  collapse  symptoms,  and 
pallor  arise,  together  with  signs  of  increasing  enlargement  of  the  spleen  or 
accumulation  of  fluid  in  the  flanks.  An  exploratory  laparotomy  should  be 
performed  without  delay. 

Prognosis. — In  a  few  instances  spontaneous  recovery  has  resulted, 
as  shown  by  the  cicatrix  when  death  has  occurred  at  a  remote  period  after 
the  accident.  Most  of  the  cases  are  promptly  fatal.  Immediate  operation 
has  been  the  means  of  saving  life.  Localized  tumors  of  the  spleen,  the 
so-called  splenic  adenomata,  which  consist  of  localized  hyperplasias  of 
splenic  tissue  within  the  spleen  itself,  fibromata,  gummata,  primary  and 
secondary  sarcomata,  hydatid  and  other  cysts  are  rare  conditions  of 
pathological   rather   than   clinical  interest. 

II.  DISEASES  OF  THE  THYMUS  GLAND. 

The  functions  of  this  transitional  organ  are  unknown.  It  has  been 
accredited  with  a  hypothetical  internal  secretion  capable  of  antagonizing 
infections,  a  hypothesis  which  accounts  for  the  comparative  immunity  of 


1168  MEDICAL  DIAGNOSIS. 

young  infants  against  many  of  the  acute  febrile  infections.  The  weight  of 
the  thymus  gland  at  birth  is  variously  estimated  at  from  8  to  13  grammes. 
It  gradually  increases  in  size  till  the  end  of  the  second  year,  from  which 
period  it  undergoes  progressive  atrophy,  until  at  puberty  it  is  a  shrivelled 
mass  containing  only  traces  of  its  original  structure. 

I.  Persistence  of  the  Thymus.^ — This  occurs  under  varied  conditions 
which  may  be  causal  or  accidental,  but  are  not  understood.  It  is  usually  a 
post-mortem  finding,  but  may  be  suspected  when  localized  dulness  along 
the  sternal  border  on  the  left  side  from  the  second  to  the  fourth  rib 
may  be  made  out.  Persistent  thymus  has  been  frequently  observed  in 
exophthalmic  goitre. 

II.  Hypertrophy. — Enlargement  of  the  thymus  has  been  regarded 
as  the  cause  of  thymic  asthma  or  laryngismus  stridulus — a  condition  attrib- 
uted to  the  pressure  of  the  enlarged  organ.  Dyspnoea,  laryngeal  cough, 
and  bronchial  rales  in  young  infants  have  been  caused  by  hypertrophy  of 
the  thymus  and  relieved  by  partial  excision,  but  that  it  is  the  cause  of 
laryngismus  stridulus  is  by  no  means  established.  Sudden  death  may  occur 
in  lymphatism  in  infants  with  hypertrophy  of  the  thymus.  The  children 
are  found  dead  in  bed  or  die  in  a  short  time  with  symptoms  of  asphyxia. 
In  certain  cases  of  sudden  death  in  adults  the  thymus  has  been  found 
greatly  enlarged  with  signs  of  status  lymphaticus.  Hypertrophy  of  the 
thymus  has  been  occasionally  present  in  epilepsy. 

III.  Atrophy. — Primary  atrophy  of  the  thymus  in  infants  may  be 
attended  with  general  atrophy  in  the  absence  of  other  symptoms. 
Secondary  atrophy  attends  tuberculous  and  other  wasting  diseases. 

IV.  Hemorrhages. — Extravasations  of  blood  in  the  substance  of  the 
gland  have  been  frequently  found  in  children  dead  of  asphyxia. 

V.  Tumors  of  the  thymus  are  sarcoma,  lymphosarcoma,  dermoid 
and  other  cysts,  and  gumma.  Miliary  tuberculosis  and  gumma  are  rare 
pathological  findings.  Mediastinal  tumors  frequently  have  their  origin 
in  the  thymus. 

The  majority  of  the  diseases  of  the  thymus  gland  cannot  be  recog- 
nized during  life,  and  are  of  pathological  rather  than  clinical  interest. 

III.     STATUS   LYMPHATICUS;  LYMPHATISM;    CON- 
STITUTIO   LYMPHATICA. 

Definition. — A  constitutional  condition  characterized  by  hyperplasia 
of  the  lymph-nodes  and  lymphatic  tissues  generally,  the  spleen,  the  thymus, 
and  the  bone-marrow,  and  the  liability  to  sudden  death. 

Morbid  Anatomy. — The  lymph-nodes  of  the  pharynx,  thorax,  and 
abdomen  are  chiefly  affected.  The  superficial  glands  of  the  cervical, 
axillary,  and  inguinal  regions  may  be  involved.  As  a  rule,  the  enlargement 
is  moderate  in  degree  and  sj^mmetrical,  and  differs  in  this  respect  from 
that  of  Hodgkin's  disease.  The  enlargement  of  the  spleen  is  moderate, 
the  thymus  is  persistent  and  usually  hypertrophied,  and  the  yellow  marrow 
of  the  long  bones  may  be  replaced  by  red  marrow.  The  thyroid  body  is 
enlarged,  and  hypoplasia  of  the  heart  and  aorta  is  present.  Many  of  the 
subjects  are  rhachitic. 


ACUTE  THYROIDITIS.  1169 

Etiology. — The  condition  has  been  variously  ascribed  to  heredity 
and  to  over-irritability  of  the  lymphatic  tissue.  It  occurs  principally  in 
children  and  young  persons.  The  association  with  rickets  is  probably 
accidental. 

Clinical  Phenomena. — The  patients  are  fat  and  flabby,  and  have 
pallid,  opaque  skins.  Hypertrophy  of  the  tonsils  and  overgrowth  of  the 
pharyngeal  adenoid  tissue,  swelling  of  the  thyroid,  overgrowth  of  the 
thymus  (as  indicated  by  dulness  over  the  manubrium  sterni,  especially  at 
its  left  border),  enlargement  of  the  superficial  lymph-nodes,  and  espe- 
cially signs  of  enlargement  of  the  mesenteric  glands,  are  present.  Moderate 
enlargement  of  the  spleen  is  suggestive. 

Diagnosis. — When  the  foregoing  signs  are  well  marked  the  diagnosis 
may  be  made  with  some  confidence,  but  a  positive  diagnosis  cannot  often 
be  affirmed.  The  number  of  cases  in  which  the  lesions  of  lymphatism  have 
been  found  after  unlooked-for  death,  under  circumstances  in  which  such 
an  event  has  appeared  unaccountable — as  the  injection  of  diphtheria  anti- 
toxin serum  for  prophylactic  purposes,  chloroform  or  ether  anaesthesia  for 
trifling  operations  in  young  children,  during  the  bathing  of  young  children 
wholly  without  apparent  cause,  and  occasionally  during  convalescence 
from  the  acute  febrile  infections — have  given  the  condition  a  sinister  signifi- 
cance. This  fatal  occurrence  has  been  attributed  to  the  pressure  of  the 
hypertrophied  thymus  upon  the  trachea,  or  to  a  perverted  or  excessive 
internal  thymus  secretion — lymphotoxsemia. 

The  DIFFERENTIAL  DIAGNOSIS  from  Hodgkiu's  disease  rests  upon  the 
more  marked  and  asymmetrical  enlargement  of  the  superficial  glands,  and 
the  absence  of  hypertrophy  of  the  pharyngeal  lymph  structures  in  the 
latter  affection;  from  glandular  fever,  upon  the  acute  and  self-limited 
course  of  the  latter  disease,  the  presence  of  fever,  and  the  subsidence  of  the 
enlargement  of  the  lymph-nodes  after  defervescence. 

Prognosis. — The  subjects  of  lymphatism  have  feeble  powers  of  resist- 
ance, and  in  consequence  of  the  hypoplasia  of  the  heart  and  aorta  are 
especially  liable  to  sudden  death. 

IV.  DISEASES  OF  THE  THYROID  GLAND, 
i.  Acute  Thyroiditis. 

Acute  inflammation  of  the  thyroid  gland  is  rare.  It  may  follow  trau- 
matism. Much  more  commonly  it  occurs  in  association  with  an  acute 
infectious  disease,  as  enteric  fever,  scarlet  fever,  diphtheria,  rheumatic 
fever,  pneumonia,  or  mumps.  In  a  case  recently  under  my  observa- 
tion it  developed  in  the  course  of  an  attack  of  influenza.  In  very 
rare  instances  acute  thyroiditis  has  been  noted  as  a  primary  affection. 

Symptoms. — The  whole  gland  may  be  affected,  or  only  one  lobe. 
The  attack  begins  with  a  chill  or  chilliness  followed  by  high  fever.  Swelling, 
,  pain,  and  tenderness  rapidly  develop.  Externally  there  may  be  redness 
with  engorgement  of  the  superficial  veins,  and  cyanosis.  Internal  pressure 
upon  the  blood-vessels,  oesophagus,  and  trachea  causes  headache,  dysphagia, 
dyspnoea,  and  stridor.     As  a  rule,  resolution   takes  place  in  the  course 

74 


1170  MEDICAL  DIAGNOSIS. 

of  several  days  or  a  week  or  two.  Occasionally  suppuration  occurs. 
Destruction  of  the  entire  gland  has  been  followed  by  myxoedema. 
(Edema  of  the  glottis  may  occur.  Myxoedema  has  been  observed  after 
an  attack  of   acute  thyroiditis. 

ii.  Goitre — Bronchocele. 

Definition. — Hypertrophy  of  the  thyroid  gland.  This  term  includes 
all  enlargements  of  the  thyroid  gland  not  caused  by  inflammation,  new 
growths,  tuberculosis,  syphilis,  Graves's  disease,  and  animal  parasites. 
The  anatomical  varieties  of  goitre  are,  (a)  parenchymatous,  (b)  vascular, 
and  (c)  cystic. 

Goitre  occurs  as  a  sporadic  and  as  an  endemic  disease. 

1.  Sporadic  Goitre. — The  temporary  congestions  which  give  rise  to 
enlargement  of  the  thyroid  body  in  girls  at  puberty,  in  many  women 
during  menstruation,  and  in  some  during  pregnancy  cannot  be  regarded 
as  goitres.  Nor  do  the  transient  swellings  caused  by  the  pressure  of  a 
tight  collar  or  excessive  use  of  the  voice  constitute  goitre.  Enlargement  of 
the  gland  due  to  parenchymatous,  vascular,  or  cystic  lesions,  and  more 
or  less  persistent,  is  not  uncommon  and  occurs  almost  without  exception 
in  the  female  sex.  Age  is  a  predisposing  factor  of  some  importance.  There 
are  rare  cases  of  congenital  goitre.  The  disease  is  uncommon  in  childhood. 
It  frequently  first  appears  after  puberty  or  in  early  adult  life,  but  may  not 
appear  until  fifty  or  later. 

2.  Endemic  Goitre. — This  affection  is  prevalent  in  circumscribed 
regions  in  many  parts  of  the  world.  These  regions  are  frequently  but  not 
exclusively  mountainous,  or  deep  valleys  surrounded  by  mountains. 
Sometimes  they  are  plains,  especially  in  lake  countries.  Parts  of  Switzer- 
land, the  southern  slopes  of  the  Italian  Alps,  the  Himalayas,  the  hill  country 
of  China,  and  some  regions  in  Siberia  are  seats  of  endemic  goitre,  either 
alone  or  in  association  with  cretinism.  The  disease  is  rare  in  North  Amer- 
ica. In  occurs  in  some  parts  of  Pennsylvania,  the  parts  about  the  eastern 
end  of  Lake  Ontario,  and  in  the  Province  of  Quebec. 

The  exciting  cause  of  endemic  goitre  is  supposed  to  be  contained  in 
the  drinking  water  of  goitrous  districts.  This  opinion  is  supported  by  the 
following  facts,  which  are  generally  accepted: 

i.  A  healthy  family  coming  to  reside  in  a  goitrous  district  presently 
may  develop  goitre  among  its  members. 

ii.  Drinking  water  from  a  new  and  distant  source  has  been  followed 
by  subsidence  of  goitre. 

iii.  An  outbreak  has  followed  the  introduction  of  water  from  a 
goitrous  region. 

iv.  Certain  wells  in  Europe  have  had  the  reputation  of  causing  goitre 
in  those  habitually  drinking  their  waters. 

Symptoms. — The  enlargement  may  involve  the  entire  gland,  or  only 
one  lobe.  Moderate-sized  goitres  cause  no  annoyance  beyond  that  due  to 
the  deformity  which  they  produce.  Large  tumors  may  give  rise  to  dyspncea 
by  pressure  upon  the  trachea;  small  tumors  extending  beneath  the  sternum 
may  compress  the  veins.     In  extreme  cases  the  goitre  may  compress  the 


EXOPHTHALMIC  GOITRE.  1171 

oesophagus  and  give  rise  to  difficulty  in  deglutition.  Sudden  death  has 
occurred  in  large  goitres  from  pressure  upon  the  vagi,  or  hemorrhage  into  the 
substance  of  the  gland  or  the  adjacent  tissues. 

Accessory  Thyroids;  Parathyroids. — These  may  He  in  the  thyroid 
or  near  it.  Their  number  varies,  rarely,  however,  exceeding  four.  In  some 
instances  thyroid  tissue  is  situated  at  the  root  of  the  tongue,  in  the  medias- 
tinum, or  even  in  the  pleural  cavity.  A  lingual  thyroid  may  exist  in  the 
substance  of  the  tongue  or  attached  to  the  hyoid  bone. 

Diagnosis. — Direct. — The  disease  may  be  readily  recognized.  It  is 
an  important  characteristic  of  all  tumors  of  the  thyroid  gland  that  they 
move  upward  in  deglutition. 

Differential. — Goitre  is  to  be  discriminated  from,  (a)  adenomata, 
simple  or  malignant;  (b)  malignant  neoplasmata,  both  carcinomatous  and 
sarcomatous.  The  important  diagnostic  criteria  are  the  smooth  parenchy- 
matous enlargement  involving  one  lobe  or  the  entire  gland;  the  uniform 
vascular  enlargement  with  distinct  varix  arrangement,  pulsation,  and 
murmur;  or  recognizable   agglomerate   cyst   formation. 

Prognosis. — Treatment  is  not  usually  satisfactory.  Iodine  and  the 
iodides,  ergot,  and  counterirritants,  much  recommended,  are  not  always 
successful.  Thyroid  extract  is  of  questionable  value.  Large  goitres  may  be 
removed. 

iii.  Exophthalmic  Goitre. 

Hyperthyrea;     Graves's    Disease;     Basedow's   or   Parry's   Disease. 

Definition.  —  A  disease  caused  by  derangement  of  the  internal 
secretion  of  the  thyroid  body,  and  characterized  by  exophthalmus, 
enlargement  of  the  thyroid,  tachycardia,  and  tremor. 

Pathology. — Various  views  in  regard  to  the  essential  nature  of  this 
affection  have  been  from  time  to  time  entertained,  but  that  which  now 
has  the  most  satisfactory  basis  of  support  is  that  it  is  a  primary  disease 
of  the  thyroid  gland,  resulting  in  an  increased  or  deranged  internal  secre- 
tion.   In  defense  of  this  view  the  following  facts  are  adduced: 

i.  The  active  proliferation  in  glandular  substance  during  the  progress 
of  the  disease. 

ii.  The  production  of  symptoms  resembling  those  of  exophthalmic 
goitre  by  the  administration  of  thyroid  extract. 

iii.  The  fact  that  thyroid  extract  usually  aggravates  the  symptoms 
of  the  disease. 

Etiology. — Predisposing  Influences. — Sex. — The  disease  is  common 
in  women;  comparatively  rare  in  men.  Age. — The  onset  usually  occurs 
in  early  adult  life,  somewhere  between  the  eighteenth  and  fortieth  years. 
Rare  cases  have  been  observed  in  infancy.  Heredity. — It  sometimes  occurs 
in  several  members  of  the  same  family,  and  has  been  observed  in  three 
successive  generations. 

Exciting  Cause. — Acute  infections,  especially  tonsillitis,  rheumatic 
fever,  and  influenza,  have  been  noted  in  many  instances  shortly  before  the 
onset  of  exophthalmic  goitre.  More  significant  are  severe  depressing 
emotions,  worry,  anxiety,  fright,  and  overfatigue  as  antecedent  conditions 


1172 


MEDICAL  DIAGNOSIS. 


and  possible  causal  factors.  There  is  a  close  resemblance  between  the 
immediate  effects  of  sudden  fright  or  terror  and  the  symptoms  of  exoph- 
thalmic goitre,  namely,  exophthalmus,  tachycardia,  and  tremor. 

Symptoms. — The   cardinal  symptoms    have   been    mentioned   in   the 
definition,   namely,    exophthalmus,    goitre,    overaction   of  the   heart,    and 

tremor.  With  these  are  usually 
associated  anaemia,  emaciation, 
sweating,  diarrhoea,  and  irregular 
or  suppressed  menstruation.  The 
cardinal  clinical  phenomena  vary 
in  degree  and  in  the  order  of 
their    development. 

1.  Exophthalmus. — In  some 
instances  the  protrusion  is  so  great 
as  to  prevent  closure  of  the  eye- 
lids. In  others  it  is  so  slight  as 
to  be  scarcely  noticeable.  It  is 
frequently  different  in  degree  upon 
the  two  sides  and  sometimes  dis- 
tinctly unilateral.  Commonly  a 
In   rare  instances 


Fig.  334. — Exophthalmic  goitre. — German  Hospital 


rim  of  white   is   seen    above    and   below  the    cornea 
the    eyes    maj^   be   dislocated   from    their   sockets. 

Graefe's  Sign. — When  the  eyeball  is  moved  downward  the  upper  lid 
does  not  follow  it  as  in  normal  conditions.  Dalrym^le' s  Sign. — The  palpe- 
bral fissure  is  wider  than  normal,  owing  to  spasmodic  retraction  of  the 
upper  lid.  Stellwag's  Sign. — Infrequent,  irregular,  and  incomplete  winking. 
Moehius's  Sign. — Insufficient  power  of  convergence  for  near  objects.  The 
foregoing  signs  are  commonly  associated.  Joffroy's  Sign. — When  the  head 
is  bowed  forward  and  the  patient 
asked  to  look  up  without  changing  P* 
his  posture,  the  forehead  is  not 
wrinkled  as  occurs  in  health. 

Pupillary  changes  and  retinal 
lesions  are  rare.  Defects  of  vision 
are  uncommon.  Subjective  ocular 
symptoms,  as  sensations  of  pres- 
sure and  phosphenes,  occur. 
Ulceration  of  the  cornea  may  take 
place,  and  in  extreme  cases  destruc- 
tion of  the  eyeball.  Pulsation  of 
the  retinal  arteries  is  frequent. 

2.    ENL.A.RGEMEXT    OF    THE 

Thyroid  Body. — The  enlargement 
is  usually  moderate.  Usually  both  lobes  are  affected,  as  a  rule  unsymmet- 
rically,  and  more  commonly  the  right  to  a  greater  extent  than  the  left. 
The  swollen  gland  is  generally  soft,  but  may  be  dense  and  hard,  espe- 
cially when  goitre  has  preceded  the  disease.  Distinct  pulsation,  thrill, 
and  a  systolic  or  continuous  murmur  are  common  phenomena.  Sometimes 
the  murmur  is  double.     The  thyroid  enlargement  undergoes  remarkable 


Fig.  33.5. — Exophthalmic  goitre. — German  Hospital. 


EXOPHTHALMIC  GOITRE.  1173 

fluctuations  in  volume,  increasing  for  a  time  and  then  subsiding,  or 
undergoing  repeated  changes  in  the  course  of  a  short  time.  The  attention 
of  the  patient  is  often  first  called  to  this  symptom  by  the  tightness  of 
the  neckband  or  collar. 

3.  Circulatory  Derangements. — This  group  of  symptoms  consti- 
tutes the  most  constant  and  striking  features  of  the  disease.  Tachycardia 
is  always  present.  The  pulse-frequency  varies  from  90  to  100  beats  in  the 
minute  in  the  early  course  of  the  disease,  to  100  to  130  and  even  140  to 
160  in  severe  and  advanced  cases.  The  rate  is  usually  increased  upon 
effort  and  under  the  influence  of  emotion.  Forcible  pulsations  of  the  ves- 
sels at  the  root  of  the  neck  are  associated  with  increased  cardiac  action 
and  a  greatly  extended  visible  impulse.  As  a  rule,  the  patients  complain  of 
palpitation  and  sometimes  feel  the  sensation  widely  over  the  body.  In 
some  cases  the  overaction  of  the  heart  causes  little  discomfort.  The  heart 
is  almost  always  dilated  and  sometimes  hypertrophied.  Its  action  is,  as 
a  rule,  regular,  but  in  grave  cases  arrhythmia  is  often  marked.  Systolic 
murmurs  are  common  at  the  apex  and  across  the  base  of  the  heart.  The 
heart  sounds  are  often  intense,  and  may,  in  some  instances,  be  heard  at 
some  distance  from  the  body  of  the  patient.  Acute  dilatation  of  the  heart 
may  occur.  There  may  be  visible  pulsation  of  the  peripheral  arteries  and 
the  pulse-beat  may  be  felt  in  the  palms  and  finger-tips.  A  capillary  pulse 
is  common  and  the  venous  pulsation  in  the  back  of  the  hand  may  often 
be  seen.    Flushing  of  the  neck  and  face  is  often  pronounced. 

4.  Tremor. — This  cardinal  symptom  is  a  variable  one.  It  may  be 
forcible  and  annoying,  involving  not  only  the  extremities  but  also  the 
head,  or  so  slight  as  to  be  discovered  only  upon  careful  examination.  It 
is  entirely  involuntary,  of  limited  extent,  and  about  eight  or  nine  to  the 
second.  It  is  usually  symmetrical,  but  may  be  more  marked  upon  one 
side,  or  confined  to,  or  more  distinct  in,  a  single  limb. 

Anaemia,  emaciation,  and  loss  of  strength  are  common.  Fever  is 
rare,  but  subjective  sensations  of  heat,  and  copious  perspirations,  are 
common  symptoms.  Vomiting  and  diarrhoea  occur  in  the  absence  of 
obvious  cause.  The  electrical  resistance  is  diminished,  a  fact  attributed 
to  the  moisture  of  the  skin  due  to  vasomotor  dilatation.  Pigmentation  is 
not  uncommon.  The  parts  chiefly  affected  are  the  face,  neck,  trunk, 
nipples,  and  flexures  of  the  arms  and  thighs.  In  rare  instances  there  is  a 
general  bronzing  like  that  of  Addison's  disease;  in  other  cases  an  irregular 
patchy  discoloration.  Patches  of  leucoderma  may  appear.  Transient 
oedema  is  common  and  myxoedema  is  occasionally  seen.  The  nutrition  of 
the  hair  suffers  and  complete  alopecia  may  occur.  The  teeth  sometimes 
undergo  rapid  decay.  Albuminuria,  glycosuria,  and  true  diabetes  are 
occasionally  encountered  in  the  course  of  the  disease.  Menstrual  derange- 
ments are  common.  When  pregnancy  occurs  the  condition  of  the  patient 
often  improves  and  the  foetus  is  born  at  term. 

Nervous  and  mental  symptoms  are  very  common.  Tremors,  cramps 
of  the  hands  and  feet,  a  sensation  of  giving  way  at  the  knees,  and  increased 
tendon  reflexes  are  observed.  Irritability,  altered  disposition,  and  mental 
depression  occur  in  most  of  the  cases.  The  acute  mania  which  sometimes 
precedes  death  has  been  attributed  to  sudden,  intense  thyroid  intoxication. 


1174  MEDICAL  DIAGNOSIS. 

Course  and  Duration. — Incomplete  forms  are  common  and  often 
overlooked.  They  may  be  characterized  by  tachycardia,  nervous  irrita- 
bility, slight  tremor,  and  little  enlargement  of  the  thyroid  or  protrusion  of 
the  eyes.  There  are  acute  and  chronic  forms.  The  latter  are  more  com- 
mon. Acute  cases  usually  occur  in  childhood.  They  may  last  a  few  days 
or  several  weeks  and  get  well.  Relapses  may  occur.  As  a  rule,  when  in 
adults  the  disease  is  well  marked,  recovery  is  infrequent.  Death  occurs 
from  intercurrent  affections. 

Diagnosis. — When  the  four  cardinal  symptoms  are  associated  a  posi- 
tive diagnosis  can  be  made.  Difficulty  may  arise  in  the  rudimentary 
forms.  Absence  of  exophthalmus  or  of  thyroid  enlargement  is  not  often 
complete.  These  symptoms  when  slight  are,  in  association  with  tremor 
and  tachycardia,  most  significant.  Anaemia,  pigmentation,  emaciation, 
and  mental  changes  aid  the  diagnosis. 

Prognosis. — The  disease  is  essentially  chronic.  Acute  cases  are  excep- 
tional. A  guarded  prognosis  should  be  given.  In  individual  cases  the  more 
urgent  the  symptoms  the  less  favorable  the  outlook.  When  the  symp- 
toms are  mild  the  prospect  of  recovery  is  proportionately  better.  Cases 
in  which  the  onset  is  sudden  and  severe,  after  fright,  sometimes  recover 
in  a  short  time, 

iv.  Myxoedema. 

Athyria;  GulVs  Disease. 

Definition. —  A  constitutional  disease  caused  by  the  impairment  or 
loss  of  function  of  the  thyroid  gland,  and  characterized  anatomically  by 
absence,  atrophy,  or  goitrous  degeneration  of  the  thyroid,  and  clinically 
,by  profound  nutritional  changes,  a  firm,  inelastic  swelling  of  the  skin  and 
subcutaneous  tissues,  and  nervous  and  mental  symptoms. 

Varieties. — Three  forms  are  recognized:  the  infantile,  or  cretinism; 
the  adult,  or  myxoedema  proper;  and  postoperative  myxcedema,  or  cachexia 
strumipriva. 

Etiology. — The  sporadic  form  of  cretinism  is  due  to  the  absence  of 
the  thyroid  or  suppression  of  its  function.  The  endemic  form  occurs  under 
local  conditions  associated  with  goitre,  and  is  encountered  in  parts  of 
France,  Switzerland,  and  Northern  Italy.  The  myxcedema  of  adults  may 
develop  at  any  period  of  life  from  puberty  to  seventy.  More  than  half 
the  cases  begin  between  thirty  and  fifty.  The  disease  is  more  common  in 
females  than  in  males  in  the  ratio  of  about  6  to  1.  In  certain  famihes 
myxcedema  has  been  observed  in  two  generations  and  there  are  numerous 
reports  of  its  occurrence  in  several  members  of  the  same  family.  With 
reference  to  its  geographical  distribution,  it  is  comparatively  common  in 
cold  chmates  and  very  rare  in  the  tropics.  More  cases  have  been  observed 
in  Great  Britain  and  Europe  than  elsewhere.  Many  cases  have  been  recog- 
nized in  America.  It  is  uncommon  in  Philadelphia.  The  colored  races 
are  said  not  to  suffer  from  the  affection.  No  walk  of  life  is  exempt,  though 
it  appears  to  be  more  common  among  the  poor,  a  fact  probably  explained 
by  the  relatively  larger  numbers  constituting  this  class.  It  is  more  fre- 
quent among  married  women  and  especially  among  those  who  have  borne 


MYXCEDEMA. 


1175 


children  than  in  others  and  has  been  thought  to  have  some  relation  to  the 
menopause,  since  many  of  the  cases  begin  about  the  age  at  which  the 
child-bearing  function  ceases.  Occasionally  it  has  followed  symptoms 
of  exophthalmic  goitre.  Postoperative  myxoedema  follows  the  total 
extirpation  of  the  thyroid  and  the  accessory  thyroids.  The  cases  of 
thyroidectomy  to  which  cachexia  has  not  supervened  are  thought  to  have 
been  incomplete,  an  unobserved  portion  of  the  gland  or  accessory  thyroids 
having  remained. 

The  symptoms  of  cretinism  differ  from  those  of  the  adult  form, 
but  those   of   the  latter   and   of  the    postoperative    form    are    identical. 

1.  Cretinism.  ^ — This  affection 
occurs  as  a  sporadic  and  as  an 
endemic  disease.  There  is  retarda- 
tion of  physical  and  mental  develop- 
ment. The  condition  is  not  usually 
recognized  until  toward  the  end  of 
the  first  year,  but  becomes  com- 
pletely developed  in  the  course  of 
the  second  year.  At  this  time  the 
clinical  picture  is  characteristic. 
The  face  is  large,  round,  and  bloated; 
the  eyelids  are  puffy  and  congested; 
the  nose  is  flattened  and  the  alse  are 
thickened  and  coarse;  the  lips  are 
full  and  swollen;  the  tongue  is  large 
and  protrudes  from  the  mouth. 
There  is  constant  drooling.  The 
eruption  of  the  teeth  is  delayed,  and 
they  soon  become  carious.  The 
complexion  is  pasty  and  sallow;  the 
expression  dull  and  fatuous.  The 
fontanelles  remain  open.  The  belly 
is  protuberant,  the  hands  and  feet 
are  clumsy  and  ill-formed,  the  legs 
short,  the  muscles  weak  and  flabby, 
and  the  child  is  unable  to  stand  or 
walk.  The  hair  is  thin  and  brittle  and  the  skin  dry  and  harsh.  The  rectal 
temperature  is  commonly  subnormal  and  there  is  great  sensitiveness  to 
cold.  The  mental  condition  remains  undeveloped.  Speech  is  acquired 
late  and  is  rudimentary.  There  are  various  degrees  of  idiocy.  Older 
cretins  are  dull  and  amiable,  not  often  vicious,  and  present  many  of  the 
characteristics  of  infancy  at  the  age  of  ten  or  fifteen  years.  The  fatty 
tumors  seen  in  the  myxosdema  of  adults  are  very  common. 

Diagnosis. — The  direct  diagnosis  is  unattended  with  difficulty. 
The  facies,  the  retardation  of  physical  and  mental  development,  the  fat 
pads,  and  the  subnormal  temperature  are  distinctive. 

Differential  Diagnosis. — The  early  cases  are  sometimes  mistaken 
for  rickets.  In  the  latter  affection  sweating  of  the  head,  craniotabes, 
restlessness  at  night  in  the  early  stages,  and  special  deformities,  as  the 


Fig.  336. — Cretinism;  female,  9  years  old. — Rotcli. 


1176 


MEDICAL  DIAGNOSIS. 


rosary,  enlargement  of  the  epiphyses  at  the  wrist  and  ankles,  and  bow- 
legs in  the  later  stages,  are  characteristic.  Juvenile  Cretinism. — The  forms 
that  begin  at  the  age  of  five  or  later  in  children  previously  well  nourished 
and  healthy,  in  consequence  of  atrophic  changes  in  the  thyroid  following 
an  acute  febrile  infection,  are  comparatively  rare.  Occasional  cases  of 
transient  mild  cretinism  are  seen  in  children  in  the  second  or  third  year 
and  may  be  ascribed  to  functional  derangements  of  the  thyroid. 

2.  Myxoedema  of  Adults;  Gull's  Disease.  —  As  a  rule,  the  disease 
develops  insidiously;  exceptionally  in  the  case  of  young  adults  it  may  be 
recognizable  in  the  course  of  a  few  weeks.  Languor,  subjective  sensations 
of  cold,  tardiness  of  movement,  change  of  expression  due  to  myxoede- 
matous  infiltration  of  the  subcutaneous  tissues  of  the  face,  and  increase  in 
the  size  and  weight  of  the  body  are  early  symptoms. 

The  following  phenomena  are  characteristic  of  the  fully  developed 
affection:     (a)    Dense,    inelastic   swelling   of   the   skin    and    subcutaneous 


Fig.  337. — a,  adult  type  of  myxoedema.     b,  six  weeks  later;  a  reduction  in  weight  of  20  pounds  under 
thyroid  therapy. — Jefferson  Hospital. 

tissues,  which  does  not  pit  upon  pressure.  This  swelHng  is  general  but  is 
most  marked  in  parts  where  the  subcutaneous  tissues  are  loose.  It  is 
frequently  first  noticed  in  the  face,  sometimes  in  the  lower  extremities 
and  the  backs  of  the  hands,  (b)  A  change  in  the  facies  due  to  the  swelling, 
which  obhterates  the  lines  of  expression.  The  eyelids  are  swollen;  the 
upper  eyelid  tends  to  droop;  the  eyebrows  are  habitually  elevated;  the 
forehead  is  corrugated  by  deep  transverse  wrinkles;  the  nose  thickened 
and  enlarged;  the  cheeks  are  full,  large,  sometimes  pendulous,  and  often 
the  seat  of  a  circumscribed,  pinkish  flush.  The  lips  are  thickened  and 
coarse  and  the  mouth  appears  to  be  enlarged.  Similar  changes  are  seen 
in  the  ears  and  the  parts  about  the  angles  of  the  jaw.  (c)  The  hands  and 
fingers  are  swollen  and  lose  their  expressiveness,  assuming  a  thick,  flat 
shape  which  has  been  described  as  "spade-like."  Similar  changes  take 
place  in  the  feet,  (d)  A  general  increase  in  the  size  and  weight  of  the 
body,  which  may  be  mistaken  for  obesity,  but  which  differs  from  that  con- 
dition in  the  distribution  of  the  swelling  and  the  texture  of  the  tissues. 


MYXCEDEMA.  1177 

(e)  Local  swellings  of  the  skin  and  subcutaneous  tissues,  especially  in  the 
supraclaviculai'  regions  and  in  the  posterior  aspect  of  the  neck.  The  occa- 
sional occurrence  of  fibrofatty  pads  in  the  retroclavicular  spaces  in  healthy 
persons  is  to  be  borne  in  mind,  (f)  Changes  in  the  thyroid  gland,  which 
cannot  be  felt  at  all  or  is  of  uncertain  size  in  many  of  the  cases,  distinctly 
atrophic  in  others,  and  normal  or  increased  in  size  in  a  very  small  propor- 
tion, (g)  Dryness  and  roughness  of  the  skin,  thinness  and  brittleness  of 
the  hair,  and  alopecia  which  affects  not  only  the  scalp  but  the  brows  and 
axillary  and  pudendal  regions.  Similar  atrophic  changes  affect  the  nails, 
which  become  cracked  and  discolored,  while  the  teeth  undergo  rapid  caries 
and  become  loose,  (h)  Subnormal  temperature.  The  range  is  often  con- 
tinuously a  degree  or  more  of  Fahrenheit's  scale  below  normal  and  fre- 
quently several  degrees.  Temperatures  of  95°-93°  F.  (35°-34°  C.)  or  even 
lower  have  often  been  observed.  Remarkable  falls  to  77°  F.  and  66°  F. 
(25°-19°  C.)  have  occurred  before  death,  (i)  Muscular  weakness  and 
slowness  of  voluntary  movements,  (j)  Mental  changes,  especially  slowness 
of  apprehension  and  response,  impairment  of  memory,  sensitiveness,  and 
irritability.  The  speech  is  tardy  and  drawling.  Hallucinations  are  com- 
mon. Fixed  delusions  may  develop,  and  insanity  terminating  in  dementia 
occurs.     Albuminuria  and  glycosuria  occasionally  occur. 

3.  Postoperative  Myxoedema ;  Cachexia  Strumipriva. — The  symp- 
toms are  those  of  the  common  form  in  adults. 

Diagnosis. — The  diagnosis  is  unattended  with  difficulty.  From  renal 
or  cardiorenal  dropsy  myxoedema  is  to  be  differentiated  by  the  character 
of  the  oedema,  its  failure  to  pit  upon  pressure,  the  absence  of  renal  and 
cardiac  lesions,  the  small  thyroid,  low  temperature,  the  mental  symptoms, 
and  the  promptly  remedial  effect  of  thyroid  extract.  From  ordinary  obesity 
the  diagnosis  is  readily  made. 

Prognosis. — Formerly  the  outlook  was  practically  hopeless.  The 
patients  improved  somewhat  in  warm  weather,  but  became  worse  as  the 
cooler  season  approached.  The  course  of  the  disease  was  chronic  and 
progressive,  sometimes  extending  over  a  period  of  ten  or  fifteen  years. 
Death  was  due  to  intercurrent  disease,  very  often  to  tuberculosis.  At 
present  in  a  majority  of  instances  the  prognosis  is  favorable.  Treatment 
by  thyroid  extract  causes  the  symptoms  to  disappear  in  a  few  months, 
and  the  continued  administration  of  this  remedial  principle  maintains 
the  improvement. 

4.  Hypoparathyreosis;  Status  Parathyreoprivus. — These  terms  have 
been  suggested  by  Halsted  to  designate  degrees  of  the  cachexia  caused 
by  the  removal  of  some  or  all  of  the  parathyroid  bodies.  It  may  also  be 
caused  by  the  arrest  of  the  blood  supply  of  those  glandules  in  ligation  of 
the  thryoid  arteries  in  partial  thyroidectomy.  Cachexia  thyreopriva  in 
many  of  the  cases  has  been  a  complex  condition  made  up  of  thyroid  and 
parathyroid  privation. 

Among  the  symptoms  of  cachexia  parathyreopriva  tetany  occupies 
the  first  place.  This  varies  in  degree  from  a  subtetanic  condition  to  the 
most  violent  manifestations  of  postoperative  tetany,  often  terminating 
in  death.  Bleeding,  with  infusion  of  salt  solution  into  the  veins,  the  sub- 
cutaneous or  intravenous  injection  of  an  extract  or  emulsion  of  the  para- 


1178  MEDICAL  DIAGNOSIS. 

thyroid  glands,  and  finally  the  injection  of  a  nucleoproteid  prepared  by 
Beebe  from  an  emulsion  of  parathyroids,  are  followed  by  temporary  relief 
of  the  tetany  in  parathyroidectomized  animals,  and  favorable  results  in 
human  beings  have  been  reported  by  several  observers  abroad  and  by 
Halsted  in  one  case  in  this  country.  Better  and  lasting  results  may  be 
confidently  expected  from  the  transplantation  or  implantation  of  the  living 
parathyroid  gland.  These  glandules  appear  to  play  an  important  part 
in  calcium  metabolism,  since  their  removal  is  followed  by  an  increased 
excretion  of  calcium  and  diminution  of  the  calcium  content  of  the 
tissues.  In  dogs  suffering  from  the  most  violent  postoperative  tetany, 
with  muscular  rigidity,  clonic  spasm,  extremely  rapid  respiration  and 
pulse,  all  the  symptoms  can  be  instantly  dispelled  by  the  injection  of  a 
calcium  salt,  the  acetate  or  lactate,  in  0.5  gramme  doses,  into  the  jugular 
vein  (MacCallum). 

V.  DISEASES  OF  THE  ADRENAL  BODIES. 

General  Considerations. — The  symptomatology  of  disease  of  the  supra- 
renal bodies  is  obscure.  Marked  lesions  of  these  organs  have  been  found 
at  autopsy  in  cases  in  which,  during  life,  no  symptoms  suggestive  of  any 
disease  involving  them  have  been  observed.  In  another  group  of  cases 
tumor,  pressure  symjDtoms,  and  lumbar  and  sacral  pain  have  suggested 
disease  of  these  bodies.  Again  metastatic  growths  in  various  organs  have 
been  ascribed  to  malignant  disease  in  the  suprarenals.  Finally,  a  charac- 
teristic symptom-complex — Addison's  disease — has  been  found  to  be  asso- 
ciated in  a  large  proportion  of  the  cases,  but  not  in  all,  with  definite  lesions 
of  these  organs. 

Addison's  Disease. 

Definition. — A  constitutional  disease,  due  to  modification  or  cessation 
of  the  internal  secretion  of  the  adrenal  glands  in  consequence  of  destruc- 
tive lesions,  usually  tuberculous,  and  characterized  by  asthenia,  gastro- 
intestinal irritability,  and  pigmentation  of  the  skin. 

Etiology.— Predisposing  Influences. — Addison's  disease  .  is  a  rare 
affection.  The  most  common  and  important  predisposing  influence  is 
tuberculosis.  It  is  somewhat  more  common  in  males  than  in  females. 
It  may  occur  at  any  period  of  life,  but  less  frequently  before  twenty  and 
after  sixty  than  in  the  intervening  stages.  Malaria,  alcoholism,  depress- 
ing emotions,  exposure,  and  traumatism  have  been  regarded  as  causes  of 
this  as  of  many  other  diseases.  In  so  far  as  they  predispose  to  tuberculous 
infection  they  may  act  in  this  way. 

Morbid  Anatomy. — Very  common  are  tuberculous  deposits  with 
caseous  changes.  Comparatively  rare  are  atrophy, — either  simple  or  result- 
ing from  chronic  interstitial  changes, — malignant  disease,  and  interstitial 
hemorrhage.  In  a  small  group  of  cases  the  organs  have  been  found  normal, 
but  inflammatory  or  pressure  changes  have  been  present  in  the  semilunar 
ganglia.  Cicatricial  tissue  implicating  the  semilunar  ganglia  and  adrenals, 
together  with  sclerotic  and  pigmentary  changes  in  the  nerves,  is  not 
uncommon.     The  thyroid  gland  in  the  absence  of  cancerous  infiltration  is 


ADDISON'S  DISEASE. 


1179 


usually  small;    the  thymous  sometimes  persistent;    the  spleen  enlarged  or 
the  seat  of  amyloid  change. 

Pathology. — Two  principal  hypotheses  have  been  advanced:  1.  That 
Addison's  disease  is  an  affection  of  the  abdominal  sympathetic  system 
caused  by  disease  involving  the  suprarenal  bodies,  or  the  solar  plexus  or 
semilunar  ganglia.  2.  That  it  is  the  result  of  loss  of  the  function  of  the 
suprarenals.  The  theory  of  an  internal  secre- 
tion essential  to  normal  metabolism  now 
appears  to  be  fully  established. 

Symptoms.^ — The  onset  is  usually  insid- 
ious. Little  has  been  added  to  the  descrip- 
tion of  Addison, — "  Anaemia,  general  languor 
or  debility,  remarkable  feebleness  of  the 
heart's  action,  irritability  of  the  stomach, 
and  a  peculiar  change  of  color  in  the  skin." 
This  description  may  be  somewhat  amplified. 

1.  Asthenia. — The  first  symptom  is 
commonly  a  sense  of  fatigue  in  the  per- 
formance of  every-day  accustomed  duties. 
Fatigue  symptoms,  at  first  intermittent, 
soon  become  constant.  Weakness  is  both 
muscular  and  circulatory.  This  may  be 
marked,  while  the  muscles  still  feel  firm  and 
the  general  nutrition  and  weight  are  pre- 
served. The  cardiac  asthenia  may  be  parox- 
ysmal and  lead  to  attacks  of  vertigo  or 
syncope.  Headache  is  common  and  pain 
in  the  loins  may  be  an  early  and  suggestive 
symptom. 

The  examination  of  the  blood  has 
yielded  variable  results.  Anaemia  is  by  no 
means  a  constant  phenomenon. 

Mental  dulness  is  frequently  observed. 

2.  Disturbances  of  the  Digestive 
Organs. — These  appear  gradually.  Ano- 
rexia, epigastric  distress,  nausea  and  vom- 
iting, and  attacks  of  diarrhoea  without 
obvious  cause  occur  with  varying  promi- 
nence in  a  majority  of  the  cases  throughout 
the  course  of  the  disease.  In  a  small  proportion  of  the  cases  they  are 
absent.  Epigastric  and  abdominal  pain  are  common  toward  the  end. 
Gastro-intestinal  symptoms  may  occur  early. 

3.  Pigmentation  of  the  Skin. — Sooner  or  later  a  dark  pigmentation 
of  the  skin  appears.  In  many  cases  this  is  the  first  symptom  to  attract 
attention.  The  pigment  accumulation  is  gradual.  The  affected  portions 
of  the  skin  are  at  first  yellowish-  or  grayish-brown  and  later  become  brown 
or  even  blackish.  The  discoloration  in  well-marked  cases  is  diffuse  but 
never  uniform.  It  usually  begins  in  the  parts  exposed  to  the  light  and  in 
those  normally  the  seat  of  pigment  deposits,  and  is  deepest  in  those  areas 


Fig 


338.  —  Addison's    disease;    s 
distribution  of  bronzing. 


1180  MEDICAL  DIAGNOSIS. 

and  in  regions  subjected  to  the  habitual  pressure  of  the  clothing.  The 
face,  backs  of  the  hands,  nipples  and  their  areolae,  the  genitalia,  axillary 
folds,  and  parts  pressed  by  the  waistband,  garters,  and  collar  are  especially 
pigmented.  There  may  be  diffuse  patches  of  deep  discoloration  with 
indistinct  borders,  or  small  dark  pigment  areas  with  well-defined  borders 
upon  a  less  deeply  pigmented  surface.  Patches  of  leucoderma  are  occa- 
sionally seen.  The  mucous  membranes  of  the  lips  and  mouth  are  frequently 
the  seat  of  an  irregular  patchy  pigmentation.  Less  commonly  a  similar 
discoloration  affects  the  conjunctivae  or  the  vaginal  mucosa.  The  course 
of  the  disease  is  essentially  chronic,  and  marked  by  normal  or  subnormal 
temperature,  subjective  sensations  of  cold,  suppression  of  menstruation, 
and  the  gradual  development  of  cachexia.  Urinary  changes  are  incon- 
stant. Increased  pigments  have  been  observed.  Dropsy  is  rare.  Death 
may  occur  early  in  the  disease  from  sudden  syncope.  More  commonly 
it  is  the  result  of  progressive  asthenia  or  advancing  tuberculous  lesions. 
It  is  sometimes  preceded  by  acute  toxaemic  phenomena,  urgent  vomit- 
ing and  diarrhoea,  delirium  with  motor  excitement,  and  convulsions  fol- 
lowed by  coma. 

Diagnosis. — Direct. — A  positive  diagnosis  may  be  made  from  the 
association  of  the  following  symptoms:  general  languor  and  debility, 
remarkable  feebleness  of  the  heart's  action,  irritability  of  the  stomach 
and  irregular  diarrhoea,  a  peculiar  pigmentation  of  the  skin  and  mucous 
membranes.  In  the  early  stages  the  diagnosis  may  be  impossible.  It  is 
to  be  borne  in  mind  that  Addison's  disease  may  occur  without  pigmentation. 

The  mere  presence  of  pigmentation  does  not,  however,  warrant  a 
diagnosis  of  Addison's  disease.  It  may  occur  in  the  following  conditions: 
physiological  peculiarities  due  to  racial  and  climatic  influence;  accidental 
pigmentation  of  the  skin  and  mucous  membranes  in  persons  otherwise 
healthy;  the  mild  cutaneous  pigmentation  of  aged  persons;  chronic 
malaria;  various  cachectic  states,  especially  those  due  to  cancer  and 
tuberculosis;  pellagra;  leukaemia;  as  the  result  of  scratching  in  various 
chronic  skin  diseases  attended  by  itching — prurigo,  eczema,  phthiriasis; 
diffuse  melanosarcoma  of  the  skin;  rare  cases  of  exophthalmic  goitre; 
scleroderma;  pregnancy  and  uterine  disease;  haemochromatosis  such  as 
may  occur  in  rare  cases  in  association  with  hypertrophic  cirrhosis  of  the 
liver  and  diabetes  mellitus — diabete  bronze;  certain  cases  of  pancreatic 
disease;  chronic  arsenical  poisoning;  and  argyria.  Chronic  jaundice  has 
been  confounded  with  the  pigmentation  of  Addison's  disease,  an  error  that 
ought  not  to  occur.  Much  difficulty  attends  the  recognition  of  the  actual 
condition  when  jaundice  develops  in  the  course  of  the  disease  and  is 
associated  with  abnormal  pigmentation. 

Differential. — In  a  doubtful  case  the  foregoing  conditions  must  be 
successively  excluded  as  the  cause  of  pigmentation  by  the  systematic 
application  of  the  rules  of  diagnosis,  and  the  presence  of  asthenia,  cardiac 
weakness,  and  gastro-intestinal  symptoms  determined  before  a  positive 
diagnosis  is  made.  In  view  of  the  tuberculous  nature  of  the  suprarenal 
disease  in  the  majority  of  the  cases  the  tuberculin  test  may  be  employed. 

Prognosis. — The  disease  is  probably  always  fatal.  The  rare  reported 
recoveries  have  been  ascribed  to  errors  in  diagnosis,  or  the  mistaking  of  a 


ACROMEGALY.  1181 

prolonged  remission  such  as  sometimes  occurs  in  the  very  chronic  cases  for 
an  actual  recovery  from  the  disease.  Cases  unattended  by  bronzing  of 
the  skin  are  often  rapidly  fatal.  The  average  duration  is  about  two  years. 
There  are  exceptional  cases  of  very  long  duration — ten  to  thirteen  years. 

VI.  ACROMEGALY. 

Definition. — A  trophic  disease  characterized  by  symmetrical  over- 
growth in  the  soft  parts  and  bones  of  the  face  and  extremities,  with 
deformities  of  the  spinal  column  and  thorax. 

Etiology. — Predisposing  Influences. — It  is  a  disease  of  early  adult 
life,  most  of  the  cases  having  first  shown  themselves  in  the  third  decade. 
No  case  has  been  noted  at  an  earlier  age  than  twenty,  and  in  only  a  few 
has  the  onset  occurred  after  thirty-five.  Males  and  females  are  equally 
liable,  with  the  exception  that  in  cases  beginning  at  a  late  period  more 
women  suffer.  The  disease  is  not  common  but  its  geographical  distribu- 
tion is  wide.  Many  of  those  who  suffer  from  acromegaly  w^ere  persons  of 
previously  large  growth. 

The  EXCITING  CAUSE  is  wholly  unknown.  The  etiological  part  often 
assigned  to  trauma  and  psychic  stress  has  no  basis  in  fact.  Nor  can  any 
causal  relation  between  acromegaly  and  the  acute  or  chronic  infections  be 
demonstrated. 

Symptoms. — The  disease  develops  gradually,  the  early  symptoms 
consisting  of  lassitude  and  vague  pains,  and  abnormal  sensations — parces- 
thesice — in  the  head  and  extremities.  Amenorrhcea  and  impotence  are 
very  common.  The  characteristic  anatomical  changes  are  first  noticed  in 
the  face.  The  lines  of  expression  are  altered  and  the  countenance  is  dis- 
torted. The  skull  is  enlarged;  the  superciliary  ridges  are  very  marked  and 
prominent;  the  zygomatic  arches  protrude,  and  there  is  remarkable  hyper- 
trophy of  the  upper  and  lower  jaw  bones,  the  latter  projecting  in  a  con- 
spicuous manner.  The  alveolar  processes  are  similarly  enlarged  and  the 
teeth  are  separated.  The  soft  parts  undergo  corresponding  and  even  more 
marked  changes.  The  eyebrows  are  bushy  and  thick  and  almost  meet  in 
the  median  line;  the  eyelids  are  greatly  thickened;  the  nose  is  conspicuously 
enlarged;  the  ears  are  enormously  hypertrophied;  and  the  lips  swollen. 
Some  degree  of  exophthalmus  is  often  present  and  may  vary  in  extent  from 
time  to  time.  Enlargement  of  the  tongue  is  a  very  common  lesion.  This 
organ  attains  in  some  cases  such  dimensions  that  it  is  impossible  to  close 
the  mouth.  Similar  and  progressively  increasing  deformities  involve  the 
hands  and  feet,  and  are  rendered  especially  noticeable  by  the  relatively 
small  size  of  the  arms  and  legs,  which  do  not  share  to  any  marked  extent 
in  the  enlargement  of  the  extremities.  The  thickening  affects  alike  the 
bones  and  soft  parts,  and  while  not  greatly  interfering  with  the  functions 
of  the  hands,  causes  the  remarkable  appearance  described  as  spade-like. 
The  nails  are  broadened  but  not  incurvated  and  the  drum-stick  bulbous 
enlargement  of  pulmonary  osteo-arthropathy  is  not  seen.  The  feet  are 
generally  enlarged,  the  great  toe  being  especially  increased  in  size.  The 
skin  of  the  affected  parts  commonly  preserves  its  natural  appearance. 
In  some  instances,  however,  it  becomes  coarse  and  pigmented.     As  the 


1182 


MEDICAL  DIAGNOSIS. 


disease  advances  the  spine  becomes  affected.  There  are  hyperostoses  and 
exostoses  of  the  vertebral  processes,  ankylosis  of  the  vertebrae,  and  kypho- 
sis. The  clavicles  are  enlarged  and  there  is  a  gradual  enlargement  of 
the  ribs.  The  thyroid  body  may  be  atrophied  or  hypertrophied,  but 
such  changes  are  not  constant.  There  are  cases  in  which  the  thymus  is 
enlarged.  In  a  very  large  proportion  of  autopsies — 73  in  77 — the  hypoph- 
ysis cerebri  has  been  found  to  be  affected. 
Very  often  it  has  been  increased  in  size,  some- 
times to  that  of  an  egg.  Sometimes  the  increase 
is  in  an  upward,  sometimes  in  a  downward  direc- 
tion. The  histological  changes  are  not  constant. 
Glandular  hyperplasia,  softening,  cystic  degenera- 
tion, and  fibrosis  are  described.  Many  of  the  cases 
have  been  regarded  as  malignant.  Symptoms 
suggestive  of  cerebral  tumor,  namely,  headache, 
vertigo,  somnolence,  are  not  infrequent.  Ocular 
symptoms,  bitemporal  hemianopia,  optic  atrophy, 
and  oculomotor  palsies  occur.  The  great  frequency 
with  which  lesions  of  the  hypophysis  have  been 
found  lends  support  to  the  hypothesis  that  this 
organ  is  the  source  of  an  internal  secretion  by 
which  the  growth  of  the  body  is  regulated,  and 
that  acromegaly  is  the  result  of  some  vitiation  or 
defect  in  that  secretion. 

Diagnosis. — The  direct  diagnosis  of  acromeg- 
aly is  unattended  with  difficulty.  In  no  other 
affection  do  similar  anatomical  changes  in  the 
bones  and  soft  parts  occur.  The  differential 
diagnosis  from  gigantism  depends  ujjon  the  specific 
nature  of  the  changes  in  acromegaly,  and  the  fact 
that  they  are  for  a  long  time  chiefly  confined  to 
the  face  and  extremities,  the  vertebral  column 
and  thorax  being  later  involved.  It  is  never- 
theless true  that  acromegaly  frequently  develops 
in  persons  of  large  frame.  From  the  rare  cases  of 
progressive  overgrowth  of  one  member  or  a  part 
of  it,  or  of  one  side  of  the  body,  acromegaly  is  to  be  distinguished  by 
the  fact  that  the  hypertrophies  are  symmetrical  and  chiefly  confined  for 
a  long  period  to  the  face  and  extremities. 

Prognosis. — The  disease  may  run  a  chronic,  progressive  course  of  a 
score  or  more  of  years.  There  are  cases  which  terminate  in  death  in  four 
or  five  years.  Restoration  to  normal  conditions  does  not  occur.  A  majority 
of  the  cases  die  of  some  intercurrent  affection,  as  diabetes,  cancer,  or 
croupous  pneumonia. 


Fig.  339.  —  Acromegaly  ; 
diabetes  mellitus;  in  a  woman 
aged  46. — Jefferson  Hospital. 


MYOCARDITIS.  1183 

XIII. 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

DISEASES  OF  THE  HEART. 

I.  ABNORMAL  POSITIONS  OF  THE  HEART. 

Congenital  displacement  is  rare.  It  occurs  in  general  transversus  vis- 
cerum.  The  apex  lies  to  the  right;  the  right  ventricle  toward  the  ante- 
rior chest  wall;  the  left  ventricle  behind  it;  while  the  pulmonary  artery 
lies  at  the  right  border  and  the  aorta  at  the  left  border  of  the  sternum. 
Transposition  of  the  heart  alone — dextrocardia — is  usually  associated  with 
complicated  developmental  anomalies  affecting  both  the  arteries  and 
chambers.  The  heart  is  displaced  to  the  left  in  congenital  arrest  of  de- 
velopment of  the  left  lung.  Children  with  complete  defect  of  the  anterior 
chest  wall  and  abdomen  with  protrusion  of  the  heart — ectopia  cordis — 
are  usually  stillborn  or  die  shortly  after  birth.  When  there  is  merely  a 
fissure  of  the  sternum  caused  by  defective  development  of  the  manubrium 
and  body,  the  heart  remains  in  its  normal  position  and  may  be  studied 
through  the  overlying  soft  tissues. 

Acquired  displacements  are  far  more  common  and  of  greater  diagnostic 
significance.  Sudden  death  which  sometimes  occurs  in  massive  pleural 
effusions  has  been  ascribed  to  abrupt,  angular  bending  or  twisting  of  the 
inferior  vena  cava.  The  upward  displacement  of  the  heart,  which  occurs 
in  the  retraction  of  the  lungs  in  patients  long  bed-ridden,  or  in  meteorism, 
ascites,  pregnancy,  and  large  abdominal  tumors,  may  lead  to  an  erroneous 
diagnosis  of  dilatation  of  the  heart.  The  high  position  of  the  apex  and  of 
the  inferior  border  of  the  lung  are  significant.  Large  subphrenic  abscesses 
displace  the  heart  toward  the  opposite  side  and  thus  increase  the  resemb- 
lance to  empyema,  while  a  massive  spleen,  as  in  leukaemia,  displaces  the 
apex  upward  and  outward. 

The  displacements  of  the  heart  toward  the  sound  side  in  pleural  effu- 
sions and  pneumothorax,  and  toward  the  affected  side  in  the  contraction 
of  the  lung  after  resorption  of  a  large  pleural  exudate,  or  in  fibroid  phthisis, 
are  too  familiar  to  lead  to  diagnostic  errors.  The  fact  that  the  displaced 
heart,  in  consequence  of  adhesions,  occasionally  remains  upon  the  sound 
side  is  less  generally  understood.  In  pulmonary  emphysema  the  disloca- 
tion of  the  heart  is  downward.  Aneurisms  of  the  ascending  and  transverse 
portions  of  the  arch  of  the  aorta  displace  the  heart  downward  and  toward 
the  left. 

II.  DISEASES  OF  THE  MYOCARDIUM, 
i.  Acute  Myocarditis. 

Definition. — Acute  inflammation  of  the  wall  of  the  heart.  Patho- 
logically parenchymatous  and  interstitial  forms  are  recognized.  There  is 
cell  infiltration  of  the  interstitial  tissue,  associated  with  granular,  fatty, 


1184  MEDICAL  DIAGNOSIS. 

and  hyaline  degeneration  of  the  muscle  fibres,  and  loss  o'i  their  contractile 
elements.  There  are  three  varieties:  1.  Primary  Acute  Myocarditis. — 
In  the  absence  of  any  recognized  cause,  or  after  a  wetting,  the  symptoms 
of  an  acute  interstitial  inflammation  of  the  myocardium  develop  with 
irregular  fever  and  great  weakness,  and  after  a  course  of  several  days 
or  a  week  or  two  terminate  in  death.  Primary  acute  myocarditis  is 
an  exceedingly  rare  affection,  the  occurrence  of  which  as  a  separate 
disease  has  been  questioned.  2.  Secondary  Acute  Myocarditis. — 
This  variety  occurs  in  the  course  of  or  during  the  convalescence  from 
many  of  the  specific  infectious  diseases.  3.  Acute  Septic  Myocarditis. 
— In  a  majority  of  the  cases  infection  of  the  myocardium  takes  place 
by  way  of  the  coronary  arteries.  There  are  commonly  multiple  miliary 
abscesses.  In  other  instances  abscess  formation  follows  the  direct  inva- 
sion of  the  heart  muscles  from  the  valvular  or  mural  lesions  of  a  septic 
endocarditis. 

Etiology. — Predisposing  Influences. — These  are  wholly  unknown. 
No  plausible  explanation  of  the  fact  that  the  myocardium  suffers  in  some 
cases  of  infectious  disease  and  sepsis,  and  escapes  in  others,  has  yet  been 
adduced.  There  is  nothing  in  age,  sex,  or  previous  health  to  account  for 
this  difference.  Acute  secondary  myocarditis  occurs  in  diphtheria,  enteric 
and  typhus  fevers,  scarlet  fever,  rheumatic  fever,  variola,  and  gonorrhoea! 
infection.  It  is  especially  frequent  in  association  with  diphtheria.  The 
septic  form  is  less  common. 

Exciting  Cause. — The  primary  form  has  followed  cold  and  exposure 
and  traumatism  to  the  left  chest.  The  local  action  of  specific  toxins,  the 
arrest  of  minute  infected  emboli  in  the  branches  of  the  coronary  arteries, 
and  direct  bacterial  invasion  from  the  endocardium  are  the  immediate 
causes  of  the  myocardial  inflammation. 

Symptoms.^ — The  clinical  manifestations  are  usualh^  obscured  by  those 
of  the  primary  affection.  Profound  cardiac  asthenia  manifests  itself  by 
feeble  heart  sounds,  a  scarcely  perceptible  radial  pulse,  arrhythmia,  and 
acute  dilatation.  Sudden  increase  of  pallor,  apathy,  somnolence,  and  pre- 
cordial distress  occur.  Vomiting  is  common  and  sometimes  urgent.  In 
some  cases  there  is  restlessness  and  agitation;  in  others  subjective  sensa- 
tions are  absent  and  the  gravity  of  the  complication  reveals  itself  only  by 
the  objective  manifestations. 

Diagnosis. — Direct. — The  diagnosis  must,  in  a  majority  of  the  cases, 
be  a  provisional  one.  Only  in  the  light  of  later  events,  often  at  a  remote 
period  in  cases  that  have  recovered,  can  the  cause  of  the  grave  cardiac 
symptoms  during  the  acute  attack  be  recognized.  The  symptoms  of  chronic 
myocardial  changes  in  an  individual  who  has  passed  through  a  grave  attack 
of  one  of  the  febrile  infections  are  significant. 

Differential. — The  intensity  of  the  process  varies.  The  average 
cases  are  to  be  differentiated  from  the  acute  cardiac  asthenia  of  influenza 
by  the  rapidity  with  which  the  latter  develops  and  the  peculiar  psychic 
manifestations  with  which  it  is  so  frequently  associated;  from  acute  cardiac 
exhaustion  from  overwork  or  athletic  excesses  by  the  history  of  the  case  ; 
and  from  all  of  these  by  their  occurrence  in  the  absence  of  especial  exposure 
to  wet  and  cold,  or  of  an  acute  infection,  or  of  sepsis. 


MYOCARDITIS.  1185 

Prognosis. — The  outlook  depends  largely  upon  that  of  the  primary 
disease,  to  which  the  complication  adds  additional  gravity.  In  diphtheria 
it  is  extremely  grave;  in  gonorrhceal  infection  scarcely  less  so.  In  rheu- 
matic fever  it  is  more  favorable,  and  in  that  form  which  occurs  in  the  con- 
valescence from  enteric  fever  and  scarlatina  recovery  is  the  rule.  The 
prognosis  in  the  septic  cases  is  unfavorable.  The  danger  of  sudden  death, 
even  in  cases  in  which  the  symptoms  are  of  moderate  grade,  is  always  to 
be  considered.  It  is  probable  that  the  sudden  death  which  occasionally 
occurs  in  the  late  convalescence  of  croupous  pneumonia  is  due  to  acute 
myocarditis. 

ii.  Chronic  Myocarditis. 

Chronic  Insufficiency  of  the  Heart  Muscle;    Myodegeneratio  Cordis. 

Definition. — Chronic  inflammation  of  the  heart  muscle,  characterized 
anatomically  by  round-celled  infiltration  of  the  interstitial  connective 
tissue,  followed  by  fibrosis  and  parenchymatous  degeneration  of  the  mus- 
cular fibres,  and  clinically  by  impairment  of  the  function  of  the  heart. 

Etiology. — Predisposing  Influences. — Chronic  myocarditis  in  its 
simplest  form  is  a  late  manifestation  of  acute  myocarditis  in  cases  that 
survive.  From  this  point  of  view  the  acute  infections  constitute  pre- 
disposing influences  of  great  importance.  It  is  especially  common  after 
rheumatic  fever,  occurring  occasionally  in  cases  without  valvular  disease, 
and  being,  to  some  extent  at  least,  a  constant  accompaniment  of  chronic 
valvular  disease.  It  often  has  its  beginning  in  extensive  pericardial  ad- 
hesions. It  may  follow  diphtheria,  enteric  fever,  variola,  scarlet  fever, 
gonorrhoea,  and  the  septic  cases  in  which  recovery  as  to  the  general  condi- 
tion takes  place.  Chronic  myocarditis  very  rarely  has  its  origin  in  the 
lesions  of  syphilis.  It  is  met  with  in  chronic  alcoholism  and  in  saturnine 
intoxication.  Arteriosclerosis,  gout,  and  chronic  renal  disease  especially 
predispose  to  this  form  of  myocarditis.  Habitual  overstrain  of  the  heart, 
such  as  occurs  in  athletes  and  those  who  follow  laborious  occupations,  as 
stevedores,  iron  workers,  coal  passers,  and  the  like,  is  a  predisposing  influ- 
ence of  great  importance;  nor  can  we  overlook  the  part  played  by  pro- 
longed mental  stress  and  depressing  emotions.  When  to  any  of  the  fore- 
going factors  are  added  improper  and  insufficient  food,  on  the  one  hand, 
or,  on  the  other  hand,  a  sedentary  life  and  habitual  overeating,  the  danger 
of  mj^ocarditis  is  greatly  increased. 

In  the  great  majority  of  the  cases  the  symptoms  first  appear  after  the 
fortieth  year.  They  may  occur  at  a  much  earlier  period.  The  insufficiency 
of  the  heart  following  the  acute  infections  with  or  without  valvular  disease 
is  due  to  myocardial  lesions.  The  average  age  of  first  manifestations  in  the 
adult  is  later  in  women  than  in'  men.  Men  suffer  more  commonly  than 
women,  a  fact  in  harmony  with  the  different  modes  of  living  in  the  sexes 
in  early  and  middle  adult  life.  Several  active  predisposing  influences  are 
frequently  present  in  the  same  case. 

Exciting  Cause. — The  immediate  causes  are,  (1)  a  disproportion 
between  the  power  of  the  heart  and  the  work  which  it  is  called  upon  to 
perform,   (2)  infectious,  and  (3)  toxic.     These  may  be  active  in  various 

75 


1186  MEDICAL  DIAGNOSIS. 

combinations.  It  is  not  always  possible  to  determine  the  actual  cause 
or  even  to  ascertain  that  which  predominates. 

Symptoms. — The  clinical  picture  is  a  variable  one.  Its  fundamental 
characters  depend  upon  a  single  pathological  condition,  namely,  cardiac 
inadequacy.  The  want  of  power  varies  in  degree.  It  may  be  shght  and 
only  manifest  upon  unusual  effort,  or  so  great  that  the  circulation  fails  to 
meet  the  ordinary  needs  of  the  organism  at  rest.  An  early  and  an  advanced 
stage  have  been  described.  This  division  is  misleading,  since  the  disease 
is  not  always  progressive,  and  there  are  cases  in  which  the  early  stage  is 
absent  or  the  advance  of  the  disease  so  rapid  that  the  beginnings  are  not 
recognized,  and  cases  in  which  periods  of  improvement  occur,  and,  finally, 
a  small  proportion  of  cases  in  which,  after  a  time,  an  actual  recovery  takes 
place.  According  as  the  grade  of  the  fibrosis  and  degeneration  and  their 
extent  vary,  so  varies  the  intensity  of  the  symptoms.  Furthermore,  the 
range  of  symptoms  varies  according  to  the  anatomical  and  physiological 
peculiarities  of  the  individual,  the  integrity  of  his  organs,  and  condition  of 
his  nervous  system. 

In  the  beginning  the  attention  of  the  patient  is  aroused  by  subjective 
symptoms,  as  palpitation,  precordial  distress,  or  pain  and  oppression  induced 
by  physical  or  mental  effort.  In  another  group  of  cases,  after  repeated 
mild  attacks  of  angina  or  a  single  severe  attack,  the  general  symptoms  of 
cardiac  insufficiency  develop.  Moderate  effort,  the  daily  work,  mounting 
stairs,  cHmbing  a  gentle  ascent,  a  generous  meal,  cause  oppression  and 
shortness  of  breath.  Presently  in  many  cases  a  moderate  dyspnoea  persists. 
Epigastric  weight,  loss  of  appetite,  constipation  or  diarrhoea,  and  slight 
pretibial  oedema  mark  an  advance  in  the  progress  of  the  malady.  Loss 
of  strength,  anaemia,  emaciation,  dizziness,  and  syncopal  attacks  may  now 
occur.  The  grave  symptoms  consist  of  continuous  dyspnoea  of  greater  in- 
tensity and  interrupted  by  asthmatic  attacks,  icterus,  ohguria,  albuminuria, 
increasing  oedema,  and  effusions  into  the  serous  sacs.  The  pallor  becomes 
more  marked,  and  cyanosis  varying  in  degree  appears  around  the  lips  and 
at  the  finger-tips.  The  nervous  symptoms  are  intensified.  Palpitation,  pre- 
cordial pain,  and  oppression  may  be  continuous  or  recur  in  alarming  par- 
oxysms. Complications  are  frequent  and  in  many  cases  terminal.  The 
more  common  are  bronchitis  and  bronchopneumonia.  Less  frequent  are 
inflammations  of  the  serous  membranes,  pleurisy,  pericarditis,  and  peri- 
tonitis. At  any  period  in  the  course  of  the  disease  blood-stained  sputa  may 
be  noted. 

Physical  Signs. — Early  in  the  disease  the  signs  of  moderate  dilatation 
of  the  left  ventricle  and,  to  a  less  extent,  of  the  right  ventricle  are  apparent. 
In  many  of  the  cases,  however,  and  especially  in  those  in  which  the  signs 
of  valvular  disease  are  absent,  and  those  characterized  by  angina  pectoris, 
the  heart  is  not  enlarged.  With  improvement  in  the  general  symptoms, 
the  early  dilatation  of  the  heart  usually  disappears.  The  sounds  may  be 
for  a  long  time  normal.  In  some  cases  the  first  sound  is  accompanied  by  a 
faint  inconstant  murmur  and  the  second  pulmonary  is  accentuated;  or 
again  a  mitral  systolic  murmur,  sometimes  indistinct  and  soft,  sometimes 
loud  and  well  marked,  accompanies  or  replaces  the  first  sound — the  murmur 
of  muscular  mitral  insufficiency.     This  murmur  sometimes  has  a  musical 


MYOCARDITIS.  1187 

quality.  Other  murmurs  are  not  common  in  the  milder  cases  of  myocar- 
ditis. In  the  graver  cases  dihatation  to  the  left  and  upward,  and  usually 
toward  the  right,  is  almost  constant.  The  transverse  dulness  is  increased 
and  the  ajoex  beat  displaced  to  the  left  and  slightly  upward.  The  enlarge- 
ment of  the  heart  frequently  increases  and  diminishes  in  accordance  with 
the  varying  intensity  of  the  symptoms,  but  a  return  of  the  heart  to  its 
normal  size  is  no  longer  to  be  hoped  for.  Upon  auscultation  the  increased 
muscular  insufficiency  is  manifest  in  a  well-characterized  mitral  systolic 
murmur,  which  after  a  time  is  associated  with  a  tricuspid  systolic  murmur. 
Very  rarely  a  faint  aortic  diastolic  murmur  may  be  recognized.  These 
murmurs  in  many  cases  undergo  rapid  changes,  corresponding  to  the  degree 
of  dilatation  with  the  gain  or  loss  in  the  power  of  the  heart,  and  sometimes 
wholly  disappear.  In  other  cases  they  are  persistent,  and,  when  associated 
with  hypertrophy,  as  in  chronic  nephritis,  they  cannot  always  be  differenti- 
ated from  the  murmurs  of  organic  valvular  disease. 

The  pulse  is  usually  weak  and  small.  Sometimes,  especially  in  the 
form  of  chronic  myocarditis  associated  with  interstitial  nephritis,  it  shows 
increased  tension.  Its  frequency  is  much  increased  by  moderate  exertion. 
In  a  majority  of  the  milder  cases  arrhythmia  does  not  occur;  exceptionally 
it  is  an  early  sign.  In  a  small  proportion  of  the  cases  the  pulse  is  slow. 
As  the  insufficiency  becomes  more  marked  the  pulse-frequency  augments 
and  arrhythmia  appears.  The  latter  is  often  of  high  grade,  both  as  to  the 
time  of  the  beats  and  as  to  their  force.  The  inequality  of  the  ventricular 
contractions  is  such  that  many  of  them  fail  to  transmit  the  pulse-wave 
to  the  radials,  so  that  the  pulse  counted  at  the  wrist  is  less  frequent  than 
the  impulse  counted  at  the  apex. 

The  following  forms  demand  separate  consideration:  The  Inflam- 
matory Form. — The  symptoms  are  those  already  described.  The  affec- 
tion occurs  as  a  later  stage  of  acute  myocarditis,  showing  itself  in  some 
instances  during  the  convalescence  from  the  primary  disease;  in  others 
not  until  a  remote  period.  There  are  cases  in  which  recovery  takes  place. 
In  this  connection  it  is  to  be  noted  that  fibroid  degeneration  is  sometimes: 
the  reparative  process  by  which  destructive  lesions  are  corrected.  The; 
Form  Due  to  Diseases  of  the  Coronary  Arteries. — Sclerosis  of  the 
Coronary  Arteries. — The  lesion  consists  chiefly  of  a  thickening  of  the  intima. 
It  is  either  diffuse  or  circumscribed,  and  leads  to  narrowing  of  the  lumen 
of  the  affected  vascular  twigs.  The  left  coronary  artery  and  its  branches 
are  involved  much  more  commonly  and  to  a  greater  extent  than  the  right. 
When  the  narrowing  of  the  lumen  is  of  high  grade,  or  there  is  complete 
occlusion  of  the  affected  vessels,  infarction  of  the  heart  muscle — myomalacia 
cordis  (Ziegler) — occurs.  The  necrotic  focus  is  invaded  by  connective- 
tissue  elements  and  converted  into  a  fibroid  cicatrix.  There  may  be  a 
diffuse  increase  of  the  interstitial  tissue.  This  variety  of  chronic  myocar- 
ditis presents  symptoms  of  muscular  insufficiency,  but  is  especially  char- 
acterized by  a  tendency  to  angina  pectoris  and  so-called  cardiac  asthma, 
a  special  liability  to  precordial  pain,  and  the  signs  of  narrowing  of  the 
aortic  orifice.  In  fact,  arteriosclerosis  of  the  coronary  arteries  is  very 
commonly  associated  with  similar  pathological  changes  in  the  aortic  valves 
and  the  beginning  of  the  vessel  itself.     A  systolic  aortic  murmur,  usually 


1188  MEDICAL  DIAGNOSIS. 

not  so  loud  and  coarse  nor  beginning  so  promptly  with  the  systole  as  in 
pure  valvular  stenosis,  and  followed  by  a  well-marked,  even  accentuated, 
second  sound,  is  usually  heard.  Dulness  to  the  right  of  the  sternum  in  the 
second  and  third  interspaces  and  jugular  pulsation  are  associated  signs. 
Embolism  and  Thrombosis  of  the  Coronary  Arteries. — These  lesions  cause 
myocardial  infarct.  Thrombosis  may  result  from  sclerosis;  embolism 
from  various  forms  of  infection,  or  very  rarely  from  fragments  of  athero- 
matous plates.  Death  directly  follows  the  closure  of  the  coronary  artery 
at  its  origin.  Elsewhere  the  occlusion  of  the  artery  is  follow^ed  by  infarc- 
tion and  death  after  several  days  or,  in  rare  cases  in  which  the  extent  of 
the  softening  is  limited,  by  recovery.  The  local  necrosis  may  lead  to  rup- 
ture of  the  heart.  The  changes  in  the  heart  muscle  depend  upon  the  extent 
and  degree  of  the  sclerosis  and  the  rapidity  with  which  the  blood  supply 
to  the  muscle  is  arrested. 


Carotid 


Cardiac  Aj>  ex'  ^^^^-^^ 

.►.    h     h    h    h     r;    h    >v    T'     "     ^     f     >■''''     ^     ■'     r.     :t    h     ^     K    h  -h ti__''_'u_j*\ .^ !l ll \-i-—i'. — h — h_A_h — h__/i._.>u_n — .\_J'_'i 

Tiwie   ^^TO"  ■ ^^ 


Fig    340  — ^Tracing  of  the  carotid  arterv  and  cardiac  apex  in  chronic  myocarditis  showing  irregularity  in 
time' and  in  force.  *  Ventricular  contraction  not  of  sufficient  strength  to  produce  a  distinct  carotid  wave. 

General  Arteriosclerosis  in  Chronic  Myocarditis.  —  Habitual 
increase  in  the  arterial  blood-pressure  is  an  important  cause  of  chronic 
myocarditis.  Prolonged  muscular  exertion,  toxic  substances,  and  arterio- 
sclerosis alone  or  associated  with  chronic  disease  of  the  kidneys  are  potent 
factors.  The  changes  in  the  myocardium  develop  gi-aduahy,  and  the  symp- 
toms and  course  of  the  disease  are  not  different  from  those  of  the  ordinary 
form.  Middle-aged  men  who  have  lived  well  suffer  from  this  form  and  the 
early  symptoms  in  such  cases  are  usually  abdominal— fulness,  weight, 
flatulence,  and  constipation. 

Syphilis  of  the  Heart. — Single  or  multiple  gummata  are  very  rare. 
Diffuse  interstitial  myocarditis  is  more  common.  SyphiHs  of  the  heart 
may  be  congenital  or  acquired.  In  the  acquired  form  it  is  usually  a  tertiary 
maiaifestation.  The  condition  is  very  often  latent,  but  when  well  developed 
it  corresponds  cUnically  to  the  ordinary  form  of  chronic  myocarditis. 

Nutritional  Disorders  and  Chronic  Myocarditis.  —  The  myo- 
cardium suffers  in  the  same  way  as  the  skeletal  muscles.  Previously 
existing  myocarditis  constitutes  an  important  predisposing  influence. 
The  cardiac  insufficiency  may  show  itself  in  the  morning  when  the  duties 
of  the  day  are  undertaken  after  an  insuflicient  breakfast.    Free  purgation 


MYOCARDITIS.  1189 

may  cause  symptoms.  A  too  strict  antidiabetic  diet  and  the  injudicious 
treatment  of  obesity  are  to  be  considered.  This  form  of  cardiac  inadequacy 
is  common  in  the  gouty,  partly  because  of  anomalous  metabolism,  partly 
because  of  insufficient  food,  and  often  as  the  result  of  an  unwise  use  of  col- 
chicum  or  other  drugs.  To  this  category  must  also  be  referred  the  feeble 
heart  of  anaemia  and  chlorosis,  together  with  the  atrophy  of  the  heart  in 
the  acute  febrile  infections,  tuberculosis,  and  starvation.  Long  recumbency, 
as  in  illness  or  those  who  from  other  causes  are  bed-ridden,  leads  to  gradual 
heart  starvation.  The  symptoms  are  those  of  cardiac  dilatation,  dyspnoea 
upon  exertion,  gastrohepatic  distress,  oedema  of  the  lower  extremities, 
and  general  asthenia. 

Diagnosis. — Direct. — Objective  phenomena  dependent  upon  changes 
in  the  heart  upon  which  to  base  a  diagnosis  are  usually  absent.  The  anam- 
nesis and  the  cardinal  condition  of  weakness  of  the  heart,  as  manifest  by 
rational  symptoms,  justify  a  provisional  diagnosis.  A  positive  diagnosis 
may  be  reached  by  the  method  of  exclusion.  In  a  considerable  proportion 
it  cannot  be  reached  at  all. 

In  the  anamnesis  the  age  of  the  patient,  his  mode  of  life,  the  history 
of  antecedent  disease  are  important.  The  present  condition  of  the  super- 
ficial arteries,  the  blood-pressure,  the  ophthalmoscopic  evidences  of  changes 
in  the  walls  of  the  retinal  arteries,  the  specific  gravity  of  the  urine  and  the 
presence  or  absence  of  albumin,  tophaceous  deposits  in  the  ears  or  around 
the  small  joints,  and  the  occurrence  of  asthma-like  seizures,  precordial 
pain,  and  angina  pectoris  are  all  to  be  carefully  investigated.  Dyspnoea, 
precordial  and  abdominal  distress,  diminution  in  the  urine,  and  oedema 
are  most  significant  symptoms;  feebleness  of  the  heart  sounds,  a  weak  or 
undiscoverable  impulse,  a  faint  or  inconstant  mitral  systolic  murmur  are 
signs  of  importance.  A  marked  increase  in  the  pulse-frequency  upon  slight 
exertion  is  very  suggestive. 

The  diagnosis  of  sclerosis  of  the  coronary  arteries  may  be  made  when, 
in  a  person  of  middle  age  presenting  the  signs  of  sclerosis  of  the  aortic 
valves  or  atheroma  of  the  ascending  aorta,  attacks  of  paroxysmal  dyspnoea 
or  angina  pectoris  occur  in  connection  with  the  manifestations  of  cardiac 
inadequacy.  The  diagnosis  of  coronary  embolism  and  thrombosis  is  usually 
impossible.  These  conditions  frequently  arise  in  advanced  cases  without 
any  chnical  manifestation  whatever.  The  evidences  of  general  arterio- 
sclerosis in  a  case  characterized  by  the  signs  of  great  and  persistent  cardiac 
weakness  are  of  diagnostic  importance.  The  symptoms  of  chronic  nephritis, ' 
and,  in  particular,  of  contracted  kidney,  are  also  significant.  Finally,  tran- 
sient attacks  of  increased  cardiac  asthenia  in  persons  improperly  nourished, 
overworked,  much  torn  by  the  stress  of  life,  or  suffering  from  acute  or 
chronic  disease,  are  very  often  the  manifestations  of  heart  starvation. 

Differential. — The  Cardiac  Neuroses. — The  differential  diagnosis  is 
rendered  uncertain,  especially  in  the  early  cases  of  chronic  myocarditis, 
by  the  fact  that  the  murmurs  and  especially  neurasthenic  symptoms  are 
very  common  in  myocarditis.  A  history  of  accidental  or  surgical  trauma, 
overwork,  anxiety,  grief,  onanism,  sexual  excess,  hysteria,  speak  for  a 
cardiac  neurosis.  The  age  of  the  patient  is  of  some  value  in  diagnosis. 
Under  forty  the  neuroses   are   more   common;    after  forty   myocarditis. 


1190  MEDICAL  DIAGNOSIS. 

Chronic  Valvular  Disease. — Here  also  the  frequent  association  of  the  two 
conditions  gives  rise  to  nice  problems  in  differential  diagnosis.  The  difficulty 
relates  usually  to  mitral  insufficiency.  The  question  concerns  the  nature 
of  the  cardiac  insufficiency.  Is  it  valvular  or  muscular?  A  systolic  murmur, 
accentuation  of  the  second  pulmonary  sound,  and  cardiac  dilatation  occur 
in  both  conditions.  Hypertrophy  of  the  left  ventricle  and  a  strong  impulse 
are  in  favor  of  valvular  disease.  These  conditions  may  be  absent  in  moder- 
ate mitral  insufficiency,  or  the  hypertrophy  may  be  due  to  renal  disease  or 
adherent  pericardium,  or  again  the  impulse  may  be  obscured  in  emphysema. 
Under  these  circumstances  a  history  of  rheumatic  fever,  or  the  infrequency 
of  myocarditis  in  childhood,  or  of  uncombined  mitral  insufficiency  in  the 
aged  is  to  be  considered.  Furthermore  the  murmur  of  muscular  insuffi- 
ciency is  changeable  and  may  wholly  disappear  with  improvement  of  the 
condition  of  the  myocardium  under  rest  and  treatment.  In  fact  the  out- 
come of  a  reasonable  management  of  the  case  is  of  diagnostic  value,  since 
interstitial  changes  and  parenchymatous  degeneration  are  usually  pro- 
gressive and  ultimately  give  rise  to  symptoms  that  cannot  be  misunderstood. 
Prognosis. — Chronic  myocarditis  can  scarcely  be  said  to  end  in  recov- 
ery. Circumscribed  lesions  may  be  repaired  by  the  development  of  fibroid 
tissue.  As  a  rule  the  outlook  is  absolutely  unfavorable.  Much  depends 
upon  the  circumstances  of  the  patient  and  his  ability  to  bring  himself  under 
discipline.  The  sooner  this  is  done  and  the  slighter  the  lesions,  the  better 
the  outlook.  Sometimes  improvement  and  the  postponement  of  the  lethal 
disaster  occur  in  the  most  alarming  cases. 

iii.  Hypertrophy  and  Dilatation. 

(a)  HYPERTROPHY  OF  THE  HEART. 

Definition.  —  An  anatomical  condition  characterized  by  an  over- 
growth of  the  myocardium.  A  single  chamber  may  be  involved,  or  one 
side,  or  the  whole  heart.     The  left  ventricle  is  most  commonly  affected. 

The  wall  may  be  thickened  without  enlargement  of  the  chamber,  or 
the  chamber  may  be  dilated, — eccentric  hypertrophy;  combined  hypertrophy 
and  dilatation, — and  this  is  by  far  the  most  common  form.  Thickening  of 
the  walls  with  diminished  capacity  of  the  chambers  may  be  simulated  by 
post-mortem  conditions — so-called  concentric  hypertrophy. 

Etiology. — The  work  of  the  heart  is  increased  but  the  nutrition  of  its 
wall  is  maintained,  (a)  In  its  simplest  form  hypertrophy  is  caused  by 
habitual  excessive  muscular  exertion.  It  is  not  possible  to  say  when  phys- 
iological increase  passes  over  to  actual  hypertrophy.  The  heart  of  the  iron 
worker  is  much  larger  than  that  of  the  clerk.  Muscular  work  increases 
blood-pressure.  General  arteriosclerosis,  particularly  that  form  associated 
with  chronic  nephritis,  toxic  substances,  as  lead,  alcohol,  and  the  poisons 
of  gout,  increases  the  arterial  tension  and  is  a  common  cause  of  hypertrophy, 
(b)  The  freedom  of  the  movements  of  the  heart  is  hampered  by  extensive 
pericardial  adhesions,  by  local  or  general  interstitial  myocarditis,  and  by 
the  neuroses  which  give  rise  to  cardiac  overaction,  especially  exophthalmic 
goitre,  tachycardia,  and  those  resulting  from  the  abuse  of  various  stimulants 


HYPERTROPHY  AND  DILATATION.  1191 

and  narcotics,  especially  tea  and  coffee.  The  heart  works  at  a  disadvantage 
and  if  its  nutrition  remains  fairly  good  undergoes  hypertrophy,  (c)  The 
amount  of  blood  which  the  heart  has  to  propel  is  increased  in  aortic  and 
mitral  insufficiency,  since  with  every  revolution  of  the  heart  a  given  quan- 
tity of  blood  passes  to  and  fro  through  the  affected  orifice  like  a  shuttle- 
cock and  demands  a  proportionate  increase  in  cardiac  power  to  maintain 
the  equihbrium  of  the  circulation.  Habitual  excesses  at  table  and,  in 
particular,  the  consumption  of  enormous  quantities  of  beer,  have  been 
shown  to  give  rise  to  cardiac  hypertrophy,  (d)  Resistance  to  the  free  out- 
flow of  blood  caused  by  narrowing  of  an  orifice  causes  hypertrophy  of  the 
wall  of  the  affected  chamber,  as  the  left  ventricle  in  aortic  stenosis,  the 
left  auricle  in  mitral  stenosis  and  lesions  of  the  pulmonary  valve.  Con- 
genital narrowing  of  the  aorta  or  of  the  arterial  system  in  general  is  another 
cause  of  hypertrophy. 

The  various  conditions  which  primarily  or  chiefly  cause  hypertrophy 
of  the  left  ventricle  ultimately  cause  also  hypertrophy  of  the  right  ventricle. 
Hypertrophy  of  the  right  ventricle  arises  also  in  other  conditions  which 
increase  the  resistance  in  the  pulmonary  vessels,  such  as  emphysema, 
fibrosis  of  the  lungs,  and  deformities  of  the  chest.  The  left  auricle  under- 
goes dilatation  with  hypertrophy  in  mitral  disease,  especially  stenosis; 
the  right  in  conditions  characterized  by  increased  blood-pressure  in  the 
pulmonary  circuit,  both  of  valvular  and  of  pulmonary  origin. 

Enormous  enlargement  of  the  heart — cor  hovinum — is  usually  due  to 
aortic  insufficiency,  chronic  mediastinitis,  or  chronic  interstitial  nephritis. 

Hypertrophy  of  the  heart  is  essentially  a  conservative  process.  Its 
development  is  gradual  and  for  a  time  keeps  pace  with  the  advance  of  the 
lesions  with  which  it  is  associated.  So  long  as  the  equilibrium  of  the  cir- 
culation is  maintained,  the  hypertrophy  is  compensatory;  when  the  hyper- 
trophy begins  to  fail,  the  compensation  is  impaired;  when  dilatation  is 
marked  and  cardiac  insufficiency  is  extreme,  the  compensation  is  said  to 
be  ruptured  or  broken.  , 

Moderate  hypertrophy  is  unattended  by  marked  direct  symptoms. 
In  fact  it  prevents  to  a  great  extent  the  manifestations  of  the  underlying 
disease.  Sensations  of  fulness,  aggravated  when  lying  upon  the  left  side, 
easily  induced  overaction,  and  the  consciousness  of  precordial  pulsation  or 
throbbing  in  the  neck  or  head  sometimes  occur  in  advanced  cases. 

The  physical  signs  depend  upon  the  degree  of  hypertrophy  and  its 
preponderance  over  the  accompanying  dilatation,  and  the  extent  to  which 
the  heart  is  covered  by  the  overlying  borders  of  the  lungs.  When  the 
hypertrophy  is  advanced  and  dilatation  yet  subordinated  to  it,  the  diagnosis 
may  be  readily  made.  Upon  inspection  the  impulse  is  strong  and  extended 
to  the  left  and  downward.  In  marked  enlargement  it  is  heaving,  and  the 
whole  precordial  area  may  pulsate.  There  is  pulsation  at  the  root  of  the 
neck.  A  visible  pulsation  in  the  epigastrium  occurs  in  hypertrophy  of  the 
right  ventricle.  Palpation  confirms  the  signs  obtained  by  inspection,  and 
in  women  with  large  mammae  may  enable  the  examiner  to  ascertain  the 
position  of  the  apex  when  inspection  and  percussion  are  ineffectual.  The 
radial  pulse  is  full,  strong,  and  rather  slow.  Upon  percussion  the  areas 
of  relative   and   absolute  dulness   are   usually  both  increased;    in  large- 


1192  MEDICAL  DIAGNOSIS. 

lunged  persons  and  cases  of  emphysema,  the  relative  dulness  only.  Exten- 
sion of  deep  dulness  to  the  left  and  upward  is  a  sign  of  hypertrophy  of  the 
left  ventricle;  to  the  right  and  downward  a  sign  of  hypertrophy  of  the  right 
ventricle.  Upon  auscultation  the  first  sound  is  loud,  often  booming  and 
prolonged;  the  second  aortic  sound  accentuated  in  left  ventricle  hyper- 
trophy, the  second  pulmonary  accentuated  when  the  right  ventricle  is 
involved.  Accentuation  of  the  second  aortic  occurs,  however,  in  those 
conditions  of  high  tension  of  the  systemic  arteries  which  cause  left  ventricle 
hypertrophy,  and  accentuation  of  the  second  pulmonary  in  those  which 
interfere  with  the  normal  flow  of  blood  through  the  pulmonary  vessels. 

(b)   DILATATION  OF  THE  HEART. 

Definition. — Dilatation  of  the  heart  is  an  anatomical  condition,  char- 
acterized by  an  increase  in  the  size  of  its  chambers  due  to  stretching  of  its 
walls.  Dilatation  may  affect  one  or  more  chambers  of  the  heart.  It  may 
be  acute  or  chronic.  Acute  dilatation  is  usually  primary;  chronic  dilata- 
tion secondary  to  cardiac  insufficiency  or  valvular  disease.  A  previously 
■diseased  heart  is  more  liable  to  acute  dilatation  than  a  normal  heart. 

The  capacity  of  the  chambers  of  the  heart  varies  considerably  within 
normal  limits.  Pathological  enlargement — dilatation — exists  when  the 
affected  cha,mber  is  unable  to  empty  itself  of  blood  in  systole,  and  is  per- 
manent. The  myocardium,  like  other  muscles,  increases  within  certain 
limits  with  use,  especially  if  the  increase  in  work  is  gradual  and  nutrition 
is  maintained. 

Etiology. — Dilatation  results  from  a  disproportion  between  the  power 
of  the  heart  muscle  and  the  work  which  it  has  to  do.  In  other  words,  the 
pressure  within  the  chambers  may  be  increased  or  the  muscular  wall  may 
be  weakened.  These  factors  may  act  singly  or  in  combination.  Increased 
pressure  arises  when  there  is  an  abnormal  quantity  of  blood  to  be  propelled 
or  an  abnormal  resistance  to  be  overcome.  Under  certain  conditions,  as 
in  the  gradually  developing  sclerotic  form  of  aortic  stenosis,  and  in  the 
cardiovascular  changes  of  chronic  nephritis,  the  left  ventricle  may  not 
undergo  dilatation  but  hypertrophy. 

Severe  and  prolonged  muscular  effort  is  a  common  cause  of  acute 
dilatation,  as  in  mountain  climbing  or  prolonged  tests  of  endurance.  The 
condition  is  known  as  heart  strain.  The  symptoms  are  breathlessness 
upon  exertion,  cyanosis,  lassitude,  mental  depression,  and  swelling  of  the 
ankles;  the  signs  feebleness  of  the  cardiac  impulse,  small,  rapid,  irregular 
and  intermittent  pulse,  faint  heart  sounds,  and  upon  percussion  the  evi- 
dences of  enlargement  of  both  the  superficial  and  deep  areas  of  dulness, 
increase  in  the  area  of  liver  dulness,  and  hypostatic  congestion  of  the  lungs. 
Relative  insufficiency  is  shown  by  the  development  of  a  mitral  systolic 
murmur,  and  the  safety  valve  function  of  the  tricuspid  by  a  systolic  murmur 
at  the  lower  border  of  the  sternum  to  the  right.  Under  appropriate  treat- 
ment, into  which  rest  in  the  recumbent  posture  largely  enters,  gradual 
recovery  takes  place  with  disappearance  of  the  signs  of  dilatation.  In 
many  cases  they  recur  upon  further  unusual  effort,  and  in  some  the  damage 
to  the  wall  of  the  heart  is  permanent.     Acute  dilatation  occurs  also  in 


FATTY  HEART.  1193 

consequence  of  undue  effort  after  acute  illness,  in  Graves's  disease,  exoph- 
thalmic goitre,  and  paroxysmal  tachycardia.  It  may  follow  any  unusual 
effort  in  a  case  of  chronic  myocarditis. 

The  ultimate  tendency  of  chronic  myocarditis  is  to  dilatation.  In 
many  forms  the  increase  in  the  size  of  the  chambers  and  stretching  of  the 
walls  begin  early;  in  others  not  until  after  an  initial  hypertrophy.  The 
symptoms  are  those  of  cardiac  insufficiency;  the  signs  those  of  enlarge- 
ment of  the  heart,  displacement  of  the  apex  to  the  left  and  downward, 
feeble,  undulating  impulse  extending  over  several  intercostal  spaces,  and 
faint  cardiac  sounds  reverting  to  the  fetal  type.  Dropsy  and  the  evidences 
of  visceral  congestion  are  present  in  well-marked  cases. 

Valvular  disease  is  a  constant  cause  of  dilatation  of  the  heart.  In 
stenosis  a  portion  of  the  normal  quantity  of  blood  that  should  pass  the 
affected  orifice  is  held  back  in  systole;  in  incompetency  a  portion  of  the 
quantity  that  has  passed  the  orifice  flows  back  in  diastole.  In  one  case  the 
blood  entering  the  chamber  meets  blood  that  should  have  passed  on;  in 
the  other  blood  enters  the  chamber  in  diastole  from  two  opposite  directions, 
one  physiological,  the  other  pathological.  The  result  is  dilatation  of  the 
affected  chamber  and  transference  of  the  increased  blood-pressure  back- 
ward from  the  site  of  the  valvular  lesion,  from  ventricle  to  auricle  on  the 
left  side,  through  the  pulmonary  circuit,  to  ventricle  and  then  to  auricle  on 
the  right. 

Hypertrophy  at  first,  then  dilatation  of  the  left  ventricle  thus  results 
from  aortic  stenosis  and  from  aortic  insufficiency;  hypertrophy  and  dila- 
tation of  the  left  auricle  from  mitral  stenosis  and  mitral  insufficiency; 
pulmonary  hypersemia  from  either  stenosis  or  insufficiency  of  the  aortic 
or  mitral  valve  systems;  hypertrophy  and  dilatation  of  the  right  ventricle 
from  pulmonary  hypersemia  due  to  valvular  disease  of  the  left  side  of  the 
heart,  or  to  intrapulmonary  conditions  which  increase  the  resistance  in  the 
pulmonary  circuit;  hypertrophy  and  dilatation  of  the  right  auricle  from 
overdistention  of  the  right  ventricle. 

Whenever  dilatation  is  in  excess  of  h5^pertrophy  there  is  a  tendency 
to  the  transference  of  blood-pressure  from  the  arterial  to  the  venous  side 
of  the  circulation. 

When  the  myocardium  is  weakened  by,  (a)  the  toxins  of  the  acute 
infections,  (b)  the  extension  of  the  inflammation  in  endocarditis  or  peri- 
carditis, (c)  the  malnutrition  of  starvation  in  any  form,  anaemia,  or  chloro- 
sis, dilatation  may  result  in  the  absence  of  increase  in  the  blood-pressure. 

iv.  Fatty  Heart. 

Fatty  Overgrowth;    Fatty  Infiltration;    Cardiac  Inadequacy  of  the  Obese; 

Cor  Adiposum. 

Definition. —  A  condition  common  in  fat  persons,  characterized 
anatomically  by  excess  of  fat  beneath  the  epicardium  and  among  the 
strands  of  muscular  fibres,  and  clinically  by  cardiac  insufficiency. 

It  has  been  customary  to  include,  under  the  designation  fatty  heart, 
fatty  degeneration  of  the  heart  muscle  and  fat  overgrowth  or  infiltration. 


1194  MEDICAL  DIAGNOSIS. 

The  present  tendency,  however,  is  to  restrict  the  term  to  the  peculiar 
changes  that  occur  in  corpulent  persons,  since  fatty  degeneration  is 
a  common  form  of  parenchymatous  degeneration  in  myocarditis  due 
to  many  different  causes,  and  wholly  without  distinctive  etiological  or 
clinical   features. 

Fatty  degeneration  of  the  heart  is  common  in  the  infectious  fevers, 
wasting  diseases,  and  the  cachexias.  It  is  very  marked  in  acute  yellow 
atrophy  of  the  Hver,  phosphorus  poisoning,  and  pernicious  anaemia.  It 
constitutes  one  of  the  most  important  changes  of  old  age.  The  degenera- 
tion may  also  under  all  these  conditions  affect  the  various  viscera.  The 
wall  of  the  heart  may  be  locally  or  generally  involved.  The  heart  muscle 
is  flabby,  relaxed,  and  friable.  The  color  is  that  of  the  ''faded  leaf."  The 
heart  when  thrown  upon  the  table  sinks  into  a  shapeless  mass.  Micro- 
scopically the  fibres  are  filled  with  minute  fat  globules. 

The  condition  under  consideration  is  entirely  different.     It  is  essen- 
tially an  affection  of  the  corpulent.     There  is  an  excess  of  the  subperi- 
cardial  fat,  so  great  in  some  instances  as  to  wholly  envelop  the  muscle  in 
a   casing   of  fat.    It  is   usually   more    abundant  in  the   intraventricular 
grooves,  along  the  course  of  the  coronary  arteries,  and  upon  the  wall  of  the 
right  ventricle.     It  penetrates  the  muscles,  separating  the  fibres,  and  may 
extend  to  the  endocardium.     The  heart  is  dilated  and  its  wall  flabby  and 
relaxed.     Upon  microscopical  examination  the  muscular  fibres  are  found 
to  be  atrophied  and  in  some  instances  to  have  undergone  fatty  degenera- 
tion.    There  is  a  disproportion  between  the  size  of  the  heart  and  the  re- 
quirements of  the  body.    In  many  fat  persons  with  well-developed  muscles 
cardiac  insufficiency  does  not  occur.     Cardiac  symptoms  are  marked  in 
that  type  of  obesity  characterized  by  anaemia,  flabby  muscles,  and  indolence. 
Etiology. — The  causes  of  fatty  infiltration  of  the  heart  are  those  of 
the  obesity  of  which  it  constitutes  such  an  important  part.     The  middle 
periods  of  life,  the  male  sex,  heredity,  addiction  to  the  pleasures  of  the  table, 
much  fluid,  malt  liquors  and  alcohol  in  general,  luxurious  habits,  and  indo- 
lence are  potent  factors  in  the  production  of  corpulence  and  the  fatty  heart. 
Symptoms. — The  cHnical  manifestations  are  those  of  cardiac  inade- 
quacy, dyspnoea,  a  feeble  pulse,  much  accelerated  upon  effort  and  com- 
monly   intermittent    and    irregular.      Poor    appetite,    much    thirst,    and 
constipation  are  common.    Such  patients  are  often  drowsy  by  day  and 
sleepless  by  night.    Dropsy  of  the  lower  extremities  is  sometimes  marked. 
Physical  Signs. — The  methods  of  physical  examination  usually  yield 
unsatisfactory  results  by  reason  of  the  excess  of  subcutaneous  fat.    This  is 
particularly  true  of  inspection,  palpation,  and  percussion.     The  results  of 
auscultation  are  sometimes  more  satisfactory.    The  heart  sounds  are  usually 
feeble  and  distant.     When,  however,  they  are  well  defined  and  the  aortic 
sound  distinct,  they  may  be  regarded  as  indicating  fairly  well-maintained 
myocardial  nutrition.    When,  on  the  other  hand,  the  first  sound  is  extremely 
faint  or  replaced  by  a  systolic  murmur,  the  aortic  sound  feeble,  and  the 
pulmonic  sound  accentuated  though  feeble,  the  integrity  of  the  heart  muscle 
is  greatly  impaired. 

Diagnosis. — The  recognition  of  fatty  heart  depends  upon  the  associa- 
tion of  cardiac  insufficiency  with  obesity. 


RUPTURE  OF  THE  HEART.  1195 

The  DIFFERENTIAL  DIAGNOSIS  between  this  condition  and  the  primary 
anaemias,  especially  chlorosis  and  pernicious  anaemia,  may  be  made  by  a 
proper  blood  examination.  The  blood  of  corpulent  persons  of  the  pallid 
type  who  suffer  from  fatty  heart  may  show  the  characters  of  a  more  or 
less  marked  secondary  anaemia,  but  not,  in  the  absence  of  specific  lesions, 
the  characters  of  the  primary  anaemias. 

Prognosis. — The  outlook  in  general  is  unfavorable  and  is  rendered 
more  so  by  unwise  attempts  to  reduce  the  weight  of  the  body  by  insufficient 
food,  unduly  increased  exercise,  exhausting  baths,  or  depressing  drugs. 
Thickened  arteries,  paroxysmal  dyspnoea,  and  angina  pectoris  are  of 
ominous  significance. 

V.  Various  Degenerations,  New  Growths,  and  Parasites 

of  the  Heart. 

Degenerations  of  the  heart  muscle  not  already  considered  ara  amy- 
loid degeneration,  the  hyaline  transformation  of  Zenker,  and  calcareous 
infiltration.  None  of  these  is  recognizable  during,  life  nor  of  clinical 
interest. 

Tumors  of  the  heart  are  commonly  carcinoma  and  sarcoma.  They 
are  usually  secondary.  Fibroma,  lipoma,  myoma,  gumma,  and  leukaemic 
infiltrations  are  extremely  rare.  Malignant  tumors  very  commonly  lead 
to  pericarditis,  which  may  be  plastic  or  purulent. 

Of  the  parasites  which  affect  the  myocardium,  the  echinococcus  is  the 
most  common.  It  selects  the  right  ventricle  twice  as  often  as  the  left. 
So  long  as  it  remains  within  the  myocardium  it  does  not  occasion  symptoms. 
When  it  finds  its  way  into  the  interior  of  the  heart  it  gives  rise  to  embolism, 
especially  in  the  lungs.  The  cysticercus  and  trichinella  find  access  to  the 
heart  muscle,  but  do  not  occasion  symptoms. 

vi.  Wounds  and  Foreign  Bodies. 

External  injuries,  as  stabs  and  gunshot  wounds,  are  very  common. 
Their  diagnosis  is  obvious.  The  subject  belongs  to  surgery,  and  has  ac- 
quired great  importance  in  consequence  of  the  recent  success  which,  in 
stab  wounds,  has  attended  the  prompt  exposure  of  the  heart  and  suturing 
of  the  wound.  Internal  injuries  are  extremely  rare.  They  are  caused  by 
foreign  bodies — a  bone  or  artificial  denture  ulcerating  its  way  from  the 
oesophagus,  or  in  the  case  of  insane  or  hysterical  persons  by  pins  or  needles 
that  have  been  swallowed.  In  the  former  instance  the  nature  of  the  lesion 
would  be  recognized  by  the  history  of  the  case  and  sudden  fatal  haema- 
temesis,  in  the  latter  pericarditis  would  occur;  but  a  positive  etiological 
diagnosis  intra  vitam  cannot  be  made. 

vii.  Rupture  of  the  Heart. 

This  accident  may  occur  as  the  result  of  the  arrest  of  the  blood  supply 
to  the  affected  area  in  consequence  of  sclerosis  or  embolism  of  a  branch 
of  a  coronary  artery,  inducing  acute  softening — myomalacia  cordis.     The 


1196  MEDICAL  DIAGNOSIS. 

heart  wall  may  undergo  similar  circumscribed  impairment  from  suppura- 
tive m3^ocarditis  or  a  softening  gumma.  Local  fatty  degeneration  is  the 
most  common  cause.  The  rupture  occurs  most  frequently  on  the  anterior 
wall  of  the  left  ventricle  near  the  septum.  The  softened  area  gradually 
yields,  and  upon  some  effort  which  causes  heightened  intraventricular 
pressure,  as  ascending  a  staircase  or  straining  at  stool,  it  suddenly  gives 
way  and  the  escape  of  blood  into  the  pericardial  sac — hcemopericardium — 
is  followed  by  death.  Rupture  in  the  posterior  wall  of  the  left  ventricle 
is  much  less  common,  and  rupture  of  the  wall  of  the  right  ventricle  or  the 
auricles  very  rare. 

Traumatic  rupture  of  the  heart  may  result  from  violent  blows  or  con- 
tusions of  the  thorax,  such  as  occur  in  falls  or  railroad  accidents.  This 
variety  of  heart  rupture  is  more  apt  to  involve  the  right  ventricle  or  an 
auricle.  In  some  cases  the  borders  of  the  rent  maintain  their  position. 
Pericardial  adhesions  may  occur  and  death  may  be  postponed  for  several 
hours  or  days. 

Diagnosis. — In  the  majority  of  the  cases  death  results  at  once  and  the 
diagnosis  is  impossible.  When  the  opening  is  small,  signs  of  internal 
hemorrhage — feeble  pulse,  oppression,  air  hunger,  ghastly  pallor,  and 
orthopnoea — are  suggestive.  When  pericardial  adhesions  exist  the  blood 
outflow  is  hindered  and  hfe  may  be  correspondingly  prolonged. 

Prognosis. — The  outlook,  however,  is  without  hope. 

viii.  Aneurism  of  the  Heart. 

Aneurism  of  a  valve  may  result  from  malignant  endocarditis.  The 
condition  is  not  common.  The  aortic  valves  are  affected  with  greater 
frequency  than  the  mitral.  The  cusp  shows  a  bulging  in  the  direction  of 
the  ventricle,  which  presently  ruptures,  causing  acute  insufficiency.  The 
signs  are  not  characteristic  and  are  obscured  by  the  primary  changes. 
A  positive  diagnosis  cannot  be  made. 

Aneurism  of  the  wall  is  also  a  rare  condition.  Its  most  common  posi- 
tion is  the  left  ventricle  in  the  region  of  the  apex,  which  is  the  portion 
of  the  wall  of  the  heart  most  commonly  affected  in  the  fibroid  degeneration 
of  chronic  myocarditis. 

Etiology. — This  condition  mostly  follows  chronic  myocarditis,  but 
has  been  observed  in  acute  mural  endocarditis.  Wounds  of  the  heart  and 
gumma  are  also  etiological  factors.  The  dilatation  is  usually  single,  but 
may  be  multiple. 

Diagnosis. — Direct. — The  symptoms  are  not  characteristic.  The 
associated  myocarditis  causes  cardiac  inadequacy,  manifest  by  the  usual 
clinical  phenomena.  When  the  tumor  attains  considerable  size  it  is  usually 
lined  by  laminated  clots  and  may  give  rise  to  irregular  enlargement  of  the 
diameters  of  deep  cardiac  dulness.  In  other  cases  there  may  be  bulging 
in  the  region  of  the  apex  and  perforation  of  the  wall  of  the  chest. 

The  DIFFERENTIAL  DIAGNOSIS  from  mediastinal  or  pleural  tumor  is 
to  be  considered.  The  feeble  pulse  of  cardiac  inadequacy  may  be  in  marked 
contrast  to  the  cardiac  impulse.  The  X-rays  may  be  of  service  in  the 
differential  diagnosis. 


PERICARDITIS.  1197 

ix.  Atrophy  of  the  Heart. 

Definition. — A  diminution  of  the  heart  in  weight  and  size.  A  single 
chamber  or  the  entire  heart  may  be  atrophied. 

The  term  hypoplasia  of  the  heart  is  used  to  designate  congenital 
undersize. 

The  myocardium  is  of  a  dark,  reddish-brown  color,  and  abnormally 
resistant.  The  surface  is  often  marked  or  puckered.  The  muscle  fibres 
are  diminished  in  size,  their  transverse  striae  indistinct  and  presenting 
collections  of  yellowish-brown  pigment  near  the  nuclei. 

Etiology. — The  small  size  of  the  left  ventricle  in  extreme  mitral  steno- 
sis may  be  looked  upon  as  an  example  of  atrophy  of  a  single  chamber  of 
the  heart.  Common  causes  are  starvation  and  wasting  diseases,  as  cancer, 
diabetes,  protracted  suppuration,  and,  in  particular,  phthisis.  Brown 
atrophy  of  the  heart  is  common  in  advanced  valvular  disease  and  old  age — 
the  senile  heart. 

Symptoms. — The  symptoms  are  those  of  cardiac  inadequacy — feeble 
and  rapid  action,  especially  upon  exertion,  weak  and  irregular  pulse,  faint 
sounds,  and  indistinct  impulse.  The  shrunken  lungs  usually  increase  the 
area  of  superficial  dulness,  but  the  diameters  of  deep  dulness  are  reduced. 

Diagnosis. — The  calcification  of  the  costal  cartilages  in  the  aged  often 
renders  the  examination  of  the  heart  by  percussion  very  difficult  and 
unsatisfactory.  The  X-ray  examination  yields  more  definite  signs  of  a 
reduction  in  the  size  of  the  organ.  The  cHnical  phenomena  are  much 
subordinated  to  those  of  the  primary  affection. 

Prognosis. — The  outlook  is  that  of  the  primary  disease.  The  ultimate 
failure  of  the  circulation  is  often  largely  due  to  cardiac  atrophy. 

III.  DISEASES  OF  THE  PERICARDIUM, 
i.  Pericarditis. 

Definition. — Inflammation  of  the  pericardium  resulting  from  trau- 
matism, infection,  the  extension  of  inflammation  from  contiguous 
structures,  or  toxic  conditions. 

Etiology. — Idiopathic  or  spontaneous  pericarditis  is  a  purely  theo- 
retical conception.  The  extremely  rare  cases  of  pericarditis  in  children 
without  other  indications  of  local  or  constitutional  disease  are  probably 
due  to  latent  tuberculosis,  or  tonsillitis  or  other  infection,  or  to  an  obscure 
toxaemia.  Traumatic  pericarditis  may  become  the  subject  of  medical 
diagnosis  when  the  injury  is  from  within,  as  in  the  case  of  the  ulceration  of 
a  foreign  body  from  the  oesophagus,  or  injury  by  needles  or  pins  that  have 
been  swallowed.  Infection  is  the  most  common  cause.  The  greater  num- 
ber of  cases  occur  in  connection  with  rheumatic  fever.  The  pericarditis 
may  precede  the  joint  affection.  Next  in  frequency  are  the  cases  due  to 
tuberculosis.  To  this  etiological  group  are  to  be  referred  the  cases  of 
pericarditis  which  follow  blows  and  contusions  of  the  chest,  and  those  which 
occur  in  alcoholics.  The  pericarditis  may,  for  a  time,  be  the  only  clinical 
manifestation  of  the  tuberculous  infection.     Less  commonly  pericarditis 


1198  MEDICAL  DIAGNOSIS. 

is  secondary  to  sepsis,  especially  that  caused  by  acute  necrosis  or  puer- 
peral infection,  or  the  toxaemia  of  scarlet  fever  and  the  other  acute 
febrile  infections. 

Extension  of  the  inflammation  from  the  endocardium  may  account  for 
the  common  association  of  endo-  and  pericarditis  in  rheumatic  fever,  or  the 
later  pericardial  inflammation  may  be  also  a  direct  manifestation  of  rheu- 
matism. This  mode  of  infection  is  common  in  pleurisy  and  pneumonia, 
and  may  occur  in  oesophageal  carcinoma,  tuberculous  or  bronchiectatic 
cavities  closely  adjacent  to  the  pericardium,  tuberculous  mediastinitis,  per- 
forating gastric  ulcer,  or  subphrenic  abscess.  That  form  which  sometimes 
occurs  in  purulent  myocarditis,  ulcerative  endocarditis,  aneurism  of  the 
aorta,  disease  of  the  ribs  and  sternum  or  the  vertebraB  arises  in  a  major- 
ity of  the  cases  by  direct  extension.  Toxic  pericarditis  is  not  rarely  a 
terminal  condition  in  chronic  nephritis,  especially  the  interstitial  variety. 
It  is  occasionally  present  but  usually  latent  in  gout,  scurvy,  diabetes,  and 
arteriosclerosis.  Among  the  infrequent  causes  of  pericarditis  are  syphilis, 
carcinoma  and  sarcoma  of  the  pericardium,  echinococci  or  cysticerci,  and 
actinomycosis.  The  micro-organisms  most  frequently  encountered  in  the 
exudate  are  the  ordinary  pyogenic  bacteria,  the  pneumococcus,  and  the 
tubercle  bacillus. 

The  inflammatory  exudate  may  be  fibrinous,  serofibrinous,  hemor- 
rhagic, or  purulent.  The  terminal  condition  in  cases  that  recover  is  that 
of  more  or  less  complete  adhesion  between  the  pericardial  surfaces — 
adherent  pericardium.  It  is  customary  to  describe  separately  dry  or  fibri- 
nous pericarditis,  pericarditis  with  effusion,  and  adherent  pericardium; 
but  it  is  important  to  bear  in  mind  the  fact  that  these,  in  a  majority  of 
instances,  are  successive  stages  in  a  continuous  process.  Like  other  inflam- 
mations, pericarditis  may  be  acute  or  chronic. 

(a)   FIBRINOUS,  PLASTIC,  OR  DRY  PERICARDITIS. 

Pericarditis  Sicca. 

In  the  simple  acute  cases  the  inflammation  involves  first  the  epicardial 
or  visceral  layer;  later  the  pericardial  layer  of  the  serous  pericardium. 
The  fibrinous  exudate  may  be  circumscribed  or  general.  Its  arrangement 
varies  greatly.  Sometimes  it  presents  the  appearance  seen  when  two 
buttered  surfaces  are  separated;  sometimes  there  are  hairy  ridges  in 
irregular  parallel  lines, — cor  villosum, — or  again  there  may  be  a  stratified 
or  a  honeycombed  appearance.  There  is,  as  a  rule,  a  variable  amount  of 
fluid  entangled  in  the  meshes  of  the  fibrin,  but  in  chronic  tuberculous 
cases  with  great  thickening  fluid  is  absent.  The  myocardium  immediately 
subjacent  is  inflamed.  The  frequent  coexistence  of  endocarditis  is  of 
clinical  as  well  as  etiological  interest. 

Symptoms. — Plastic  pericarditis  is  sometimes  latent.  Even  in  marked 
cases  the  subjective  phenomena  may  be  indefinite.  Pain  is  common.  It 
is  usually  substernal  or  referred  to  the  region  of  the  apex.  Less  frequently 
it  radiates  to  the  neck  and  arm,  especially  on  the  left  side.  It  may  be- 
stitch-like  and  lancinating,  or  dull  and  heavy;    persistent  or  paroxysmal.. 


PERICARDITIS.  1199 

The  fever  of  the  primary  disease  may  be  aggravated,  but  the  terminal 
pericarditis  of  nephritis  may  be  unattended  by  a  rise  of  temperature. 

Physical  Signs. — Upon  inspection  the  signs  are  usually  negative. 
The  breathing  may  be  rapid  and  shallow  or  there  may  be  orthopnoea. 
Palpation  in  a  considerable  proportion  of  the  cases  reveals  a  more  or  less 
distinct  friction  fremitus.  The  pulse  is  usually  accelerated — 120  to  140 
to  the  minute.  The  percussion  borders  of  the  heart  are  not  enlarged  in 
simple  fibrinous  pericarditis.  In  old  cases  the  myocardium  may  undergo 
dilatation.  Auscultation. — The  pericardial  friction  sound  is  most  vari- 
able in  character.  It  is  frequently  of  a  soft  grazing  or  brushing  quality. 
More  commonly  it  is  rubbing  or  grating  and  has  been  compared  with  the 
creaking  of  new  leather.  It  appears  to  be  superficial,  as  though  produced 
close  to  the  surface,  and  is  increased  by  moderate  pressure,  in  some  cases 
obHterated  by  strong  pressure  with-  the  stethoscope.  Its  intensity  varies 
from  a  scarcely  audible  whiff  to  a  loud  coarse  sound,  directly  appreciable 
to  the  ear.  Its  loudness  is  not  dependent  upon  the  amount  of  fibrinous 
exudate.  It  is  sometimes  absent  when  the  fibrin  is  abundant,  as  in  cor 
villosum;  sometimes  distinct  when  there  is  merely  a  thin  layer.  The 
intensity  is  modified  by  posture  and  undergoes  remarkable  changes  from 
day  to  day  in  the  course  of  the  attack.  The  pericardial  friction  sound  is 
usually  to-and-fro,  corresponding  to  the  systole  and  diastole  of  the  ven- 
tricles, but  it  does  not  bear  the  definite  relations  of  endocardial  murmurs 
to  the  cardiac  cycle.  It  is  sometimes  single  and  in  rare  instances  triple, 
having  a  somewhat  irregular  canter  rhythm.  Its  systolic  and  diastolic 
portions  have  usually,  but  not  invariably,  the  same  quality  and  pitch. 
They  are  almost  always  of  unequal  length.  It  is  heard  over  the  body  of 
the  heart;  sometimes  most  distinctly  in  the  second,  third,  and  fourth  left 
intercostal  spaces  and  adjacent  parts  of  the  sternum,  sometimes  at  the 
base  over  the  pericardial  reflections  upon  the  great  vessels,  and  again  in 
the  region  of  the  apex.  It  is  usually  limited  to  a  small  area,  but  may  be 
distinctly  heard  over  a  large  part  of  the  pericardium.  It  is,  however, 
always  circumscribed  and  never  transmitted  beyond  the  boundaries  of  the 
heart  in  definite  lines  corresponding  to  the  vessels,  as  is  the  case  with  endo- 
cardial murmurs.  When  pericardial  effusion  takes  place  the  friction  sound 
disappears  over  the  body  of  the  heart,  but,  except  in  large  effusions,  may 
still  be  heard  in  a  limited  region  at  the  base. 

Diagnosis. — The  direct  diagnosis  of  fibrinous  pericarditis  depends 
upon  the  recognition  of  a  friction  sound  having  the  foregoing  characters, 
location,  and  correspondence  to  the  revolution  of  the  heart. 

Differential. — The  distinction  between  endocardial  murmurs  and 
exocardial  friction  sounds  is  based  upon  the  well-recognized  characters  of 
each.  A  double  aortic  murmur,  particularly  when  accompanied  by  a 
thrill,  may  lead  to  error,  but  not  if  due  heed  be  given  to  its  sameness  from 
time  to  time,  lines  of  propagation,  the  correspondence  of  its  systoHc  and 
diastolic  elements  with  the  cycle  of  the  heart,  and  the  associated  arterial 
changes. 

Pleurisy. — Pleural  friction  is  not  usually  restricted  to  the  cardiac 
borders  of  the  lung,  and  when  heard  elsewhere  serves  to  explain  a  pleuro- 
pericardial  friction,   which  is  due  to   movements  of  the  pleural  surfaces 


1200  MEDICAL  DIAGNOSIS. 

induced  by  the  action  of  the  heart.  This  sign  is  by  no  means  infrequent 
at  the  left  anterior  margin  of  the  lung  in  croupous  pneumonia,  and  is  some- 
times encountered  in  phthisis.  It  disappears  upon  full-held  inspiration, 
and  on  ordinary  breathing  is  more  distinct  during  the  expiratory  period. 
Clicking  and  crepitant  rales,  occasionally  heard  in  the  region  of  the  apex 
and  recurring  with  the  ventricular  systole,  are  readily  differentiated  from 
pericardial  friction. 

It  is  stated  that  pericardial  friction  sounds  are  sometimes  produced 
by  milk  spots  on  the  surface  of  the  ventricles,  concretions,  and  in  the  dry 
condition  of  the  tissues  occurring  in  cholera,  but  such  conditions  are  not 
to  be  confounded  with  true  pericarditis. 

Prognosis. — The  course  of  fibrinous  pericarditis  as  such  is  favorable. 
In  some  days  or  weeks  recovery  may  take  place  without  any  cHnical  mani- 
festation of  injury  to  the  heart.  The  inflammation  may  indeed  run  its 
course  in  the  absence  of  subjective  phenomena,  the  friction  sound  being 
the  only  objective  sign.  More  commonly  there  are  more  or  less  urgent 
symptoms.  The  danger  of  serofibrinous,  hemorrhagic,  or  purulent  effusion,^ 
of  impHcation  of  the  myocardium  with  acute  symptoms,  and  of  extensive 
pericardial  adhesions  leading  to  chronic  myocarditis  invests  every  case 
with  importance.  As  an  intercurrent  affection  it  adds  to  the  gravity 
of  the  primary  disease. 

(b)   PERICARDITIS  WITH  EFFUSION. 

Pericarditis  Exudativa. 

There  is  no  abrupt  hne  of  separation  between  dry  pericarditis  and 
pericarditis  with  effusion.  In  the  meshes  of  an  abundant  fibrinous  exu- 
date there  are  small  collections  of  serum;  in  serofibrinous  effusions  the 
pericardial  surfaces  are  covered  with  fibrin,  flakes  of  which  float  free  in 
the  fluid.     The  effusion  may  be  serofibrinous,  hemorrhagic,  or  purulent. 

Etiologically  serofibrinous  effusion  is  usually  a  so-called  second  stage 
in  the  evolution  of  the  attack  of  pericarditis,  and  may  arise  in  any  of  the 
conditions  in  which  plastic  pericarditis  occurs.  Blood  elements  are  present 
in  varying  amounts.  Hemorrhagic  effusions  owe  their  characteristic  ap- 
pearance to  an  excess  of  blood.  They  are  met  with  in  tuberculous  and 
cancerous  pericarditis,  and  in  those  forms  which  occur  in  hemorrhagic 
conditions,  as  scorbutus  and  purpura,  and  in  the  aged.  The  quantity  of 
blood  varies  from  an  amount  only  appreciable  upon  microscopical  or  chem- 
ical examination  to  almost  pure  blood.  The  effusion  may  be  purulent  in 
tuberculous  cases.  It  is  Hkely  to  be  so  in  those  due  to  sepsis  or  internal 
or  external  traumatism,  or  when  an  effusion  arises  in  consequence  of  infec- 
tion from  a  contiguous  bronchiectatic  cavity  or  vomica.  The  volume  of 
the  effusion  is  extremely  variable.  Experimentally  the  normal  sac  will 
contain  without  distention  150  to  200  c.c.  Upon  forcible  distention,  with 
compression  of  the  heart,  from  500  to  800  c.c.  may  be  injected.  The  in- 
flamed pericardium  is  more  distensible,  and  with  the  adjustments  which 
take  place  under  the  gradual  accumulation  of  an  effusion,  as  much  as  1500 
or  even  2000  c.c.  have  been  observed. 


PERICARDITIS.  1201 

Symptoms. — The  condition  is  frequently  latent.  There  are  cases  in 
which  moderate  pericardial  effusions  run  a  favorable  course  without  heart 
symptoms,  resorption  taking  place  in  the  course  of  two  or  three  weeks. 
More  commonly  the  early  symptoms  consist  of  chilliness,  precordial  pain, 
and  fever.  In  well-developed  cases  there  are  two  main  groups  of  symptoms, 
constitutional  and  local.  The  constitutional  symptoms  are  very  often 
masked  by  those  of  the  primary  affection,  and  moderate  terminal  effusions 
are  more  frequently  recognized  in  the  post-mortem  room  than  in  the  ward. 
In  children  general  symptoms,  as  feverishness,  dyspnoea,  loss  of  appetite, 
fretfulness,  languor,  and  a  rapidly  developing  pallor,  may  occur  in  the 
absence  of  precordial  pain  or  other  symptoms  suggestive  of  the  actual 
condition.  Pallor,  weakness,  insomnia,  loss  of  appetite,  dyspnoea  and 
orthopnoea,  melancholia  and  a  disposition  to  suicide,  and  in  grave  cases 
restlessness,  somnolence,  delirium,  and  a  tendency  to  coma  are  among  the 
symptoms  of  pericardial  effusion.  The  local  symptoms  arise  from  the 
inflammation,  from  the  derangement  of  the  circulation,  and  from  pressure. 
The  pain  is  referred  to  the  precordium;  less  commonly  to  the  epigastrium. 
It  is  usually  sharp  and  lancinating;  sometimes  dull  and  aching;  excep- 
tionally it  amounts  only  to  a  sense  of  distress  and  discomfort.  It  is  usually 
continuous  with  exacerbations,  but  may  be  paroxysmal  with  intervals  of 
relief.  It  is  intensified  by  pressure  with  the  stethoscope.  Derangements 
of  the  circulation  are  manifest  in  cyanosis  of  varying  intensity,  shortness 
of  breath,  anxiety,  and  the  sensation  of  air  hunger.  The  patient  prefers 
to  lie  upon  the  left  side;  in  large  effusions  he  is  obliged  to  be  propped  up 
with  pillows  in  the  semirecumbent  posture  or  to  sit  up  in  bed.  The  pulse 
is  rapid,  small,  and  frequently  arrhythmic.  In  large  effusions  with  thicken- 
ing of  the  parietal  pericardium  the  pulse  may  become  very  feeble  or  quite 
imperceptible  during  inspiration — pulsus  paradoxiciis.  It  is  sometimes 
smaller  in  the  left  than  in  the  right  carotid  and  radial  arteries.  The 
circulatory  symptoms  are  due  in  part  to  the  direct  pressure  of  the 
effusion  upon  the  heart,  the  effects  of  which  are  greater  upon  the  thin- 
walled  auricles  than  upon  the  ventricles,  and  to  the  implication  of  the 
myocardium  directly  in  relation  with  the  inflamed  epicardium.  The 
symptoms  due  to  pressure  upon  other  organs  are  a  sense  of  precordial 
oppression  and  weight  in  the  epigastrium,  dysphagia,  aphonia,  a  laryn- 
geal cough,  distention  of  the  veins  of  the  neck,  and  dyspnoea  from 
compression  of  the  left  lung. 

Physical  Signs. — Inspection. — In  small  effusions  there  are  no  dis- 
tinctive signs.  In  moderate  and  large  effusions  the  respiratory  excursus 
upon  the  left  side  is  diminished  in  consequence  of  pressure  atelectasis  of 
the  lower  lobe.  Pericardial  effusions  compress  the  left  lung  to  a  far  greater 
extent  than  the  right.  The  epigastrium  is  prominent,  owing  to  the  depres- 
sion of  the  diaphragm  and  liver.  In  children  and  young  persons  precordial 
prominence,  widening  and  slight  bulging  of  the  lower  intercostal  spaces, 
and  in  some  cases  a  feeble  wavy  cardiac  impulse  may  be  present.  Palpa- 
tion.— A  cardiac  impulse  due  to  the  contraction  of  the  right  ventricle 
may  be  feebly  felt  in  the  fourth  interspace;  in  other  cases  the  apex  beat 
may  be  lower  than  normal  in  consequence  of  the  depression  of  the  dia- 
phragm.    Very  often  no  precordial  impulse  can  be  detected.     Friction 

76 


1202 


MEDICAL  DIAGNOSIS. 


fremitus  vanishes  as  the  layers  of  the  pericardium  are  separated  by  the 
effusion,  except  at  the  base,  where  it  may  sometimes  be  felt,  especially  in 
the  erect  posture.  Fluctuation  is  not  a  sign  of  pericardial  effusion.  In 
massive  effusions  bulging  of  the  left  retroclavicular  space  has  been  observed 
and  elevation  of  the  clavicle,  so  that  the  first  rib  may  be  palpated  to  the 
sternum— ^rs^  rib  sign.  Percussion. — This  method  of  physical  diagnosis 
yields  most  important  signs.  The  effusion  collects  first  in  the  most  depend- 
ent part  of  the  sac  and  gradually  rises  as  it  increases  in  amount.  Its  presence 
may  be  first  appreciated  by  an  absence  of  resonance  at  the  sternal  end  of 
the  fifth  right  intercostal  space— the  cardiohepatic  angle.  At  this  point 
in  normal  and  dilated  hearts  the  vertical  border  of  the  cardiac  dulness 
and  the  transverse  upper  border  of  the  hepatic  dulness  make  a  well-defined 
right  angle.  In  early  effusion  and  in  certain  cases  of  obesity  this  angle  is 
replaced  by  a  curve  having  its  concavity  upward  and  outward  toward  the 
lung — Rotch's  sign.      As  the  effusion  increases  the  precordial  dulness  extends 


Fig.  341. — Moderate  pericardial  effusion; 
quadrilateral  flatness  with  border  of  relative 
dulness;    effacement  of  cardiohepatic  angle. 


Fig.  342. — Massive  pericardial  effusion; 
pyramidal  area  of  flatness  with  truncated  apex; 
right  border  of  relative  dulness;  downward 
displacement  of  liver. 


toward  the  left  and  upward,  later  toward  the  right,  displacing  the  borders 
of  the  lung  and  forming  at  first  a  quadrilateral  area  of  dulness  with  rounded 
corners,  which  with  larger  effusions  assumes  a  pear-shaped  outline,  the 
larger  end  lying  at  the  inferior  border  and  extending  beyond  the  sternal 
margin  on  the  right,  and  beyond' the  position  of  the  apex  and  the  mid- 
clavicular line  on  the  left.  In  large  effusions  the  dulness  may  invade 
Traube's  semilunar  space.  The  truncated  apex  of  this  figure  reaches  into 
the  upper  sternal  region.  As  the  diameters  of  this  figure  are  gradually 
reached,  the  area  of  superficial  precordial  dulness  advances  more  rapidly 
than  that  of  the  deep  or  absolute  dulness,  until  at  length  they  nearly  coin- 
cide. A  circumscribed  area  of  dulness  or  flatness  may  sometimes  be 
found  at  the  base  of  the  left  chest  posteriorly  between  the  inferior  angle  of 
the  scapula  and  the  vertebrae.  Old  pericardial  adhesions,  compression  of 
the  left  lung,  and  coexistent  pleural  effusions  greatly  modify  these  changes 
in  the  percussion  signs.  Auscultation. — The  friction  sound  disappears 
over  the  body  of  the  heart  but  may  be  heard  at  the  base,  very  rarely  at 
the  apex.     The  first  sound  is  obscure  and  indistinct;  the  second  pulmo- 


PERICARDITIS.  1203 

nary  sound  accentuated.  The  action  of  the  heart  is  rapid  and  often 
arrhythmic.  A  systolic  endocardial  murmur  may  sometimes  be  detected. 
As  resorption  takes  place  the  first  sound  becomes  more  distinct  and  the 
friction  sound  may  be  again  heard. 

Diagnosis. — The  direct  diagnosis  of  pericardial  effusion  may  be 
made  without  difficulty  when  the  case  has  been  seen  from  the  outset 
and  the  above-described  percussion  signs  have  supervened  upon  peri- 
cardial friction  sounds.  Of  especial  value  in  the  early  recognition  of  effu- 
sion is  Rotch's  modification  of  the  cardiohepatic  angle.  Very  important 
is  the  triangular  outhne  of  dulness  in  large  effusions.  A  sign  too  httle 
appreciated  is  the  progressive  encroachment  of  the  borders  of  the  super- 
ficial dulness  upon  the  area  of  deep  dulness.  The  X-ray  examination 
may  be  of  service. 

Differential. — Dilatation  of  the  heart  very  often  presents  extreme 
difficulty  in  the  differential  diagnosis.  Careful  cHnicians  have  tapped  the 
right  ventricle  instead  of  a  pericardial  sac  distended  with  fluid.  Dulness 
in  the  cardiohepatic  angle,  a  quadrilateral  area  of  dulness  with  rounded 
corners,  the  close  approach  of  the  borders  of  superficial  to  those  of  deep 
dulness,  especially  when  the  dulness  extends  to  the  left  beyond  the  apex 
beat,  constitute  an  association  of  physical  signs  of  great  importance.  The 
truncated  apex  of  the  triangular  area  of  dulness  in  large  effusions,  a  cir- 
cumscribed area  of  dulness  near  the  angle  of  the  left  scapula,  and  signs  of 
compression  of  the  left  lung  have  also  diagnostic  value.  But  most  of  these 
conditions  may  be  present  in  dilated  heart.  In  some  cases  of  hypertrophy 
of  the  right  ventricle  the  deep  cardiac  dulness  due  to  the  left  ventricle 
extends  beyond  the  position  of  the  visible  impulse.  An  undulatory 
impulse  seen  or  felt  in  two  or  more  interspaces,  distinct  though  feeble 
heart  sounds,  valvular  in  character  and  having  the  fetal  rhythm,  and 
postural  changes  in  the  upper  borders  of  the  dulness,  are  signs  suggestive 
of  effusion.  Overfilled  veins,  cyanosis,  aphonia,  dysphagia,  and  other 
pressure  symptoms  are  without  value  in  the  differential  diagnosis,  since 
they  may  occur  alike  in  large  pericardial  effusions  and  extreme  dilatation 
of  the  heart. 

Left-sided  Pleural  Effusion. — This  condition,  unless  the  fluid  be  en- 
cysted, is  not  often  mistaken  for  pericardial  effusion,  but  large  pericardial 
effusions  may  closely  simulate  pleurisy.  In  the  latter  condition  the  heart 
is  displaced  toward  the  right,  its  impulse  and  sounds  are  distinct,  the  flat- 
ness extends  around  the  base  of  the  chest,  the  overlying  compressed  luno- 
yields  tympanitic  percussion  resonance,  Traube's  semilunar  space  is  oblit- 
erated, the  spleen  is  displaced  downward  and  its  respiratory  excursus 
restricted,  and  finally  dysphagia  is  not  a  pressure  symptom  in  pleurisy. 
Vocal  fremitus  is  usually  distinct  over  an  atelectatic  lung,  feeble  or  absent 
over  fiuid.  The  pericardial  effusions  which  occasionally  occur  in  pneu- 
monia present  unusual  difficulties  in  diagnosis.  The  signs  are  masked  by 
those  of  the  primary  lesion.  There  is  no  border-line  change  from  dulness 
to  clearness  or  tympany;  at  the  left  border  of  the  heart  the  extension  of 
dulness  to  the  right  of  the  sternum  may  be  ascribed  to  the  dilatation  of  a 
failing  right  heart.  The  modification  of  the  cardiohepatic  angle  would 
suggest  pericarditis,  but  it  is  likely  to  be  overlooked. 


1204  MEDICAL  DIAGNOSIS. 

The  recognition  of  tumors  of  the  lung,  pleura,  or  mediastinum,  or 
of  aneurisms  of  the  aortic  or  pulmonary  artery,  depends  upon  a  cHnical 
course  and  physical  signs  that  are  widely  divergent  from  those  of 
pericarditis  with  effusion. 

The  character  of  the  fluid  can  be  determined  with  certainty  only  by 
an  exploratory  puncture.  Paracentesis  of  the  pericardium  for  diagnostic 
purposes  cannot,  however,  be  considered  a  justifiable  procedure.  When 
performed  as  a  measure  of  treatment  the  gross  and  microscopical  charac- 
ters of  the  fluid  are  of  diagnostic  importance.  Various  sites  are  recom- 
mended for  the  insertion  of  the  needle.  The  fourth  or  fifth  left  intercostal 
space  near  the  sternum;  the  same  interspaces  to  the  left  of  the  midclavic- 
ular line  and  within  the  border  of  the  flatness  on  percussion;  a  point 
high  in  the  angle  formed  by  the  ensiform  cartilage  and  the  left  costal 
margin  and  the  fifth  right  interspace  2  cm.  from  the  sternal  border  when 
this  area  is  flat  upon  percussion,  are  situations  recommended.  A  small 
aspirator  needle  should  be  employed  and  strict  surgical  antisepsis 
observed.  In  rheumatic,  renal,  and  tuberculous  cases  the  fluid  is  usually 
serofibrinous;  in  senile,  purpuric,  and  cancerous  cases  hemorrhagic;  and  in 
septic  conditions  it  is  commonly  purulent.  The  gravity  of  the  general  symp- 
toms usually  depends  upon  the  nature  and  intensity  of  the  primary  dis- 
ease. When  this  is  not  the  case  it  corresponds  rather  to  the  severity  of 
the  pericarditis,  the  amount  of  the  effusion,  and  the  rapidity  with  which  it 
is  formed,  than  to  its  character. 

Prognosis. — The  signs  of  effusion  may,  in  many  cases,  be  recognized 
within  a  few  days  of  the  detection  of  the  friction  sound.  The  accumulation 
in  rheumatic  fever,  nephritis,  scurvy,  and  some  septic  cases  is  rapid,  while 
in  tuberculous  cases  it  is  usually  slow.  Serofibrinous  effusions  of  moderate 
volume  frequently  undergo  resorption,  which  may  be  complete  as  shown 
by  the  retrogression  of  the  dulness  in  the  course  of  four  or  five  weeks. 
Reappearance  of  the  friction  sound  may  occur  but  is  less  common  than  in 
pleural  effusions.  Occasional  post-mortem  findings,  namely,  grayish 
material  in  various  stages  of  calcareous  change  in  the  pericardium,  render 
it  probable  that  under  certain  circumstances  a  purulent  effusion  may 
undergo  resorption.  Very  large  effusions  show  little  tendency  to  undergo 
resorption,  and  unless  removed  by  operative  measures — dissection  layer 
by  layer,  or  paracentesis — rapidly  prove  fatal  by  compression  of  the  heart 
and  other  mechanical  effects.  Purulent  effusions,  unless  reheved  by  opera- 
tion and  drainage,  terminate,  as  a  rule,  in  death.  The  pericarditis  with 
effusion  in  scurvy,  chronic  nephritis,  and  pysemia  is  almost  always  a  ter- 
minal condition.  Heart  comphcations  are  frequently  present.  There  is 
myocarditis  involving  the  myocardium  directly  in  relation  with  the  inflamed 
epicardium.  Endocarditis  is  often  also  present,  particularly  in  the  rheu- 
matic cases.  Old  valvular  lesions  with  associated  myocardial  changes  may 
at  the  same  time  obscure  the  diagnosis  and  unfavorably  affect  the  prog- 
nosis. When  recovery  takes  place  the  pericardial  surfaces  become  adherent. 
The  prognosis  is  relatively  unfavorable  as  the  primary  constitutional 
condition  is  grave,  the  effusion  large,  and  its  accumulation  rapid. 


ADHERENT  PERICARDIUM.  1205 

ii.  Adherent  Pericardium. 

Synechia  Pericardii;  Obliteration  of  the  Pericardial  Sac. 

Pericardial  adhesions  constitute  a  constant  anatomical  sequel  of 
pericarditis,  both  in  its  latent  and  manifest  forms.  The  extent  of  the 
adhesions  is  exceedingly  variable.  In  many  cases  there  are  merely  thread- 
like strings  or  bands  of  organized  tissue  extending  from  the  visceral  to  the 
parietal  pericardium;  in  others  the  adhesion  between  their  membranes  is 
universal  and  so  close  as  to  suggest  congenital  absence  of  the  pericardium. 
The  adjacent  pleura  is  frequently  involved  and  in  extreme  cases  the  heart 
is  embedded  in  a  dense,  thick  connective-tissue  mass  including  the  fibrous 
pericardium  and  the  structures  with  which  it  is  in  relation — chronic 
adhesive  mediastinitis. 

The  cases  of  simple  pericardial  adhesion  may  be  divided  into  two 
groups: 

(a)  Those  presenting  no  clinical  manifestations  and  found  upon  post- 
mortem examination.  This  group  includes  the  cases  of  limited  adhesions 
and  the  threads  and  bands  which  scarcely  affect  the  free  movement  of 
the  heart  within  the  sac,  and  some  of  the  cases  in  which  more  general 
adhesions  exist. 

(b)  Those  in  which,  as  a  result  of  the  pericarditis  and  adhesions, 
chronic  myocarditis  has  occurred,  with  hypertrophy  and  dilatation  and  the 
symptoms  of  cardiac  inadequacy.  These  cases  do  not  always  show  general 
obliteration  of  the  sac.  A  high  grade  of  hypertrophy  may  occur  with  only 
partial  adhesion  between  the  layers. 

Symptoms. — There  are  cases  in  which  the  history  and  physical  signs 
are  positive,  but  for  a  long  period  symptoms  of  heart  disease  are  absent. 
After  a  time  the  symptoms  are  those  of  hypertrophy,  then  dilatation  and 
a  failing  heart. 

Physical  Signs. — Inspection. — In  young  persons  there  may  be  promi- 
nence of  the  pericardium  in  consequence  of  hypertrophy,  with  an  impulse 
visible  in  the  fourth,  fifth,  and  sometimes  the  sixth  interspace  and  to  the 
left  of  the  midclavicular  line.  While  the  hypertrophy  remains  marked  the 
impulse  may  be  strong  and  heaving,  but  when  it  gives  way  to  dilatation 
the  impulse  becomes  more  extended  and  undulatory,  and  there  is  systolic 
retraction  in  the  neighborhood  of  the  apex.  The  systolic  indrawing  may 
extend  to  other  parts  of  the  cardiac  area.  It  is  sometimes  seen  at  the  base 
of  the  heart  and  may  be  confined  to  this  region.  An  energetic  retraction 
in  the  parts  about  the  ensiform  cartilage  upon  the  left  is  sometimes  seen. 
In  cases  in  which  there  are  strong  cardiodiaphragmatic  adhesions  a  visible 
systolic  retraction  may  be  detected  in  the  lower  left  ribs  and  interspaces 
behind — Broadbent's  sign.  Respiratory  movement  of  the  epigastrium 
may  be  embarrassed  by  the  pericardial  adhesions.  Friedreich's  sign, 
diastolic  collapse  of  the  cervical  veins,  is  sometimes  seen.  Palpation. — 
The  signs  obtained  by  inspection  are  confirmed  and  there  is  often  to  be 
felt  a  distinct  diastolic  shock.  The  movements  of  the  apex,  under  the 
influence  of  gravity,  upon  change  of  posture  are  less  marked  than  under 
normal  conditions.    Pulsus  paradoxus  may  be  present.    Percussion  shows 


1206  MEDICAL  DIAGNOSIS 

an  increase  in  the  transverse  diameter  of  the  heart,  and  since  there  are 
usually  also  pleural  adhesions  the  area  of  superficial  cardiac  dulness  may 
not  be  influenced  by  the  respiratory  movements.  Auscultation. — The 
signs  are  not  distinctive.  There  is  very  often  the  murmur  of  an  associated 
endocarditis,  especially  in  the  rheumatic  cases.  With  dilatation  there  is 
usually  the  systolic  mitral  murmur  of  relative  insufficiency.  Other  murmurs 
have  been  described,  especially  a  presystolic  murmur,  but  these  are 
inconstant  and  accidental. 

Diagnosis. — The  direct  diagnosis  of  pericardial  adhesion  rests  upon 
the  history  of  pericarditis  and  the  presence  of  the  foregoing  signs  upon 
physical  examination.  In  some  cases  a  positive  diagnosis  cannot  be  made; 
in  others  it  can  be  made  with  certaint}''  even  in  the  absence  of  a  history  of 
pericarditis.  The  cases  that  present  the  greatest  difficulty  are  those  in 
which  there  are  adhesions  between  the  pericardium  and  epicardium  with- 
out adhesions  to  the  adjacent  structures;  the  cases  in  which  the  diagnosis  * 
may  often  be  made  with  confidence  are  those  in  which  there  are  extensive 
adhesions,  not  only  between  the  visceral  and  parietal  pericardium,  but  also 
between  the  fibrous  pericardium  and  the  surrounding  parts — chronic 
indurative  mediastinitis.  Too  great  importance  may  be  given  to  systohc 
retraction  of  the  intercostal  space  in  the  region  of  the  apex.  This,  in  the 
absence  of  pericardial  adhesions,  may  be  due  to  atmospheric  pressure 
when  the  energetically  contracting  ventricles  are  not  followed  by  the  border 
of  the  lung  with  sufficient  promptness.  It  may  also  occur  in  hypertrophy 
and  dilatation  of  the  right  ventricle  when  the  left  ventricle  remains  small. 
The  impulse  is  that  of  the  right  ventricle,  and  to  the  left  of  it  there  may  in 
some  cases  be  seen  distinct  systoHc  retraction.  As  a  rule,  to  which  there 
are,  however,  exceptions,  the  retraction  in  adherent  pericardium  is  more 
energetic  than  that  induced  by  atmospheric  pressure.  When  systoHc 
retraction  occurs  under  observation  after  an  attack  of  pericarditis  the 
diagnosis  of  adherent  pericardium  may  be  made.  In  a  doubtful  case  the 
shadow  cast  by  the  Rontgen  rays  may  be  of  service.  It  may  show  irregular 
contour  of  the  heart,  a  feeble,  restricted  cardiac  pulsation,  and  diminished 
play  of  the  diaphragm,  especially  in  its  central  parts. 

Prognosis. — The  outlook  in  simple  obliteration  of  the  pericardium 
depends  upon  the  influence  of  the  primary  pericarditis  and  the  subsequent 
adhesions  upon  the  myocardium.  So  long  as  the  heart  retains  its  function 
the  prognosis  is  favorable.  Upon  the  supervention  of  the  signs  of  cardiac 
insufficiency  it  becomes  unfavorable. 

iii.   Hydropericardium;  Hydrops  Pericardii. 

Dropsy  of  the  pericardium  occurs  in  connection  with  general  dropsy 
in  the  course  of  renal,  less  frequently  of  heart  disease,  and  in  association 
with  effusions  into  the  other  great  serous  sacs,  the  pleurae  and  peritoneum. 
In  rare  cases  of  scarlet  fever  this  condition  has  been  observed  in  the  absence 
of  dropsy  in  other  parts.  Normally  the  pericardial  sac  contains  a  small 
amount  of  clear  yellow  serum,  5-10  c.c.  In  hydropericardium  the  quantity 
rarely  exceeds  150-200  c.c.  This  transudate  is  clear,  yellowish,  and  may 
contain  a  few  red  blood-corpuscles.    The  pericardium  is  smooth  and  glisten- 


ENDOCARDITIS.  1207 

ing.  Chylous  effusion  is  a  very  rare  condition.  Hydropericardium  presents 
the  physical  signs  of  a  moderate  pericardial  effusion,  from  which  it  cannot 
be  differentiated  except  by  the  history  and  the  associated  clinical  phenom- 
ena. It  does  not  directly  tend  to  cause  death,  but  constitutes  an  additional 
danger  in  the  serious  affections  in  which  it  arises  as  a  complication. 

iv.  Hsemopericardium. 

Hemorrhage  into  the  pericardial  sac  is  to  be  differentiated  from 
hemorrhagic  pericardial  effusion.  It  results  from  wounds  or  rupture  of 
the  heart  or  of  an  aneurism  of  the  aorta,  pulmonary  artery,  or  coronary 
arteries,  and  has  been  observed  as  a  consequence  of  ulceration  in  malig- 
nant endocarditis.  As  a  rule,  death  occurs  immediately  with  the  symptoms 
of  internal  hemorrhage.  In  extremely  rare  instances  the  bleeding  is  more 
slow,  especially  in  cases  of  rupture  of  the  heart,  and  time  permits  an  exam- 
ination of  the  cases  with  a  view  to  their  diagnosis  and  treatment.  The 
signs  are  then  of  a  more  or  less  rapidly  accumulating  pericardial  effusion; 
the  symptoms  those  of  more  or  less  abundant  internal  hemorrhage. 
The  prognosis  is  in  the  highest  degree  unfavorable.  Traumatic  cases  may 
recover  after  immediate  operation — suturing  the  incised  wall  and  draining 
the  pericardium. 

V.  Pneumopericardium. 

Air  or  gas  in  the  pericardial  sac  is  an  exceedingly  rare  condition. 
It  may  result  from  external  wounds,  perforation  of  the  oesophagus  or  stom- 
ach, subphrenic  pyopneumothorax,  a  tuberculous  cavity  involving  the  peri- 
cardium, or  spontaneously  without  solution  of  continuity  in  the  sac  from 
the  presence  of  the  Bacillus  aerogenes  capsulatus.  The  area  of  cardiac  dul- 
ness  is  replaced  by  tympany.  The  impulse  in  the  recumbent  posture  dis- 
appears, though  it  may  be  felt  when  the  patient  sits  up.  The  movements 
of  the  heart  are  accompanied  by  coarse,  churning,  gurgling  noises,  and  the 
heart  sounds  have  a  loud,  metallic  ring,  which  may  be  heard  at  some 
distance  from  the  chest.     Fluid  is  usually  also  present. 

vi.  Calcification  of  the  Pericardium. 

Deposition  of  lime  salts  sometimes  takes  place  in  tuberculous  peri- 
carditis and  in  pyopericardium  with  resorption  of- the  fluid.  The  condition 
may  be  partial  or  complete,  so  that  the  heart  is  encased  in  a  sort  of  bony 
shell.  Strangely  enough  it  is  usually  latent,  though  a  diagnosis  of  adherent 
pericardium  has  been  made.    The  lesion  is  exceedingly  rare. 

IV.  DISEASES  OF  THE  ENDOCARDIUM. 
i.  Endocarditis. 

Definition. — Inflammation  of  the  lining  membrane  of  the  heart. 

In  by  far  the  greater  number  of  the  cases  the  inflammatory  process  is 
restricted  to  the  valves — valvular  endocarditis;  exceptionally  it  extends 
to  the  lining  membrane  of  the  wall  of  the  heart — mural  endocarditis. 

Two  forms  of  endocarditis  are  recognized,  acute  and  chronic. 


1208  MEDICAL  DIAGNOSIS. 

(a)   Acute  Endocarditis. 

Acute  endocarditis  is  of  every  grade  of  intensity.  Its  milder  forms 
run  a  favorable  course,  and  the  inflammatory  lesions,  though  they  impair 
the  function  of  the  valves,  are  not  destructive.  Its  severe  forms  are  at- 
tended with  grave  symptoms  and  usually  end  in  death,  and  the  lesions 
comprise  ulceration  and  necrosis  of  the  affected  valves  and  adjacent  parts. 
It  is  convenient  to  describe  separately  acute  simple  or  benign  endocarditis, 
and  acute  idcerative,  infective,  or  malignant  endocarditis.  Between  these 
two  forms  there  is  no  abrupt  anatomical  or  clinical  dividing  line. 

The  lesions  in  simple  endocarditis  consist  of  minute  wart-like  vegeta- 
tions, hence  the  descriptive  terms  vegetative  or  verrucose  endocarditis. 
The  left  side  of  the  heart  is  involved  more  commonly  than  the  right,  and 
the  mitral  than  the  aortic  leaflets.  These  vegetations  are  arranged  in  lines 
upon  the  auricular  surface  of  the  auriculoventricular  leaflets  and  the  ventric- 
ular surface  of  the  sigmoid  cusps  a  little  distance  back  of  the  free  edges  of 
the  valves.  The  clinical  course  of  the  disease  is  determined  by  the  subse- 
quent changes  in  the  valvular  lesions,  which  may  result  in  organization 
with  trifling  permanent  alteration;  in  progressive  sclerotic  changes  and 
deformity — chronic  valvidar  disease;  in  the  detachment  of  loose  vegetations 
and  embolism;  or  finally  in  an  overgrowth  of  the  vegetations  and  ulcerative 
destruction  of  the  valve  leaflets — malignant  endocarditis.  In  the  last,  not 
only  the  leaflets  but  also  adjacent  parts  may  be  destroyed,  with  perfora- 
tion of  a  valve,  the  septum,  or  the  wall  of  the  heart,  and,  owing  to 
the  loosely  organized  character  of  the  exuberant  vegetations,  multiple 
embolism  is  common. 

The  valve  systems  affected  are  in  the  order  of  frequency  as  follows: 
mitral  alone,  aortic  alone,  aortic  and  mitral  together,  tricuspid,  and  pul- 
monary. The  walls  of  the  heart  are  involved,  as  a  rule,  only  in  connection 
with  the  valves.  Endocarditis  in  fetal  life  usually  involves  the  right  side 
of  the  heart. 

Etiology.  —  Predisposing  Influences.  —  Acute  endocarditis,  both 
simple  and  malignant,  has  been  met  with  under  circumstances  in  which 
no  antecedent  or  primary  disease  or  lesion  could  be  demonstrated.  In 
the  majoritj^  of  instances  it  is  a  secondary  affection.  Simple  Endocarditis. — 
Rheumatic  fever  is  by  far  the  most  common  jDrimary  affection.  Chorea, 
tonsilhtis,  scarlet  fever,  and  croupous  pneumonia  are  very  frequent.  It  is 
rare  in  enteric  fever,  measles,  diphtheria,  variola,  and  varicella.  In  gout, 
diabetes,  chronic  nephritis,  and  cancer  simple  endocarditis  is  occasionally 
observed.  Acute  endocarditis  is  common  in  old  cases  of  valvular  disease — 
recurrent  endocarditis.  Malignant  Endocarditis. — Here  also  rheumatic 
fever,  pneumonia,  and  other  acute  infections  play  an  important  part  as 
the  primary  disease.  But  it  is  especially  in  septic  processes  that  mahgnant 
endocarditis  occurs.  Recurrent  endocarditis  is  frequently  mahgnant  in 
type.  Mahgnant  endocarditis  constitutes  a  grave  danger  in  gonorrhoeal 
infection,  especially  in  the  male.  The  malignant  form  is  exceedingly  rare 
in  enteric  fever,  diphtheria,  tuberculosis,  dysentery,  and  scarlet  fever. 

Heredity  plays  an  important  role  in  the  predisposition  to  endocarditis. 
There  are  many  families  in  which  the  liability  is  plainly  manifest  in  succes- 


ENDOCARDITIS.  1209 

sive  generations.  Rheumatic  endocarditis  is  especially  common  in  child- 
hood and  early  adult  life.  It  may,  however,  occur  at  any  age.  After  forty 
the  liability  to  a  first  attack  of  rheumatic  fever  is  slight.  Chorea  is  more 
common  in  girls  than  in  boys,  and  it  is  in  accordance  with  this  fact  that  the 
incidence  of  simple  endocarditis  is  somewhat  greater  in  females.  The 
especial  liability  to  sepsis  which  attends  the  child-bearing  function  con- 
stitutes an  important  predisposing  influence  to  the  graver  forms  of 
endocarditis. 

Exciting  Cause. — The  pyogenic  bacteria  which  are  present  in  the 
lesions  of  the  primary  disease  are  found  in  the  valvular  vegetations  and  in 
the  infected  emboli  common  in  mahgnant  endocarditis.  One  or  more 
varieties  may  be  identified  in  the  same  case.  The  more  common  are  strep- 
tococci, staphylococci,  pneumococci,  and  gonococci.  Much  less  frequently 
the  bacillus  of  enteric  fever,  diphtheria,  tuberculosis,  and  the  Bacillus  coli 
communis  have  been  found.  In  the  simple  endocarditis  of  chronic  diseases 
and  cachectic  states  micro-organisms  are  frequently  absent. 

SIMPLE  ENDOCARDITIS. 

Symptoms. — This  form  very  often  runs  a  latent  course  without  modi- 
fication of  the  symptoms  of  the  primary  affection.  In  other  cases  increased 
pulse-frequency,  slight  irregularity  in  the  action  of  the  heart,  a  sense  of 
precordial  oppression,  and  attacks  of  dyspnoea  occur.  There  may  or  may 
not  be  a  rise  of  temperature  in  rheumatic  cases  without  fresh  joint  affection. 
In  young  children  rheumatic  endocarditis  may  occur  with  trifling  mani- 
festations of  illness  and  without  arthritis,  the  true  nature  of  the  attack 
being  revealed  by  the  physical  signs,  the  subsequent  valvular  disease, 
and  recurrent  attacks  of  well-characterized  articular  rheumatism.  Again, 
to  these  symptoms  there  may  be  added  the  manifestations  of  acute  cardiac 
insufficiency  and  grave  constitutional  disturbances — irregular,  rapid,  and 
feeble  pulse,  faintness,  oppression,  orthopnoea,  high  fever  not  conforming 
to  type,  profuse  perspirations,  and  extreme  pallor.  Such  cases  lie  on  the 
border-line  between  simple  and  malignant  endocarditis. 

Physical  Signs. — A  murmur  may  develop  at  one  of  the  valvular 
areas.  Commonly  the  first  sound  is  impure  at  the  beginning  or  slightly 
rough.  This  change  increases  to  a  murmur  which  gradually  becomes 
distinct.  The  second  sound  may  be  reduplicated,  its  pulmonary  element 
accentuated.  There  may  be  slight  increase  in  the  transverse  diameter 
of  the  heart  and  displacement  of  the  apex  to  the  left,  signs  of  implication 
of  the  myocardium. 

Diagnosis. — Simple  endocarditis  in  many  of  the  cases  is  discovered 
only  by  systematic  routine  examination.  Very  often  it  is  not  recognized 
at  all.  Recent  endocarditis  is  sometimes  found  in  cases  of  nephritis  or 
carcinoma  in  which  no  murmur  has  been  heard.  When  heard  the  murmur 
may  be  due  to  relative  or  muscular  insufficiency,  or  to  valvular  disease 
resulting  from  acute  endocarditis  in  the  past.  If  it  has  developed  under 
observation  the  latter  possibility  may  be  excluded  but  not  the  former. 
If  it  becomes  more  distinct  and  persists  beyond  the  convalescence  from  the 
primary  disease,  a  diagnosis  of  acute  endocarditis  is  justified. 


1210  MEDICAL  DIAGNOSIS. 

MALIGNANT  ENDOCARDITIS. 

Symptoms. — There  are  two  groups  of  symptoms:  those  due. to  the 
primary  disease  or  the  sepsis  to  which  it  has  given  rise,  and  those  due  to 
the  endocarditis.  Either  of  these  groups  may  dominate  the  cHnical  picture. 
To  the  first  belong  irregular  fever,  copious  sweating,  profound  anaemia, 
delirium,  and  loss  of  strength;  to  the  second  group  a  curious  air  hunger, 
paroxysmal  dyspnoea,  orthopnoea,  palpitation,  frequent  and  irregular  action 
of  the  heart,  and  the  phenomena  caused  by  emboli  in  various  tissues  and 
organs.  A  very  common  point  of  entrance  for  the  infection  is  in  lesions 
of  the  female  reproductive  organs.  Injuries  of  the  integument,  boils  and 
abscesses,  suppuration  of  the  middle  ear,  inflamed  hemorrhoids,  gonor- 
rhoea in  the  male,  croupous  pneumonia,  and  suppurative  disease  of  the 
liver  or  of  bone  are  frequent  causes.  Old  valvular  disease  of  the  heart  is 
very  common.  The  anamnesis  is  of  great  value  in  the  diagnosis.  In  a 
doubtful  case  this  ground  must  be  carefully  gone  over.  Septic,  typhoid, 
cerebral,  and  cardiac  forms  are  described,  but  the  picture  is  a  very  diverse 
one  and  the  distinctions  are  by  no  means  clear.  The  Septic  Form. — There 
is  usually  a  history  of  puerperal  infection,  a  neglected  wound,  acute  necro- 
sis, or  gonorrhoea.  Severe  rigors,  irregular  pyrexia,  colliquative  sweating, 
and  vomiting  are  common.  Heart  symptoms  are  sometimes  subordinate 
and  the  signs  overlooked.  Embohsm  is  common.  The  Typhoid  Form. — 
The  temperature  is  high  and  subcontinuous  or  remittent  in  type.  There 
are  great  depression,  diarrhoea,  sometimes  tympany,  drenching  sweats,  de- 
lirium, somnolence,  and  a  tendency  to  coma.  Heart  symptoms  are  often 
obscure.  Murmurs  may  be  absent.  The  Cerebral  Form. — The  onset 
is  abrupt  with  the  signs  of  a  basilar  or  cerebrospinal  meningitis.  Sud- 
den violent  delirium  is  followed  by  coma.  The  Cardiac  or  Recurrent 
Form. — This  variety  occurs  in  individuals  who  are  the  subjects  of  chronic 
valvular  disease.  The  symptoms  are  very  variable.  The  attack  may  run 
a  rapidly  fatal  course  with  septic  or  so-called  typhoid  phenomena  and 
high  fever,  or  recovery  take  place  after  several  weeks.  Repeated  attacks 
with  the  clinical  manifestations  of  an  acute  endocarditis  may  occur. 

Embolism  may  cause  the  most  diverse  manifestations,  among  which 
are  delirium,  coma,  hemiplegia,  monoplegia,  and  central  derangements  of 
vision  and  hearing  in  consequence  of  implication  of  arterial  branches  in  the 
brain  or  meninges;  pain  in  the  splenic  area  from  infarction  and  perisplen- 
itis; pain  in  the  lumbar  region  and  bloody  urine  from  Infarction  of  one  or 
both  the  kidneys;  and  abscesses  in  the  subcutaneous  tissues,  which  are 
often  multiple.  The  last  are  common  in  the  legs  and  feet,  less  so  in  the 
arms,  occasional  in  the  buttocks  or  shoulders,  and  infrequent  in  the  face 
or  neck.  To  this  cause  must  also  be  ascribed  the  retinal  hemorrhage  which 
sometimes  occurs,  and  the  rare  complication  of  suppurative  panophthal- 
mitis. Erythematous  and  petechial  rashes  are  common.  Jaundice  occa- 
sionally occurs.  As  in  other  forms  of  sepsis,  diarrhoea  is  often  troublesome. 
Leucocytosis  is  usually  present. 

Physical  Signs.' — There  are  no  signs  of  importance  upon  inspection. 
Palpation  yields  valuable  information  as  to  the  character  and  extent  of  the 
impulse,  which  is  frequently  somewhat  displaced  to  the  right  and  may  be 


ENDOCARDITIS.  1211 

sometimes  felt  in  two  interspaces.  Thrills  in  the  mitral  and  aortic  areas 
may  be  felt.  Percussion  shows  the  heart  to  be  moderately  enlarged  in  its 
transverse  diameter,  especially  to  the  right  of  the  sternal  border — dilata- 
tion of  the  right  ventricle.  Upon  auscultation  the  signs  are  by  no  means 
constant.  Errors  in  diagnosis  may  be  avoided  by  bearing  in  mind  the  fact 
that  in  a  considerable  proportion  of  the  cases  no  murmur  can  be  detected 
upon  careful  search.  Usually,  how^ever,  there  are  well-marked,  often  harsh, 
murmurs  in  the  mitral  and  aortic  areas,  mostly  systolic  in  time,  but  fre- 
quently also  presystolic  or  diastolic  as  the  case  may  be,  and  often  chang- 
ing their  quality,  rhythm,  and  intensity  from  time  to  time.  This  variability 
in  the  murmurs  and  in  thrills  when  present  corresponds  to  changes  in  the 
dimensions  and  other  physical  characters  of  the  lesions,  and  constitutes  a 
diagnostic  sign  of  the  highest  importance. 

Diagnosis  of  Malignant  Endocarditis. — Direct. — In  the  absence  of 
the  physical  signs  of  endocarditis  and  of  embolism  the  recognition  of  the 
disease  may  be  impossible.  Sepsis,  associated  with  murmurs  which  vary 
in  character  and  intensity,  or  the  signs  of  embolism  form  the  basis  for  a 
positive  diagnosis. 

Differential. — The  following  conditions  are  to  be  considered:  Acute 
Simple  Endocarditis. — The  general  symptoms  in  the  malignant  form  are 
much  more  intense.  Recurrent  chills,  irregular  pyrexia,  and  profuse 
sweating  occur.  Embolic  processes  are  far  more  common.  There  are  border- 
line cases  which  may  be  referred  to  either  category,  but  in  these  the  absence 
of  a  focus  of  infection  is  in  favor  of  a  severe  form  of  the  benign  type  of  the 
disease.  In  the  malignant  cases  leucocytosis,  petechial  eruptions,  and  the 
urinary  findings  of  acute  nephritis  are  of  diagnostic  importance.  Blood 
cultures  may  yield  conclusive  results.  Enteric  Fever. — Many  of  the  cases 
are  at  first  regarded  as  irregular  forms  of  enteric  fever.  The  gradual  rise 
of  temperature  in  the  latter  disease,  the  slowness  of  the  pulse  in  proportion 
to  the  pyrexia,  the  greater  enlargement  of  the  spleen,  the  rose  rash,  and  a 
positive  Widal  reaction  constitute  a  symptom-complex  not  seen  in  any 
other  affection.  It  is  true  that  a  rose  spot  or  two  may  sometimes  be  found 
in  a  septic  case.  Grave  cases  of  enteric  fever  with  secondary  infection  may 
become  distinctly  septic  and  develop  malignant  endocarditis.  Typhus 
Fever. — This  now  infrequent  disease  usually  occurs  in  local  outbreaks,  and 
is  characterized  by  early  intense  headache,  stupor,  a  peculiar  petechial 
rash  appearing  about  the  fourth  day  and  all  over  the  body  except  the  face, 
and  an  average  course  of  about  fourteen  days.  Hemorrhagic  Smallpox. — 
This  rare  malignant  vaiiety  of  variola  occurs  only  in  the  unvaccinated 
and  has  little  in  common  with  ulcerative  endocarditis  except  its  profoundly 
infectious  nature  and  rapidly  fatal  issue.  Malarial  Fever. — In  some  of  the 
cases  of  malignant  endocarditis  the  ague-like  paroxysms  of  chill,  fever,  and 
sweating  recur  with  a  periodicity  suggestive  of  malarial  infection.  The 
absence  of  the  blood  parasite  and  the  total  failure  of  quinine  to  influence 
the  progress  of  the  disease  are  conclusive. 

Prognosis. — The  immediate  outlook  in  the  simple  form  of  acute  endo- 
carditis is  favorable.  In  the  majority  of  instances,  however,  it  proves  to 
be  the  point  of  departure  for  chronic  valvular  disease.  The  remote  conse- 
quences are  therefore  often  grave.     An  attack  in  early  life  may  prove  the 


1212  MEDICAL  DIAGNOSIS. 

cause  of  protracted  and  irremediable  disability  and  ill  health.  The  prog- 
nosis in  the  malignant  form  is  highly  unfavorable.  Most  of  the  cases  end 
in  death.  Those  that  recover  are  of  the  cardiac  type  and  recurrences  are 
common.  The  duration  of  malignant  endocarditis  varies  from  a  few  days 
to  several  weeks. 

(b)  Chronic  Endocarditis. 

Definition. — Connective-tissue  new  formation  in  the  valvular  endo- 
cardium, having  its  beginning  in,  (a)  acute  endocarditis,  (b)  the  extension 
of  arteriosclerosis  from  the  arterial  system,  or  (c)  occurring  as  a  primary 
affection  and  leading  to  various  deformities  of  the  valves  and  impairment 
of  their  function. 

(a)  The  vegetations  and  thrombi  become  organized,  with  the  pro- 
duction of  nodular  fibroid  thickening  at  the  margins  and  later  throughout 
the  substance  of  the  leaflets.  The  connective-tissue  overgrowth  undergoes 
contraction,  with  thickening,  incurving  of  the  edges  of  the  leaflets,  and  other 
coarse  deformities.  This  process  affects  the  left  side  of  the  heart  and  the 
mitral  valve  system  more  frequently  than  the  aortic,  (b)  The  sclerotic 
change  in  the  valves  arises  independently  of  an  antecedent  acute  endo- 
carditis, and  is  one  of  the  manifestations  of  a  general  or  more  or  less  exten- 
sive fibroid  transformation  affecting  the  arterial  system — arteriosclerosis. 
In  antenatal  life  the  right  heart  is  usually  affected;  after  birth  the  left 
heart.  This  process  generally  involves  the  aortic  valves  but  often  extends 
to  the  mitral,  and  in  rare  instances  affects  the  mitral  without  implication 
of  the  aortic,  (c)  Primary  sclerosis  occurs  as  the  result  of  habitual  pro- 
longed and  severe  muscular  effort.  The  aortic  valves  especially  suffer  in 
this  form  of  chronic  endocarditis.  The  toxins  of  syphihs  and  gout,  the 
intoxications  of  lead  and  alcohol,  prolonged  anxiety,  grief  and  worry,  and 
the  tissue  changes  incident  to  old  age  are  credited  with  the  production  of 
sclerotic  changes  in  the  valves.  Whatever  the  mode  of  origin  the  result  is 
the  same,  deformity  and  impairment  of  function. 

The  deformities  are  various  and  arise  from  thickening,  curling,  adhe- 
sions, superficial  necrotic  changes,  the  deposition  of  lime  salts,  loss  of 
elasticity,  and  the  stretching  of  parts  still  capable  of  yielding  to  pressure. 
The  papillary  muscles  show  sclerotic  changes,  particularly  at  their  tips. 
The  chordge  tendinese  are  shortened  and  thickened  and  in  some  instances 
destroyed.  Chronic  mural  endocarditis  shows  itself  in  grayish-white  patches 
upon  the  endocardium  of  the  wall  and  may  be  due  to  myocardial  changes. 

The  effect  of  the  valvular  lesions  is  insufficiency  or  stenosis,  which  may 
be  single  or  combined. 

The  derangement  of  function  in  both  insufficiency  and  stenosis  con- 
sists in  an  interference  of  the  normal  course  of  a  part  of  the  blood  stream. 
In  insufficiency  the  affected  blood  is  permitted  to  flow  back  through  the 
orifice — regurgitation;  in  stenosis  it  is  held  back  at  the  orifice.  In  the 
combined  lesions  some  of  the  blood  is  held  back  and  some  passes  back. 
The  altered  valves  can  neither  be  completely  closed  nor  fully  opened.  The 
over-filled  chamber  and  increased  resistance  demand  increased  work  on 
the  part  of  the  heart,  and  this  leads  to  hypertrophy.  When  the  increase 
in  work  and  the  increase  in  power  are  equal  the  balance  of  the  circulation  is 


ENDOCARDITIS.  1213 

maintained  and  the  lesion  is  said  to  be  compensated.  The  tendency  on 
the  part  of  the  valvular  lesion  is  to  progress.  That  on  the  part  of  the  com- 
pensating hypertrophy  is  to  advance  at  an  equal  rate.  Thus  compensation 
advances  hand  in  hand  with  the  lesion,  and  symptoms  are  absent.  This 
process  goes  on,  however,  at  the  cost  of  corresponding  impairment  of  the 
reserve  power  of  the  heart.  There  may  be  no  symptoms  while  the  heart 
does  only  its  ordinary  work,  but  the  capacity  for  extraordinary  work  is 
progressively  impaired.  A  sudden  violent  effort,  hill  climbing,  worry,  the 
stress  of  life,  an  acute  illness  reveal  beginning  cardiac  inadequacy.  It  is 
fortunate  that  in  the  physical  signs  of  valvular  disease  we  have,  while  com- 
pensation is  still  maintained,  the  means  of  recognizing  the  condition  and 
can  institute  measures  to  avert  disaster.  There  are  cases,  however,  in 
which  compensation  does  not  occur.  The  lesion  is  too  great  or  has 
developed  too  rapidly,  or  the  myocardium  is  unsound,  and  dilatation 
takes  place  at  once. 

After  a  time  the  compensation  becomes  impaired.  This  change  may 
be  due  to  further  advance  in  the  valvular  lesion,  with  which  the  heart 
muscle  is  unable  to  keep  pace,  or  to  the  insufficiency  to  which  the  hyper- 
trophied  muscular  tissue  is  peculiarly  prone.  The  manifestations  are  not 
different  from  those  of  chronic  myocarditis  due  to  other  causes.  They 
vary  progressive!}^  in  degree.  Hence  the  terms  impaired  compensation. 
broken  or  lost  compensation,  de-compensation. 

It  is  in  valvular  disease  that  a  functional  diagnosis  is  of  the  highest 
importance.  Not  so  much  what  is  the  lesion  or  the  valve  system  involved, 
as  how  it  affects  the  function  of  the  heart,  is  the  question  in  the  individual 
case.  The  condition  of  the  heart  muscle  is  far  and  away  more  important 
than  the  valvular  lesion.  Is  the  compensation  maintained  or  impaired? 
This  is  the  main  point.  If  impaired,  to  what  extent?  Upon  the  reply 
to  these  questions  the  management  of  the  case  and  the  future  of  the 
patient  depend. 

When  the  valvular  lesion  is  compensated  the  arterial  pressure  is  normal. 
Under  ordinary  circumstances  there  is  no  dyspnoea  upon  moderate  exertion. 
Cyanosis  is  not  present.  The  liver  is  not  enlarged,  and  the  normal  amount 
of  urine  is  voided.  We  think  too  much  of  the  condition  of  the  valves;  too 
little  of  that  of  the  myocardium.  The  former  is  beyond  the  reach  of  j^ro- 
phylaxis  and  cure.  Intelligent  attention  to  the  latter  means,  in  many  cases, 
the  relief  of  distressing  symptoms  and  the  postponement  of  disaster.  When 
compensation  fails  the  heart  is  enlarged  toward  the  right,  there  is  dys- 
pnoea upon  slight  exertion  or  even  at  rest,  orthopnoea,  faint  cyanosis, 
enlargement  of  the  area  of  liver  dulness,  a  feeble  impulse,  and  a  small, 
rapid,  often  irregular  pulse, — all  manifestations  of  cardiac  inadequacy. 

About  75  per  cent,  of  the  cases  are  due  to  acute  endocarditis,  about 
12  per  cent,  to  arteriosclerosis,  and  the  remainder  to  primary  valvular 
sclerosis  and  other  causes.  Of  the  cases  resulting  from  acute  endocarditis 
nearly  60  per  cent,  are  due  to  rheumatic  fever.  The  distribution  of  the 
lesions  in  valvular  disease  following  rheumatism  is,  according  to  Romberg, 
as  follows :  mitral  about  59  per  cent. ;  mitral  and  aortic  29  per  cent. ;  aortic 
alone  9  per  cent.;  and  mitral  and  triscupid,  and  with  these  the  aortic  and 
pulmonary,  3  per  cent. 


1214  MEDICAL  DIAGNOSIS. 

As  to  age,  the  greater  number  of  the  cases  originating  in  rheumatic 
endocarditis  are  first  recognized  between  the  tenth  and  thirtieth  years. 
The  chronic  endocarditis  of  early  Hfe  is  mostly  due  to  acute  endocarditis; 
that  of  advancing  years  to  sclerosis.  The  two  sexes  are  liable  nearly  to  the 
same  degree.     Other  predisposing  influences  are  unimportant. 

V.  CHRONIC  VALVULAR  DISEASE, 
i.  Aortic  Insufficiency. 

Aortic  Incompetence;    Aortic  Regurgitation;    Corrigan's   Disease. 

The  valves  fail  to  close  the  aortic  orifice  and  a  portion  of  the  blood 
that  has  passed  into  the  aorta  with  the  systole  returns  to  the  ventricle 
during  diastole. 

The  loss  of  function  is,  in  a  great  majority  of  the  cases,  the  result  of 
deformity  of  the  valves;  in  others  it  is  due  to  dilatation  of  the  aortic  ring — 
relative  aortic  incompetency. 

The  deformity  may  be,  (a)  congenital,  and  arise  from  the  fusion  of 
two  semilunar  leaflets  at  their  lateral  borders,  or  from  a  narrow  slit  par- 
allel with  and  close  to  the  free  edge.  Such  valves  frequently  show  sclerotic 
changes,  (b)  The  result  of  acute  endocarditis  in  which  the  insufficiency  is 
caused  by  the  vegetations,  or  by  ulceration  and  necrosis,  or  by  adhesions 
with  the  later  changes  which  attend  sclerosis,  (c)  The  manifestation  of 
progressive  sclerotic  processes,  thickening,  rigidity,  incurving  at  the 
borders,  and  shortening  of  the  valves,  (d)  Rupture  of  a  valve  segment, 
an  accident  due  to  excessive  muscular  strain,  probably  never  occurring 
in  previously  sound  valves  and  very  infrequent  in  disease,  if  the  ulcerated 
and  necrotic  valves  of  malignant  endocarditis  be  excepted. 

Dilatation  of  the  outlet  may  occur  in  arteriosclerosis  involving  the 
aorta  immediately  above  the  outlet,  in  aneurism  of  the  ascending  portion 
of  the  aortic  arch,  and  in  advanced  age  as  a  senile  change.  In  aortic  in- 
sufficiency due  to  acute  endocarditis  there  is  frequently  also  some  degree 
of  stenosis;  in  the  form  associated  with  arteriosclerosis  narrowing  is 
comparatively  rare. 

Etiology. — Aortic  insufficiency  may  occur  at  any  age.  It  is,  however, 
chiefly  met  with  in  middle  life  and  is  far  more  common  in  males  than  in 
females.  Rheumatic  fever  and  other  acute  infections  associated  with 
acute  endocarditis,  conditions  which  favor  arteriosclerosis,  as  occupations 
involving  continuous  and  prolonged  excessive  muscular  effort,  injudicious 
devotion  to  athletics,  poisons  such  as  lead  and  alcohol,  and  gout  and 
syphilis  are  important  etiological  factors. 

Direct  Effects  upon  the  Heart  and  Vessels. — The  reflux  of  blood  causes 
overdistention  of  the  left  ventricle  and  diminution  of  the  normal  amount 
in  the  aorta  and  its  branches.  The  failure  of  the  valves  to  close  deprives 
the  blood  in  the  arterial  tree  of  its  normal  base  of  support,  which  is  trans- 
ferred in  a  degree  corresponding  to  the  valvular  defect  to  the  ventricular 
wall.  The  cavity  of  the  ventricle  is  overdistended.  Dilatation  occurs 
and  is  followed  by  hypertrophy.     In  the  sclerotic  forms  the  compensation 


AORTIC  INSUFFICIENCY.  1215 

follows  the  lesion  and  symptoms  do  not  for  a  time  occur.  In  the  suddenly 
developing  cases — ulcerative  lesions,  rupture — compensation  does  not 
occur,  and  the  gravest  symptoms  of  acute  dilatation  of  the  heart  imme- 
diately follow.  The  cardiac  hypertrophy  and  dilatation  are  often  extreme. 
There  may  be  associated  lesions  of  the  mitral  leaflets.  Relative  mitral 
insufficiency  results  from  the  enlargement  of  the  mitral  ring.  The  left 
auricle  thereupon  undergoes  dilatation  and  hypertrophy,  and  "as  the  case 
progresses  similar  changes  take  place  in  the  right  chambers  of  the  heart. 
With  each  systole  the  dilated  and  hypertrophied  ventricle  sends  into  the 
arteries  an  increased  amount  of  blood  with  augmented  force.  There  is 
immediate  but  momentary  widening  and  elongation  of  these  vessels 
visible  in  their  superficial  branches — locomotor  pulsation. 

Symptoms. — Compensation  may  be  fully  maintained  for  a  long  time. 
Pain  is  among  the  earlier  symptoms.  It  is  sometimes  dull  and  limited  to 
the  precordia;  sometimes  sharp  and  paroxysmal,  radiating  to  the  neck 
and  left  arm.  Angina  pectoris  is  common.  Anaemia  is  also  a  compara- 
tively early  manifestation. 

As  compensation  fails,  symptoms  of  cerebral  anaemia  occur  upon 
sudden  effort,  rising  from  bed,  or  in  the  act  of  defecation.  Among  these 
are  headache,  vertigo,  phosphenes,  and  faintness.  Presently  to  these  are 
added  precordial  distress,  and  sometimes  palpitation,  dyspnoea,  and 
oedema  of  the  feet.  Cyanosis  is  not  common  and  blood-streaked  sputa 
less  frequent  than  in  other  forms  of  chronic  valvular  disease.  Insomnia 
and  annoying  dreams,  delirium  and  hallucinations,  and  a  suicidal  tendency 
are  symptoms  of  the  later  stages.  Irregular  fever  and  embolism  in  various 
arterial  distributions  may  be  the  manifestations  of  an  intercurrent  acute 
endocarditis. 

Physical  Signs. — Inspection  yields  characteristic  signs.  This  is  a 
valvular  disease  which  may  often  be  recognized,  when  the  patient  is 
stripped  to  the  waist,  by  inspection  alone.  There  are  the  evidences  of  a 
high  grade  of  cardiac  hypertrophy,  namely,  dislocation  of  the  apex  beat 
to  the  left  and  downward  occasionally  as  far  as  the  line  of  the  anterior 
axillary  fold  and  the  seventh 
or  eighth  interspace;  a  widely 
extended  heaving  impulse; 
prominence  in  the  precordial 
area,  especially  in  young  per- 
sons; throbbing  at  the  root  of 
the  neck.  The  superficial  arte- 
ries abruptly  expand  and  almost 
as   suddenly  collapse.     With 

each  pulsation  they  are  thrown  Fig.  343.— Aortic  regurgitation;    carotid  tracing. 

into  sinuous  curves,  which  are 

conspicuous  in  the  temporals,  brachials,  and  radials.  The  pulsating  aorta 
may  be  seen  in  the  episternal  notch  and  in  the  epigastrium.  Capillar)^ 
pulsation  follows  the  line  drawn  upon  the  forehead  with  the  finger-tip, 
or  may  be  seen  in  the  finger-nails,  or,  in  marked  cases,  it  may  occur 
at  times  spontaneously  in  the  hands  and  face.  Venous  pulsation  is 
sometimes    visible,    especially    in    the    large    veins    of    the    back   of   the 


1216  MEDICAL  DIAGNOSIS. 

hands.  The  pulse  has  the  pecuHarities  of  the  Corrigan  or  water-nammer 
pulse.  It  is  appreciably  retarded,  large,  quick,  and  rapidly  receding. 
It  is  for  this  reason  spoken  of  as  the  collapsing  pulse.  This  last  pecul- 
iarity is  intensified  when  the  hand  is  raised.  Upon  palpation  a  forcible 
impulse  may  be  located  in  two  or  three  intercostal  spaces,  and  general 
heaving  of  the  chest  perceived  by  palpation  with  the  whole  hand.  A 
diastoHc  thrill  may  sometimes  be  felt.  SystoHc  depression,  when  present, 
is  not  so  often  the  sign  of  pericardial  adhesion  as  of  atmospheric  pressure. 
Upon  ophthalmoscopic  examination  the  retinal  arteries  are  seen  to  pul- 
sate. In  aortic  regurgitation  of  high  grade  there  is  sometimes  seen  distinct 
backward  nodding  of  the  head  corresponding  to  the  systole.  Upon  per- 
cussion, since  the  hypertrophied  heart  pushes  the  lung  before  it,  the  area 
of  superficial  dulness  and  that  of  deep  dulness  are  alike  greatly  increased, 
especially  downward  and  to  the  left.  In  extreme  enlargement  of  the  left 
ventricle  the  right  heart  is  displaced  to  the  right. 

Upon  auscultation  there  is  to  be  heard  at  the  base  of  the  heart  and 
downward  a  diastohc  murmur,  caused  by  the  reflux  of  blood  through  the 
insufficiently  guarded  aortic  orifice  into  the  ventricle.     This  murmur  is 


Fig.  344. — Aortic  regurgitation;    radical  tracing. 

often  faint  at  the  aortic  cartilage,  but  usually  distinct  or  loud  at  the  sternal 
end  of  the  third  left  intercostal  space  or  third  cartilage,  over  the  seat  of 
the  valve,  and  propagated  along  the  left  border  of  the  sternum  to  the 
ensiform  cartilage.  The  diastolic  murmur  of  aortic  insufficiency  is,  in 
many  cases,  more  distinct  in  the  pulmonary  than  in  the  aortic  punctum 
maximum.  It  usually  is  loud  at  the  beginning  and  rapidly  becomes  fainter 
and  lasts  throughout  the  period  of  diastole.  The  murmur  of  aortic  insuf- 
ficiency may,  in  some  cases,  be  more  distinct  in  the  recumbent  than  in 
the  erect  posture.  The  second  aortic  sound  is  either  wholly  inaudible, 
being  replaced  by  the  murmur,  or  faintly  heard  over  the  aortic  cartilage, 
or  finally,  when  absent  at  that  point,  it  may  be  heard  over  the  carotid. 
The  first  sound  may  be  normal  at  the  base.  A  systolic  murmur  is  not 
always  the  sign  of  combined  stenosis.  It  is  commonly  short,  and  when 
coarse  and  accompanied  by  a  thrill  it  may  be  the  sign  of  rigid  lesions  pro- 
jecting into  the  aortic  space  without  actual  narrowing,  or  of  abrupt  aortic 
dilatation.  While  compensation  remains  good,  the  first  sound  at  the  apex 
is  normal  or  simply  intensified  and  prolonged.  When  it  fails,  the  systolic 
murmur  of  relative  mitral  insufficiency  is  heard. 

Flint's  Murmur. — A  coarse,  rumbhng  murmur,  presystolic  in  time, 
heard  in  a  limited  area  just  above  the  apex,  and  accompanied  by  a  thrill. 
This  murmur  has  the  same  qualities  and  time  relation  to  the  cardiac  revolu- 
tion as  the  murmur  of  mitral  stenosis,  but  it  is  not  associated  with  the  sharp 
first  sound,  the  abrupt  impulse,  and  the  pulsation  in  the  second  and  third 


AORTIC  STENOSIS.  1217 

interspaces  which  characterize  well-marked  cases  of  mitral  stenosis.  It 
is  not  heard  continuously,  but  comes  and  goes  under  conditions  not 
well  understood,  and  is  met  with  in  a  large  proportion  of  the  cases  of 
uncomplicated  aortic  insufficiency. 

Over  the  larger  arteries,  and  especially  over  the  femoral,  there  is  some- 
times heard  a  double  murmur — Duroziez's  murmur.  The  arteries  between 
the  pulse-beats  are  abnormally  empty  and  soft.  The  systolic  blood-pres- 
sure is  high  and  the  diastolic  pressure  abnormally  low.  The  sphygmo- 
gram  is  characterized  by  abrupt  high  ascent,  sharp  summit,  and  faintly 
marked  dicrotic  notch. 

Diagnosis. — The  direct  diagnosis  of  aortic  insufficiency  rests  upon 
the  presence  of  a  diastolic  murmur,  cardiac  hypertrophy,  and  the  pulse 
of  Corrigan — pulsus  celer.  It  finds  support  in  the  occurrence  of  Flint's 
murmur,  or  an  associated  aortic  systolic  or  mitral  systolic  murmur, — rela- 
tive insufficiency, — and  in  the  tendency  to  massive  hypertrophy.  There 
are  cases  in  which  the  diastolic  murm^ur  cannot  be  heard,  or  a  systolic  mur- 
mur only  is  present,  yet  the  pulse  and  cardiac  hypertrophy  point  to  insuf- 
ficiency of  the  aortic  valve.  In  high  fever  with  great  loss  of  arterial  tone, 
intense  anaemia,  some  cases  of  hysteria  and  neurasthenia,  and  the  more 
acute  forms  of  exophthalmic  goitre,  the  conditions  of  the  peripheral  cir- 
culation are  very  suggestive  of  aortic  insufficiency,  but  in  all  these  the 
history  of  the  case  and  the  concomitant  symptoms  and  physical  signs  are 
of  help  in  the  differential  diagnosis. 

Prognosis. — The  compensation  may  be  maintained  for  years  without 
symptoms  referable  to  the  heart,  and  the  patient  lead  a  fairly  active  life. 
The  outlook  is  better  when  the  valvular  defect  follows  acute  endocarditis 
and  develops  early  in  life.  Associated  mitral  lesions  are  unfavorable. 
Relative  mitral  insufficiency,  by  which  the  arterial  conditions  are  modified, 
tends  to  transfer  the  stress  of  compensation  from  the  left  ventricle  to 
the  auricle  and  thence  to  the  right  heart.  Sudden  death  is  a  danger. 
It  often  occurs  without  marked  previous  symptoms  of  heart  disease. 
When  compensation  fails  more  gradually,  the  characteristic  symptoms 
of  progressive  cardiac  inadequacy  arise. 


ii.  Aortic  Stenosis. 

Aortic   Obstruction. 

The  aortic  outlet  is  narrowed  or  constricted.  A  portion  of  the  blood 
which  should  pass  into  the  aorta  with  the  ventricular  systole  is  held  back 
with  every  revolution  of  the  heart.  That  function  of  the  valve  which 
consists  in  the  retreat  of  its  segments  into  contact  with  the  wall  of  the  aorta 
before  the  blood  stream  is  impaired.     This  affection  is  comparatively  rare. 

The  lesion  may  be,  (a)  congenital,  in  which  case  the  cusps  may  be 
united  to  form  a  thin  diaphragm-like  membrane  with  a  small  slit-like 
opening,  or  there  may  be  a  subvalvular  stenosis  the  result  of  prenatal 
endocarditis;  (b)  the  result  of  an  acute  endocarditis  with  adhesions,  stif- 
fening, and  vegetations  which  have  undergone  fibroid  and  calcareous 
changes;  or  (c)  the  outcome  of  an  arteriosclerotic  process.  Very  often  the 
77 


121S  MEDICAL  DIAGNOSIS. 

last  are  associated  with  extensive  atheromatous  changes  in  the  aorta,  and 
the  sigmoid  valves  are  buttressed  out  by  rigid  calcareous  masses  in  the 
sinuses  of  Valsalva.  Under  these  circumstances  the  blood  supply  to  the 
coronary  arteries  is  diminished  and  myocardial  degeneration  hastened. 

The  obstruction  to  the  outflow  of  the  blood  throws  increased  work 
upon  the  left  ventricle,  which  undergoes  hypertrophy.  Thus  compensa- 
tion is  established.  So  long  as  compensation  is  maintained,  the  ventricle 
undergoes  little  or  no  dilatation,  but  it  appears  small  in  view  of  the  great 
thickness  of  the  wall  and  is,  therefore,  sometimes  spoken  of  as  concentric 
hypertrophy  in  contradistinction  to  the  ordinary  eccentric  hypertrophy 
seen  in  aortic  or  mitral  insufficiency.  When  compensation  fails  the  left 
auricle  undergoes  dilatation  and  hypertrophy  of  its  wall,  there  is  increase 
of  the  blood-pressure  in  the  pulmonary  circuit  and  stress  upon  the  right 
ventricle. 

Of  aortic  stenosis  it  is  especially  true  that  the  valves  can  neither  fully 
open  nor  completely  close.  Combined  stenosis  and  insufficiency  are 
therefore  common;    uncomplicated  stenosis  is  rare. 

Relative  stenosis  is  that  condition  in  which  with  a  normal  aortic  ring 

and  valve  cusps  there  is  abrupt  dilatation  of  the  aorta  immediately  beyond. 

Etiology. — This  is  a  rare  valvular  affection.     Its  incidence  is  greater 

in  males  than  females,  and  it  occurs  with  more  frequency  in  old  men  with 

atheromatous  arteries  than  at  an  earlier  period  of  life. 

Symptoms. — With  fair  compensation  there  are  no  special  symptoms, 
and  aortic  stenosis  may  reach  a  high  grade  without  marked  .evidences  of 
derangement  of  the  general  health.  Among  the  symptoms  which  attract 
the  attention  of  the  patient  to  his  circulation  are  those  indicative  of  tran- 
sient cerebral  anaemia — vertigo  and  faintness.  In  some  cases  epileptiform 
seizures  have  been  observed.  Palpitation  and  precordial  pain  are  less 
common.  As  compensation  fails  the  symptoms  of  cardiac  inadequacy 
are  progressively  developed. 

Physical  Signs. — Inspection  shows,  as  a  rule,  a  heaving  impulse  due 
to  the  left  ventricle  hypertrophy,  situated  at  the  normal  place  or  slightly 
to  the  left.  As  compensation  fails  and  dilatation  of  the  left  and  later  of 
the  right  ventricle  takes  place,  the  impulse  is  displaced  beyond  the  mid- 
clavicular   line.     A  distinct   thrill    corresponding    in    time    and    duration 

to  the  systolic  murmur 
may  be  detected  at  the 
sternal  border  or  at  the 
right  side  of  the  root 
of  the  neck  over  the 
carotid.  The  pulse  is 
somewhat  retarded.    In 

Fig.  345. — Aortic  stenosis:   radial  tracing.  , ,  ,  ■, 

other  respects,  namely, 
as  to  volume  and  tension,  it  often  preserves  its  normal  characters,  though  in 
stenosis  of  high  grade  it  may  be  small  and  slow,  with  the  filling  of  the 
arteries  well  maintained  between  the  beats.  The  sphygmogram  shows  a 
slow  rise,  a  broad  summit,  and  a  slow  decline.  There  is  in  most  of  the  cases 
in  advanced  life  evidence  of  marked  arteriosclerosis.  Upon  palpation  the 
position  of  the  apex  beat  may  be  obscured  by  pericardial  adhesions  or  an 


AORTIC  STENOSIS.  1219 

emphysematous  lung.  Upon  percussion  while  compensation  is  still  main- 
tained, the  transverse  diameter  of  the  absolute  dulness  and  that  of  the 
relative  dulness  of  the  heart  are  little  if  at  all  increased.  Auscultation 
discloses  in  the  second  right  intercostal  space  at  the  sternal  border  a  very- 
distinct  systolic  murmur,  usually  coarse  and  harsh.  This  murmur  is  among 
the  loudest  of  the  heart  murmurs  and  may  sometimes  be  heard  at  a  distance 
of  some  feet  from  the  patient.  Not  infrequently  it  has  a  musical  quality 
during  some  part  of  its  course.  It  is  distinctly  transmitted  to  the  carotids 
and  subclavians,  especially  upon  the  right  side;  less  plainly  over  the  heart, 
but  in  some  cases  it  may  be  heard  at  the  apex.  Very  characteristic  is  the 
absence  of  the  second  aortic  sound.  A  second  sound  heard  at  the  aortic  car- 
tilage is  in  most  cases  transmitted  from  the  pulmonary  valve.  When  compen- 
sation fails  the  murmur  may  be  faint  and  distant  and  the  thrill  disappear. 

Diagnosis.  —  Direct.  —  Aortic  stenosis  may  be  recognized  by  the 
association  of  a  loud,  rough,  or  musical  systolic  murmur  having  its  point 
of  maximum  intensity  at  the  aortic  punctum  maximum,  and  accompanied 
by  a  thrill,  the  signs  of  hypertrophy  of  the  left  ventricle,  an  inaudible  or 
faint  aortic  second  sound,  and  a  slow,  regular  pulse  of  moderate  tension. 

Differential. — Errors  of  diagnosis  are  common.  They  arise  from 
attaching  too  great  importance  to  a  systolic  murmur  in  the  aortic  area 
in  the  absence  of  actual  signs  of  lesions  of  the  valve  and  hypertrophy  of 
the  ventricle.  The  following  conditions  in  which  such  a  murmur  may  be 
heard  are  to  be  considered :  Sclerosis  of  the  aorta  directly  beyond  the  valve, 
or  of  a  cusp  without  narrowing  of  the  orifice  may,  particularly  when  asso- 
ciated with  the  cardiac  hypertrophy  of  nephritis,  closely  simulate  aortic 
stenosis.  In  favor  of  the  former  condition  would  be  an  accentuated  aortic 
second  sound,  and  a  small,  regular,  and  rather  slow  pulse.  Aneurism  of 
the  Ascending  Portion  of  the  Arch. — A  history  of  syphilis  or  strain,  pressure 
symptoms, — as  pain,  dyspnoea,  or  cough, — inequality  of  the  pulses,  displace- 
ment of  the  heart  as  a  whole  rather  than  hypertrophy  of  the  left  ventricle, 
circumscribed  dulness  and  bulging  with  or  without  a  thrill,  tracheal  tugging, 
and  diastolic  shock,  all  or  several,  when  present,  justify  a  diagnosis  of 
aneurism.  An  X-ray  examination  may  be  of  great  service  in  a  doubtful 
case.  In  ancemic  conditions  the  basic  murmur  is  often  loudest  in  the  aortic 
area.  This  soft  bruit  is  very  different  from  the  loud,  harsh  murmur  of 
stenosis;  the  aortic  second  sound  is  heard,  there  is  not  usually  hypertrophy 
of  the  left  ventricle,  the  pulse  is  more  frequent,  and  anaemia  may  be  dem- 
onstrated upon  examination  of  the  blood.  Relative  aortic  stenosis  may 
be  suspected  when,  with  a  systolic  aortic  murmur,  the  second  aortic  sound 
is  preserved,  left  ventricle  hypertrophy  is  lacking,  and  signs  of  dilatation 
of  the  aorta  are  found  upon  percussion  or  by  palpation  with  the  finger-tip 
in  the  episternal  notch. 

Prognosis. — Cases  following  acute  endocarditis  in  early  life  with  good 
compensation  may  go  on  without  cardiac  symptoms  for  many  years. 
Those  due  to  arteriosclerosis  beginning  in  advancing  life  are  of  much  less 
favorable  outlook.  The  changes  are  essentially  progressive,  the  coronary 
arteries  are  liable  to  become  involved,  and  with  the  development  of  myo- 
carditis compensation  fails.  This  form  of  chronic  valvular  disease  is  not 
attended  with  an  especial  liability  to  sudden  death. 


1220  MEDICAL  DIAGNOSIS. 

iii.  Mitral  Insufficiency. 

Mitral  Incompetence;    Mitral  Regurgitation. 

A  portion  of  the  blood  in  the  left  ventricle,  which  upon  systole  should 
pass  onward  into  the  aorta,  leaks  back  through  the  auriculoventricular 
orifice  into  the  left  auricle.  Mitral  insufficiency  is  the  result  of  valvular 
disease,  or  it  may  occur  without  lesions  of  the  valves  in  consequence  of 
dilatation  of  the  heart — relative  insufficiency — or  of  derangement  of  the 
mechanism  by  which  the  leaflets  are  brought  into  effectual  coaptation — 
muscular  insufficiency. 

Mitral  Insufficiency  Due  to  Chronic  Valvular  Disease. — The 
structural  defects  in  the  valves  are  in  the  great  majority  of  the  cases  the 
result  of  acute  endocarditis;  infrequently  the  outcome  of  primary  sclerotic 
processes.  They  consist  of  an  overgrowth  of  fibroid  tissue  with  thickening 
and  shortening  of  the  segments,  adhesions  between  their  borders,  shorten- 
ing of  the  chordae  tendinese,  and  the  deposition  of  lime  salts  in  the  new- 
formed  tissues.  In  advanced  cases  the  altered  valves  are  often  transformed 
into  a  thick,  rigid  calcareous  diaphragm  perforated  by  an  irregular  oval 
opening.  Owing  to  the  nature  of  the  lesions  uncomplicated  mitral  insuf- 
ficiency is  rare,  the  condition  being,  as  a  rule,  associated  with  some  degree 
of  stenosis. 

The  effect  upon  the  heart  is  as  follows: 

(a)  With  each  ventricular  systole  a  quantity  of  blood,  varying  accord- 
ing to  the  valvular  defect,  is  returned  from  the  ventricle  to  the  left  auricle. 
This  results  in  an  overdistention  of  the  auricle  with  dilatation  and 
hypertrophy. 

(b)  The  left  ventricle  undergoes  dilatation  in  consequence  of  the 
increased  volume  of  blood  received  from  the  overfilled  auricle.  It,  how- 
ever, empties  itself  in  the  normal  time  and  becomes  hypertrophied  to 
meet  the  increased  work.  Notwithstanding  the  amount  of  blood  returned 
to  the  auricle,  the  normal  quantity  enters  the  general  circulation. 

(c)  In  the  minor  degrees  of  mitral  insufficiency,  the  dilatation  and 
hypertrophy  of  the  left  chambers  of  the  heart  suffice  for  compensation. 

(d)  In  higher  grades,  the  increased  blood-pressure  due  to  the  over- 
filling of  the  left  auricle  is  transferred  to  the  pulmonary  veins,  and  by  way 
of  the  capillaries  to  the  branches  of  the  pulmonary  artery,  and  thence  to 
the  right  ventricle,  which  in  turn  undergoes  hypertrophy. 

(e)  So  long  as  the  compensation  thus  established  is  maintained  the 
right  ventricle  does  not  undergo  dilatation. 

(f)  The  prolonged  overfilling  of  the  pulmonary  vessels  produces  brown 
induration  of  the  lungs. 

(g)  The  compensation  may  be  indefinitely  prolonged,  but  after  a 
time  it  fails,  the  left  ventricle  no  longer  discharges  the  normal  amount  of 
blood  into  the  aorta,  the  right  ventricle  begins  to  dilate,  there  is  relative 
insufficiency  of  the  tricuspid  valves,  and  the  right  auricle  becomes  dilated. 
The  pressure  is  transferred  to  the  venous  system,  and  the  passive  visceral 
congestions,  dropsies,  anaemic  and  other  symptoms  of  cardiac  dyscrasia 
begin  to  show  themselves. 


MITRAL  INSUFFICIENCY.  1221 

Etiology. — -Mitral  insufficiency  is  the  most  common  of  the  chronic 
valvular  diseases.  Predisposing  Influences. — These  are  found  chiefly 
in  the  acute  infections,  in  the  course  of  which  acute  endocarditis  occurs, 
especially  rheumatic  fever.  Age,  therefore,  also  constitutes  an  important 
predisposing  factor,  mitral  valvular  disease  being  especially  a  disease  of 
childhood  and  early  adult  life.  It  may  be  said  that  the  valvular  diseases 
of  early  life  are  of  inflammatory  origin;  those  of  advanced  life  sclerotic. 
Sex  appears  to  be  wholly  without  influence. 

Exciting  Cause. — The  immediate  cause  of  the  deformity  of  the 
valves  is  to  be  found  in  the  advance  of  lesions  having  their  point  of  depar- 
ture in  previous  inflammation  or  sclerosis. 

Symptoms. — While  compensation  is  maintained  there  are  no  dis- 
tinctive symptoms.  With  insufficiency  of  high  grade  there  may  be  merely 
slight  dyspnoea  upon  unusual  effort,  and  a  rather  marked  tendency  to 
attacks  of  bronchial  catarrh.  When  compensation  is  incomplete  the 
symptoms  are  very  suggestive.  Faint  cyanosis,  dilated  superficial  venules, 
dyspnoea  and  palpitation  upon  moderate  effort,  and  frequently  recurring 
bronchitis,  often  accompanied  by  blood-streaked  sputa  or  haemoptysis, 
constitute  the  clinical  picture.  Nevertheless,  such  patients  often  continue 
to  work  and  take  pleasure  in  life  for  a  long  period. 

With  broken  compensation  the  disability  is  complete.  The  symptoms 
are  those  of  advanced  cardiac  inadequacy,  palpitation,  feeble,  irregular 
heart  action,  an  irregular,  feeble  pulse,  arrhythmia,  dyspnoea,  and  harass- 
ing cough  with  thin  blood-stained  sputa  containing  alveolar  cells  with 
pigment  granules — Herzfehlerzellen.  Precordial  distress  and  a  sensation 
of  heart  failure  are  common.  Another  group  of  symptoms  comprise  those 
due  to  passive  congestions.  Among  these  are  pallor,  faint  cyanosis,  yel- 
lowness of  the  skin,  drowsiness,  insomnia,  dropsy  beginning  at  the  ankles 
and  rising  to  the  body  with  accumulations  in  the  loose  tissues  around  the 
pudenda,  in  parts  that  are  dependent,  as  the  buttocks  and  flanks,  and  in  the 
serous  sacs,  and  diminished  urine  with  albumin,  casts,  and  blood-corpuscles. 
Even  at  this  stage  compensation  may  be  by  rest  and  treatment  to  some 
extent  restored,  only  to  be  lost  again  in  a  little  while.  Death  is  not  usually 
sudden,  although  at  the  last  it  may  come  quickly.  Recurrent  endocar- 
ditis is  common  and  frequently  of  the  malignant  type.  Subacute  peri- 
carditis is  common.  Among  the  intercurrent  diseases  to  which  the  patients 
appear  to  be  especially  liable  are  bronchitis,  bronchopneumonia,  pleurisy, 
pulmonary  infarct,  and  cerebral  embolism.  There  is  also  a  marked  ten- 
dency to  cerebral  and  retinal  hemorrhage  and  to  epistaxis.  Febrile  attacks 
are  common  in  the  absence  of  assignable  cause.  But  the  rise  in  temperature 
may  often  be  explained  by  demonstrable  infectious  or  septic  conditions. 

Physical  Signs.  —  With  fair  compensation  the  cardiac  enlargement 
is  moderate.  The  impulse  is  displaced  to  the  left  and  stronger  than  normal. 
When  the  compensation  is  l:)roken  it  is  extended,  undulatory,  and  feeble. 
Palpation  determines  the  force  and  extent  of  the  impulse.  With  compen- 
sation it  is  forcible  and  heaving;  in  failure  it  is  feeble  and  extended.  In 
a  small  proportion  of  the  cases  a  faint  systolic  thrill  may  be  detected  at 
the  apex.  The  pulse  with  compensation  is  full  and  regular,  but  it  may  be 
of  low  tension.     As  compensation  fails  it  becomes  small,  feeble  usually, 


1222 


MEDICAL  DIAGNOSIS. 


somewhat  increased  in  frequency,  and  arrhythmic.  The  irregularity  per- 
sists when  compensation  is  restored,  and  the  pulse  of  mitral  insuflEiciency 
once  irregular  is  almost  always  irregular.  The  transverse  dulness  is 
increased  toward  the  left  and  to  some  extent  upward.  It  does  not  usually 
extend  to  the  right  while  compensation  is  maintained.  Exceptionally 
in  large  hypertrophy  of  the  left  ventricle  the  right  ventricle  may  be  dis- 
placed beyond  its  normal  position  toward  the  right.  With  failing  com- 
pensation the  dilated  right  ventricle  gives  increased  dulness  to  the  right 
of  the  sternal  border.  Upon  auscultation  there  is  heard  a  systohc  murmur 
having  its  point  of  maximum  intensity  at  the  apex  and  being  transmitted 
in  all  directions,  but  most  distinctly  in  the  direction  of  the  axilla.    In 


Fig.  346. — Mitral  regurgitation;   good  compensation;  radial  tracing. 

some  cases  this  murmur  is  loudest  along  the  left  border  of  the  sternum 
or  in  the  pulmonary  area.  It  may  also  be  heard  along  the  lower  part 
of  the  inner  border  of  the  left  scapula.  It  is  sharp,  less  frequently 
soft  and  blowing,  and  sometimes  musical,  especially  toward  the  end. 
Its  intensity  varies  from  time  to  time.  It  may  be  more  distinct  in  the 
erect  than  in  the  recumbent  posture,  but  it  is  usually  audible  in  both 


Fig.  347. — Mitral  regurgitation;  radial  tracing. 

attitudes.  It  may  accompany  or  wholly  replace  the  first  sound  of  the 
heart.  The  second  pulmonary  sound  is  accentuated.  A  more  or  less 
distinct  presystolic  murmur  is  the  sign  of  a  combined  stenosis  but  it  is 
by  no  means  always  to  be  heard. 

Relative  and  Muscular  Insufficiency.  —  (a)  Relative  insuffi- 
ciency of  the  left  auriculoventricular  valve — mitral  valve  system — results 
from  overdistention  of  the  auriculoventricular  ring.  It  occurs  in  acute 
dilatation  of  the  heart, — heart-strain;  the  heart  starvation  of  acute  illness 
and  chlorosis  or  anaemia,— and  is  then  described  as  primary;  and  in  aortic 
regurgitation  and  aortic  stenosis  upon  failure  of  compensation,  when  it 
is  known  as  secondary  relative  insufficiency. 

The  etiological  factors  are  those  of  acute  or  gradual  dilatation.  The 
pathological  condition  is  stretching  of  the  ventricular  ring;  the  derange- 
ment of  function,  incompetence  of  the  valve  system.  The  rational 
symptoms  and  physical  signs  are  those  of  valvular  insufficiency. 


MITRAL  INSUFFICIENCY.  1223 

(b)  Muscular  insufficiency  may  involve  the  mitral  or  the  tricuspid 
valve  system.  It  is  due  to  a  derangement  of  the  mechanism  by  which  the 
closure  takes  place.  There  may  be  evidences  of  moderate  dilatation  of  the 
auriculoventricular  ring,  but  these  are  often  absent.  Pathological  changes 
in  the  myocardium  are,  however,  present.  There  is  myocarditis  involving 
the  ring  muscle  at  the  base  of  the  ventricle  and  the  papillary  muscles. 
The  occasional  occurrence  of  transitory  systolic  mitral  murmurs  in  other- 
wise healthy  men,  in  the  absence  of  a  history  of  acute  cardiac  dilatation, 
justifies  the  assumption  that  muscular  insufficiency  may  sometimes  be 
purely  functional.  It  may  aid  the  understanding  of  this  somev/hat  obscure 
subject  to  recall  the  fact  that  the  auriculoventricular  valves  are  held  in  close 
contact  during  systole,  not  merely  at  their  margins  but  throughout  their 
auricular  faces,  by  the  pressure  of  the  blood  upon  their  ventricular  surfaces. 

Diagnosis. — The  direct  diagnosis  of  mitral  insufficiency  may  be 
attended  with  difficulty.  A  systolic  murmur  having  its  point  of  maximum 
intensity  at  the  apex,  propagated  to  the  axilla,  and  heard  at  the  angle  of  the 
scapula;  accentuation  of  the  pulmonary  second  sound;  and  the  signs  of  hyper- 
trophy of  the  left  ventricle,  namely,  increase  in  the  transverse  diameter  to 
the  left,  and  a  strong  impulse,  are  important  but  not  in  every  case  conclusive. 

The  DIFFERENTIAL  DIAGNOSIS  between  valvular  and  relative  and 
muscular  insufficiency  cannot  always  be  made.  Here  the  anamnesis  is 
very  useful.  In  the  latter  groups  of  cases  a  history  of  acute  illness,  as 
diphtheria,  enteric  fever,  or  influenza,  but  no  history  of  recent  rheumatism 
or  scarlet  fever,  recent  blood  loss  or  other  cause  of  secondary  anaemia,  and 
primary  anaemias,  as  chlorosis  or  pernicious  anaemia,  are  very  suggestive. 
The  signs  of  arteriosclerosis  and  of  chronic  nephritis  must  be  considered 
when  the  diagnosis  is  obscure.  These  conditions  are  frequently  associated 
with  myocarditis  and  muscular  insufficiency.  The  almost  constant  asso- 
ciation of  some  degree  of  stenosis  with  insufficiency  gives  to  a  presystolic 
murmur  and  thrill  great  value  in  a  doubtful  case. 

Prognosis. — Mitral  insufficiency  is  the  most  common  and  the  least 
deadly  of  the  chronic  valvular  diseases.  Whether  or  not  minor  lesions 
ever  terminate  in  recovery  may  well  be  questioned.  It  is  certain,  however, 
that  there  are  many  cases  in  which  full  compensation  is  early  established 
and  maintained  through  life.  The  signs  persist,  but  cardiac  symptoms  are 
absent.  The  outlook  is  more  favorable  in  the  cases  which  follow  acute 
endocarditis  than  in  those  originating  in  sclerotic  processes;  when  the 
disease  begins  in  adolescence  or  early  adult  life  than  in  childhood  or  the 
aged;  in  those  who  are  able  and  willing  to  lead  quiet,  orderly,  and  well- 
disciplined  lives  than  in  those  whose  circumstances  demand  unremitting 
toil,  or  whose  habits  are  irregular  and  self-indulgent.  The  extent  of  the 
leakage,  as  indicated  by  the  degree  of  dilatation  and  hypertrophy,  the  com- 
pleteness of  compensation,  the  presence  of  secondary  morbid  conditions 
or  of  other  valvular  lesions  or  extensive  pericardial  adhesions  has  an  impor- 
tant bearing  upon  the  prognosis.  The  liability  to  recurrent  acute  endo- 
carditis adds  to  the  gravity  of  the  condition.  Among  the  common  causes 
of  death  are  cardiac  insufficiency  in  the  sense  of  complete  loss  of  contrac- 
tile power,  pulmonary  infarct,  cerebral  embolism,  nephritis,  and  acute 
intercurrent  disease. 


1224  MEDICAL  DIAGNOSIS. 

iv.  Mitral  Stenosis. 

The  mitral  orifice  is  narrowed  or  constricted  and  the  passage  of  the 
blood  from  the  left  auricle  to  the  left  ventricle  is  impeded.  The  lesion 
is  commonly  the  result  of  acute  endocarditis  in  early  life.  It  consists  of 
thickening  and  contraction  of  the  segments  of  the  mitral  valve  or  the 
ring,  or  both.  Anatomically  there  are  various  forms.  The  more  impor- 
tant are,  (a)  great  thickening  of  the  valves  with  a  mere  oblong  fissure  or 
chink — buttonhole  contraction.  The  ring  is  often  much  contracted,  (b) 
The  projection  from  the  line  of  the  base  of  the  segments  of  thick  nodular 
fibroid  masses,  often  in  part  calcareous,  into  the  lumen  of  the  orifice.  The 
segments  themselves  may  be  thickened  but  are  sometimes  but  slightly 
affected,  (c)  The  valves  are  adherent  at  their  borders  but  thin  and  elon- 
gated, projecting  into  the  ventricle  and  opening  at  the  tip  by  a  constricted 
orifice — funnel-shaped  stenosis,  (d)  Narrowing  of  the  mitral  ring  without 
marked  changes  in  the  valve — probably  a  congenital  condition.  The 
chordae  tendinese  are  shortened  and  thickened,  and  in  some  instances  the 
tips  of  the  papillary  muscles  are  inserted  into  the  deformed  valves. 

The  degree  of  stenosis  varies  from  the  tip  of  the  finger  to  an  opening 
that  will  only  admit  a  medium-sized  Bowman's  probe.  The  heart  is  mod- 
erately enlarged,  the  hypertrophy  affecting  the  left  auricle  and  right  ven- 
tricle. The  left  ventricle,  except  in  cases  in  which  there  is  also  marked 
insufficiency  of  the  valve,  is  usually  small.  The  derangement  of  function 
consists  in  the  overfiUing  of  the  auricle  with  increase  in  its  work  during  the 
ventricular  diastole.  The  wall  of  the  auricle  undergoes  hypertrophy,  which 
for  a  time  may  compensate  the  defect.  The  pressure  is  transferred  through 
the  pulmonary  circuit  to  the  right  ventricle,  upon  which  the  compensation 
largely  falls,  and  which  at  first  undergoes  hypertrophy  without  dilatation. 
When  compensation  fails,  there  is  relative  incompetency  of  the  tricuspid 
valve  and  transference  of  pressure  to  the  venous  side  of  the  general  circula- 
tion. In  consequence  of  the  inabihty  of  the  left  auricle  to  maintain  compen- 
sation, as  a  rule,  and  the  action  of  the  hypertrophied  right  ventricle  through 
the  pulmonary  circuit,  the  compensation  in  mitral  stenosis  is  rarely  complete. 

Etiology. — Predisposing  Influences. — Uncomplicated  mitral  ste- 
nosis is  a  rare  affection.  In  almost  all  the  cases  there  is  some  degree  of 
mitral  insufficiency.  Age  is  important.  A  few  of  the  cases  are  congenital; 
the  greater  number  occur  in  early  life.  The  evidences  of  the  lesion  may 
first  attract  attention  at  any  period  of  life.  There  is  a  remarkable  pre- 
ponderance of  cases  in  females.  The  ratio  varies  according  to  various 
statistics  from  2  to  even  4  to  1.  This  disparity  of  incidence  affects  only 
the  cases  in  persons  under  middle  age  in  whom  the  lesions  are  commonly 
due  to  endocarditis,  and  does  not  appear  in  the  statistics  of  the  old  cases^ 
which  are  almost  always  of  sclerotic  origin. 

Exciting  Cause. — Acute  endocarditis  in  the  course  of  an  attack  of 
rheumatism,  chorea,  scarlet  fever,  or  one  of  the  other  acute  infections  of 
childhood  may  be  the  starting-point  of  mitral  stenosis.  The  acute  and 
repeated  tension  upon  the  heart  valves  in  whooping-cough  may  act  in  the 
same  way.  In  a  remarkably  large  proportion  of  the  cases  the  anamnesis 
is  silent  as  to  the  cause. 


MITRAL  STENOSIS. 


1225 


Symptoms. — Fair  compensation  is  often  maintained  for  years,  during 
which  symptoms  are  absent.  As  it  gradually  fails  dyspnoea  upon  exertion 
first  attracts  attention.  Pressure  paralysis  of  the  left  recurrent  laryngeal 
nerve  from  the  enlarged  auricle  has  been  observed.  Cerebral  embolism  is  by 
no  means  rare.  The  frequency  with  which  haemoptysis  occurs  while  compen- 
sation is  yet  fair  is  interesting.  The  cases  are  often  mistaken  for  incipient 
phthisis.    The  tendency  to  dropsy  is  less  marked  than  in  mitral  insufficiency. 

Physical  Signs. — Upon  inspection  there  is  very  often,  especially  in 
the  young,  precordial  prominence  due  to  hypertrophy  of  the  right  ven- 
tricle. The  apex  beat  is  commonly  displaced  but  sHghtly  toward  the  left, 
and  may  be  indistinct,  the  visible  impulse  being  at  the  lower  end  of  the 
sternum  and  extending  to  the 
left  costal  cartilages.  The  pul- 
sation of  the  conus  arteriosus 
may  often  be  visible  at  the  ster- 
nal end  of  the  third  and  fourth 
left  interspaces.  As  compensa- 
tion fails,  the  impulse  loses  its 
power,  and  signs  of  back  pressure  in  the  systemic  veins  appear,  as  distention 
of  the  superficial  veins,  especially  the  jugulars,  with  pulsation  due  to  con- 
traction of  the  right  ventricle  and  enlargement  of  the  liver.  Upon  palpation 
there  is  recognized  in  at  least  three-fourths  of  the  cases  a  very  distinct 
thrill.  This  sign  is  usually  coarse  in  character,  diastolic  or  presystolic  in 
time,  confined  to  an  area  above  the  apex,  usually  in  the  fourth  and  fifth 
interspaces,  and  circumscribed.  It  is  more  intense  and  slightly  more 
extended  during  expiration  and  runs  up  to  a  short,  sharp  apex  beat.     This 


Fig.  348. — Mitral  stenosis;    carotid  tracing. 


Fig.  349. — Mitral  regurgitation  and  stenosis;   radial  tracing. 

thrill  is  of  the  highest  diagnostic  significance.  It  is  the  tactile  equivalent 
of  the  characteristic  murmur  of  mitral  stenosis.  It  may,  however,  fre- 
quently be  felt  when  no  murmur  can  be  detected  at  this  time  in  the  cardiac 
cycle.  In  stenosis  of  moderate  grade,  so  long  as  compensation  is  good  the 
pulse  has  no  special  characters.  Upon  failure  of  compensation  it  becomes 
small,  soft,  and  arrhythmic.  Upon  percussion  the  dulness  in  fair  compen- 
sation extends  but  slightly  to  the  left  of  the  normal  line,  rarely  much  beyond 
the  midclavicular  line,  and  little  to  the  right  of  its  normal  limits.  When, 
however,  compensation  is  broken,  the  transverse  diameter  of  deep  cardiac 
dulness  is  decidedly  increased,  reaching  beyond  the  midclavicular  line  on 
the  left  and  beyond  the  parasternal  line  on  the  right.  Auscultation  reveals , 
a  characteristic  murmur  which  corresponds  in  situation  and  in  time  of  its 
occui'rence  in  the  revolution  of  the  heart  to  the  thrill  which  has  been! 
described    above,    and    which   is    its    auditory    equivalent.      This    mur-i 


1226  MEDICAL  DIAGNOSIS. 

mur  is  rough  and  A'ibratile  in  character,  increasing  in  intensity  toward 
its  close,  and  terminates  abruptly  in  the  tap  which  constitutes  the  first 
sound.  It  occurs  in  four  modifications.  In  the  greater  number  of  cases 
it  occupies  the  entire  period  of  the  diastole,  and  is  increased  in  intensity 
at  the  time  of  the  auricular  contraction  which  immediately  precedes  the 
ventricular  systole;  it  maybe  heard  at  the  beginning  and  at  the  close 
of  the  diastole;  it  may  be  present  in  the  mid-diastoHc  period;  and 
finally  it  is  in  some  cases  heard  only  in  the  moment  immediately  preceding 
the  first  sound.  The  intensity  of  this  murmur  is  extremely  variable.  It 
may  be  the  loudest  of  heart  murmurs,  or  very  soft  and  faint,  or,  finally, 
it  may  be  wholly  inaudible  when  the  patient  is  at  rest,  and  only  heard 
after  exertion.  It  may  at  times  have  a  pecuHar  rumbling  quahty.  Its 
loudness  depends  in  part  upon  the  character  of  the  lesions  and  in  part  upon 
the  force  of  the  blood  stream.  It  is  in  accordance  with  this  fact  that,  as 
compensation  fails,  the  murmur  can  no  longer  be  heard,  but  only  the  sharp 
first  sound  in  the  mitral  area,  or  the  one,  two,  three  of  the  gallop  rhythm. 
If,  however,  under  rest  and  treatment  compensation  is  for  a  time  re-estab- 
Hshed  the  murmur  reappears.  This  change  is  often  met  with  in  actual 
practice  and  has  been  the  cause  of  many  disputes  as  to  diagnosis. 

The  first  sound  is  short,  valvular,  and  very  loud.  It  has  in  many  cases 
the  character  of  the  second  sound  and  is  frequently  mistaken  for  it.  Under 
this  error  the  murmur  is  naturally  assumed  to  be  systoHc  and  the  condi- 
tion that  of  mitral  insufficiency.  This  mistake  is  to  be  avoided  by  deter- 
mining the  time  of  the  auscultatory  signs  by  palpation  of  the  cardiac  impulse 
or  carotid  pulse  at  the  moment  of  auscultation.  The  alteration  in  the  first 
sound  is  due  to  the  quick  contraction  of  the  left  ventricle  upon  an  abnor- 
mally small  blood  content.  The  second  pulmonary  sound  is  strongly 
accentuated. 

Diagnosis. — The  direct  diagnosis  is  in  well-marked  cases  not  diffi- 
cult. It  rests  upon  the  association  of  the  presystolic  thrill  and  murmur 
with  the  signs  of  hypertrophy  of  the  right  ventricle,  the  absence  of  signs 
of  enlargement  of  the  left  ventricle,  the  loud  snapping  character  of  the 
first  sound,  and  the  accentuation  of  the  pulmonary  second  sound. 

Prognosis. — In  general  the  outlook  is  less  favorable  than  in  mitral 
insufficiency.  This  form  of  chronic  valvular  disease  is  only  second  to 
aortic  insufficiency  in  the  gravity  of  the  prognosis.  Sudden  death  is  some- 
what more  frequent  than  in  mitral  insufficiency,  but  occurs  usually  after 
the  compensation  has  become  greatly  impaired.  Among  the  more  common 
causes  of  death  are  progressive  cardiac  asthenia,  pulmonary  infarction  or 
oedema,  and  acute  intercurrent  disease.  More  than  any  other  chronic 
valvular  disease  of  the  heart,  mitral  stenosis  is  associated  with  tuberculosis, 
and  to  the  latter  the  termination  must  in  many  of  the  cases  be  attributed. 

V.  Pulmonary  Insufficiency  and  Stenosis. 

Lesions  of  the  pulmonary  valves  are  extremely  rare.  Murmurs  having 
their  point  of  maximum  intensity  in  the  pulmonary  area  are  common. 
They  are  usually  systolic.  They  are  sometimes  present  in  health,  especially 
in  children,  and  are  best  heard  during  expiration  and  in  the  recumbent 


TRICUSPID  INSUFFICIENCY  AND  STENOSIS. 


1227 


posture,  in  the  rapidly  acting  heart,  in  anaemia  and  chlorosis;  and  it  is 
in  the  last  that  cardiorespiratory  murmurs  are  usually  heard. 

Insufficiency. — This  is  a  rare  congenital  lesion.  It  may  occur  in  malig- 
nant endocarditis.  Relative  insufficiency  may  result  from  overdistention 
of  the  pulmonary  artery.  There  are  dilatation  and  hypertrophy  of  the 
right  ventricle,  epigastric  pulsation,  a  heaving  impulse  over  the  lower 
sternal  region,  and  a  soft  diastolic  murmur  at  the  second  left  costal  carti- 
lage and  third  intercostal  space,  much  more  distinct  upon  expiration. 
This  condition  is  to  be  differentiated  from  aortic  insufficiency,  to  which 
it  has  superfi^jial  resemblances,  by  the  presence  of  epigastric  pulsation  and 
other  signs  of  hypertrophy  of  the  right  ventricle,  and  the  condition  of  the 
systemic  arteries. 

Stenosis. — This  practically  occurs  only  as  a  congenital  lesion  and  is 
always  associated  with  other  developmental  anomahes.  Sclerotic  changes 
occur  and  the  deformed  valves  are  especially  disposed  to  acute  endocar- 
ditis. There  are  no  special  symptoms.  Among  the  physical  signs  are  a 
systolic  murmur  and  thrill  in  the  second  left  intercostal  space  at  the  sternal 
border,  a  faint  or  inaudible  second  sound,  and  the  evidences  of  hypertrophy 
of  the  right  ventricle.  The  pressure  of  an  aortic  aneurism  may  narrow  the 
pulmonary  outlet,  or  the  cicatrices  of  syphilitic  lesions  the  conus  arteriosus, 
and  give  rise  to  similar  signs.  The  diagnosis  may  sometimes  be  made  with 
precision. 

vi.  Tricuspid  Insufficiency  and  Stenosis. 

Insufficiency. — This  valvular  defect  is  extremely  rare  as  the  result  of 
endocarditis  involving  the  right  side  of  the  heart.  Relative  insufficiency  is, 
however,  very  common  as  a  secondary  condition  in  the  period  of  failing 
compensation  in  disease  of  the  aortic  and  mitral  valves,  especially  the 
latter.  It  occurs  also  in  advanced 
fibroid  phthisis,  emphysema,  and 
other  pulmonary  d  i  s  e  a  s  e  s-  in 
which  there  is  permanent  obstruc- 
tion of  the  pulmonary  circulation. 
The  auricle  is  dilated  and  hyper- 
tr  op  hied.  The  return  of  the 
venous  blood  is  impeded  and  the 
supply  to  the  pulmonary  artery 
diminished.  The  symptoms  of 
retarded  pulmonary  circulation 
and  visceral  congestions  charac- 
terize this  condition.  The  physi- 
cal signs  are  chiefly  due  to  the 
enlargement  of  the  right  auricle 

and  the  reflux  of  blood  from  the  right  ventricle  through  the  tricuspid  orifice. 
They  consist  of  increase  in  the  transverse  dulness  to  the  right  of  the  sternum 
with  occasional  pulsation  at  the  sternal  ends  of  the  lower  interspaces;  a  sys- 
tolic murmur,  usually  soft  and  low-pitched,  having  its  point  of  maximum 
intensity  over  the  lower  part  of  the  sternum  and  propagated  in  the  direction 
of  the  right  axilla;  and  finally  pulse-waves  in  the  veins  of  the  neck,  more 


Fig.  350. — Venous  pulse  of  tricuspid  insufficiency. 
Upper  tracing — venous  pulse;  lower  tracing — apex  beat. 


1228 


MEDICAL  DIAGNOSIS. 


marked  upon  the  right  side.  The  venous  pulse  is  synchronous  with  the 
carotid  pulse  and  apex  beat.  It  is  sometimes  transmitted  to  the  subclavian 
and  axillary  veins.  It  may,  by  way  of  the  vena  cava  and  hepatic  veins, 
reach  the  liver  and  cause  the  phenomenon  known  as  pulsating  liver,  an 
expansile  pulsation  in  the  organ  best  appreciated  upon  bimanual  palpation^ 


vii.  PHYSICAL  SIGNS  OF  UNCOMBINED  VALVULAR  LESIONS  OF  THE  LEFT 
HEART,  COMPENSATION  BEING  MAINTAINED. 


Mitral 

AortiQf 

Insufficiency 

Stenosis 

Insufficiency 

Stenosis 

Impulse 

Increased    in    extent. 

Often  ill-defined  and 

Extended,    heaving. 

Variable;      some- 

Displaced to  left 

extended,    but    not 

forcible     and   dis- 

times  feeble   and 

much    beyond    the 

placed  downward 

indistinct ;     often 

midclavicular  line. 

and  to  the  left 

slow,      heaving 

Preceded  by  thrill 

and      forcible. 
Moderately     dis- 
placed to  the  left. 

Cardiac   dul- 

Increased  transverse- 

Increased to  the  right 

Increased  to  a  greater 

Moderately    in- 

ness 

ly    and    downward. 

of  the  sternum  and 

extent  than  in  any 

creased  to  the  left. 

It  may  extend   be- 

along its  left  border; 

other  valvular    le- 

yond the  right  bor- 

not usually  beyond 

sion.    Principally 

der  of  the  sternum 

the     midclavicular 

downward   and    to 

and  beyond  the  left 

line 

the  left 

midclavicular  line 

Murmurs 

Systolic  at   apex  ac- 

Coarse,   presystolic, 

Diastolic,     prolonged, 

Coarse,    systolic,   of 

companying   or  re- 

terminating   in    the 

accompanying 

maximum  inten- 

placing   the    first 

first  sound  and  lim- 

or wholly  replacing 

sity  at  aortic  car- 

sound.   Transmit- 

ited to  the  region  of 

the   aortic    second 

tilage  and  propa- 

ted toward   left  ax- 

the apex 

sound,    and    propa- 

gated   into   the 

illa.    May  be  heard 

gated  from  the  base 

great  vessels. 

at  the  back  ;  some- 

of the  heart  down- 

times  widely  over 

ward  along  the  ster- 

chest 

num  and  to  the  left 

As  social ed 

Accentuation  of  pul- 

Presystolic thrill ;  im- 

A   systolic    shock    in 

Systolic  thrill    in 

signs 

monary      second 

pulse    of    conus  ar- 

the   larger    arteries 

aortic  area,  absent 

sound 

teriosus    of    right 

and   sometimes  a 

or    feeble    aortic 

ventricle    in    fourth 

double    murmur— 

second     sound. 

and    third,    some- 

Duroziez's  sign. 

Occasionally  a  di- 

times in  second  left 

The   aortic    second 

astolic  murmur. 

interspaces.  A  clear. 

sound  may  be  heard 

well-defined  first 

over   the    right    ca- 

sound.     Accentu- 

rotid   when    absent 

ation  of  pulmonary 

in  aortic  area 

second  sound.     Re- 

duplication    of 

second  sound 

Pulse 

Full,  regular,  frequent 

Smaller  in  volume 

Water-hammer,    c  o  1- 

Small,   of  fair  ten- 

and  usually  of  low 

than  normal   and 

lapsi  ng  —  Corrigan  's 

sion,  regular,  and 

tension.     Upon  fail- 

frequently arrhyth- 

pulse 

usually  somewhat 

ure  of  compensation 

mic 

slower   than   nor- 

there is  usually  ar- 

mal. 

rhythmia   which    is 

commonly     persist- 

ent 

and  to  be  differentiated  from  the  ''jogging"  liver,  which  rises  and  sinks 
under  the  influence  of  the  movements  of  the  heart  or  aorta  but  does  not 
expand  and  contract. 

Stenosis. — Tricuspid  stenosis  is  a  rare  form  of  valvular  disease.  It 
may  be  congenital,  in  which  case  it  is  almost  invariably  associated  with 
other  cardiac  anomahes;  or  acquired,  when  it  presents  deformities  similar 
to  those  seen  in  mitral  stenosis.  It  is  usually  associated  with  some  degree 
of  incompetence  of  the  tricuspidahs  and  with  diseases  of  the  other  valve 


COMBINED  VALVULAR  DISEASES.  1229 

systems,  most  commonly  the  mitral.  In  a  large  proportion  of  the  cases 
there  has  been  a  history  of  rheumatic  fever;  in  a  few  a  history  of  syphilis. 
This  form  of  chronic  valvular  disease  is  far  more  common  in  females  than 
in  males.  It  has,  in  a  majority  of  the  cases,  been  first  observed  early  in 
adult  life.  It  is  so  rarely  an  isolated  lesion  that  its  symptoms  are  commonly 
obscured  by  those  of  the  associated  affections.  They  are  those  of  general 
venous  engorgement.  Distention  of  the  jugulars,  cyanosis  of  the  lips  and 
face,  tenderness  over  the  liver,  and  dropsy  are  common.  The  physical 
signs  are  also  usually  subordinate  to  those  of  the  associated  valvular  disease. 
Percussion  shows  increased  dulness  to  the  right  of  the  sternum.  When,  in 
a  case  of  mitral  stenosis,  there  is  a  second  presystolic  murmur  best  heard 
at  the  base  of  the  ensiform  cartilage  at  the  right,  associated  with  a  pre- 
systolic thrill,  and  these  are  of  different  character  from  those  in  the  mitral 
area,  tricuspid  stenosis  may  be  diagnosticated.  The  clinical  diagnosis  is, 
however,  uncertain.  Almost  all  the  cases  have  been  discovered  upon  the 
post-mortem  table,  the  condition  not  having  been  suspected  during  life. 

viii.  Combined  Valvular  Diseases. 

There  are  two  cardinal  facts  in  regard  to  chronic  valvular  disease. 
First,  that  the  lesions  are  very  rarely  uncompHcated,  and  second,  that  the 
condition  of  the  myocardium  is  much  more  important  than  the  state  of 
the  valves.  While  the  recognition  of  these  facts  renders  heart  disease 
complex  and  difficult  as  regards  diagnosis,  it  greatly  simplifies  it  in  respect 
of  prognosis  and  the  recognition  of  the  indications  for  treatment.  The 
valvular  damage  is  irreparable,  but  injury  to  the  myocardium  may  be 
postponed  or  to  some  extent  repaired.  The  diagnosis,  to  be  of  service, 
must  be  at  once  anatomical  and  functional.  It  undertakes  to  determine 
what  valve  system  is  defective;  whether  the  defect  gives  rise  to  obstruction 
or  incompetence  or  both,  and  in  the  last  of  these  conditions  which  defect 
predominates;  whether  more  than  one  valve  system  is  involved,  and  in 
what  manner;  and  finally  the  condition  of  the  myocardium — is  its  contrac- 
tile function  increased  to  the  point  of  full  compensation?  Is  the  increase 
maintained?  Is  it  failing?  From  this  point  of  view  the  combined  lesions 
acquire  especial  clinical  importance.  In  aortic  and  mitral  insufficiency 
resulting  from  acute  endocarditis  a  progressive  stenosis  may  favorably 
modify  the  condition  of  the  heart  by  diminishing  the  regurgitation.  Aortic 
lesions  and,  in  particular,  aortic  regurgitation  are  more  frequently  simple 
than  mitral  lesions.  Relative  and  muscular  mitral  and  tricuspid  insuffi- 
ciency are  frequently  uncombined. 

Especially  common  is  the  combination  of  mitral  insufficiency  with 
steftosis  of  the  mitral  orifice.  The  greater  the  one,  the  less  the  other  of 
these  defects.  This  combination  is  very  often  associated  with  other  valvu- 
lar lesions.  Next  in  order  of  frequency  is  the  association  of  aortic  insuffi- 
ciency and  mitral  insufficiency,  or  combined  mitral  insufficiency  and 
stenosis.  Combined  aortic  insufficiency  and  stenosis  is  less  common  but 
not  rarely  associated  with  other  valvular  lesions.  In  proportion  as  the 
stenosis  is  marked  the  insufficiency  is  diminished  and  a  progressive 
narrowing  of  the  orifice  in  insufficiency  may  be  conservative. 


1230 


MEDICAL  DIAGNOSIS. 


The  frequent  association  of  tricuspid  disease  with  mitral  lesions  has 
already  been  noted,  especially  that  of  tricuspid  and  mitral  stenosis.  The 
diagnosis  of  these  and  other  combined  lesions  depends  upon  the  recognition 
of  the  associated  signs  and  demands  the  painstaking  study  of  every  phe- 
nomenon in  any  particular  case. 

VI.  CONGENITAL  LESIONS  OF  THE  HEART. 

These  lesions  are  of  two  kinds,  developmental  and  inflammatory. 
Developmental   Defects. — To  this   group    are  to  be    referred  the 
following  anomalies: 

(a)   Defects  of    the  whole  heart,   as    acardia,  double  heart,  ectopia 

cordis — conditions  not,  as  a  rule,  of 
diagnostic  interest,  (b)  Defects  of 
the  septa,  which  may,  by  the  absence 
of  both  the  auricular  and  ventricu- 
lar septum,  convert  the  heart  into  a 
double  chamber — the  bilocular heart; 
or  by  the  absence  of  the  ventricular 
septum  only,  convert  it  into  a  three- 
chambered  viscus — the  trilocular 
heart,  (c)  Patent  foramen  ovale, 
(d)  Defects  of  the  valves,  which 
may  be  increased  or  diminished  in 
number,  or  adherent.  These  ana- 
tomical defects  involve  the  semilunar 
cusps  of  the  aortic  and  pulmonary 
valves,  but  not  the  segments  of  the 
auriculoventricular  valves,  (e) 
Transposition  of  the  large  vessels. 

Fetal  Endocarditis. — The 
right  heart  is  usually  affected.  Pul- 
monary stenosis  is  a  common  result. 
Complete  obliteration  of  the  pul- 
monary orifice  is  associated  with 
persistence  of  the  ductus  arteriosus 
and  patulence  of  the  foramen  or 
other  defect  in  the  ventricular  wall. 
Congenital  lesions  at  the  aortic 
orifice  are  rare. 

Developmental  anomalies  are 
usually  multiple.  They  not  infre- 
quently are  the  seat  of  sclerotic 
processes. 

Symptoms. — Cyanosis,  general 

duskiness  of  the  surface,  a  persistent 

low  external  temperature,  dyspnoea 

and  cough,  increase  in  the  red  blood-corpuscles,  the  drum-stick  deformity 

of  the  fingers  and  toes,  and  finally  retarded  physical  and  mental  develop- 


351.— Chilibf. 


German 


HEART  BLOCK.  1231 

merit  are  usually  present.  Associated  developmental  defects  in  the  mouth, 
genitalia,  or  elsewhere  are  common.  In  infants  the  presence  of  endocardial 
murmurs  with  or  without  enlargement  of  the  heart  constitutes  an  important 
diagnostic  criterion. 

Diagnosis. — The  diagnosis  rests  upon  the  association  of  several  or 
all  of  the  above  conditions  in  a  child  or  young  adult  in  whose  case  there  is 
a  history  of  having  been  a  "blue  baby,"  or  having  had  ''the  blue  disease." 
The  differential  diagnosis  of  the  various  congenital  defects  must  be  deter- 
mined by  a  special  study  of  the  physical  signs  in  individual  cases.  In  many 
of  the  cases  a  positive  diagnosis  of  the  particular  lesions  cannot  be  made. 

VII.  HEART  BLOCK;   THE  STOKES- ADAMS 
SYNDROME. 

Definition. — A  condition  characterized  by  bradycardia,  with  transient 
attacks  of  vertigo  and  syncope,  and  momentary  epileptiform  seizures. 

Erlanger's  classification  based  on  that  of  Wenckebach  (Osier)  is  as 
follows : 

Arrhythmia  resulting  from  decreased  conductivity  in  the  auriculo- 
ventricular  function — heart  block.  Characteristics:  auricular  rhythm  per- 
fect, rate  normal  or  accelerated;  ventricular  rhythm  may  or  may  not  be 
perfect;  if  perfect  its  rate  will  be  one-half  of  that  of  the  auricles,  or  less; 
if  not  perfect  the  irregularities  will  bear  some  direct  relation  to  the  con- 
tractions of  the  auricles. 

(a)  Partial  heart  block:  (1)  occasional  ventricular  silence;  (2) 
regularly  recurring  ventricular  silence,  either  one  ventricular  beat  missed 
in  7,  6,  5,  4,  etc.,  auricular  beats,  or  a  2  :  1,  3  :  1,  4:1  rhythm,  or  either 
of  these  alternating. 

(b)  Complete  heart  block:  auricular  and  ventricular  rhythms  perfect 
but  independent. 

(c)  Paroxysmal  bradycardia  (Stokes-Adams  disease  affecting  the  ven- 
tricular rate  alone). 

Etiology. — Arteriosclerosis  and  syphilis  play  an  important  part  in  the 
causation  of  heart  block.  The  lesions  involve  the  auriculoventricular 
bundle  of  His,  a  narrow  neuromuscular  band  constituting  the  only  muscular 
connection  between  the  auricles  and  ventricles,  which  serves  as  a  path- 
way for  the  stimulus,  by  which  the  heart  contracts,  from  the  auricles,  in 
which  it  originates,  to  the  ventricles.  Robinson  found  in  the  Museum  of 
the  Pennsylvania  Hospital  a  heart  in  which  a  gumma  is  situated  upon  the 
septum  in  such  a  position  as  to  involve  this  muscular  bundle,  and  upon 
looking  up  the  clinical  records  discovered,  after  the  lapse  of  twenty-five 
years,  that  bradycardia  had  been  a  prominent  symptom  in  the  case.  There 
is  a  group  of  cases  in  which  no  lesions  are  found  after  death  and  in  which 
the  condition  appears  to  be  a  neurosis.  The  cases  due  to  syphilis  have 
occurred  in  early  adult  life;  those  due  to  sclerotic  processes  at  a  later 
period.    One  of  my  cases,  a  woman,  was  fifty-two;  another  a  man  of  seventy. 

Symptoms. — Bradycardia  is  usually  persistent,  sometimes  paroxys- 
mal. The  ventricular  beats  may  fall  to  20,  or  as  low  as  5  per  minute. 
The  pulse  is  usually  tense.    Its  frequency  is  not  increased,  as  under  normal 


1232 


MEDICAL  DIAGNOSIS. 


conditions,  by  posture,  exercise,  excitement,  or  stimulants.  A  feeble  venous 
pulsation  may  be  detected  in  the  right  jugular  synchronous  with  the 
auricular  contractions.  The  cerebral  symptoms  are  attributable  to  the 
delay  between  the  ventricular  contractions.  Momentary  vertigo  and  syn- 
cope are  common,  the  attacks  recurring  many  times  in  the  course  of  twenty- 
four  hours.  The  loss  of  consciousness  is  often  attended  by  slight  muscular 
twitchings  which  especially  involve  the  face  and  arms. 

Diagnosis. — The  Stokes-Adams  disease  is  to  be  distinguished  from  the 
physiological  bradycardia  occasionally  seen  in  pregnancy,  from  that  of 
old  age,  and  that  which  occurs  in  the  inanition  of  hunger.  It  must  also 
be  differentiated  from  the  pathological  slow  pulse  of  convalescence  from 


Jugular 


Carotid 


Ca>rdiao  Ap&x 


o.  as 


RJUUi-JUuuuiJU\-JVJiJuu'LJiJLJUi-ru;uup. 


uu'iJuuun_,TJUui_^jouuuui_n_pJV-run._n_'i_n_ruii_.r 


Fig.  352. — Stokes-Adams  syndrome.    Tracing  of  the  jugular,  carotid  and  apex  beat, 
traction;   s,  ventricular  contraction. — Jefferson  Hospital. 


a,  auricular  con- 


acute  disease,  of  certain  gastric  affections,  especially  ulcer  and  carcinoma, 
of  jaundice,  of  fatty  heart,  and  of  uraemia.  Abnormal  slowness  of  the  pulse 
is  present  also  in  some  cases  of  anaemia  and  chlorosis,  and  in  diseases  of  the 
nervous  system,  as  brain  tumor,  affections  of  the  cervical  cord,  and  apoplexy. 
Certain  poisons,  as  opium,  alcohol,  lead,  and  digitahs,  cause  bradycardia. 
The  differential  diagnosis  between  heart  block  and  any  of  these  conditions 
rests  upon  the  essential  difference  between  the  frequency  of  the  auricular 
contractions  as  manifest  in  the  jugular  pulsation  and  those  of  the  ventricles 
as  felt  in  the  radials  and  at  the  apex,  the  occurrence  of  cerebral  symptoms, 
and  the  exclusion  of  other  causes.  In  many  cases  of  cardiac  insufficiency 
a  considerable  proportion  of  the  ventricular  systoles  fail  to  transmit  a 
pulse-wave  to  the  wrist.  The  apex  beats  must  be  counted  in  all  cases  of 
slow  pulse. 


ANGINA  PECTORIS.  1233 

Prognosis. — The  outlook  is  favorable  in  the  neurotic  cases.  Ener- 
getic antiluetic  treatment  should  be  instituted  when  a  history  or  mani- 
festations of  syphilis  are  in  evidence.  In  aged  persons  with  arteriosclerosis, 
treatment  has  little  effect  and  the  condition  continues  until  death. 


VIII.  ANGINA  PECTORIS. 

Stenocardia;  Angina  Pectoris  Vera. 

Definition. — True  angina  pectoris  is  a  symptom-complex  occurring 
in  individuals  who  suffer  from  sclerotic  changes  involving  the  ascending 
aorta  and  coronary  arteries,  and  characterized  by  recurrent  paroxysms 
of  agonizing  pain  in  the  precordial  region,  extending  to  the  neck  and  arms, 
especially  upon  the  left  side,  and  often  accompanied  by  a  sense  of  impend- 
ing death. 

Etiology. — Predisposing  Influences. — All  conditions  which  tend 
to  the  production  of  arteriosclerosis  may  be  looked  upon  as  influences  pre- 
disposing to  angina  pectoris.  Age  is  of  great  importance.  The  great 
majority  of  the  cases  first  declare  themselves  after  the  fiftieth  year.  At- 
tacks occasionally  occur  at  an  earlier  age,  but  they  are  comparatively  infre- 
quent, while  the  few  cases  which  have  been  recorded  in  childhood  do  not 
militate  against  the  general  rule.  Sex  exerts  a  remarkable  influence,  not 
in  itself,  but  in  the  bearing  which  it  has  on  the  mode  of  life  of  the  individual. 
Heredity  plays  an  important  part.  It  is  by  no  means  rare  for  angina  pec- 
toris to  occur  in  successive  generations.  To  gout,  syphilis,  and  alcohol  are 
justly  attributed  causal  influences  of  weight.  Diabetics  are  prone  to  the 
attacks.     It  has  occurred  after  influenza. 

Exciting  Cause. — Any  exertion,  especially  any  sudden  exertion  which 
calls  upon  the  heart  for  increased  effort,  may  bring  on  the  attack.  The 
effort  is  usually  a  familiar  one,  as  hurry  to  catch  a  car,  ascending  a  flight 
of  stairs,  or  stooping  over  to  lace  the  shoes.  Emotional  excitement  is  a 
common  exciting  cause.  A  fit  of  anger  may  precipitate  a  fatal  attack. 
The  paroxysm  frequently  follows  a  hearty  meal.  I  often  say  to  patients: 
Do  not  hurry,  do  not  worry,  and  do  not  eat  too  much.  Exposure  to  cold 
is  a  common  cause  of  the  attack.  Several  of  these  causes  are  often  asso- 
ciated, as  hurry  and  exposure  to  cold,  or  some  annoyance  after  a  full  meal. 
The  attack  seldom  comes  on  when  the  patient  is  at  rest  both  physically 
and  mentally.  On  the  other  hand  there  are  cases  in  which  the  attack  occurs 
immediately  upon  waking  from  sleep. 

The  Paroxysm. — The  attack  begins  suddenly,  very  often  without 
warning,  and  in  a  few  moments  attains  its  full  intensity.  There  are  three 
essential  phenomena:  (1)  Pain,  commonly  described  as  agonizing,  referred 
to  the  precordium  and  mostly  to  the  region  beneath  the  manubrium.  This 
pain  radiates  to  the  left  side  of  the  chest,  to  the  neck,  and  to  the  ulnar 
distribution  in  the  left  arm.  In  rare  cases  the  pain  is  first  felt  in  the  wrist 
or  arm.  The  right  side  is  in  some  instances  also  affected.  (2)  The  steno- 
cardia of  Heberden.  The  sensation  is  that  of  being  crushed  in  a  vice, 
or  as  if  the  heart  were  being  "grasped  by  a  mailed  hand."  It  is  to  this 
sensation  that  the  fixation  of  the  muscles  of  the  patient  is  probably 
78 


1234  MEDICAL  DIAGNOSIS. 

due,  for  at  the  height  of  the  paroxysm  he  is  usually  motionless,  almost 
rigid,  while  at  the  beginning  and  end  he  is  agitated,  restless,  and  anxious. 
(3)  The  sense  of  impending  death.  The  face  denotes  the  anguish  which 
the  patient  feels.  It  is  pallid,  gray,  and  bathed  in  sweat.  The  pulse  is 
often  full  and  slow;  its  tension  greatly  increased.  It  may,  however,  he 
nearly  normal.  The  heart  sounds  are  commonly  feeble,  but  clear,  and  not 
rarely  a  soft  apex  murmur  may  be  heard.  Vomiting  is  not  unusual,  and 
death  may  occur  during  the  act.  The  duration  of  the  attack  does  not 
usually  exceed  four  or  five  minutes,  but  recurrences  are  common,  so  that 
the  agony  may  last,  with  remissions  all  too  brief,  for  several  hours.  This 
is,  however,  unusual.  Nocturnal  attacks  are  usually  very  severe  and 
longer  in  duration  than  those  which  occur  by  day.  Instant  death  during 
the  attack  is  not  uncommon.  In  other  cases  the  patient  may  fall  into  a 
syncope  and  not  revive.  Those  who  suffer  from  angina  pectoris  are  liable 
to  sudden  death  in  the  intervals  between  the  attacks.  The  paroxysm 
subsides  as  suddenly  as  it  came  on,  often  with  belching,  the  passing  of  a 
large  quantity  of  clear  urine,  exhaustion,  and  asthmatic  symptoms.  There 
are  other  cases  in  which  the  patient,  while  much  distressed  and  exhausted, 
is,  in  the  course  of  an  hour  or  two,  able  to  resume  his  occupation.  The  first 
paroxysm  has  in  many  cases  proved  fatal;  in  other  cases  the  attacks  recur 
at  varying  intervals  for  many  years.  The  first  attack  may  not  be  followed 
by  a  second  for  a  period  of  months  or  years,  and  there  are  instances  of 
a  series  of  violent  attacks  followed  by  no  recurrence  for  a  long  period. 

Angina  sine  Dolore. — Gairdner  used  this  term  to  designate  ''an 
element  of  subjective  abnormal  sensation  present  in  cardiac  diseases, 
which  when  it  is  not  localized  through  the  coincidence  of  pain  is  a  specially 
indefinable  and  indescribable  sensation."  There  are  undoubtedly  cases 
of  heart  disease  in  which  paroxysms  of  profound  disturbance  of  the  nervous 
system  referable  to  the  heart  occur  in  the  absence  of  pain,  but  with  an 
agonizing  fear  of  impending  death. 

There  are  many  explanations  concerning  the  attack  of  angina  pectoris, 
among  which  that  of  paroxysmal  ischsemia  or  intermittent  claudication  is 
the  best  as  a  working  hypothesis,  but  none  of  which  as  yet  fully  meets  the 
requirements  of  the  condition. 

Diagnosis. — The  direct  diagnosis  rests  upon  the  association  of  par- 
oxysms having  the  foregoing  characteristics  with  the  evidences  of  general 
arteriosclerosis  and  chronic  myocarditis.  Increased  arterial  tension,  a 
history  of  gout,  alcoholism,  or  syphilis,  and  advanced  life  are  of  the  nature 
of  corroborative  evidence. 

FUNCTIONAL  ANGINA  PECTORIS;    PSEUDO=ANQINA  PECTORIS. 

Two  principal  groups  are  described:   the  neurotic  and  the  toxic. 

Neurotic  Angina  Pectoris. — This  form  is  common  in  hysterical  and 
neurasthenic  women.  It  may  occur  at  any  age.  The  attacks  are  not 
precipitated  by  muscular  effort  or  cold,  but  by  the  multitudinous  worries 
to  which  such  persons  subject  themselves,  and  not  rarely  by  injadicious 
eating.  They  recur  with  a  periodicity  which  is  remarkable  and  are  more 
common  in  the  night,  a  point  in  which  they  especially  differ  from  angina 


FUNCTIONAL  AFFECTIONS  OF  THE  HEART.  1235 

associated  with  coronary  or  aortic  sclerosis.  They  are  usually  attended  by 
nervous  symptoms  — flatulent  distention  of  the  stomach  and  belching  — 
and  are  often  prolonged  for  several  hours,  with  continuous  agitation  and 
restlessness.  There  are  forms  in  which  the  paroxysm  is  characterized  by 
coldness  and  numbness  of  the  extremities,  with  agonizing  substernal 
pains,  great  restlessness,  and  a  tendency  to  syncope — vasomotor  variety. 

Toxic  Angina.- — This  form  is  attributed  to  excesses  in  tea,  coffee,  and 
tobacco.  It  includes  ''tobacco  heart."  As  a  rule  pain  is  less  marked  than 
sensations  of  anxiety  and  precordial  oppression,  with  derangements  of  the 
cardiac  rhythm.  Attacks  occur  which  are  characterized  by  vertigo,  pallor, 
a  small,  tense  pulse,  faintness,  precordial  distress,  perspirations,  and  cold- 
ness of  the  hands  and  feet.  There  are  three  groups  of  cases:  first,  the 
irritable  heart  of  smokers;  second,  cases  characterized  by  precordial  pain, 
which  may  be  persistent  and  severe  but  is  not  agonizing;  and  third,  cases 
in  which  the  symptoms  are  those  of  an  organic  angina  and  there  are  evi- 
dences of  arteriosclerosis.  In  the  first  two  of  these  groups  recovery  follows 
abstinence  from  the  narcotic,  but  in  the  third  recovery  is  only  partial. 

The  diagnosis  of  functional  angina  pectoris  depends  upon  the  presence 
of  the  neurotic  constitution,  the  absence  of  the  signs  of  arteriosclerosis  or 
chronic  myocarditis,  the  character  of  the  paroxysms,  which,  however  severe 
they  may  be,  have  neither  the  short  duration  nor  the  essential  features  of 
angina  vera.  The  younger  age,  the  sex,  and  the  different  nature  of  the  causes 
by  which  the  paroxysms  are  excited  have  diagnostic  significance.  There 
are  varying  grades  of  intensity,  both  in  organic  and  in  functional  angina 
pectoris,  as  shown  in  the  recurring  paroxysms  in  the  same  patient,  and  it 
is  not  the  intensity  but  the  character  of  the  attack  which  is  diagnostic. 

IX.  THE  FUNCTIONAL  AFFECTIONS  OF  THE 

HEART. 

The  Cardiac  Neuroses. 

Definition. — The  functional  affections  of  the  heart  include  those 
motor  and  sensory  derangements  which  occur  in  the  absence  of  demon- 
strable anatomical  changes  in  the  organ. 

The  qualifying  adjective  "functional"  is  used  in  its  common  sense,  to 
denote  the  absence  of  anatomical  lesions  demonstrable  during  life  or  after 
death.  It  is  appropriately  employed  in  this  connection  to  designate,  not 
lesions  of  the  heart  itself,  but  rather  disorders  of  its  innervation.  Hence 
these  affections  are  also  properly  spoken  of  as  cardiac  neuroses. 

It  is  important  to  observe  that  all  the  morbid  phenomena  noted  in 
functional  disorders  may  attend  the  structural  diseases  of  the  heart. 

The  functional  affections  of  the  heart  are: 
A.  Motor: 

1.  Derangements  of  rhythm, 

(a)  Arrhythmia. 

(b)  Rapid  heart — tachycardia. 

(c)  Slow  heart — bradycardia  (brachycardia). 

2.  Momentary  arrest — syncope. 


1236  MEDICAL  DIAGNOSIS. 

B.  Sensory: 

Subjective  sensations  referred  to  the  precordia. 

(a)  Heart  consciousness. 

(b)  Precordial  distress. 

(c)  Precordial  pain. 

C.  Motor  and  sensory  combined: 

Palpitation. 

Etiology. — Predisposing  Influences. — These  comprise,  (a)  a  weak 
and  delicate  organization  associated  with  an  impressionable  nervous 
system;  (b)  anaemic  conditions;  (c)  lithsemia  and  allied  derangements  of 
metabolism  and  excretion;  and  (d)  morbid  conditions  directly  affecting 
the  nervous  system,  as  organic  diseases  of  the  brain  and  cord,  chorea, 
epilepsy,  and  the  acute  and  chronic  infections. 

Certain  of  these  conditions  are  inherited,  others  acquired.  Thus  the 
descendants  of  nervous  or  insane  parents,  those  begotten  of  elderly  persons, 
those  who  have  in  infancy  been  exposed  to  privation  and  neglect,  or  who 
have  suffered  from  serious  or  protracted  disease,  are  especially  prone  to 
functional  disturbances  of  the  heart.  To  a  less  extent  is  this  true  of  gouty, 
tuberculous,  and  syphilitic  persons. 

Functional  derangements  of  the  heart  are  much  less  frequent  in 
childhood  than  in  adult  life. 

The  EXCITING  CAUSES  include:  (A)  those  acting  upon  the  nervous 
system,  (a)  directly,  as  intense  mental  emotion,  fear,  anger,  grief;  or  (b) 
reflexly,  as  gastro-intestinal  irritation,  intestinal  parasites,  or  foreign  bodies 
in  the  intestinal  canal;  and  (B)  those  acting,  by  means  of  mechanical 
disturbance  of  the  circulation,  upon  the  heart,  as  violent  exercise  or  exertion. 

Symptoms. — In  general  terms  the  symptoms  of  the  functional  disorders 
of  the  heart  consist  in  derangement  of  the  motor  functions  and  abnormal 
sensations  referred  to  the  precordia.  These  motor  and  sensory  derange- 
ments are  not  always  associated.  More  commonly  the  movement  of  the 
heart  is  deranged,  its  action  being  accelerated,  retarded,  or  irregular, 
without  abnormal  sensations;  occasionally  derangement  of  rhythm  occurs 
in  connection  with  precordial  distress  or  pain  or  a  sense  of  oppression;  and 
in  comparatively  rare  instances  precordial  pain  occurs  in  the  absence  of 
motor  disturbance. 

When  the  functional  disorder  is  paroxysmal  or  of  a  high  grade  of 
intensity,  it  is  usually  accompanied  by  increased  frequency  of  respiration, 
and  very  often  by  pallor  of  the  face  and  slight  cyanosis.  Especially  is 
pallor  associated  with  syncope. 

When  the  derangement  is  not  paroxysmal,  but  persistent,  the  rhythm 
of  the  respiration  is  not  usually  disturbed. 

Physical  examination  yields  a  limited  number  of  definite  signs.  The 
frequency  of  the  heart's  action  and  the  degree  and  character  of  the  arrhyth- 
mia are  recognized  upon  palpation.  By  this  method  of  examination  we 
also  detect,  especially  on  palpation,  the  change  in  the  character  of  the 
impulse,  which  is  increased  in  force.  We  observe  also  by  this  means  and 
by  inspection  that  the  impulse  is  extended.  We  determine  by  the  position 
of  the  apex  beat,  and  may  confirm  the  observation  by  percussion,  that  the 
heart  is  not  enlarged.     Upon  auscultation  the  first  sound  is  found  to  be 


FUNCTIONAL  AFFECTIONS  OF  THE  HEART.  1237 

sharp  and  valvular  and  shortened  in  duration,  while  the  second  sound 
remains  distinct  or  is  accentuated.  In  very  rapidly  acting  or  very  irregular 
hearts  transient  murmurs,  usually  mitral  systolic,  are  common. 

A.  Motor:  1.  Derangements  of  Rhythm. — The  cardiac  mechanism 
is  now  regarded  as  myogenic  rather  than  neurogenic;  that  is  to  say,  inherent 
in  the  heart  muscle  rather  than  due  to  the  influence  and  control  of  the  vagi 
and  sympathetic  nerves  under  the  influence  of  higher  centres.  The  fol- 
lowing classification  of  the  forms  of  arrhythmia  is  that  of  Joseph  Erlanger, 
based  upon  that  of  Wenckeback:  ^ 

T.  Arrhythmia  Resulting  from  Decreased  Conductivity  in  the  Auriculoventric- 
ular  Junction — Heart  Block. 
A.  Partial   heart  block.     B.  Complete  heart  block.     C.  Paroxysmal 
bradycardia. 
II.  Arrhytlimia  Resulting  from  Increased  Irritability  of  the  Heart. 

A.  Ventricular  extra-systoles,  characterized  by  an  early  systole,  which 

is  associated  with  the  phenomena  of  a  retrograde  impulse.  There 
may  be  one  or  more  extra-systoles  following  a  normal  systole ; 
when  regularly  recurring,  one  or  more  extra-systoles  after  5,  4,  3, 
2,  or  1  normal  systoles,  the  last  giving  the  bigeminal  or  trigeminal 
pulse,  or  there  may  be  irregularly  recurring  extra-systoles  causing 
delirium  cordis. 

B.  Auricular  extra-systoles. 

III.  Arrhythmia  Resulting  from  the  Influence  of  Extrinsic  Nerves  upon  the 

Heart-rate. — (1)  Vagus  effects.     (2)  Accelerator  effects. 

IV.  Arrhythmia  Resulting  from  Disturbed  Diastolic  Filling  of  the  Heart. 

A.  Disturbed  filling  resulting  from  violent   respiratory    movements  ; 

may  give  the  paradoxical  pulse. 

B.  Disturbed  filling  from  adherent  pericardium  or  mediastinal  tumor  ; 

may  give  the  paradoxical  pulse. 

C.  Associated  respiratory  and  cardiac  rhythm.     Alternating  pulse  (?). 

(a)  Arrhythmia  in  time  and  volume  and  intermission  of  the  pulse  is 
due  to  extra-systoles,  which  occur  in  various  groupings  and  combinations, 
giving  rise  to  pulsus  bigeminus,  trigeminus,  and  so  on,  according  to  the 
transmission  of  the  extra  pulse-beats  to  the  peripheral  arteries.  Extra- 
systoles  occur  under  the  most  varying  conditions.  Arrhythmia  may  be 
manifest  as  an  individual  peculiarity,  wholly  independent  of  health  or 
disease.  There  are  individuals  who  have  marked  cardiac  irregularity, — 
arrhythmia,  intermission, — wholly  without  derangement  of  the  fvmction 
of  the  circulation  and  usually  without  consciousness  of  the  abnormality. 
Extra-systoles  are  common  in  irritable  heart,  such  as  occurs  in  debilitated 
and  neurasthenic  persons;  in  overtrained  athletes;  in  those  who  are  given 
to  the  abuse  of  narcotics,  as  tea,  coffee,  tobacco,  and  alcohol,  or  to  sexual 
excesses;  and  in  the  subjects  of  autointoxications  of  various  kinds.  They 
are  common  in  overdistention  of  the  stomach  with  food,  and  in  various 
forms  of  dyspepsia,  especially  gastric  flatulency — probably  as  manifesta- 
tions of  reflex  irritation.  They  may  be  the  result  of  abnormall}^  high  blood- 
pressure.  Finally,  they  are  common  in  organic  disease  of  the  heart,  as 
myocarditis,  dilatation,  sclerosis  of  the  coronary  arteries,  and  rupture  of 
compensation  in  chronic  valvular  disease  of  various  kinds.  It  is  evident 
that  the  extra-systoles  of  organic  disease  are  far  more  important  and 
significant  than  those  due  to  irregular  physiological  stimuli  or  abnormal 
reflex  or  toxic  stimuli,  that  are  controllable  or  transient. 

1  Osier,  Practice  of  Medicine,  6th  ed.,  1905,  p.  834. 


1238  MEDICAL  DIAGNOSIS. 

(b)  Rapid  Heart ;  Tachycardia. — Frequent  revolution  of  the  heart 
is  sometimes  an  individual  peculiarity.  The  pulse  may  be  100  per  minute, 
and  more  frequent  after  meals  and  under  excitement  or  active  exercise. 
The  rapid  pulse  caused  by  fright  may  continue  for  an  indefinite  time. 
The  accelerated  pulses  symptomatic  of  fever  and  of  exophthalm;c  goitre 
are  of  toxic  causation  and  cannot  be  regarded  as  cardiac  neuroses,  nor  does 
the  frequent  pulse  sometimes  present  at  the  menopause,  or  that  due  to 
reflex  influences  from  disease  of  the  pelvic  organs,  belong  to  this  category. 

Paroxysmal  or  Essential  Tachycardia.- — This  remarkable  affection  occurs 
in  the  absence  of  the  ordinary  nervous  or  organic  conditions  which  give 
rise  to  symptomatic  heart  hurry.  It  may  begin  early  in  life  and  continue 
for  years  without  manifestations  of  organic  disease  of  the  heart.  The 
attacks  occur  abruptly  in  the  midst  of  ordinary  health,  and  continue  for 
some  minutes,  hours,  or  days,  and  cease  as  suddenly  as  they  began.  They 
are  characterized  by  faintness,  oppression,  moderate  palpitation,  pallor, 
dyspnoea,  and  a  pulse-frequency  that  may  exceed  200  per  minute.  The  heart 
sounds  are  of  fetal  type.  Occasionally  simple  intermissions  occur.  In  some 
cases  there  is  distinct  arrhythmia.  At  the  close  of  the  attack  the  pulse 
becomes  relatively  slow  and  full,  sometimes  not  exceeding  in  frequency 
half  or  even  one-third  that  of  the  paroxysm.  The  attacks  recur  at  intervals 
of  days  or  years,  the  general  condition  of  the  patient  being  meanwhile 
normal.  They  are  brought  on  in  many  cases  by  physical  effort  or  emotional 
stress.  In  other  instances  they  occur  in  the  absence  of  recognizable  exciting 
cause.  The  attack  is  rarely  if  ever  fatal.  In  exceptional  cases  the  disease 
ceases  after  a  series  of  paroxysms. 

(c)  Slow  Heart;  Bradycardia. — Slow  heart  may  be  an  individual  pe- 
culiarity. The  physiological  and  pathological  conditions  under  which 
slowness  of  the  pulse  may  occur  have  already  been  considered.  It  is  of 
cardinal  importance  to  determine  the  heart  frequency  by  palpation  of  the 
apex  beat  or  auscultation  of  the  heart  sounds,   since  there  are  cases  in 

.  which  half  the  beats  do  not  transmit  a  pulse-wave  to  the  wrist. 

A  form  of  paroxysmal  bradycardia  has  been  described  (Hoffman). 
■  2.  Momentary  Arrest;  Syncope. — Faintness  is  common  in  nervous 
and  impressionable  persons.  It  may  result  from  sudden  shock  or  intense 
excitement.  Blood  loss  (even  when  sHght),  profuse  diarrhoea,  extreme 
fatigue,  and  severe  pain  may  cause  faintness  or  actual  syncope.  Emotional 
children  may  faint  at  the  sight  of  blood.  A  boy  of  seven  fainted  at  the 
sight  of  the  denuded  spot  upon  his  arm  caused  in  vaccination.  A  healthy 
girl  of  eight,  of  shy  and  timid  disposition,  fainted  at  the  dinner  table  upon 
being  suddenly  addressed  by  a  person  whom  she  did  not  know. 

B.  Sensory. — Subjective  sensations  referred  to  the  precordia. 

(a)  Heart  Consciousness. — Neurotic  and  neurasthenic  individuals 
frequently  complain  of  disagreeable  sensations  in  the  region  of  the  heart. 
They  feel  the  extra-systole  and  the  compensatory  pause,  and  use  such 
phrases  as  'Hhe  heart  stumbled,"  or  "the  heart  turned  over,"  to  express 
the  sensation.  But  in  many  cases  of  arrhythmia  there  are  no  subjective 
sensations.  It  is  a  mistake  to  call  the  attention  of  patients  to  arrhythmia 
or  intermissions  of  which  they  are  unaware,  since  the  consciousness  of  such 
irregularities  is  often  a  cause  of  great  distress. 


ARTERIOSCLEROSIS.  1239 

(b)  Distress. — Precordial  distress  is  common  in  neurotic  individuals, 
both  in  functional  and  organic  disease  of  the  heart.  It  is  extreme  in  the 
overacting  heart  of  violent  exertion  and  is  the  essential  element  in  palpita- 
tion. It  is  common  in  intense  emotion.  It  may  be  reflex  in  character  and 
is  frequently  due  to  gastro-intestinal  derangements.     It  is  often  transient. 

(c)  Precordial  Pain. — This  neurosis  is  common  in  nervous  indi- 
viduals. It  occurs  in  valvular  disease  of  the  heart,  especially  in  aortic 
and  mitral  stenosis  and  the  later  periods  of  aortic  insufficiency,  and  in  the 
forms  of  myocarditis  associated  with  sclerosis  of  the  coronary  arteries. 
It  is  the  chief  element  in  angina  pectoris  and  an  important  symptom  in 
aneurism  of  the  aorta. 

C.  Motor  and  Sensory  Combined. — Palpitation. — The  most  extreme 
motor  disturbance  of  the  cardiac  rhythm  may  occur  in  the  absence  of 
consciousness  of  any  cardiac  irregularity,  and  distressing  precordial  sensa- 
tions may,  on  the  other  hand,  be  experienced  while  the  heart's  action  is 
regular  and  orderly.  In  palpitation  there  is  irregular  or  forcible  action, 
perceptible  and  usually  distressing  to  the  individual.  This  combination  of 
motor  and  sensory  derangements  constitutes  palpitation.  It  is  of  frequent 
occurrence  in  neurotic  individuals,  and  is  common  at  puberty,  the  grand 
climacteric,  and  during  menstruation.  It  is  frequently  encountered  in 
hysteria  and  in  neurasthenia,  and  constitutes  an  important  element  in  the 
symptom-complex  known  as  cardiac  neurasthenia.  It  may  occur  in  normal 
individuals  in  consequence  of  violent  emotion.  It  is  a  symptom  of  irritable 
heart  whether  due  to  over-exercise,  excesses  in  venery,  or  over-indulgence 
in  tea,  coffee,  tobacco,  or  alcohol;  and  finally  it  is  a  common  factor  of 
cardiac  insufficiency  from  any  cause.  As  a  rule,  palpitation  is  more  violent 
and  distressing  in  irritable  heart  than  in  valvular  or  myocardial  disease. 
The  symptoms  vary  from  a  mere  fluttering  of  the  heart  to  a  violent  pulsa- 
tion with  great  distress  and  anxiety.  In  the  latter  case  the  heart's  action 
may  be  slow  or  rapid;  regular  or  irregular.  The  sounds  may  be  clear  and 
ringing,  the  second  accentuated,  and  murmurs  wholly  absent.  In  some 
cases  there  are  basic  or  apex  murmurs,  which  disappear  when  the  attack  is 
over.  The  attacks  are  of  variable  duration,  but  do  not  often  exceed  an 
hour  or  two. 

DISEASES  OF  THE  ARTERIES. 

I.  ARTERIOSCLEROSIS. 

Definition. — A  disease  of  the  arterial  system  characterized  anatomi- 
cally by  nutritional  changes  in  the  media  and  adventitia  with  compensatory 
thickening  in  the  intima,  which  thickening  subsequently  involves  all  the 
coats;  and  clinically  by  functional  derangements  in  the  various  viscera. 

The  anatomical  changes  may  be  diffuse  or  localized.  In  the  diffuse 
variety  the  arteries  are  dilated  and  tortuous,  their  walls  thickened  and 
inelastic,  and  the  intima  the  seat  of  irregular  thickening,  calcareous 
plates,  and  atheromatous  ulcers;  in  the  localized  or  circumscribed  form 
yellowish-white,  rounded,  nodular  patches,  raised  above  the  surface,  are 
irregularly  scattered  along  the  intima.  Diffuse  and  nodular  sclerosis  are 
commonly  associated. 


1240  MEDICAL  DIAGNOSIS. 

In  senile  arteriosclerosis  the  arteries  are  dilated  and  tortuous,  the  walls 
thin  and  rigid,  and  the  subendothelial  tissue  the  seat  of  circumscribed 
collections  of  softened  or  broken-down  material — atheromatous  abscesses. 
When  these  collections  rupture  into  the  lumen  of  the  artery  they  give 
rise  to  atheromatous  ulcers. 

In  the  various  forms  the  degeneration  of  the  media  may  be  marked 
in  the  smaller  arteries.  The  capillaries  are  thickened  and  may  be  obliter- 
ated. The  connective-tissue  overgrowth  leads  to  more  or  less  complete 
atrophy  of  the  muscular  and  connective-tissue  elements.  In  some  cases 
characterized  by  general  or  local  increase  in  blood-pressure  the  muscular 
fibres  of  the  media  may  be  preserved  or  even  hypertrophied. 

In  consequence  of  these  changes  the  larger  and  middle-sized  arteries 
are  dilated;  the  smaller,  by  reason  of  the  thickening  of  the  intima,  are 
narrowed  and  very  often  wholly  obliterated — endarteritis  obliterans. 

The  ramifications  of  certain  arteries  are  involved  with  greater  fre- 
quency than  others.  In  the  series  of  cases  studied  by  pupils  of  Thoma 
and  analyzed  by  Bergmann,  sclerotic  changes  were  found  in  the  ulnar 
artery  in  94  per  cent.,  the  tibialis  antica  93,  the  subclavian  88,  arteries  of 
the  brain  87,  internal  carotid  87,  radial  86,  splenic  82,  popliteal  79,  external 
carotid  78,  axillary  71,  femoral  69,  common  carotid  68,  ascending  aorta 
67,  abdominal  aorta  64,  external  iliac  58,  and  brachial  55.  The  minute 
arteries  of  the  various  organs  are  involved  in  the  arteriosclerotic  process. 
These  lesions  are  especially  common  in  the  heart,  brain,  kidneys,  liver,  and 
pancreas.  Sclerosis  of  the  pulmonary  artery  and  its  branches  is  a  constant 
concomitant  of  lesions  such  as  chronic  disease  of  the  mitral  valve,  emphy- 
sema, and  fibroid  phthisis,  which  cause  persistent  increase  of  the  blood- 
pressure  in  the  pulmonary  circulation.  The  artery  may  be  dilated,  with 
insufficiency  of  the  semilunar  valve  system,  its  primary  and  secondary 
branches  the  seat  of  aneurismal  dilatation,  and  its  smaller  branches  highly 
sclerotic.  The  sclerotic  process  frequently  extends  to  the  capillaries  and 
may  also  affect  the  veins,  which  not  infrequently  are  sclerotic  in  the  absence 
of  similar  changes  in  the  arteries. 

Etiology. — The  following  factors  are  of  importance  in  the  causation  of 
arteriosclerosis : 

1.  Persistent  High  Blood-pressure  and  Sudden,  Frequent,  and  Extreme 
Alternations  of  Pressure. — There  are  many  conditions  which  bring  about 
habitual  strain  upon  the  arteries.  Among  the  more  important  are:  (a) 
Habitual  hard  work.  This  accounts  for  the  great  frequency  of  arterio- 
sclerosis among  the  laboring  classes,  and  the  fact  that  working  men  more 
frequently  suffer  from  sclerotic  changes  in  the  upper  extremities  and 
women  in  the  same  walk  of  life  in  the  lower  extremities,  while  such  changes 
in  the  arteries  of  the  extremities  are  infrequent  in  persons  whose  occupa- 
tions are  not  laborious  (Romberg).  The  muscular  effort  habitually  increases 
the  peripheral  resistance  and  raises  the  intra-arterial  pressure,  (b)  Ner- 
vous influences — the  strenuous  fife  in  which  physical  effort,  mental  stress, 
and  excitement  combine  to  tax  alike  the  brain  and  the  heart.  In  this  con- 
nection the  frequency  with  which  arteriosclerosis  is  present  in  neurasthenia 
is  to  be  considered,  (c)  Obesity.  The  increased  effort  demanded  by  the 
ordinary  movements  of  fife  and  by  the  larger  volume  of  the  circulating 


ARTERIOSCLEROSIS.  1241 

blood  tends  to  arteriosclerosis,  and  especially  to  arteriosclerosis  of  the 
coronary  arteries,  (d)  Chronic  interstitial  nephritis  is  associated  with 
persistent  increase  of  blood-pressure  and  sclerotic  changes  in  the  arterial 
walls.  (e)  Frequently  repeated  and  extreme  changes  in  temperature, 
such  as  are  necessary  in  certain  crafts,  tend  by  the  abrupt  contraction  and 
dilatation  of  the  superficial  vessels  to  the  production  of  arteriosclerosis, 
(f)  The  strain  upon  the  arteries  in  aortic  insufficiency  rapidly  brings 
about  sclerosis  of  their  walls. 

2.  Chronic  Intoxications. — (a)  The  abuse  of  tea,  coffee,  tobacco,  and 
alcohol  is  credited  with  a  causal  influence  which  is  doubtless  over-estimated. 
These  narcotics,  and  especially  alcohol,  may  exert  an  indirect  effect  by 
increasing  nervous  excitability,  (b)  Lead,  diabetes,  and  gout  play  an 
important  role.  The  mode  of  action  has  not  been  explained.  Their  asso- 
ciation with  interstitial  nephritis  is  to  be  considered,  (c)  Renal  disease. 
There  are  two  groups  of  cases,  primary  interstitial  nephritis  and  nephritis 
associated  with  general  arteriosclerosis.  (d)  The  infectious  diseases, 
especially  malaria,  rheumatic  fever,  and  enteric  fever,  appear  in  some 
cases  to  be  the  starting-point  of  progressive  arteriosclerotic  changes,  (e) 
Excesses  at  table.  There  can  be  no  doubt  of  the  importance  of  over-eating 
as  a  factor  in  the  causation  of  arteriosclerosis,  and  that  the  results  of  such 
excesses  belong  in  the  category  of  the  chronic  intoxications  is  equally 
beyond  question. 

3.  Syphilis  is  a  causal  factor  of  great  moment.  In  syphilitic  subjects 
arteriosclerosis  develops  early  and  attains  a  high  grade.  The  distinction 
between  arteriosclerosis  and  the  specific  vascular  lesions  of  syphilis  is  to 
be  made. 

4.  Heredity. — The  predisposition  to  arteriosclerosis  varies  greatly  in 
different  families.  Inherited  anatomical  peculiarities,  as  congenital  nar- 
rowness of  the  arteries  and  thickness  of  their  walls,  are  attended  with  the 
liability  to  early  sclerosis.  These  arterial  changes  appear  early  among  the 
peasant  immigrants  from  Italy  and  other  countries  of  Southern  Europe. 

5.  Age. — The  view  is  generally  entertained  that  arteriosclerosis  is  a 
manifestation  of  senile  involution.  There  are,  however,  aged  persons  in 
whom  little  or  no  evidence  of  the  disease  is  apparent.  It  is  probable  that 
in  many  cases  the  arteriosclerosis  of  old  persons  is  a  late  result  of  the  action 
of  other  causes  operative  in  earlier  life.  In  fact  several  of  the  above 
etiological  factors  are  usually  to  be  recognized  in  the  anamnesis.  This  is 
especially  the  case  in  connection  with  syphilis. 

It  is  in  accordance  with  the  above  facts  that  arteriosclerosis  is 
more  common  after  middle  life  than  at  an  earlier  period,  and  in  men 
than  in  women. 

Symptoms. — Arteriosclerosis  begins  insidiously  and  may  long  remain 
latent.  There  are,  however,  cases  in  which  the  vascular  changes  attain  a 
high  grade  in  the  course  of  a  very  few  years.  When  symptoms  become 
manifest  they  may  be  general  or  local,  according  to  the  vascular  distribu- 
tion chiefly  affected. 

The  general  symptoms  are  in  many  cases  not  different  from  those  of 
old  age.  The  skin  becomes  harsh,  wrinkled,  and  inelastic;  subcutaneous  fat 
is   reduced   over   the    chest  and  extremities  and   accumulates   upon   the 


1242  MEDICAL  DIAGNOSIS. 

abdomen;  the  muscles  waste;  the  viscera  undergo  atrophic  changes;  and 
there  is  manifest  loss  of  bodily  and  mental  power.  Dyspeptic  symptoms 
are  often  prominent.  Characteristic  phenomena  relate  to  the  circulation. 
The  blood-pressure  is  increased,  the  superficial  arteries  are  thickened  and 
hard,  there  is  hypertrophy  of  the  left  ventricle  and  accentuation  of  the 
aortic  second  sound,  which  has  often  a  clear,  ringing  quality.  There  are, 
however,  cases  in  which  the  blood-pressure  remains  low  and  the  hyper- 
trophy of  the  left  ventricle  is  moderate.  An  increased  flow  of  urine  of  low 
specific  gravity  and  transient  traces  of  albumin,  together  with  occasional 
hyaline  casts,  is  not  uncommon. 

The  local  symptoms  depend  upon  the  grade  of  the  vascular  lesions  and 
the  organ  or  structure  principally  involved,  as  the  heart,  brain,  kidneys, 
or  extremities. 

1.  Cardiac  Symptoms  and  Signs. — The  effect  of  persistent  resistance 
to  the  flow  of  the  blood  in  the  peripheral  arteries  is  hypertrophy  of  the  left 
ventricle,  with  the  symptoms  and  physical  signs  of  that  condition.  When 
the  coronary  arteries  are  involved,  local  or  general  myocardial  degenera- 
tions occur  with  their  attendant  symptoms,  which  are  those  of  cardiac 
insufficiency.  Angina  pectoris,  aneurism  of  the  heart,  local  softening, 
rupture,  or  sudden  death  may  result.  When  dilatation  supervenes  the 
systolic  apex  murmur  of  relative  mitral  insufficiency  is  heard,  and  the 
symptoms  of  extreme  cardiac  insufficiency  arise,  dyspnoea  while  at  rest, 
somnolence,  scanty  urine,  dropsies  and  effusions  into  the  serous  sacs. 
Dilatation  of  the  ascending  aorta  may  give  rise  to  tympany  or  dulness  at 
the  sternal  end  of  the  second  right  intercostal  space  or  palpable  pulsation 
in  the  episternal  notch  and  a  soft  systolic  murmur  with  an  accentuated 
second  aortic  sound  when  the  aortic  valves  are  capable  of  closure,  and 
may  be  well  shown  by  the  Rontgen  rays. 

2.  Cerebral  Symptoms. — Among  the  early  symptoms  are  sensations 
of  fulness  and  pressure  in  the  head,  insomnia,  distress,  anxiety,  and  vertig- 
inous attacks.  As  the  vascular  lesions  progress  mental  symptoms  develop. 
The  attention  flags,  the  recollection  of  recent  events  fails,  the  patient 
becomes  indifferent  about  his  personal  appearance  and  less  considerate  of 
others.  Self-restraint  may  be  impaired.  Actual  vertigo,  transient  loss  of 
consciousness,  and  temporary  derangements  of  speech  are  among  the 
symptoms  of  advanced  arteriosclerosis.  Repeated  attacks  of  hemiplegia, 
monoplegia,  and  aphasia  may  occur  with  the  signs  of  organic  lesions  and 
terminate  in  complete  recovery  in  the  course  of  a  few  hours  or  a  day  or  two. 
The  Stokes-Adams  syndrome  is  occasionally  observed.  Tinnitus  cerebri 
and  tinnitus  aurium  are  common  and  often  distressing  symptoms.  The 
cerebral  symptoms  of  arteriosclerosis  include  those  of  the  lesions  of  the 
brain  due  to  persistent  obstruction  of  the  smaller  vessels,  and  accidents, 
such  as  thrombosis,  embolism,  and  hemorrhage. 

3.  Renal  Symptoms. — These  correspond  to  those  of  chronic  inter- 
stitial nephritis.  The  association  of  this  form  of  renal  disease  and  arterio- 
sclerosis is  common.  Arteriosclerosis  predisposes  to  nephritis;  chronic 
nephritis  to  general  sclerosis.  When  the  patient  has  not  been  under  obser- 
vation from  the  beginning  it  is  impossible  to  determine  which  is  the  primary, 
which  the  secondary,  affection.     In  either  case  the  renal  symptoms  may 


ARTERIOSCLEROSIS.  1243 

dominate  the  clinical  picture;  more  commonly,  however,  the  cardinal 
symptoms  are  those  of  myocardial  disease.  The  condition  constitutes  one 
of  the  forms  of  cardiorenal  disease.  Glycosuria  is  a  frequent  indication  of 
sclerosis  of  the  pancreatic  arteries. 

4.  Vasomotor  Symptoms. — Sensations  of  cold  and  numbness  in  the 
hands  and  feet,  fulness  or  lightness  in  the  head,  tingling  and  pulsation  in 
the  fingers,  dynamic  pulsation  in  the  abdominal  aorta,  and  congestion 
of  the  feet  and  legs  are  very  common. 

5.  The  Extremities. — The  symptoms  due  to  sclerosis  of  the  periph- 
eral vessels  are  comparatively  infrequent.  The  diminished  capillary  cir- 
culation gives  rise  to  more  or  less  marked  pallor,  which  is  not  rarely  an 
early  symptom.  Its  association  with  loss  of  weight  and  strength  suggests 
anaemia  or  even  the  development  of  visceral  cancer,  especially  in  cases  in 
which  the  signs  of  changes  in  the  heart  or  brain  are  not  prominent. 

Intermittent  Claudication;  Dysbasia  Angiosclerotic  a;  Crural  Angina. 
— This  constitutes  a  somewhat  common  and  very  striking  clinical  mani- 
festation of  sclerosis  in  the  arteries  of  the  lower  extremities.  It  depends 
upon  the  fact  that  while  at  rest  the  blood  supply  to  the  muscles, 
diminished  as  it  is  by  the  narrowing  of  the  lumen  of  the  peripheral  vessels, 
is  yet  sufficient  for  their  physiological  requirements  or  even  for  moderate 
use,  but  when  muscular  effort  is  made  the  blood  supply  is  inadequate  and 
severe  cramp-like  contractions  ensue.  After  walking  a  short  distance  the 
patient  experiences  in  one  or  both  legs  sensations  of  numbness,  tingling, 
heat  or  cold,  tension  and  pain.  The  skin  becomes  pale  and  cyanotic.  If 
the  effort  is  not  discontinued  more  or  less  severe  cramp  and  muscular 
disability  follow.  These  symptoms  cease  upon  rest,  only  to  return  upon 
further  effort.  In  extreme  cases  the  spasms  recur  upon  moderate  effort 
and  the  muscles  undergo  gradual  atrophy. 

Diagnosis. — The  direct  diagnosis  of  arteriosclerosis  may  be  made  when 
increased  blood-pressure,  thickened  and  tortuous  superficial  arteries, 
hypertrophy  of  the  left  ventricle,  and  accentuation  of  the  aortic  second 
sound  are  present.  The  thickened  radial  artery  can  often  be  rolled  under 
the  finger  upon  the  radius  like  a  whip-cord,  or  it  may  show  irregular,  nodular 
projections  along  its  course  like  a  string  of  wampum,  or  present  little  aneu- 
rismal-like  circumscribed  dilatations.  A  high  degree  of  sclerosis  in  the 
superficial  arteries  may  exist  without  a  corresponding  condition  in  the 
arteries  of  the  parenchymatous  organs,  and  the  converse  is  true.  Another 
important  fact  in  diagnosis  is  that  advanced  arteriosclerosis  may  involve 
a  vascular  territory  or  organ,  as  the  kidneys  or  brain,  without,  in  the  absence 
of  general  sclerotic  changes,  increasing  the  blood-pressure,  and,  therefore, 
without  causing  left  ventricle  hypertrophy  or  marked  accentuation  of 
the  aortic  second  sound.  When  there  is  marked  deposition  of  lime  salts 
in  the  affected  arterial  walls  in  the  legs  and  feet,  the  X-ray  examination 
yields  positive  results,  but  it  is  useless  in  the  deeply  seatetl  arteries  of  the 
trunk,  with  the  exception  of  the  aorta,  the  shadow  of  which  is  broadened 
and  intensified  in  places  by  the  presence  of  thickened  atheromatous  plates. 
Etiological  considerations  are  important  in  the  diagnosis. 

Prognosis.— The  course  of  arteriosclerosis  shows  extreme  variations. 
The  disease  may  involve  the  peripheral  circulation  and  be  wholly  latent  as 


1244  MEDICAL  DIAGNOSIS. 

to  symptoms.  Cases  of  this  kind  go  on  from  year  to  year  without  serious 
impairment  of  health.  It  may,  on  the  other  hand,  rapidly  give  rise  to 
distinctive  changes  in  organs  that  are  necessary  to  life.  Finally,  it  not 
uncommonly  sets  up  a  vascular  dyscrasia  in  which  the  entire  body  and  its 
organs  are  involved  in  progressive  nutritional  and  atrophic  changes,  which 
terminate  in  death  in  the  course  of  a  few  years.  In  selected  cases  of  pe- 
ripheral sclerosis  the  removal  of  the  cause  and  regulation  of  the  mode  of 
life  very  often  favorably  influence  the  progress  of  the  disease  and  may 
arrest  it.  In  cases  due  to  syphilis  an  energetic  antiluetic  treatment  may 
be  followed  by  an  arrest  of  the  sclerotic  process. 

II.  ANEURISM. 

Definition. — A  circumscribed  dilatation  of  an  artery.  This  anatomical 
condition  is  to  be  distinguished  from  the  diffuse  widening  of  the  larger 
arteries  which  occurs  in  arteriosclerosis. 

Aneurisms  are  divided: 

(a)  According  to  their  form  into  fusiform  or  cylindroid,  in  which  there 
is  uniform  dilatation  of  the  vessel,  and  sacculated,  in  which  there  is  a  lateral 
bulging  or  protrusion  of  the  wall. 

(b)  According  to  the  composition  of  the  wall  into  tme,  in  which  the 
wall  is  composed  of  one  or  more  of  the  coats  of  the  artery,  and  false,  in 
which  there  is  a  rupture  of  all  the  coats  and  the  blood  is  confined  by  the 
surrounding  tissues.  This  distinction  is  not  important,  since  a  false  aneu- 
rism is  in  reality  a  hematoma  and  the  differentiation  between  true  and 
false  aneurisms  cannot  in  all  cases  be  made  after  death,  much  less  during  life. 

(c)  According  to  other  anatomical  peculiarities  into  cirsoid,  in  which 
an  artery  and  its  branches  are  involved  in  the  dilatation,  dissecting,  in  which 
the  blood  collects  between  the  coats  of  the  artery — this  type  occurs  in  the 
aorta  and  occasionally  forms  a  complete  double  tube — and  arteriovenous, 
in  which  there  is  a  communication  between  an  artery  and  a  vein.  There 
may  be  a  sac  between  the  artery  and  vein,  but  more  commonly  the  com- 
munication is  direct  and  the  vein  which  yields  to  the  intra- arterial  pressure 
is  dilated,  tortuous,   and  pulsating — aneurismal  varix. 

i.  Aneurism  of  the  Aorta. 

Aneurisms  of  the  aorta  are  usually  fusiform  or  sacculated.  The  latter 
is  more  common.  The  combination  of  these  forms  is  occasionally  encoun- 
tered. Dissecting  aneurisms  are  rare.  Still  more  rare  are  arteriovenous 
aneurisms.  The  essential  anatomical  condition  is  dilatation,  under  the 
intra-arterial  pressure,  of  the  vessel  wall,  weakened  by  disease.  In  fusi- 
form dilatation  all  three  coats  of  the  vessel  are  dilated.  In  sacculated 
aneurism  the  intima  may  extend  into  the  sac  some  distance;  the  media 
undergoes  atrophic  changes  and  extensive  destruction.  The  wall  of  the 
sac  is  in  the  greater  part  of  its  extent  formed  by  the  adventitia,  which  is 
thickened,  infiltrated,  and  fused  with  the  surrounding  tissues.  The  com- 
munication with  the  aorta  is  by  an  opening  of  variable  size.  The  interior 
of  the  sac  is  lined  by  superimposed  laminae  of  coagulated  blood,  those 


ANEURISM.  1245 

which  are  peripheral  being  dense  and  of  a  whitish  color;  those  which  are 
central  being  soft  and  red.  The  arrangement  of  these  coagula  is  neither 
symmetrical  nor  constant,  and  important  modifications  of  the  pressure 
symptoms  and  physical  signs  arise  in  consequence  of  the  yielding  of  the  sac 
to  the  internal  pressure  in  various  directions  at  different  periods  in  the 
course  of  the  affection.  In  rare  instances,  small  aneurisms  having  narrow 
communications  with  the  lumen  of  the  aorta  are  completely  filled  with 
coagula  and  thus  undergo  spontaneous  obliteration  with  the  formation  of 
a  small  nodular  tumor.  As  the  conditions  which  give  rise  to  sacculated 
aneurism  involve  different  portions  of  the  wall  of  the  aorta  multiple  aneu- 
risms are  by  no  means  rare.  In  size  sacculated  aneurisms  vary  from  a 
walnut  to  a  large  cocoanut;  in  shape  they  are  globular,  but  as  they 
increase  in  size  the  wall  yields  more  at  one  point  than  another  in  such  a 
manner  that  irregular  protrusions  occur.  Aneurisms  may  occur  in  any 
part  of  the  aorta,  from  just  above  the  ring  to  the  iliac  bifurcation.  The 
most  common  site  is  in  the  ascending  portion  of  the  arch  to  the  right. 

Etiology. — Arteriosclerosis,  syphilitic  aortitis,  and  trauma  are  the 
most  important  etiological  factors.  The  great  majority  of  aortic  aneurisms 
are  due  to  those  causes  acting  singly  or  in  combination.  Far  less  frequent 
are  cases  due  to  the  action  of  micro-organisms. 

(a)  Arteriosclerosis  leads  to  diffuse  weakening  of  the  wall,  which 
yields  to  the  pressure  of  the  blood  at  a  period  when  compensatory  thick- 
ening of  the  intima  has  not  yet  occurred,  and  undergoes  dilatation. 
Sacculated  aneurism  may  occasionally  have  its  origin  in  arteriosclerosis. 

(b)  Syphilis  plays  a  most  important  role.  Sacculated  aneurism  is  in 
a  large  proportion  of  the  cases  syphilitic.  Whether  the  process  has  its 
beginning  comparatively  early  in  the  changes  in  the  wall  due  to  gumma 
or  at  a  later  period  in  consequence  of  the  loss  of  elasticity  in  scar  tissue 
remains  undetermined.  The  lesions  of  a  patch  of  syphilitic  aortitis 
constitute  the  point  of  diminished  resistance. 

(c)  Traumatism. — When  the  media  and  adventitia  are  weakened,  a 
sudden  increase  of  the  blood-pressure  may  lacerate  the  intima.  A  violent 
contusion,  a  fall,  a  blow  upon  the  chest  may  be  followed  by  the  gradual 
development  of  an  aneurism. 

(d)  Micro-organisms.  —  Multiple  aneurisms  of  the  aorta  and  other 
arteries  have  occasionally  been  observed  in  connection  with  malignant 
endocarditis.  Various  bacteria  have  been  found  in  the  lesions.  Weakening 
of  the  wall  of  the  vessel  in  consequence  of  an  ulcerative  process  analogous 
to  that  affecting  the  valves  doubtless  constitutes  the  early  lesion. 

(e)  Traction  Aneurisms. — An  exceedingly  rare  form  of  aneurism  is 
caused  in  the  concavity  of  the  aortic  arch  at  the  point  of  insertion  of  an 
insufficiently  elongated  remnant  of  the  duct  of  Botallo. 

Among  other  predisposing  influences  of  secondary  importance  are  the 
following:  Age. — Aortic  aneurism  is  much  more  common  between  the 
fortieth  and  sixtieth  years  than  at  any  other  period  of  life.  Sex. — Men 
suffer  more  frequently  than  women  in  the  proportion  of  4  or  5  to  1,  a  pre- 
ponderance due  not  to  inherent  anatomical  differences  but  to  the  far  greater 
exposure  to  the  common  causes.  Habits. — The  direct  influence  of  alcohol 
has  probably  been  over-rated.     Its  indirect  influence  in  leading  to  exposure 


1246  MEDICAL  DIAGNOSIS. 

to  the  danger  of  contracting  syphilis  is  very  great.  Occupations  which 
involve  great  muscular  effort  and  those  which  are  attended  with  the 
danger  of  violent  blows  and  contusions  of  the  chest  may  be  regarded  as 
predisposing  to  thoracic  aneurism. 

An  aneurism  of  the  aorta  is  a  vascular  tumor  which  may  be  wholly 
latent  or  manifest  itself  by  symptoms,  usually  effects  of  pressure,  and 
physical  signs  which  differ  according  to  its  situation  and  the  relative  amount 
of  stratified  clot  and  blood  which  it  contains.  It  is  convenient  to  consider 
separately  aneurism  of  the  thoracic  aorta  and  aneurism  of  the  abdominal 
aorta. 

(a)  ANEURISM  OF  THE  THORACIC  AORTA. 

Symptoms. — The  relative  prominence  of  subjective  symptoms  and 
physical  signs  depends  upon  the  situation  and  size  of  the  aneurism.  The 
cases  may  be  arranged  in  four  groups. 

1.  The  Aneurism  is  Latent. — Symptoms  are  wholly  absent,  or 
vague  and  not  suggestive  of  the  actual  condition.  There  are  no  physical 
signs.  This  group  includes  the  cases  of  moderate  fusiform  dilatation, 
small  sacculated  aneurisms  in  the  ascending  aorta,  and  especially  those 
immediately  above  the  sinuses  of  Valsalva.  The  last  not  rarely  rupture 
into  the  pericardium.     The  diagnosis  is  made  after  death. 

2.  Symptoms  are  Prominent. — Pressure  symptoms  are  present,  but 
the  nature  of  the  lesion  cannot  be  determined.  To  this  category  are  to 
be  referred  small  sacculated  aneurisms  of  the  transverse  and  descending 
portions  of  the.  arch  compressing  the  trachea  or  left  main  bronchus  and  the 
recurrent  laryngeal  nerve,  and  larger  sacs  in  various  situations,  containing 
much  laminated  clot  and  yielding  the  signs  of  a  solid  tumor  rather  than 
those  of  an  aneurism,  and  sacs  upon  the  descending  aorta  just  above  the 
diaphragm,  especially  those  eroding  the  vertebrae. 

3.  Signs  are  Prominent. — There  are  associated  subjective  symp- 
toms but  they  are  distinctly  subordinate  to  the  objective  manifestations 
of  expansile  pulsation,  circumscribed  dulness,  thrill,  diastolic  shock,  and 
tracheal  tugging.  This  group  comprises  certain  aneurisms  of  the  convexity 
of  the  ascending  portion  of  the  arch  which  project  to  the  right  and  exert 
moderate  pressure  chiefly  upon  the  right  lung,  and  some  large  aneurisms 
in  this  situation  which  have  eroded  the  chest  wall  and  formed  projecting 
external  tumors,  with  great  relief  from  the  pressure  symptoms  of  an 
earlier  period  in  the  course  of  the  disease.  In  both  these  sub-groups 
the  contrast  between  the  prominence  of  the  physical  signs  and  the 
moderate  intensity  of  the  symptoms  may  be  very  marked.  Broadbent's 
division  into  the  aneurism  of  symptoms  and  the  aneurism  of  physical 
signs  serves  an  important  purpose  in  indicating  the  data  upon  which  to 
base  a  diagnosis. 

4.  Symptoms  are  Severe  and  Signs  are  Distinctive. — Under 
this  heading  may  be  grouped  a  great  majority  of  aneurisms  of  the  ascend-' 
ing  and  transverse  portions  of  the  arch  which  have  attained  considerable 
size  and  are  sufficiently  free  from  coagula  to  constitute  pulsating  tumors. 
Both  those  still  within  the  chest  and  those  which  have  perforated  the  chest 
wall  and  form  external  masses  belong  to  this  group;   also  those  aneurisms 


ANEURISM. 


1247 


of  the  descending  aorta  which  compress  the  left  lung  or  erode  the  vertebrae, 
and  in  particular  those  which  erode  the  ribs  and  appear  as  external  tumors 
at  the  back. 

The  connective-tissue  overgrowth  in  the  inflammatory  capsule  involves 
and  compresses  the  nerve-trunks  with  which  the  tumor  comes  into  con- 
tact. To  this  fact  is  to  be  attributed  the  pain  so  characteristic  of  growing 
aneurismal  tumors,  the  palsies  of  the  recurrent  laryngeals  and  pneumo- 
gastric,  and  derangements  of  the  sympathetic. 

When  neighboring  blood-vessels  are  implicated  in,  the  growth,  to 
which  the  venous  trunks  and  the  pulmonary  artery  are  particularly  liable, 
they  are  narrowed  and  the  veins  may  be  completely  compressed,  or  per- 


FiG.  353. — Aneurism  of  the  arch  of  tlie 
aorta  protruding  through  the  sternum. — Ger- 
man Hospital. 


Fig.  3.54. — Aneurism  of  the  arch  of  the  aorta 
protruding  through  the  sternum.  The  same 
patient  one  year  later.  Death  occurred  suddenly 
from  external  rupture  through  the  skin. 


foration  into  the  superior  vena  cava  may  take  place.  In  a  similar  manner 
the  trachea,  a  main  bronchus,  or  the  oesophagus  may  be  involved  and 
compressed,  or  the  sac  may  rupture  into  these  organs. 

The  sternum,  costal  cartilages,  ribs,  and  the  bodies  of  the  vertebrae 
undergo  more  or  less  extensive  erosion  under  the  pressure  of  the  distending 
sac.  In  rare  instances  portions  of  the  bony  wall  of  the  chest  are  enclosed 
in  the  advancing  sac,  and  a  fragment  of  a  rib  or  the  end  of  a  partly  eroded 
clavicle  is  found  within  its  capsule. 

Hemorrhage. — The  adventitia,  even  when  reinforced  by  encapsulating 
connective  tissue,  may,  in  the  course  of  a  short  time,  yield  to  the  blood- 
pressure.  When  the  rupture  takes  place  into  the  trachea,  a  bronchus, 
the  oesophagus  or  stomach,  the  pleura  or  pericardium,  death  usually  occurs 
at  once.     If  the  sac  is  surrounded  bv  dense  connective  tissue  a  hsematoma 


1248 


MEDICAL  DIAGNOSIS. 


is  formed  immediately  at  the  seat  of  rupture  and  infiltrating  the  adjacent 
parts.  Under  these  circumstances  the  bleeding  may  be  arrested  for  a 
period/ only,  however,  to  recur  from  time  to  time  until  fatal  hemorrhage 
ultimately  takes  place.  The  blood  loss  depends  upon  the  amount  of  throm- 
bus within  the  sac.  If  there  is  a  considerable  quantity  of  stratified  clot, 
as  is  usually  the  case  in  aneurisms  that  have  perforated  the  wall  of  the 
chest  and  ruptured  externally,  the  bleeding  may  be  moderate  and  for  a  time 
controllable.    Recurrent  hemorrhage  frequently  takes  place  in  such  cases 

for  weeks  or  months.  Protracted 
or  recurrent  small  bleedings  may 
occur  under  similar  conditions  into 
the  trachea,  bronchi,  or  oesophagus. 
Pain  is  an  early  and  important 
symptom.  It  may  be  in  the  sac 
itself, — intrinsic, — due  to  irritation 
of  the  sac  or  internal  pressure.  This 
pain  is  dull,  aching,  and  substernal. 
More  commonly  it  is  in  the  adjacent 
parts, — extrinsic, — due  to  irritation 
of  nerve-trunks  implicated  in  the 
advancing  capsule  or  subjected  to 
pressure.  This  kind  of  pain  is  con- 
tinuous, with  paroxysmal  exacerba- 
tions of  great  intensity,  and  is 
particularly  severe  at  the  time  of 
erosion  of  the  vertebrae  or  the  wall  of 
the  chest.  It  is  described  as  sharp, 
lancinating,  cutting,  boring,  and  the 
like.  It  often  radiates  along  the 
intercostal  nerves,  or  into  the  side 
of  the  neck  and  down  the  left  arm. 
When  the  bodies  of  the  vertebrae  are 
eroded,  the  pain  radiates  in  the  course 
of  the  intercostal  nerves  and  is  often 

_  .Fig.  355.— Aneurism  of  ascending  aorta.  Relief  intense.  Suggesting  herpeS  ZOSter  Or 
of  pain  upon  appearance  of  external  tumor,  which        •     ,  ,     n  i     •  ^t^^  •  r 

occurred  under  observation.— Jefferson  Hospital.  lUterCOStal    Ueuraigia.         i  he    pam    01 

aneurism,  usually  spoken  of  as  neu- 
ralgic, is  in  point  of  fact  a  symptom  of  pressure  neuritis.  When  the  aneurism 
is  situated  at  the  root  of  the  aorta,  attacks  of  angina  pectoris  of  varying 
intensity  may  occur,  with  radiation  to  the  left  side  of  the  neck  and  arm. 

Cough  is  a  common  symptom.  It  may  be  caused  by  irritation  pressure 
upon  the  vagus  or  recurrent  laryngeal  nerve,  compression  of  the  trachea 
or  a  main  bronchus,  in  which  event  it  is  often  associated  with  stridor,  or 
by  bronchitis.  The  expectoration  is  often  blood-stained  from  interference 
with  the  venous  circulation  or  from  granulations  at  a  point  of  impending 
rupture.  In  bronchitis  and  bronchiectasis  it  is  thin  and  abundant.  It  is 
sometimes  purulent  and  offensive. 

Dyspnoea  may  be  laryngeal,  tracheal,  or  pulmonary,  and  these  forms 
are  sometimes  present  in  the  same  case.     Laryngeal  dyspnoea  is  due  to 


A 


ANEURISM. 


1249 


irritation  of  the  recurrent  nerve  and  is  usually  associated  with  a  ringing 
brassy  cough,  aphonia,  and  hoarseness.  The  tracheal  form  has  its  origin 
in  direct  compression  of  the  windpipe  or  left  primary  bronchus  and  is 
accompanied  by  stridor;  wMle  pulmonary  dyspnoea  may  be  caused  by 
compression  of  one  or  both  lungs  by  an  enormous  aneurism  of  the  lower 
or  posterior  wall  of  the  transverse  arch. 

Dysphagia    may   arise   when    the  sac    develops  in    relation   with   the 
gullet.     It   may  be  due  to  oesophagismus  or  stenosis  from  compression. 
A   clinical   rule,    in    no    case    to    be   disregarded,    is   never   to    pass    an 
oesophageal   bougie  if  there  is  rea- 
son   to    suspect  thoracic   aneurism. 

The  signs  of  a  thoracic  aneurism 
are  due,  (a)  to  the  tumor  itself,  and  (b) 
to  pressure  upon  adjacent  structures. 

Physical  Signs.  —  Inspection. 
— In  a  large  proportion  of  the  early 
cases,  and  in  many  throughout  the 
whole  course  of  the  disease,  this 
method  yields  no  physical  signs.  The 
tumor  while  still  wholly  intrathoracic 
may  cause  local  bulging  of  the  chest 
wall  with  widening  of  the  intercostal 
spaces  and  visible  pulsation.  The 
signs  may  elude  observation  save  in 
a  good  light  and  with  oblique  illu- 
mination. When  perforation  of  the 
chest  has  occurred  there  is  a  more 
or  less  prominent  external  pulsating 
tumor,  at  the  summit  of  which,  in 
late  cases,  the  skin  may  be  livid  or 
necrotic  and  the  seat  of  hemorrhagic 
oozing.  Such  tumors  are  most  com- 
mon at  the  upper  part  of  the  sternum 
and  to  the  right,  and  are  sometimes 
of  large  size,  extending  also  to  the 

left.  When  the  innominate  is  involved  the  pulsating  prominence  pro- 
jects above  the  right  clavicle  and  episternal  notch.  An  aneurism  of  the 
descending  aorta  may  give  rise  to  a  tumor  to  the  left  of  the  spine. 
Pressure  upon  venous  trunks  frequentl}^  causes  congestion  of  the  face  and 
eyes,  and  enlargement  of  the  superficial  veins  of  the  trunk  and  arm.  These 
signs  are  much  more  common  upon  the  right  side.  In  consequence  of  pres- 
sure upon  the  sympathetic  occasional  differences  in  the  pupils  arise.  Irri- 
tation of  the  upper  dorsal  or  lower  cervical  ganglion  upon  the  affected 
side  is  attended  with  dilatation  of  the  pupil,  which  may  or  maj^  not  be 
accompanied  by  pallor  of  the  face  upon  the  same  side;  while  destructive 
pressure  is  followed  by  contraction  of  the  pupil  and  in  some  cases  by  flush- 
ing and  sweating  upon  the  same  side  of  the  face.  The  larynx  may  be  seen 
to  be  displaced  to  the  left,  much  more  frequently  to  the  right,  by  the  pres- 
sure of  an  aneurismal  tumor,  and  in  large  aneurisms  of  the  arch  tracheal 

79 


Fig.  356. — Aneurism  of  the  aorta  and  innominate 
artery. 


1250  MEDICAL  DIAGNOSIS. 

tugging  may  sometimes  be  seen.  The  visible  apex  beat  is  displaced  down- 
ward and  to  the  left,  indicating  more  commonly  dislocation  of  the  heart 
from  pressm-e  than  dislocation  of  the  apex  from  hypertrophy. 

Palpation. — This  method  confirms  the  signs  obtained  upon  inspec- 
tion. The  extent,  force,  and  expansile  character  of  the  pulsation  are  deter- 
mined by  this  method  of  physical  diagnosis.  Intrathoracic  aneurisms  of 
considerable  size  may  cause  general  expansion  of  the  upper  part  of  the 
thorax  in  its  anteroposterior  diameter,  which  is  best  recognized  by  biman- 
ual palpation,  one  hand  being  firmly  applied  to  the  back,  the  other  to  the 
front  of  the  chest.  There  may  be  merely  a  diffuse  pulsation.  An  aneurism 
which  has  perforated  the  wall  of  the  chest  forms  a  distinct  tumor  with 
expansile  pulsation,  the  denseness  of  which  is  determined  by  the  amount 
of  coagula.  Very  rarely  the  sac  is  thin-walled  and  fluctuating.  There 
is  usually  a  distinct  diastolic  shock,  which  may  be  intense  and  is  of  diag- 
nostic significance.  A  systolic  thrill  may  often  be  felt  but  is  to  be  distin- 
guished from  the  thrill  of  a  dilated  aorta  and  from  the  thrill  which  is  pres- 
ent in  aortic  stenosis.     Retardation  of  the  pulse  is  common.     The  radials 

maybe  unequal  in  time 
and   volume.     When 


l/vJ 


'^Afi       A 


the  sac  is  very  large 
the  pulse  in  the  arterial 
trunks  beyond  it  may 
be  scarcely  perceptible. 
Tracheal  tugging 
is    common    in    aneu- 

FiG.  357.— Upper  tracing— carotid  pulse  in  a  case  of  aneurism  of  the        ,,;s,^^s,   ^.f  fl-,p  tranSVerse 
arch  of  the  aorta.     Lower  tracing— thrill  over  aneurismal  tumor.  lisms  Oi    Llie    Udlibveibe 

arch  and  is  a  very 
important  sign  in  deep-seated  sacs  not  manifest  by  other  signs.  This 
phenomenon  is  not,  however,  pathognomonic  of  aortic  aneurisms.  It 
may  occur  in  mediastinal  tumors  and  in  enlargement  of  the  peribronchial 
lymph-nodes  when  so  situated  as  to  cause  close  adhesions  between  the 
aorta  and  the  left  primary  bronchus. 

Percussion. — Deeply  situated  aneurisms  of  small  size  yield  no  signs. 
The  percussion  signs  of  larger  aneurisms  which  approach  the  chest  wall 
depend  upon  the  fact  that  they  displace  the  lungs.  The  pulmonary  reso- 
nance is  replaced  in  aneurisms  of  the  ascending  Hmb  of  the  arch  by  circum- 
scribed flatness,  usually  to  the  right  of  the  manubrium  sterni;  in  aneurisms 
of  the  transverse  arch  by  flatness  in  the  upper  sternal  region  to  the  left  of 
the  sternal  border;  and  in  those  of  the  descending  aorta  by  flatness  along 
the  left  side  of  the  spine  and  in  the  scapular  region.  The  area  of  flatness 
corresponds  to  the  region  of  contact  between  the  tumor  and  the  inner  wall 
of  the  thorax,  and  is  surrounded  by  a  very  narrow  border  of  dulness  and 
an  outer  border  of  tympanitic  resonance,  the  width  of  which  is  determined 
by  the  extent  to  which  the  circumjacent  lung  is  compressed. 

Auscultation.— Murmurs  may  be  absent  even  in  aneurisms  of  large 
size.  The  greater  the  amount  of  stratified  coagula  the  more  nearly  the 
aneurism  resembles  a  solid  mediastinal  tumor.  An  accentuated  second 
sound  is  a  common  and  significant  sign.  A  systohc  murmur  is  often  heard; 
less  frequently  a  diastohc  murmur,  which  is  not  a  sign  of  the  aneurism  but 


ANEURISM.  1251 

of  an  associated  aortic  insufficiency.  An  extremely  rare  continuous  mur- 
mur with  rhythmical  whiffs  corresponding  to  the  systole  heard  over  the 
manubrium  is  a  sign  of  an  arteriovenous  aneurism  or  communication  with 
the  pulmonary  artery.  A  systolic  murmur  may  sometimes  be  heard  over 
the  trachea  or  at  the  open  mouth  of  the  patient. 

The  following  clinical  phenomena  associated  with  aneurisms  of  differ- 
ent parts  of  the  aorta  are  of  diagnostic  importance: 

Aneurism  of  the  Ascending  Portion  of  the  Arch. — Small  sacs  close  to 
the  root  of  the  aorta  are  latent.  Larger  aneurisms  arise  most  frequently 
from  the  convexity  and  develop  toward  the  right.  Deep-seated  pain  is 
an  early  symptom.  It  is  most  severe  behind  the  manubrium  and  radiates 
to  the  neck,  shoulders,  and  arms,  more  frequently  the  left  than  the  right. 
Flatness  in  the  sternal  end  of  the  second,  third,  and  sometimes  also  the 
first  intercostal  space  indicates  the  extension  of  the  tumor  to  the  right. 
In  this  region  the  heart  sounds  are  loud  and  the  second  aortic  sound  is 
commonly  ringing  and  accentuated. 
Expansile  pulsation  is  present.  The 
apex  of  the  heart  is  displaced  down- 
ward and  to  the  left.  Aneurisms  of 
this  part  of  the  aorta  may,  in  rare 
instances,  communicate  with  the 
superior  vena  cava  or  compress  the 
inferior  vena  cava,  causing  oedema  of 
the  lower  extremities,  and  ascites. 
An  aneurism  springing  from  the  con- 
cavity of  the  ascending  portion  may 
extend  beyond  the  left  sternal  border. 
The  right  recurrent  laryngeal  nerve 

is    exposed   to    pressure.       Sclerosis    of       Fig.  358.— Aneurism  of  ascendinfr  portion    of   the 
■■^  ■■-        .  ,  .     ,       .  arch  of  the  aorta. 

the  coronary  arteries,  sclerotic  lesions 

of  the  aortic  cusps,  and  relative  insufficiency  are  common.  When  a 
sacculated  aneurism  in  this  position  attains  considerable  size,  the  over- 
lying manubrium  and  cartilages  and  ribs  to  its  right  form  a  distinct, 
rounded,  pulsating  prominence,  which  in  the  course  of  time  may  cause 
absorption  of  the  wall  of  the  chest  and  appear  as  an  external  tumor. 
Systolic  murmurs  are  common  and  are  occasionally  audible  at  a  distance 
from  the  chest.  Compression  of  the  neighboring  veins  occurs  early.  The 
jugulars,  especially  the  right,  are  prominent.  The  little  venous  twigs  over- 
lying the  tumor  are  enlarged.  The  trachea  and  left  bronchus  are  frequently 
compressed.  Tracheal  tugging  may  occur  when  firm  adhesions  with 
the  trachea  or  bronchus  are  established.  Difficulty  in  swallowing  is  not 
common  in  aneurisms  in  this  situation. 

Aneurism  of  the  Transverse  Portion  of  the  Arch. — The  sac  may  cause 
prominence  of  the  manubrium  and  the  cartilages  and  ribs  to  its  right,  as 
in  aneurisms  of  the  ascending  aorta.  The  innominate  is  frequently  involved, 
with  the  appearance  of  an  external  pulsating  tumor  at  the  sternoclavicular 
articulation  and  extending  upward  into  the  neck.  Compression  of  the  left 
recurrent  laryngeal  nerve  is  common.  An  early  symptom  is  hoarseness 
with  a  curious  high-pitched  vibrating  quality  of  the  voice.     In  slight  palsy 


1252 


MEDICAL  DIAGNOSIS. 


Fig.  359. — Unilateral  clubbed  fingers  in  aneurism  of  the 
descending  arm  of  the  aortic  arch. — Groedel's  case. 


and  in  older  cases  the  voice  may  be  unchanged.  Pupillary  derangements 
are  sometimes  observed.  Compression  of  the  trachea  and  left  bronchus, 
and  tracheal  tugging  are  very  common.  Dysphagia  is  more  frequent 
than  in  aneurisms  in  other  portions  of  the  aorta.  The  sac  sometimes 
includes  portions  of  the  ascending  and  transverse  arch,  causing  dulness  to 
the  right  and  upward,  and  can  often  be  felt  pulsating  in  the  episternal  notch. 
Sacculated  aneurisms  in  the  concavity  of  the  arch  are  always  difficult  of 
recognition.    Even  when  of  moderate  size  they  may  cause  persistent,  even 

fatal,  haemoptysis.  They  elude 
physical  examination  and  rarely 
attain  a  size  sufficient  to  displace 
the  heart.  This  form  of  aneu- 
rism may  be  suspected  when, 
with  persistent  or  recurring 
haemoptysis  in  the  absence  of  rec- 
ognizable cause,  are  associated 
paralysis  of  the  left  recurrent 
nerve,  dislocation  of  the  trachea 
and  larynx  to  the  right,  tracheal 
tugging,  stridor,  and  dysphagia; 
but  none  of  these  is  constant. 
Aneurism  of  the  Descending  Arch. — These  tumors  may  also  be  latent. 
Pain  is  a  common  symptom.  It  may  be  intrinsic.  Very  often,  how^ever, 
it  is  due  to  erosion  of  the  dorsal  vertebrae.  Dyspnoea  and  stridor  from 
compression  of  the  left  bronchus  and  lung,  bronchitis,  bronchiectasis,  and 
bronchorrhoea  may  occur.  Left-sided  recurrent  nerve  palsy  or  paralysis, 
difficulty  in  deglutition,  left  pupillary  phenomena  are  of  diagnostic  impor- 
tance. When  the  sac  is  large,  retardation  of  the  crural  pulse  as  compared 
with  the  radials  or  the  apex  beat  is  a  less  important  sign.  At  the  left  ster- 
nal border  in  the  first  and  second 
intercostal  spaces  there  may  be  dul- 
ness, with  distinct  heart  sounds, 
murmurs,  and  pulsation.  Perfora- 
tion may  take  place  and  an  external 
tumor  present  in  this  region — an 
uncommon  event. 

Aneurisms  of  the  Descending 
Thoracic  Aorta. — The  sac  is  usually 
low  down,  resting  upon  the  dia- 
phragm and  the  left  side  of  the 
bodies  of  the  lower  dorsal  vertebrae, 

which  are  eroded.  Among  the  pressure  phenomena  are  dysphagia,  intense 
pain  radiating  to  the  left,  pleuritic  friction,  impaired  resonance,  together 
with  feeble  respiratory  sounds  and  small  mucous  rales  in  the  lower  scapular 
region  near  the  spine.  A  pulsating  external  tumor  may  present  in  the 
back.  Pain  is  usually  present,  but  the  other  phenomena  may  be  wholly 
absent  and  the  condition  overlooked. 

As  a  rule  large  aneurisms  are  sacculated  and  increase  in  size  without 
involving  other  portions  of  the   aorta  than  that  from  which  they  spring. 


Fig.  360. — Sphygmograms  in  aneurism  of  the 
descending  arm  of  aortic  arch.  I,  right  radial  pulse; 
II,  left  radial.     Same  case  as  Fig.  359. — Groedel. 


ANEURISM. 


1253 


Fig.  361. — Orthodiagraphic  outline  of  left  bor- 
der of  aneurism  of  descending  limb  of  arch  of  the 
aorta,  showing  displacement  of  the  heart  downward 
and  to  the  left.     Same  case  as  Fig.  359. — Groedel. 


Exceptionally  an  aneurism  arising  from  one  portion  enlarges  by  involving 
adjacent  parts  of  the  aorta  until  several  parts  are  successively  implicated, 
as  the  ascending  portion,  the  transverse  arch,  and  to  some  extent  the 
descending  arch.  Under  such  circumstances  the  rational  symptoms  and 
physical    signs    of    aneurism    in    the    various    localities    are    successively 

developed.  Still  more  rarely  mul- 
tiple aneurisms  are  present.  In  the 
latter  case  one  may  be  recognized 
by  suggestive  symptoms  and  char- 
acteristic signs,  while  the  others 
may  escape  detection. 

®_w^^^^^^^T^^;&^>^  o )  Diagnosis. — Direct.  —  There 

^^^^^^^^^^#^-';^?^  are  cases  in  which  a  positive  diag- 

nosis cannot  be  made.  Aneurisms 
of  the  root  of  the  aorta  and  of  the 
concavity  of  the  arch,  when  small,  are 
usually  wholly  latent.  The  anamne- 
sis is  important.  Syphilis,  occupa- 
tion, strain,  blows  and  contusions 
of  the  chest  are  highly  suggestive. 
Alcoholism  is  of  secondary  impor- 
tance. Middle  age  and  the  male  sex 
are  predisposing  influences  of  weight. 
Among  the  symptoms  those  which  arise  from  intrathoracic  pressure  are 
significant.  These  comprise  pain,  dyspnoea,  stridor,  cough,  dysphagia, 
pupillary  differences,  and  a  peculiar  hoarseness  with  a  high-pitched,  shrill, 
vibrating  quality  of  the  voice.  Among  physical  signs  which  point  strongly 
to  aneurism  are,  in  the  areas  named,  circumscribed  flatness  shading  off  to 
dulness,  prominence  with  pulsation,  a  systolic  murmur,  systolic  thrill,  dia- 
stolic shock,  displacement  of  the  apex  downward  and  to  the  left  (especially 
when  the  signs  of  cardiac  enlarge- 
ment are  absent),  enlargement  of 
superficial  veins,  inequality  of  radial 
pulses,  a  retardation  or  absence  of 
crural  pulsation  and  tracheal  tug- 
ging. None  of  these  clinical  phenom- 
ena is  diagnostic.  The  association 
of  all  of  them  is  conclusive.  When 
several  of  them  are  present  the  diag- 
nosis becomes  probable.  An  external 
tumor  with  distinctly  expansile  pul- 
sation and  diastolic  shock  justifies  a 
positive  diagnosis.  Two  facts  are  to  be  borne  in  mind.  First,  an  enlarged 
lymph-node  lying  directly  over  a  large  vessel  may  pulsate  synchronously 
with  the  action  of  the  heart,  but  the  pulsation  is  not  expansile;  and  second, 
tracheal  tugging  may  be  present  when,  in  mediastinal  tumor  or  enlarged 
peribronchial  lymph-nodes,  there  are  close  adhesions  between  the  aorta  and 
the  left  bronchus.  Tracheal  tugging  is,  therefore,  not  a  pathognomonic  sign 
of  aneurism.    The  X-ra^  are  of  great  value  as  showing,  upon  fluoroscopic 


Fig.   362.- 


.\neurism   of    the   descending   thoracic 
aorta. 


1254  MEDICAL  DIAGNOSIS. 

examination,  a  shadow  in  an  abnormal  situation,  the  borders  of  which  expand 
and  contract  with  the  diastole  and  systole  of  the  heart.  Such  a  shadow  is 
to  be  differentiated  from  the  non-expansile  movement  which  attends  the 
advance  and  retreat  of  a  tumor  moved  by  the  pulsation  of  the  aorta  or  heart. 
The  shadow  of  an  aneurism  attached  to  the  trachea  or  left  bronchus  may 
rise  with  the  act  of  deglutition,  while  tumors,  in  consequence  of  their  firm 
attachments  to  the  surrounding  structures,  are  not  affected  by  swallowing. 
The  situation  of  an  aneurism  may  be  determined  by  the  foregoing 
symptoms  and  signs.  But  there  are  exceptions  to  this  rule.  Thus  a  sac 
springing  from  the  ascending  portion  of  the  arch  may  present  at  the  left 
border  of  the  arch,  while  one  connected  with  the  descending  portion  may 
extend  to  the  right  of  the  manubrium  and  cause  pulsation  in  the  right 
interscapular  space;  and  the  possibility  that  an  elongated  aneurism  of  the 
ascending  portion  may  cause  dulness  and  pulsation  to  the  right  of  the 
lower  part  of  the  sternum  must  be  considered. 

Differential. — Sclerosis  of  the  aorta  can  scarcely  be  differentiated 
from  fusiform  aneurismal  dilatation  of  the  aorta.  The  fluoroscopic  shadow 
is  circumscribed  in  saccular  aneurisms;  diffuse  and  uniform  in  arterioscle- 
rosis and  the  dilatation  which  occurs  in  functional  derangements,  as  some 
cases  of  neurasthenia  and  exophthalmic  goitre.  Pain,  which  is  an  early 
and  continuing  symptom  in  aneurism,  is  not  a  prominent  symptom  in 
sclerosis.  Dynamic  Pulsation. — Increased  dulness  at  the  level  of  the  upper 
part  of  the  manubrium  and  pulsation  in  the  episternal  notch  are  sometimes 
present  in  cases  in  which,  at  the  autopsy,  no  dilatation  of  the  aorta  is 
found.  This  form  of  widening  of  the  aorta,  if  persistent,  cannot,  during 
life,  be  differentiated  from  fusiform  aneurism.  Dislocation  of  the  Aorta 
in  Spinal  Curvature. — The  convex  border  of  the  ascending  limb  of  the  arch 
may  be  displaced  in  such  a  manner  as  to  cause  dulness  and  forcible  pulsa- 
tion beyond  the  right  border  of  the  sternum  and  simulate  an  aneurism. 
Pressure  symptoms  and  pain  are  usually  absent,  the  pulsation  is  not  expan- 
sile, and  there  is  no  diastoHc  shock.  Solid  Intrathoracic  Tumors. — These 
are  very  often  malignant.  They  take  origin  in  the  mediastinal  lymph- 
nodes,  the  pleura  or  lungs,  the  thyroid  body,  or  the  oesophagus.  A  per- 
sistent thymus  may  be  greatly  enlarged.  Such  new  growths  commonly 
show  a  tendency  to  develop  both  to  the  right  and  left  of  the  sternal  borders, 
and  not,  as  is  usually  the  case  in  aneurism,  upon  one  side.  The  heart 
sounds  are  not  so  loud  as  in  aneurism,  and  diastolic  shock  is  not  felt.  Mur- 
murs may  occur  but  are  far  less  common.  Differences  in  the  radial  and 
retardation  in  the  crural  pulse  are  Hkewise  absent.  Glandular  metastases 
may  be  present  in  the  neck — a  sign  of  great  significance.  Pulsation  is 
common  but  not  expansile.  Symptoms  of  pressure  upon  the  recurrent 
laryngeal  nerves  are  common,  but  other  pressure  symptoms  are  less  prom- 
inent than  in  aneurism.  The  outline  of  an  aneurismal  sac  is  rounded  and 
usually  regular;  that  of  a  tumor  uneven  and  irregular.  The  course  of 
malignant  disease  is  rapid,  emaciation  pronounced,  and  cachexia  early 
developed;  that  of  aneurism  relatively  slow,  and  the  fatal  issue  may  occur 
while  the  general  nutrition  is  yet  fair.  There  may  be  the  history  of  a 
primary  growth  which  has  been  removed,  or  the  indications  of  its  presence 
in  a  distant  organ  or  part.     Thoracic  tumors  and  aneurisms  containing 


ANEURISM. 


1255 


much  stratified  clot  cannot  always,  when  deep  seated,  be  differentiated. 
New  Growths  Involving  the  Wall  of  the  Chest. — Osteosarcoma  may  involve 
the  sternum  or  ribs.  The  overlying  veins  are  greatly  enlarged  and  tortuous. 
The  osseous  structures  are  palpably  enlarged  and  involved.  There  is  local 
prominence,  but  the  symptom-complex  of  aneurism  is  not  present.  Caries, 
osteomyeHtis,  or  actinomycosis  may  cause  a  rounded,  fluctuating  tumor 
near  the  sternum  or  ribs.  In  aneurism  the  bony  structures  of  the  chest 
wall  may  be  recognized  as  overlying  the  tumor,  and,  when  perforation  has 
taken  place,  as  entering  into  the  formation  of  the  opening  through  which 
the  tumor  protrudes,  while  in  abscess  they  may  be  recognized  as  under- 
lying the  fluctuating  tumor  and  separating  it  from  the  cavity  of  the  thorax. 
In  the  very  rare  cases  of  mediastinal  abscess  the  onset  is  abrupt,  substernal 


Fig.  363. — Bulging  of  the  anterior  wall 
of  the  chest  in  a  case  of.  mediastinal  tumor. 
— Jefferson  Hospital. 


Fig.  364.- 


-Abscess   of  the   chest   wall. — Jefferson 
Hospital. 


pain  is  intense  and  persistent,  and  there  are  grave  constitutional  symptoms. 
Pulsating  Empyema.  —  Intrathoracic  pulsating  empyemata  give  rise  to 
more  or  less  diffuse  pulsation  upon  the  left  side  in  the  anterolateral  aspect 
of  the  chest.  The  signs  of  pleural  effusion  are  present,  the  heart  is  usually 
displaced  to  the  right,  and  Traube's  semilunar  space  modified.  Empyema 
necessitatis,  when  the  tumor  is  in  relation  with  the  heart  and  pulsates, 
may  simulate  aneurism.  The  signs  of  left-sided  pleural  effusion,  the  fact 
that  the  tumor  diminishes  upon  inspiration  and  increases  upon  expiration, 
the  absence  of  heaving,  forcible  impulse,  and  diastolic  shock,  of  the 
pressure  symptoms  incident  to  aneurism,  and  of  tracheal  tugging  are 
conclusive.  Aortic  Stenosis. — A  systolic  murmur  and  thrill  may  suggest 
aneurism,  but  a  consideration  of  the  history  of  the  case,  the  nature  of  the 
subjective  symptoms,  and  the  objective  signs  of  the  two  conditions  render 
the  differential  diagnosis  an  easy  matter. 


1256  MEDICAL  DIAGNOSIS. 

The  Course. — The  progress  is  irregular.  Symptoms  usually  precede 
signs.  There  are  periods  of  arrest.  The  contour  of  the  sac  and  the  pres- 
sure phenomena  undergo  from  time  to  time  changes  due  to  changes  in  the 
accumulation  of  clot,  its  organization  or  failure  to  organize  at  different 
places,  and  uneven  yielding  of  the  wall  under  arterial  pressure  in  various 
regions.  In  sacs  that  have  perforated  the  chest  wall  such  local  expansions 
and  retractions  not  rarely  take  place  under  the  eye.  They  may  be  invoked 
in  explanation  of  changes  in  the  degree  of  dysphagia,  the  dyspnoea  and 
stridor,  the  pupillary  differences,  and  the  locality  and  intensity  of  the  pain. 
A  knowledge  of  these  facts  justifies  caution  in  ascribing  diminution  or  even 
disappearance  of  certain  pressure  symptoms  to  an  actual  improvement 
in  the  underlying  condition.  Sacs  that  rapidly  increase  in  size  give  rise 
to  more  urgent  pressure  symptoms  and  are  more  liable  to  early  perfora- 
tion than  those  whose  growth  is  slow.  The  urgency  of  pressure  symptoms 
depends  in  part  upon  the  size  of  the  sac  and  in  part  upon  its  location. 
Aneurisms  of  the  ascending  aorta  cause  compression  of  the  trachea,  a 
primary  bronchus,  or  the  oesophagus,  only  when  they  have  attained  con- 
siderable size;  while  a  small  sac  in  the  concavity  of  the  arch  may  compress 
the  left  bronchus,  or  a  medium-sized  sac  springing  from  the  inner  aspect 
of  the  descending  portion  may  cause  difficulty  in  deglutition.  Perforation 
"occurs  earlier  in  dissecting  than  in  other  forms  of  aneurism.  In  sacs  con- 
taining much  clot  the  perforation  may  be  small  and  the  bleeding  moderate. 
The  blood  loss  is  oftenj  however,  rapid  and  fatal.  It  may  be  spontaneously 
arrested  by  a  layer  of  clot  which  may  permanently  close  the  rent.  As 
a  rule,  when  hemorrhage  is  arrested  it  recurs  from  time  to  time  and  finally 
proves  fatal.  Rupture  takes  place  most  frequently  into  the  pleural  sac  or 
a  bronchus;  less  commonly  externally,  into  the  pericardium,  the  retro- 
peritoneal connective  tissue,  or  the  peritoneal  cavity;  not  often  into  the 
oesophagus,  stomach,  or  intestine;  and  extremely  rarely  into  the  descending 
vena  cava,  the  pulmonary  artery,  or  an  auricle.  When  the  hemorrhage  is 
free,  death  occurs  at  once  with  symptoms  of  internal  bleeding.  Perfora- 
tion into  the  pericardium  is  usually  fatal  at  once;  into  the  retroperitoneal 
tissues  it  is  usually  delayed  for  a  longer  period.  In  the  latter  situation 
perforation  is  attended  with  intense  pain  and  may  at  first  simulate  per- 
foration peritonitis  or  embolism  of  the  mesenteric  artery.  When  the  rent 
is  small  or  the  bleeding  restrained  by  the  adjacent  structures,  there  are 
signs  of  internal  hemorrhage,  but  life  is  prolonged  for  a  period.  I  saw  a 
patient  who  lived  eight  hours.  Bleeding  into  a  pleural  sac  causes  the 
signs  of  an  effusion;  into  a  bronchus,  haemoptysis  which  may  suggest 
phthisis  or  be  moderate  and  prolonged,  giving  rise  to  a  suspicion  of  pul- 
monary cancer;  into  the  stomach,  hsematemesis;  into  the  gut,  bloody 
stools.  Fragments  of  a  thrombus  may  be  detached,  causing  embolism, 
most  commonly  of  a  cerebral  artery. 

Prognosis.— Spontaneous  cure  cannot  occur  in  fusiform  aneurisms. 
Small  sacs  with  narrow  openings  in  rare  instances  become  filled  with  clot 
which  undergoes  organization.  In  dissecting  aneurisms  a  distant  com- 
munication with  the  lumen  of  the  aorta  may  be  established,  thus  forming 
along  the  old  course  a  new  channel  for  the  blood  stream.  These  are  rare 
events.     In  a  majority  of  instances,  aneurism  of  the  aorta  terminates  in 


ANEURISM. 


1257 


death  in  the  course  of  six  months  to  three  years.  The  average  duration 
is  about  one  year.  Exceptionally  life  may  be  prolonged  for  several  years. 
A  time  prognosis  in  individual  cases  is  hazardous.  Slowly  developing 
and  arrested  aneurisms  are  of  relatively  favorable  prognosis  as  compared 
with  those  of  rapid  growth,  but  unforeseen  accidents  may  at  any  moment 
occur.  Favorable  conditions  of 
life  and  treatment  render,  in 
exceptional  instances,  the  prog- 
nosis less  unfavorable. 

(b)  ANEURISM  OF  THE  AB- 
DOMINAL AORTA. 

Aneurism  of  the  aorta  is  far 
less  common  below  the  diaphragm 
than  above  it.  It  may  be  fusi- 
form or  sacculated.  In  rare 
instances  there  are  two  or  more 
— multiple  aneurism.  Still  more 
rare  in  this  region  is  dissecting 
aneurism.  The  most  common 
situation  is  directly  below  the 
diaphragm  and  upon  the  anterior 
wall  of  the  aorta,  where  the  sac 
forms  a  distinct  rounded  tumor 
in  the  epigastric  region  in  the 
median  line  and  extending  to  the 
left.  As  the  sac  enlarges  it  pro- 
jects into  the  left  hypochondrium 
and  may  occupy  a  large  part  of 
the  left  side  of  the  abdomen. 
When  it  projects  posteriorly  it 
causes  erosion  of  the  vertebral 
bodies,  or  may  give  rise  to  distinct 
spinal  symptoms,  and,  increasing 
in  dimension,  may  extend  into 
the  chest  and  rupture  into  the 
pleura  or  form  an  external  tumor 
in  the  lumbar  region.  Perfora- 
tion into  the  retroperitoneal  space 

may  give  rise  to  a  progressively  enlarging  haematoma  extending  into  the 
left  lumbar  region  and  simulating  a  sarcoma. 

Symptoms. — Pain  is  an  early  symptom.  It  is  referred  to  the  back 
and  is  often  persistent,  radiating  to  the  left  flank  and  marked  by  intense 
exacerbations,  suggestive  of  intercostal  neuralgia,  or  renal  colic.  In  many 
of  the  cases  there  are  pain-free  intervals,  or  a  dull,  deep-seated  pain  in 
the  back  increased  by  movement  or  jarring  of  the  body.  The  pain 
not  rarely  extends  into  the  abdomen  with  exacerbations  which  simulate 
colic — belly-ache. 


Fig.  365 


iniiial  aorta. — Inter 


1258  MEDICAL  DIAGNOSIS. 

Physical  Signs. — Upon  inspection  epigastric  pulsation  may  be  pres- 
ent, frequently  a  diffuse  prominence,  and  occasionally  a  distinct  circum- 
scribed tumor.  Palpation  reveals  a  tumor  mass,  rounded,  smooth,  and  the 
seat  of  forcible,  expansile  pulsation.  A  systohc  thrill  is  common.  Percus- 
sion.— A  large  sac  approaches  the  anterior  wall  of  the  abdomen  and  causes 
dulness,  which  may  be  continuous  with  that  of  the  left  lobe  of  the  liver. 
Auscultation  reveals  a  systolic  murmur  usually  best  heard  over  the  tumor 
and  transmitted  into  the  crural  arteries,  sometimes  more  distinct  over  the 
lower  dorsal  and  upper  lumbar  vertebrae.  In  some  cases  there  is  also  a 
diastolic  murmur.  These  murmurs  do  not  accompany  the  heart  sounds, 
but  follow  them.  Large  aneurisms  of  the  abdominal  aorta  displace  the 
stomach  and  to  some  extent  also  the  liver  downward.  Distinct  retarda- 
tion of  the  pulse  in  the  crural  arteries  occurs  when  the  sac  is  large. 

Diagnosis. — Direct. — A  distinct  circumscribed  epigastric  tumor  in  the 
median  line  and  extending  to  the  left,  which  can  be  grasped  and  which  is  the 
seat  of  expansile  pulsation,  justifies  a  positive  diagnosis  of  abdominal  aneu- 
rism. In  the  absence  of  this  symptom-complex  the  diagnosis  cannot  be 
made.  It  is  of  use  to  note  that  in  aneurism  the  pulsation  is  epigastric,  while 
dynamic  pulsation  is  most  marked  immediately  above  or  at  the  umbilicus. 

Differential. — Dynamic  Pulsation. — The  throbbing  aorta  is  very 
common  in  nervous  women.  This  pulsation  is  often  very  forcible  and  to 
a  slight  extent  distinctly  expansile,  but  it  is  not  associated  with  a  tumor, 
and  the  course  of  the  aorta  may  often  be  felt  upon  palpation.  A  systolic 
murmur  may  be  easily  produced  by  the  pressure  of  the  stethoscope.  Asso- 
ciated nervous  symptoms,  and  the  disappearance  of  pulsation  under  the 
influence  of  suggestion  or  other  powerful  psychic  influences  are  of  diagnos- 
tic importance.  Tumors  of  the  Pylorus,  Pancreas,  or  the  Left  Lobe  of  the 
Liver. — New  growths  overlying  the  aorta  in  the  epigastrium  rise  and  sink 
with  the  movements  of  the  arterial  wall  and  are  frequently  mistaken  for 
aneurism.  The  fact  that  the  tumor  is  not  expansile  is  of  diagnostic  impor- 
tance. The  absence  of  murmurs  points  to  tumor  rather  than  aneurism. 
The  pressure  of  a  tumor  in  contact  with  the  aorta  may  cause  stenosis  and 
a  systolic  murmur.  The  crural  pulse  is  not  affected.  The  disappearance 
of  pulsation  in  the  knee-elbow  posture,  when  the  tumor  falls  away  from 
the  aorta,  is  an  important  sign.  The  X-rays  are  of  less  value  as  aids  to 
diagnosis  in  abdominal  than  in  thoracic  aneurisms. 

Prognosis. — Aneurisms  of  the  abdominal  aorta  almost  always  end 
in  death.  In  rare  instances  small  sacs  with  a  narrow  communication  with 
the  lumen  of  the  aorta  have  undergone  obliteration  by  the  deposit  and 
organization  of  clots.  Death  commonly  follows  rupture,  which  may  take 
place  into  the  retroperitoneal  tissues,  pleura,  peritoneum,  or  intestine. 
Far  less  frequently  death  is  due  to  embolism  of  the  superior  mesenteric 
artery,  complete  occlusion  of  the  aorta  by  clot,  or  paraplegia  following 
erosion  of  the  spine  and  compression  of  the  cord. 

ii.  Aneurism  of  the  Coeliac  Axis  and  its  Branches. 

This  branch  is  frequently  involved  in  aneurism  of  the  abdominal  aorta. 
A  negro,  twenty-six  years  old,  who  was  syphilitic,  suffered  from  intense 


ANEURISM.  1259 

paroxysmal  pain  radiating  to  the  back  and  both  sides  of  the  abdomen. 
No  tumor  could  be  discovered.  Death  occurred  suddenly  with  symptoms 
of  internal  hemorrhage.  At  the  autopsy  there  was  found  an  aneurism 
of  the  axis  the  size  of  a  small  orange,  which  had  ruptured  into  the  peri- 
toneum. The  splenic  artery  is  occasionally  the  seat  of  small,  sometimes 
of  large,  aneurismal  sacs.  Epigastric  pain,  vomiting,  haematemesis,  and 
hemorrhage  from  the  bowel  may  occur.  A  deep-seated  tumor  extending 
to  the  left  with  or  without  pulsation,  and  dulness  reaching  to  the  spleen, 
are  significant.  Rupture  into  the  colon  may  occur.  Aneurism  of  the 
superior  mesenteric  artery  may  cause  a  movable  pulsating  tumor,  which 
is  often  the  seat  of  a  systolic  murmur  but  is  not  associated  with  retardation 
of  the  crural  pulse.  Symptoms  of  mesenteric  infarction  may  occur.  Aneu- 
rism of  the  hepatic  artery  is  extremely  rare.  The  symptoms  are  obscure 
and  a  positive  diagnosis  is  impossible.  Rupture  into  the  bile  passages 
may  occur.  The  differential  diagnosis  between  aneurisms  of  these  arteries 
and  aneurisms  of  the  aorta  is  commonly  attended  with  insurmountable 
difficulties. 

iii.  Arteriovenous  Aneurism. 

That  form  which  results  from  the  rupture  of  an  aneurism  of  the  ascend- 
ing portion  of  the  arch  of  the  aorta  into  the  descending  vena  cava  is  of 
special  clinical  interest.  It  is,  however,  extremely  rare.  The  symptoms 
usually  occur  abruptly  and  consist  of  marked  dilatation  of  the  veins  of 
the  upper  part  of  the  body,  with  cyanosis  and  cEdema.  A  continuous 
murmur  with  systolic  intensification  and  a  systolic  thrill  may  be  recognized. 

iv.  Periarteritis  Nodosa ;  Congenital  Aneurism. 

The  medium-sized  arteries,  especially  those  of  the  muscles,  and  the 
heart,  spleen,  liver,  kidneys,  intestines,  and  the  skin  are  the  seat  of  whitish 
nodular  masses,  varying  in  size  from  a  small  shot  to  a  large  pea,  and  great 
numbers  of  small  aneurismal  dilatations.  The  disease  has  occurred  in 
both  sexes.  It  manifests  itself  most  commonly  in  early  and  middle  adult 
life.  It  has  been  ascribed  to  syphilis  and  to  septic  conditions.  It  is  ex- 
tremely rare.  The  prominent  symptoms  are  weakness,  anaemia,  and 
rapidity  of  the  pulse.  There  is  at  first  fever,  which  presently  falls  without 
a  corresponding  decline  in  the  pulse-frequency.  When  the  muscular 
branches  are  involved,  pain,  weakness,  and  atrophy  occur.  When  the 
arteries  of  the  gastro-intestinal  canal  are  the  seat  of  the  lesions,  epigastric 
pain,  thirst,  anorexia,  nausea  and  vomiting,  and  diarrhoea  or  constipation 
are  prominent  symptoms.  Hemorrhage  from  the  bowels  has  been  observed. 
Scanty  urine,  of  low  specific  gravity,  albumin,  and  casts  occur.  Urea  is  di- 
minished. Anaemia  is  marked.  Leucocytosis  is  common.  The  course  of  the 
disease  is  progressive,  and  death  occurs  at  the  end  of  the  second  or  third 
month.  Recovery  is  exceptional.  The  diagnosis  is  usually  post  mortem. 
The  nature  of  the  affection  may  be  suspected  when,  in  connection  with 
the  foregoing  symptom-complex,  nodular  thickenings  may  be  felt  in  the 
course  of  accessible  arteries. 


1260  MEDICAL  DIAGNOSIS. 


XIV. 

'  THE  DIAGNOSIS  OF  DISEASES  OF  THE  NERVOUS  SYSTEM. 

DISEASES  OF  THE  BRAIN. 

I.  MENINGITIS. 

Inflammation  of  the  membranes  of  the  brain  is  common  to  a  variety 
of  affections.  Thus,  there  are  purulent  meningitis,  tuberculous  meningitis, 
syphilitic  meningitis,  and  meningitis  due  to  injury,  or  associated  with 
disease  of  bone,  or  with  general  paresis.  For  descriptive  purposes  we 
distinguish  between  inflammation  of  the  dura — pachymeningitis — and 
inflammation  of  the  pia, — le2:>tomeningitis,— although  the  two  membranes 
are  often  involved  together. 

Inflammation  of  the  dura  mater  may  occur  from  septic  infection,  and 
may  be  purulent.  The  commonest  causes  are  injury,  infection,  and  necro- 
sis of  bone.  Thus  disease  of  the  middle  ear  is  the  most  frequent  cause, 
but  cases  may  arise  from  infection  through  the  nose  by  way  of  the  cribri- 
form plate.  Fracture  of  the  skull  may  sometimes  be  the  starting-point. 
Large  quantities  of  pus  may  be  present,  and  the  pia  mater  and  brain 
substance  may  be  involved  as  well  as  the  dura.  There  is  a  variety  in 
which  the  pus  is  localized  or  pocketed  between  the  skull  and  the  dura, 
usually  secondary  to  injury  of  the  skull  or  to  caries  or  bone  syphilis — the 
so-called  pachymeningitis  externa. 

A  distinct  form  of  pachymeningitis  is  the  disease  known  as  hsematoma 
of  the  dura  mater — the  pachymeningitis  hcemorrhagica  of  Virchow.  It 
occurs  especially  in  the  chronic  insane  and  in  old  alcoholic  patients.  There 
is  observed  beneath  the  dura  a  layer,  quite  thick,  which  looks  like  organized 
blood-clot;  this  often  exists,  in  fact,  in  several  layers,  as  though  caused 
by  successive  hemorrhages.  Sometimes  the  appearance  is  that  of  a  very 
delicate  vascular  membrane,  enclosing  in  its  meshes  blood  which  is  more 
or  less  organized.  Cysts  may  be  found  and  other  evidences  of  breaking 
down  of  the  new  tissue. 

The  symptoms  of  pachymeningitis  are  obscure,  being  masked  by  the 
general  condition  of  the  patient,  who  is  usually  a  chronic  lunatic  or  a 
confirmed  inebriate.  A  similar  lesion  has  been  described  after  sunstroke^ 
and  may  account  for  the  headache  and  mental  changes. 

Simple,  idiopathic,  or  isolated  inflammation  of  the  pia  mate?  is  such 
a  debatable  condition  as  scarcely  to  be  considered' a  chnical  entity.  The 
forms  of  leptomeningitis  which  we  usually  distinguish  at  the  bedside  are 
those  that  occur  in  septic  infection,  such  as  in  otitis  media,  and  in  cerebro- 
spinal fever,  syphilis,  and  tuberculosis.  A  very  characteristic  form  is  that 
seen  in  general  paresis,  in  which  the  pia  mater  is  thickened  and  opaque  and 
so  adherent  to  the  summits  of  the  convolutions  that  it  is  stripped  with  diffi- 
culty, and  usually  carries  away  with  it  a  portion  of  the  brain  substance. 
Quincke   has   described   a  serous   meningitis  in   which   the  pia-arachnoid 


ACUTE  HEMORRHAGIC  ENCEPHALITIS.  1261 

especially  is  involved;  it  is  characterized  by  mild  symptoms,  slight  fever, 
and  headache,  with  some  stiffness  of  the  back  of  the  neck;  and  optic 
neuritis  is  not  uncommon  with  it. 

Symptoms. — The  general  symptoms  of  leptomeningitis  are  headache, 
fever,  delirium,  convulsions,  rigidity  of  the  neck  and  face  muscles,  exag- 
gerated reflexes,  followed  later  by  paralysis  and  coma. 

Tuberculous    Meningitis  (see  page  790). 

Epidemic  Cerebrospinal    Meningitis  (see  page  730). 

Septic  meningitis  may  be  caused  by  otitis  media,  in  which  case  the 
microbe  is  usually  a  streptococcus  or  staphylococcus;  or  it  may  be  caused 
by  the  pneumococcus.  This  meningitis  is  associated  with  pus  forma- 
tion, also  with  pachymeningitis  and  purulent  cerebritis,  and  in  not  a 
few  cases  leads  to  brain  abscess. 

Diagnosis. — Meningitis,  whether  in  the  dura  or  the  pia  mater,  depends 
upon  so  many  causes  and  is  associated  with  so  many  pathological  proc- 
esses that  it  is  difficult  to  lay  down  uniform  rules  for  the  diagnosis.  The 
first  essential  is  to  seek  for  the  cause,  such  as  a  middle-ear  disease, 
tuberculosis,  meningococcic  or  other  infection,  injury  to  the  bones  of  the 
skull,  caries,  sunstroke,  syphilis,  etc. 

Symptoms  of  irritation  appear  early.  These  are  headache  simulat- 
ing neuralgia,  vomiting,  optic  neuritis,  fever,  stiffness  of  muscles,  and 
perhaps  convulsions,  with  irritability  of  temper,  change  of  disposition, 
and  even  somnolence,  delirium,  or  stupor.  Later  the  symptoms  are 
indicative  of  pressure  and  profound  toxsemia:  thus  we  see  various 
paralyses,  increasing  stupor  merging  into  coma,  rapid  pulse,  and 
failing  powers. 

Meningitis  of  various  kinds  may  be  mistaken  for  mere  neuralgia,  but 
the  history  and  associated  symptoms  of  organic  disease  should  prevent 
error.  Where  headache,  vomiting,  and  constipation  are  early  symptoms, 
as  in  tuberculous  meningitis,  the  case  may  suggest  gastric  or  intestinal 
disorder,  but  the  onset  of  more  pronounced  brain  symptoms,  such  as 
convulsions,  stupor,  and  various  paralyses,  is  unmistakable.  The  best 
single  general  rule  for  the  distinguishing  of  meningitis  is  to  be  on  the  look- 
out in  suspected  cases  for  the  evidences  of  organic  disease  of  the  brain, 
and  to  trace  these  to  their  cause.  Lumbar  puncture  may  shed  important 
light  in  cases  of  infection. 

II.  ACUTE  HEMORRHAGIC  ENCEPHALITIS. 

The  disease  is  characterized  by  multiple  foci  of  congestion  and 
both  punctate  and  massive  hemorrhage,  with  infiltration  of  leucocytes, 
minute  emboli,  and  localized  necrosis  of  the  brain-tissue.  The  mem- 
branes are  usually  not  involved.  The  reported  cases  have  mostly 
followed  the  infectious  diseases,  such  as  influenza,  mumps,  erysipelas, 
pneumonia,  typhoid  and  typhus  fever,  and  malaria.  Nephritis  has  been 
observed  in  some  cases.  The  disease  is  probably  caused  by  the  local  action 
of  micro-organisms  or  by  their  toxins.  Oppenheim  called  attention  to  the 
resemblance  of  the  disease  process  to  the  polioencephalitis  superior  of 
Wernicke  and  to  the  polioencephalitis  anterior  of  Striimpell. 


1262  MEDICAL  DIAGNOSIS. 

Symptoms. — The  symptoms  are  suggestive  of  meningitis,  which, 
however,  is  not  present.  There  are  headache,  vomiting,  convulsions, 
localized  palsies,  and  affections  of  consciousness.  Rigidity  of  the  neck 
sometimes  occurs.  Fever  is  not  constant,  and  there  may  even  be  sub- 
normal temperature.  The  pulse  at  first  may  be  slow,  but  in  fatal  cases 
the  pulse  becomes  rapid,  the  respirations  shallow,  coma  sets  in,  and 
death  occurs  in  a  few  days  or  weeks.  Recovery  has  been  claimed  in 
a  few   cases. 

Diagnosis. — The  disease  is  likely  to  be  confounded  with  meningitis, 
and  the  distinction  between  the  two  is  not  of  practical  importance,  as  the 
course  and  treatment  are  nearly  the  same.  In  most  cases  an  accurate 
diagnosis  has  only  been  made  after  death.  This  form  of  encephalitis  may 
be  suspected  when  grave  cerebral  symptoms  occur  in  the  course  of,  or 
immediately  following,  any  of  the  infectious  diseases  mentioned. 

III.  PURULENT  MENINGO-ENCEPHALITIS  AND 
BRAIN   ABSCESS. 

Pus-forming  inflammation  within  the  cranium  assumes  several  forms. 
There  may  be  a  diffuse  purulent  meningitis,  or,  as  is  more  common,  a 
meningo-encephalitis;  and  there  may  be  abscess.  The  clinical  distinction 
between  these  forms  is  not  easy. 

Etiology.  —  The  causes  are  the  various  pyogenic  micro-organisms. 
One  of  the  commonest  is  seen  in  purulent  otitis  media;  and  more  rarely 
other  cranial  bones,  especially  the  bones  of  the  nose  and  the  orbit,  and  their 
sinuses,  may  be  the  starting-point.  Accessory  sinuses  of  the  nose  are  fre- 
quently infected,  and  this  infection  may  travel  by  way  of  the  frontal  sinus, 
sphenoidal  sinus,  ethmoid  cells,  or  the  antrum  of  Highmore.  The  strepto- 
coccus is  the  chief  germ  in  otitic  brain  abscess.  Septic  infection,  arising 
from  any  focus  in  the  body,  may  cause  a  metastatic  brain  abscess,  but 
this  complication  is  rather  more  common  in  ulcerative  endocarditis, 
abscess  of  the  liver,  abscess  and  gangrene  of  the  lung,  and  empyema. 
Trauma  of  the  skull  may  also  cause  abscess  of  the  brain.  Suppurative 
meningitis  occurs  in  tuberculosis  and  in  cerebrospinal  fever. 

Pathology. — The  membranes,  especially  the  pia-arachnoid,  are  inflamed 
and  opaque  in  purulent  meningitis,  and  pus  is  diffused  beneath  them. 
This  pus  often  follows  along  the  perivascular  spaces  and  the  fissures  of  the 
brain,  appearing  as  white  streaks.  In  some  cases  it  is  more  copious,  and 
forms  collections  beneath  the  membranes,  especially  at  the  base.  The 
cerebral  tissue  is  often  involved,  the  gray  and  white  matter  being  infil- 
trated, oedematous,  and  softened  in  places.  There  may  also  be  sinus  throm- 
bosis, with  engorgement  of  veins  on  the  outside  surface  of  the  skull.  When 
abscess  forms  it  is  either  diffuse  or  circumscribed.  In  the  former  case  the 
collection  of  pus  is  merely  an  accident  of  a  more  or  less  diffused  purulent 
meningitis.  The  circumscribed  abscess  is  contained  within  a  limited  area, 
and  its  walls  may  even  be  thickened,  forming  a  barrier  between  the  pus 
and  the  brain  tissue.  These  circumscribed  abscesses  are  most  common 
in  the  temporal  lobe  of  the  cerebrum  and  in  the  cerebellum.  In  some 
cases  multiple  abscesses  are  formed,  especially  in  metastasis. 


MENINGO-ENGEPHALITIS  AND  BRAIN  ABSCESS.        1263 

Symptoms. — These  are  general  and  focal.  Among  the  general  symp- 
toms we  include  those  which  indicate  a  grave  cerebral  disorder;  and  among 
the  focal  symptoms  those  which  indicate  its  location  in  the  brain.  The 
general  symptoms  are  fever,  headache,  vomiting,  convulsions,  paralysis, 
optic  neuritis,  and  affections  of  consciousness.  Fever  is  not  constant  nor 
always  of  one  type;  it  may  be  slight  and  easily  overlooked;  again  it  may 
be  more  pronounced,  and  accompanied  with  chills  and  sweating.  It 
may  depend  as  much  on  the  primary  condition  (otitis  media,  abscess  of 
the  lung,  etc.)  as  on  the  brain  lesion.  Per  contra,  in  some  cases  of  brain 
abscess  the  temperature  is  subnormal  and  the  pulse  very  slow.  Headache 
is  usually  present  in  suppurative  meningitis,  but  it  is  not  an  altogether 
constant  symptom  in  brain  abscess.  It  was  present  in  78  out  of  169  cases 
in  AUport's  table.  In  some  cases,  however,  it  is  an  early  indication  of  an 
insidious  onset.  Its  localizing  value  is  not  always  great;  in  cerebellar 
abscess,  for  instance,  the  pain  has  been  observed  in  other  parts  of  the 
cranium,  even  in  the  frontal  region.  Occasionally,  however,  the  pain  is 
strictly  localized  at  the  region  of  the  abscess,  and  pressure  and  percussion 
on  the  skull  at  that  point  may  be  painful.  Vomiting  is  frequent  in  cerebel- 
lar abscess,  but  more  rare  in  diffuse  purulent  meningitis;  and  it  is  usu- 
ally of  the  cerebral  type — propulsive  and  not  dependent  on  food  in  the 
stomach.  Convulsions  may  or  may  not  be  present;  there  is  no  posi- 
tive rule  about  them.  They  sometimes  have  localizing  value.  The  same 
can  be  said  of  paralysis.  Optic  neuritis  is  a  most  important  symptom  of 
abscess  of  the  brain,  although  not  present  in  all  cases.  In  children,  if  the 
pus  formation  be  rapid,  optic  neuritis  will  soon  ensue.  It  has  no  localiz- 
ing value,  but  its  presence  in  cases  of  latent  or  suspected  abscess  is  most 
significant.  Affections  of  consciousness  are  common  in  all  forms  of 
suppurative  disease  of  the  brain,  and  they  range  from  mere  apathy  and 
stupor  to  wild  delirium  and  profound  coma.  In  cases  of  latent  abscess 
changes  in  the  temper  and  personality,  such  as  irritability  and  depression, 
are  observed. 

By  the  focal  symptoms  we  attempt  to  determine  the  site  of  the 
abscess.     These  symptoms  are    mostly  pain,   paralysis,  and    convulsions. 

Pain,  as  already  said,  is  not  altogether  reliable  as  a  guide.  Both  in 
cerebellar  and  temporosphenoidal  abscess  the  pain  is  sometimes  frontal, 
or  it  may  be  more  generally  diffused.  When  sharply  localized,  as  in  the 
occiput  or  nuchal  region,  especially  if  it  is  increased  by  percussion,  it 
may  prove  a  safe  guide. 

Paralysis  may  be  clearly  indicative  of  the  site,  especially  if  the  abscess 
involves  the  motor  regions,  as  the  pre-Rolandic  area  and  its  subcortical 
connections.  This  may  occur  either  in  frontal  or  parietal  abscess,  the  pus 
extending  backward  or  forward  respectively.  We  then  have  hemiplegia 
or  monoplegia  (facial,  brachial,  or  crural),  according  to  the  centres  involved, 
and  in  left-sided  lesions  there  is  aphasia.  Sensory  aphasia,  especially 
word  deafness,  is  strongly  indicative  of  a  temporal  abscess  on  the  left  side, 
such  as  is  common  to  ear  disease,  and  it  has  led  the  way  to  successful 
operation.  Temporal  abscess  may  also  give  rise  to  hemiplegia  by  pressure 
across  the  Sylvian  fossa  upon  the  internal  capsule;  hence  this  symptom 
may  be  misleading.     Hemiplegia  has  even  been  caused  by  abscess  of  the 


1264  MEDICAL  DIAGNOSIS. 

cerebellum.  The  hemiplegia  in  such  cases  is  probably  caused  by  pres- 
sure on  the  pons  or  medulla  oblongata.  In  this  way  also  cerebellar  abscess 
may  cause  other  pontile  symptoms,  as  paralysis  of  the  fifth,  sixth,  seventh, 
and  eighth  nerves,  and  the  mid-brain  may  even  suffer,  with  a  conse- 
quent partial  ophthalmoplegia.  According  to  Allport's  table  strabismus 
occurred  in  10  out  of  98  cases  of  abscess  of  the  brain,  not  all  cerebellar. 
From  these  various  data  it  is  seen  that  paralytic  symptoms  must  be 
interpreted  with  care.  For  instance,  thrombus  of  the  cavernous  sinus, 
which  might  occur  in^any  purulent  process  in  the  brain,  causes  an  oph- 
thalmoplegia, as  may  also  an  abscess  of  the  temporal  lobe  by  pressure 
on  the  third  and  sixth  nerves. 

Involvement  of  the  sensory  tract,  causing  hemiansesthesia  and  hemi- 
anopsia, has  been  reported,  especially  in  abscess  of  the  right  temporal 
lobe.  Various  affections  of  the  visual  fields  may  be  caused  by  abscess 
in  the  occipital  lobe. 

Focal  epilepsy  usually  indicates  a  lesion  in  or  about  the  motor  region, 
but  this  symptom  is  not  so  common  as  in  brain  tumor.  Unilateral  con- 
vulsions have  been  reported  in  cases  of  abscesses  at  various  sites,  even 
in  the  cerebellum.  Tonic  spasm  in  the  nape  of  the  neck  may  be  caused 
by  abscess  of  the  cerebellum. 

When  a  thrombus  forms  in  a  sinus  the  veins  on  the  outside  of  the 
skull  may  be  congested:  thus  in  thrombus  of  the  cavernous  sinus  the 
veins  of  the  orbit  are  engorged;  and  the  veins  at  the  base  of  the  nose  and 
on  the  brow  are  sometimes  congested  from  thrombus  of  the  superior 
longitudinal  sinus. 

Among  other  noteworthy  symptoms  are  vertigo,  incoordination,  loss 
of  equilibration,  especially  but  not  always  in  cerebellar  abscess,  and 
abolished  knee-jerks.  Macewen  has  noted  this  last  symptom  in  cases  of 
cerebellar  abscess,  and  it  has  been  seen  in  cerebellar  tumor,  especially  of 
the  middle  lobe.  Occasionally  it  is  not  continuous,  the  reflex  disappearing 
and  reappearing.  Knapp  has  seen  a  case  of  cerebellar  lesion  in  which 
only  one  knee-jerk  was  lost,  and  that  on  the  side  opposite  to  the  lesion. 
Abscess  of  the  frontal  lobe  may  cause  obscure  mental  symptoms,  especially 
retarded  cerebration.  In  Allport's  collection  of  98  cases  of  abscess  of  the 
brain,  40  occurred  in  the  temporal  lobe,  31  in  the  cerebellum,  7  in  the 
parietal  lobe,  and  the  remainder  in  various  other  regions.  In  5  cases 
there  was  diffuse  subdural  abscess. 

Diagnosis. — Purulent  meningitis  and  brain  abscess,  although  included 
here  under  one  heading  and  having  much  in  common,  should  be  distin- 
guished from  each  other  if  possible.  The  two  conditions  may  coexist, 
or  the  one  merge  into  the  other,  and  the  dividing  fine  is  not  easily 
detected.  Focal  symptoms  are  not  likely  to  be  seen  in  diffuse  purulent 
meningitis,  and  the  course  of  this  disease  is  more  acute  and  rapid;  in  fact, 
death  may  occur  in  a  few  days.  Abscess  is  likely  to  be  much  slower, 
especially  the  circumscribed  abscess  with  well-formed  walls;  and  in  this 
connection  the  latent  abscess  must  not  be  overlooked;  this  may  endure 
for  weeks,  even  months,  with  only  very  obscure  symptoms.  In  fact,  a 
latent  or  premonitory  stage  is  not  uncommon  in  solitary  abscess  of  the 
brain,  but  in  diffuse  abscess,  and  especially  multiple  abscess,  such  as  is 


SINUS  THROMBOSIS.  1265 

caused  by  metastasis  from  some  septic  process  outside  the  brain,  the  case 
is  Hkely  to  be  more  rapid  and  more  like  a  diffuse  suppurative  meningo- 
encephahtis. 

Some  authors  attempt  to  distinguish  extradural  abscess,  such  as  may 
occur  in  trauma  and  even  in  otitis.  The  local  symptoms  of  such  an  infec- 
tion are  usually  evident,  as  pain,  swelling,  venous  engorgement.  The 
presence  of  an  external  wound  is  important. 

Tumor  of  the  brain  is  distinguished  from  abscess  by  its  different 
■clinical  history,  its  slower  onset,  the  absence  of  a  septic  process  of  origin, 
and,  as  a  rule,  of  chill  and  fever.  But  in  rare  cases  tumor  of  the  brain  is 
complicated  with  suppuration.  Optic  neuritis  is  rather  more  common  in 
tumor,  but  only  little  reliance  can  be  placed  on  that  fact.  The  evolution 
of  symptoms  is  usually  more  gradual  and  progressive  in  the  case  of  tumor. 

Cerebellar  abscess  may  simulate  Meniere's  disease  by  vertigo  and 
occasional  deafness.  The  clinical  history,  however,  is  different,  and  in 
case  of  abscess  there  are  likely  to  be  fever,  headache,  and  mental  changes. 

Cerebral  hemorrhage  and  softening  may  simulate  abscess  when  the 
latter  is  fully  formed,  but  the  clinical  history  is  so  entirely  different  that 
the  distinction  is  easy,  as  a  rule.  An  abrupt  onset  of  symptoms  may 
occur  in  case  of  latent  abscess,  if  the  pus  breaks  from  its  cavity,  causing 
paralysis,  convulsion,  coma,  etc.;  and  in  such  a  case  the  differentiation 
is  perplexing. 

In  all  cases  of  septic  infection,  such  as  suppurating  otitis,  abscess  of 
the  lung,  etc.,  the  onset  of  cerebral  symptoms  should  excite  suspicion, 
and  the  case  should  be  carefully  scrutinized.  Lumbar  puncture  may  give 
valuable  information. 

IV.  SINUS  THROMBOSIS. 

Thrombosis  of  the  cranial  sinuses  is  either  primary  or  secondary. 
In  the  former  the  thrombus  arises  from  some  general  blood  state,  in  the 
latter  from  some  disease,  usually  septic,  in  the  immediate  neighborhood. 

Etiology. — Primary  thrombosis  is  seen  in  conditions  of  exhaustion, 
often  as  a  terminal  symptom;  thus  it  occurs  in  advanced  stages  of  tuber- 
culosis, carcinoma,  the  infectious  diseases,  as  typhoid  fever,  and  in  the 
diarrhoeas  of  infancy.  It  is  favored  by  a  weakened  heart  and  by  the 
sluggish  circulation  in  the  sinuses.  It  has  been  seen  also  in  chlorosis 
and   anaemia. 

Secondary  thrombosis  results  from  disease  of  the  walls  of  the  sinus, 
hence  especially  from  injury  or  caries  of  bone.  Its  commonest  cause  is 
otitis  media,  in  which  case  the  lateral  and  transverse  sinuses  especially 
are  involved.  It  also  arises  by  way  of  the  nasal  bones,  and  in  fact,  though 
rarely,  from  any  other  bones  of  the  cranium  which  become  the  seat  of 
caries.  It  is  sometimes  caused  by  fractures;  and  it  also  arises  from 
septic^  processes  within  the  skull,  such  as  a  purulent  meningitis  from  any 
cause,  or  from  a  general  septicaemia  or  pyaemia  arising  from  causes  outside 
the  cranium.     Facial  erysipelas  may  be  a  cause. 

Pathology. — In  septic  or  secondary  thrombosis  the  sinus  is  partly 
or  entirely  filled  with  a  white  or  grayish-white  mass,  adherent  to  the  walls. 

80 


1266  MEDICAL  DIAGNOSIS. 

This  mass  may  be  purulent  and  sanious,  and  the  walls  of  the  sinus  are 
inflamed;  infiltrated,  and  discolored,  while  the  contiguous  bone  in  many- 
cases,  as  in  otitis,  is  carious  and  softened.  In  recent  cases  the  thrombic 
mass  is  soft  and  easily  broken  up,  but  in  older  cases  it  is  quite  firm  and 
fibrous.  It  may  extend  for  some  distance  through  the  sinus,  even  into 
some  of  the  tributary  veins,  thus  causing  engorgement  of  veins,  with 
swelling  and  oedema,  on  the  outside  of  the  skull.  These  septic  thrombi 
are  not  seldom  associated  with  other  septic  lesions,  such  as  purulent 
meningitis,  purulent  encephalitis,  and  even  brain  abscess. 

Symptoms. — These  are  general  and  local.  In  the  case  of  the  second- 
ary septic  thrombi  the  general  symptoms  may  be  masked  by  those  of  the 
general  pyaemia;  thus  there  is  fever,  usually  of  a  septic  type,  with  headache 
and  changes  in  consciousness,  and  there  are  not  seldom  the  evidences  of 
meningitis.  Convulsions  sometimes  occur,  and  various  paralyses,  and 
occasionally  a  high  grade  of  choked  disk.  In  the  case  of  primary  throm- 
bosis we  have  to  consider  the  original  disease  and  its  exhausting  effects, 
but  superadded  to  these  we  observe  grave  cerebral  symptoms  of  sudden 
onset,  such  as  headache,  vomiting,  stupor,  followed  by  a  gradually  deep- 
ening coma,  possibly  with  convulsions;  but  local  paralytic  symptoms  are 
rare  in  this  form.  There  may,  however,  be  hemiplegia,  or  even  a  general 
flaccid  paresis. 

The  local  symptoms  are  sometimes  conspicuous.  They  depend  usually 
upon  engorgement  of  tributary  veins  on  the  outside  of  the  skull  and  upon 
paralysis  of  certain  cranial  nerves. 

In  thrombosis  of  the  cavernous  sinus  there  are  protrusion  of  the  eye, 
sweUing  and  discoloration  of  the  tissues  about  the  eye,  engorgement  of 
the  veins  of  the  orbit  and  the  frontal  veins,  which  communicate  through 
the  orbit  with  this  sinus,  possibly  choked  disk,  and  paralysis  of  the  third, 
fourth,  and  sixth  nerves,  which  run  through  the  sinus.  There  may  also 
be  pain  or  anaesthesia  in  the  ophthalmic  division  of  the  fifth  nerve.  The 
central  retinal  vein  may  also  be  the  seat  of  a  thrombus. 

Thrombosis  of  the  superior  longitudinal  sinus  may  cause  cyanotic 
swelling  and  oedema  on  the  brow,  and  in  rare  cases  nose-bleed.  Infection 
of  this  sinus  may  occur  through  the  nasal  bones  and  be  accompanied  with 
a  purulent  meningo-encephahtis.  The  commonest  site  of  cranial  throm- 
bosis is  in  the  lateral  and  transverse  sinuses  in  cases  of  otitis  media.  The 
local  symptoms  are  disguised  by  the  local  bone  disease.  The  most  signifi- 
cant are  pain  and  oedema  over  the  mastoid.  Otitis  media  is  the  most 
common  cause  of  grave  general  infection  of  the  cranial  contents,  the  most 
serious  being  abscess.  Irritation  from  this  focus  may  cause  recurring  epi- 
leptic fits.  The  jugular  vein,  external  or  internal,  may  be  the  seat  of 
thrombus,  which  may  even  be  palpable.  A  gravity  abscess  may  simulate 
phlebitis  of  the  jugular;  and  the  glossopharyngeal,  vagus,  accessory,  and 
hypoglossal  nerves  have  been  paralyzed  in  some  of  these  cases. 

Diagnosis. — A  local  diagnosis  is  hardly  practicable  for  any  other  of 
the  cranial  sinuses  than  those  mentioned  above.  It  is,  of  course,  much 
simphfied  in  cases  in  which  circumscribed  oedema  occurs.  The  general 
diagnosis  is  often  difficult  and  problematical.  Thrombosis  is  to  be  sus- 
pected when  grave  cerebral. symptoms,  such  as  headache,  vomiting,  con- 


CEREBRAL  HEMORRHAGE.  1267 

vulsions,  stupor,  and  unconsciousness,  occur  suddenly  in  cases  of  septic 
infection,  such  as  otitis  media  and  facial  erysipelas,  and  in  wasting 
diseases,  such  as  tuberculosis,  carcinoma,  infectious  diseases,  and  infan- 
tile diarrhoea.  But  a  differential  diagnosis  from  meningitis,  abscess,  and 
softening  is  not  always  possible,  and  in  fact  some  of  these  conditions  may 
be  associated  with  thrombosis.  Thrombi  of  the  cerebral  veins  are  some- 
times the  cause  of  hemiplegia  and  diplegia  in  young  children.  Smithers 
has  recently  called  attention  to  hemiplegia  in  typhoid  fever,  caused  by 
thrombi  in  the  cerebral  arteries.^ 

V.  CEEEBRAL  HEMORRHAGE. 

Etiology. — The  cause  of  this  accident  is  primarily  some  disease  of  the 
blood-vessels,  excluding,  as  we  do  here,  hemorrhage  from  trauma.  The 
diseases  of  the  blood-vessels  are  chiefly  arterial  sclerosis  or  atheroma, 
occurring  usually  after  middle  life,  and  more  rarely  syphilis,  occurring  at 
any  period  of  life  and  not  rarely  in  young  adults.  It  is  not  to  be  over- 
looked, however,  that  the  hemiplegia  of  syphilis  is  usually  due  to  an 
inflammation  and  thickening  of  the  walls  of  a  blood-vessel  rather  than  to 
a  hemorrhage. 

Pathology. — Atheroma  of  the  blood-vessels  is  a  common  affection  in 
later  life.  It  is  rare  to  see  an  autopsy  in  a  person  past  fifty  without  some 
evidences  of  it,  and  in  persons  of  sixty  and  seventy  it  is  not  unusual  to  see 
the  circle  of  Willis  at  the  base  of  the  brain  so  thickened  and  hardened  that 
the  vessels  are  like  pipe-stems.  From  these  main  arteries  at  the  base 
the  branches  that  pass  up  through  the  anterior  perforated  space  to  the 
lenticular  nucleus  and  internal  capsule  are  especially  liable  to  suffer. 
More  rarely  the  branches  from  the  posterior  cerebral  or  those  from  the 
basilar,  vertebral,  and  cerebellar  arteries  are  affected.  The  atheromatous 
arteries  are  frequently  the  seat  of  minute  dilatations,  aneurismal  in 
character,  and  it  is  one  of  these  that  is  likely  to  give  way.  The  hemor- 
rhage is  usually  within  the  substance  of  the  brain;  meningeal  hemorrhage 
from  arterial  disease  being  rare,  although  common  from  trauma.  Occa- 
sionally, however,  a  hemorrhage  breaks  through  to  the  surface.  The 
most  common  seat  of  hemorrhage  is  in  the  lenticular  nucleus,  which  is  a 
part  of  the  basal  ganglion  (corpus  striatum)  within  the  brain.  The 
hemorrhage  occurs  in  such  a  way  as  to  press  upon  or  destroy  the  internal 
capsule  which  contains  the  motor  and  sensory  tracts.  The  weakened  artery 
at  this  point  was  called  by  Charcot  the  "  artery  of  cerebral  hemorrhage." 

In  recent  cases  the  blood  is  either  still  fluid  or  partly  clotted,  and  it 
occupies  a  ragged  cavity  which  it  has  torn  out  of  the  substance  of  the 
brain.  In  old  cases  this  cavity  is  often  found  walled  off,  forming  a  cyst, 
filled  with  a  reddish  or  yellowish  fluid.  In  rapidly  fatal  cases  it  is  some- 
times found  that  the  blood  has  broken  through  into  the  lateral  ventricle, 
or  even  to  the  outer  surface  of  the  brain.  Multiple  hemorrhages  may 
occur,  and  sometimes  the  hemorrhage  is  in  the  parietal  or  occipital  lobe, 
or  even  in  the  pons.  Hemorrhage  in  the  cerebellum  is  less  common  than 
in  the  cerebrum. 

1  Journal  of  the  Am.  Med.  Assn.,  Aug.  3,  1907,  p.  389. 


1268 


MEDICAL  DIAGNOSIS. 


Instead  of  hemorrhage  a  diseased  blood-vessel  may  cause  thrombosis. 
There  is  then  secondary  softening,  but  clinically  the  two  conditions  are 
much  aHke  and  it  is  quite  impossible,  as  a  rule,  to  distinguish  them.  Soft- 
ening is  also  caused  by  embolism,  with  very  similar  results. 

In  long-standing  cases  of  hemiplegia  there  occurs  a  descending  degen- 
eration of  the  motor  tract,  which  may  be  traced  through  the  peduncle, 

the    pons,   the    decussation    in    the 
medulla,  and  the  spinal  cord. 

Symptoms. — Cerebral  hemor- 
rhage causes  what  is  popularly 
known  either  as  a  "stroke"  or  an 
'^  apoplexy."  These  two  conditions 
are  distinguished  chiefly  by  the  state 
of  the  consciousness;  in  the  former 
the  mind  may  be  clear,  in  the  latter 
there  is  stupor  or  coma.  In  either 
case  there  is  likely  to  be  paralysis, 
according  to  the  site  of  the  lesion. 
In  the  lenticular  nucleus  and 
internal  capsule,  the  most  common 
site,  hemorrhage  causes  hemiplegia 
on  the  opposite  side.  The  arm  and 
leg  are  paralyzed,  the  arm  rather 
more  so,  and  in  some  cases  the  lower 
part  of  the  face  and  one  side  of  the 
tongue.  The  upper  portion  of  the 
face  is  not  involved,  so  the  patient 
can  still  shut  his  eyes  and  wrinkle  his 
forehead.  The  tongue,  if  involved, 
is  protruded  toward  the  paralyzed 
side.  In  some  cases  there  is  hemi- 
ansesthesia,  and  even  hemianopsia, 
the  affection  of  the  sensory  fibres 
showing  that  the  clot  has  involved 
the  posterior  portions  of  the  internal 
capsule.  There  may  also  be  various 
forms  of  aphasia  if  the  lesion  is  in 
the  left  hemisphere. 

When  the  hemorrhage  involves 
the  island  of  Reil  and  the  posterior 
end  of  the  third  frontal  convolution 
on    the    left    side    there    is    motor 


Fig. 


366. — Old  left  hemiplegia  with  contractures. 
— Lloyd. 


aphasia.  When  the  left  superior 
temporal  convolution  is  involved  there  is  auditory  aphasia,  word-deafness 
and  object-deafness;  and  when  the  left  angular  gyrus  is  invaded  there  is 
visual  aphasia,  word-blindness  and  object-blindness.  Various  mixed  forms 
of  aphasia,  the  so-called  sensorimotor  aphasia,  may  occur  from  hemor- 
rhage into  various  portions  of  these  speech  centres  (the  so-called  language 
zone)  and  their  subcortical  connections  in  the  left  hemisphere. 


CEREBRAL  HEMORRHAGE.  1269 

Hemorrhage  in  the  frontal  lobe,  if  it  does  not  involve  the  motor  centres 
or  tracts,  may  cause  very  obscure  symptoms,  more  especially  mental 
changes,  such  as  retardation  of  the  mental  processes,  loss  of  the  power  of 
attention,  etc. 

Hemorrhage  in  the  superior  parietal  lobule  may  cause  ataxia  of  the 
limbs  on  the  opposite  side,  and  sensory  changes,  especially  astereognosis. 

Hemorrhage  in  the  occipital  lobe  may  cause  hemianopsia  and  other 
partial  defects  in  the  visual  fields,  and  also  some  inability  to  recognize  and 
name  objects  by  sight. 

In  the  cerebellum  hemorrhage  may  cause  intense  vertigo,  loss  of 
equilibration,  forced  and  pitching  movements,  and  vomiting;  and  if  the 
clot  is  big  enough  to  make  pressure  on  the  mid-brain  and  pons,  there  may 
be  hemiplegia,  hemianaesthesia,  and  involvement  of  the  oculomotor,  fifth, 
sixth,  seventh,  and  eighth  nerves;  but  these  latter  symptoms  are  rare, 
and  are  rather  indicative  of  either  a  mid-brain  or  a  pontile  lesion.  Thus 
hemorrhage  in  the  pons  causes  the  hemiplegia  alternans,  in  which  the 
arm  and  leg  are  paralyzed  on  the  opposite  side  while  the  sixth,  seventh, 
eighth,  and  possibly  the  fifth  nerves  are  paralyzed  on  the  side  of  the  lesion; 
this  is  so  especially  if  the  lesion  is  low  in  the  pons.  If  the  lesion  is  high, 
the  cranial  nerves  named  may  be  paralyzed  on  the  opposite  side,  that  is, 
on  the  same  side  as  the  hemiplegia.  In  rare  cases  a  very  circumscribed 
lesion  that  involves  the  nucleus  of  the  sixth  nerve  may  also  cause  diabetes 
or  polyuria. 

In  hemorrhage  in  the  mid-brain  (corpora  quadrigemina  and  cerebral 
peduncles)  the  oculomotor  and  fourth  nerves  may  be  paralyzed  on  the  side 
of  the  lesion,  while  the  hemiplegia  is  on  the  opposite  side,  presenting  a  type  of 
hemiplegia  alternans  which  is  sometimes  called  the  "syndrome  of  Weber." 

Hemorrhage  in  the  medulla  oblongata  is  extremely  rare,  and  is  incom- 
patible with  prolongation  of  life  if  the  respiratory  centres  are  involved. 

In  the  apoplectic  state  consciousness  may  be  partially  or  entirely  lost; 
the  breathing  becomes  stertorous,  the  cheeks  puff  out  with  every  breathy 
and  the  pulse  may  be  full  and  strong.  If  the  case  advances  toward  an 
unfavorable  ending,  the  pulse  becomes  thin  and  rapid,  the  temperature 
rises,  unconsciousness  is  profound,  the  pupils  do  not  react  to  light  and  may 
be  unequal.  Cheyne-Stokes  respiration  may  set  in,  and  death  is  often 
hastened  by  an  oedema  of  the  lungs.  In  the  apoplectic  cases  the  hemi- 
I^legia  can  sometimes  be  determined  by  the  loss  of  resistance  to  passive 
motion  on  the  paralyzed  side. 

In  some  cases  the  reflexes  are  not  at  first  greatly  affected.  In  cases 
of  massive  hemorrhage  with  shock  and  unconsciousness,  the  knee-jerk  on 
the  paralyzed  side  may  be  abolished.  In  patients  who  survive  and 
partially  recover,  the  deep  reflexes  become  exaggerated  on  the  paralyzed 
side,  the  muscles  are  contractured,  and  there  results  a  characteristic 
hemiplegic  attitude  and  gait.  Ankle  clonus  and  Babinski's  reflex  are 
usually  present  in  these  patients. 

The  state  of  the  pupils  is  not  constant;  in  the  early  stages  the  light 
reflex  may  be  preserved;  but  with  deep  unconsciousness  it  is  usually  abol- 
ished. The  pupils  are  sometimes  slightly  unequal;  or  they  may  be  of  normal 
size  or  even  dilated.     In  pontile  hemorrhage  they  may  be  contracted. 


1270  MEDICAL  DIAGNOSIS. 

Lateral  deviation  of  the  head  and  eyes  is  sometimes  seen  in  the  apo- 
plectic cases,  the  head  and  eyes  being  turned  away  from  the  paralyzed 
side — conjugate  deviation.  If  a  spastic  state  sets  in  from  irritation  of  the 
brain-cortex  or  motor  tracts,  especially  if  convulsions  occur,  as  sometimes 
happens,  the  head  and  eyes  are  forcibly  drawn  towards  the  paralyzed 
side.  In  rare  cases  there  results  a  "posthemiplegic  chorea" — a  bad  term, 
as  the  disorder  is  not  a  true  chorea,  but  a  wide  to-and-fro  tremor. 

Diagnosis. — Cerebral  hemorrhage,  especially  when  it  causes  uncon- 
sciousness, requires  to  be  distinguished  from  uraemia,  diabetic  coma,  post- 
epileptic coma,  opium  poisoning,  alcoholic  drunkenness,  and  trauma. 
The  problem  is  sometimes  a  difficult  one.  As  a  general  rule  hemorrhage 
causes  a  hemiplegia,  which  can  usually  be  determined,  even  in  cases  of 
unconsciousness,  by  some  difference  in  the  resistance  to  passive  motion  on 
the  two  sides:  on  the  paralyzed  side  the  limbs  are  entirely  flaccid  and 
fall  dead,  while  on  the  other  side  there  is  usually  some  resistance.  In 
profound  unconsciousness,  however,  the  difference  may  be  difficult  to 
recognize.  In  cases  of  a  simple  paral3'tic  "stroke"  without  unconscious- 
ness the  problem  is  much  simplified,  as  the  history  of  a  sudden  attack  of 
hemiplegia  is  usually  determinative.  Even  in  these  cases  there  may  be 
at  first  some  confusion  of  mind  and  clouding  of  consciousness. 

Uraemic  com-a  is  often  ascertainable  from  the  history  of  the  case. 
The  presence  of  albumin  and  casts  in  the  urine  cannot  determine  the 
question  positively  because  a  patient  with  nephritis  may  have  a  cerebral 
hemorrhage  or  thrombus,  while  a  patient  with  apoplexy  may  have  albu- 
minuria. Moreover,  there  are  sometimes  seen  in  nephritis  attacks  of 
hemiplegia,  which  pass  away  with  other  ursemic  symptoms.  Transient 
aphasia  and  brachial  monoplegia  of  ursemic  origin  sometimes  occur  and 
may  simulate  organic  lesion  in  the  brain.  In  uraemic  coma  there  may  be 
prolonged  subnormal  temperature.  In  spite  of  the  exceptions  noted, 
uraemic  coma  is,  on  the  whole,  indicated  by  the  state  of  the  urine,  the 
history  of  the  case,  the  subnormal  temperature,  the  usual  absence  of 
hemiplegia  and  other  symptoms  of  a  focal  lesion,  and  sometimes  by  the 
uraemic  odor.  Convulsions  are  in  favor  of  uraemia,  although  they  some- 
times occur  in  hemorrhage.  Albuminuric  retinitis  is  also  in  favor  of 
uraemia.     These  are  doubtful  cases  which  only  time  can  solve. 

Diabetic  coma  is  indicated  by  the  glycosuria,  diaceturia,  and  acet- 
onuria,  the  history  of  the  case,  and  the  absence  of  hemiplegia.  The  crisis 
may  be  ushered  in  with  headache  and  delirium,  and  the  peculiar  dys- 
pnoea, called  by  Kiissmaul  "air-hunger,"  but  these  prodromes  are  not  seen 
in  every  case. 

Postepileptic  coma  usually  clears  up  in  a  few  hours  at  most.  The 
history  of  the  case  is  significant.  Convulsions  may  occur  in  cerebral 
hemorrhage,  but  they,  are  rare.  Focal  epilepsy,  in  which  a  hemiplegia  or 
monoplegia  may  persist  for  some  time,  may  be  puzzling,  but  the  history 
of  the  case  and  the  course  should  prevent  error,  especially  if  focal  symp- 
toms are  caused  by  organic  lesion,  such  as  tumor.  In  epileptic  "status" 
the  fits  recur  at  frequent  intervals  (as  many  as  twenty-five  and  even  more 
in  a  day),  the  patient  profoundly  unconscious  between  the  paroxysms,  with 
weak  pulse,  and  sometimes  with  high  temperature. 


CEREBRAL  SOFTENING.  1271 

Opium  poisoning  is,  as  a  rule,  easily  recognized  by  the  history, 
the  contracted  pupils,  and  the  slow  respiration;  in  cases  in  which 
the  history  is  unknown  mistakes  are  possible.  Massive  hemorrhage, 
especially  ventricular  hemorrhage,  may  cause  profound  unconsciousness, 
immobile  rather  than  contracted  pupils,  and  labored  breathing,  while  the 
hemiplegia  may  be  masked;  pontile  hemorrhage  is  said  particularly  to 
simulate  opiums  poisoning,  especially  in  the  contracted  pupils.  The 
extremely  slow  breathing  of  opium  narcosis,  however,  is  not  likely  to  be 
seen  in  hemorrhage;  while  in  the  poisoning  there  is  never  hemiplegia, 
nor  conjugate  deviation  of  the  head  and  eyes;  and,  finally,  the  extreme 
bilateral  myosis  is  hardly  equalled  in  cases  of  apoplexy,  in  which 
inequality  of  the  pupils  is  more  common.  The  pupil  dilates  as  death 
approaches  in  opium  poisoning. 

Alcoholic  intoxication  is  known  by  the  history,  by  the  odor  of  alcohol, 
and  by  the  fact  that  the  stupor  or  unconsciousness  is  usually  not  so  pro- 
found as  in  apoplexy.  None  of  these  data  is  entirely  reliable.  A 
drunken  man  may  have  a  cerebral  hemorrhage,  hence  the  odor  of  alcohol 
on  the  breath  is  a  most  unreliable  test  for  this,  as  for  any  case.  Hemi- 
plegia is,  of  course,  conclusive  as  against  mere  alcoholism,  and  unequal 
pupils  suggest  apoplexy.  A  few  hours  usually  determine  whether  a 
doubtful  case  is  one  of  drunkenness. 

Trauma  may  cause  a  condition  closely  simulating  or  even  identical 
with  apoplexy,  as,  for  instance,  when  it  causes  a  cerebral  hemorrhage. 
The  history  is  most  important.  In  all  cases  a  careful  inspection  of 
the  scalp  and  skull  should  be  made  in  order  to  detect  contusion  or  fracture. 

Hysteria  may  possibly  simulate  apoplexy,  but  only  superficially. 
The  unconsciousness  is  usually  not  profound;  the  patient  is  often  open  to 
suggestion;  there  may  be  characteristic  stigmata;  the  pupils  respond 
freely  to  light;  and  deep  ovarian  pressure  usually  brings  some  response. 

The  differential  diagnosis  between  cerebral  hemorrhage  and  embolism 
is  difficult  and  may  be  impossible.  At  most  there  are  suggestions,  not 
positive  grounds,  for  an  opinion.  Hemorrhage  usually  occurs  in  persons 
at  and  beyond  middle  life;  embolism  in  persons  at  anj?-  age  in  whom  there 
has  been  a  vegetative  endocarditis.  Hemorrhage  is  rather  more  prone 
to  cause  loss  of  consciousness  than  is  an  embolus.  Associated  cardiac  and 
renal  disease,  being  productive  of  diseased  blood-vessels,  may  cause  hem- 
orrhage. The  same  is  true  of  syphilis,  although  syphilitic  hemiplegia  is 
more  frequently  caused  by  meningitis  and  endarteritis  at  the  base  of 
the  brain. 

VI.  CEREBRAL  SOFTENING. 

Softening  may  result  from  any  process  that  obstructs  a  blood-vessel; 
hence  an  endarteritis,  causing  thickening  of  an  artery,  as  in  syphilis;  a 
thrombus  from  disease  of  the  arterial  walls,  as  in  atheroma;  and  finally, 
an  embolus,,  from  the  vegetations  of  endocarditis — all  these  may  cause 
cerebral  softening. 

Pathology. — Thrombus  and  embolus  produce  results  so  nearly  iden- 
tical that  they  cannot  be  distinguished  clinicalh^  The  special  impor- 
tance of  embolus,  from  the  clinical  standpoint,  lies  in  the  fact  that  it  may 


1272  MEDICAL  DIAGNOSIS. 

occur  in  young  persons  and  produce  all  the  symptoms  of  an  apoplectic  or 
hemiplegic  stroke.  It  occurs  in  vegetative  endocarditis.  It  is  also  com- 
mon in  malignant  endocarditis,  and  sometimes  occurs  in  other  forms  of 
sepsis.  Thus  hemiplegia  may  happen  in  the  puerperium.  Thrombosis 
occurs  in  some  blood  states  other  than  sepsis,  such  as  anaemia  and 
chlorosis;  it  is  most  common,  however,  in  disease  of  the  coats  of  the 
blood-vessels,  as  atheroma  and  syphilis.  The  vessels  most'  involved  are 
those  that  form  the  circle  of  Willis  or  some  of  their  branches,  especially 
the  middle  cerebral  artery.  Softening  of  the  cei-ebellum  and  pons  is 
occasionally  seen. 

The  area  involved  does  not  always  break  down  at  once;  in  fact  a 
comparatively  long  time  may  elapse  before  it  softens.  This  leads  to 
deceptive  appearances  at  autopsies.  When  the  tissue  has  once  become 
soft  it   may  be  quite  diffluent,   and  in   color   may  be  white,  yellow,  or 

red;    according    to   the    amount    of 
blood  elements  contained  in  it. 

Symptoms. — These  are  similar 
to  those  caused  by  hemorrhage. 
Hemiplegia  is  the  commonest  result, 
but  other  paralyses,  such  as  mono- 
plegia, hemianesthesia,  and  hemi- 
anopsia, occur,  as  in  hemorrhage, 
according  to  the  seat  of  the  lesion. 
Aphasia  is  not  uncommon  when  the 
softening  occurs  in  the  lenticular 
nucleus  or  the  cortical  speech  cen- 
tres or  in  their  subcortical  connecting 

Fig.  367. — Softening  of  the  brain  in  the  motor  area       -j.„„pj-„    •       fl-,p  Ipff    V,prm'«nViPrf>         A  r^n 
ofihe  right  hemisphere,  due  to  embolus.— Lloyd.  ^ractb  m  lUO  leit    UemiSpUere.      ApO- 

plectic  symptoms,  with  confusion, 
stupor,  or  loss  of  consciousness,  may  be  present  if  a  large  area  is 
involved,  but  they  are  rather  more  uncommon  than  in  hemorrhage. 
Occasionally  the  onset  of  symptoms  is  gradual  and  the  course  pro- 
gressive, especially  if  small  successive  thrombi  occur,  but  usually  in  the 
case  of  embolus  the  onset  is  sudden.  Prodromes  also  occur  in  case  of 
atheroma,  such  as  vertigo,  headache,  and  failure  of  memory  and  other 
mental  powers.  In  some  cases  we  see  transient  hemiplegia  and  other 
paralyses,  due  doubtless  to  the  fact  that  the  circulation,  after  being 
obstructed,  may  be  restored.  But  in  most  cases  there  is  left  some  per- 
manent loss,  such  as  hemiplegia  and  aphasia.  Thrombus  of  the  carotid 
or  of  the  basilar  artery  causes  grave  symptoms,  such  as  profound  uncon- 
sciousness and  failure  of  respiration;  and  in  the  case  of  the  basilar  artery 
there  may  at  first  be  staggering,  ataxia,  or  even  a  cerebellar  gait. 

Diagnosis. — The  distinction  between  hemorrhage  and  embolus  largely 
depends  on  the  presence  of  a  lesion  in  the  heart  producing  emboli,  and 
this  is  more  common  in  young  persons.  Hemorrhage  due  to  atheroma  is 
an  affection  of  advanced  life.  Apoplectic  symptoms,  such  as  coma,  are 
more  common  in  hemorrhage;  but  the  distinction  between  these  two 
states  is  often  problematical.  Sinus  thrombosis  or  syphilitic  endarteritis 
may  cause  a  hemiplegia.    Syphilitic  hemiplegia  cannot    always  be  posi- 


CEREBRAL  PALSIES  OF  CHILDREN. 


1273 


tively  recognized  unless  there  is  a  clear  luetic  history.  If  there  are  head- 
ache, involvement  of  cranial  nerves,  especially  the  third,  and  an  irregular 
mode  of  onset,  the  diagnosis  is  much  more  probable.  In  a  young  adult 
the  absence  of  a  cardiac  lesion,  such  as  could  cause  embolism,  is 
further  suggestive  of  syphilis  as  the  cause  of  the  hemiplegia. 

VII.  THE  CEREBRAL  PALSIES  OF  CHILDREN. 

Children  are  sometimes  the  victims  of  hemiplegia,  diplegia,  para- 
plegia, and  speech  defects,  due  to  affections  of  the  brain.  As  these  condi- 
tions present  some  special  features  they  demand  special  notice  apart 
from  similar  affections  in  adults. 

Pathology. — Cerebral  hemorrhage  is  rare  in  children,  unless  in  the 
case  of  accident  or  trauma,  especially  at  birth.  These  birth  palsies  are 
usually  due  to  meningeal  hem- 
orrhage, caused  by  a  general 
asphyxia,  which  in  its  turn  is 
caused  by  prolonged  pressure 
on  the  placenta.  This  is  indi- 
cated by  the  fact  that  hemor- 
rhage in  the  new-born  is  some- 
times observed  beneath  other 
serous  membranes,  as,  for 
instance,  the  capsule  of  the 
liver.  Hence  intracranial  hem- 
orrhage is  not  necessarily  caused 
by  tlie  forceps,  although  this 
may  be  a  factor  in  some  cases. 
Hemorrhage  may  also  be  caused 
by  the  paroxysms  of  whooping- 
cough.  A  cerebral  sclerosis 
occurs   in  young  children;   and 

Striimpell  suggested  that  there  may  be  also  a  polioencephahtis.  Vascular 
lesions,  as  periarteritis  and  embolism,  are  doubtless  the  causes  of  extensive 
destructive  changes  in  the  brains  of  children,  following  upon  the  infectious 
diseases.  It  is  not  to  be  forgotten  that  hereditary,  or  even  acquired, 
syphilis  may  cause  cerebral  palsies  in  children.  Thrombosis  of  the  cere- 
bral veins  may  cause  juvenile  hemiplegia  and  diplegia.  It  occurs 
occasionally  in  typhoid  fever,  measles,  etc.  Thrombosis  of  the  cranial 
sinuses  is  also  occasionally  observed.  Hemorrhage  is  sometimes  present 
beneath  the  membranes  of  the  spinal  cord. 

A  destructive  lesion  may  result  in  the  formation  of  a  cavity  in  the 
cerebrum — the  so-called   porencephalus. 

Symptoms. — The  commonest  forms  of  these  palsies  in  children  are 
hemiplegia,  diplegia,  and  paraplegia. 

The  onset  of  the  affection  may  be  insidious,  or  at  least  not  promptly 
recognized,  as  in  very  young  children,  and  especially  in  the  birth  cases. 
When  the  onset  is  acute  the  affection  may  be  ushered  in  with  con- 
vulsions  and    coma,   but    this  is    by  no   means   a  universal    rule.      The 


Fig.  368. — Porencephalus. — Lloyd. 


1274 


MEDICAL  DIAGNOSIS. 


"stroke"    caused    by    embolus    is    sudden,    just    as    in    adults.      Among 
other    and    minor    symptoms    are    slight    fever,    vertigo,    and    vomiting. 

Confusion  and  delirium  are  sometimes  seen. 
Hemiplegia  is  the  most  common  form. 
At  first  the  paralysis  is  flaccid,  but  in  a 
later  stage  contractures  set  in  and  the  para- 
lyzed limbs  are  much  hampered  and  even 
deformed.  They  do  not  grow  quite  normally, 
but  true  muscular  atrophy,  as  seen  in  spinal 
cases,  is  not  present.  The  deep  reflexes  are 
exaggerated.  In  some  cases  athetosis  is 
present.  If  the  lesion  is  in  the  left  cerebral 
hemisphere  grave  speech  defects  are  present, 
but  these  differ  somewhat  from  genuine 
aphasia,  because  if  the  lesion  comes  on  in 
very  early  life  before  the  child  has  learned 
to  talk,  the  speech  is  undeveloped  rather 
than  impaired.  The  face  in  old  standing 
cases  is  usually  not  paralyzed,  and  the  arm 
is  more  paralyzed  and  contractured  than  the 
leg.  As  a  rule  there  is  no  hemiansesthesia. 
The  limbs  may  be  cold  and  blue,  but  the 
reactions  of  degeneration  are  not  present, 
and  fibrillation  is  not  seen.  The  gait  is  typi- 
cally hemiplegic,  and  the  arm  is  usually  carried 
flexed  and  contractured  at  both  the  elbow  and 
wrist.  The  bladder  and  bowel  are  not  paralyzed. 
Diplegia  is  simply  a  double  hemiplegia, 
and  is  sometimes  called  bilateral  spastic  hemi- 
-oid  infantile  hemiplegia,  piggj^.  The  Spasticity  of  the  limbs  is  espe- 
cially noticeable,  not  because  the  contractures  are  worse  than  in  hemiplegia, 
but  because,  being  on  both  sides,  they  give  the  patient  a  characteristic 


Fig.  369. 


Fig.  370. — Congenital  diplegia;   earlj- stage. — Young. 


aspect.     In  one  respect,  however,  the  contractures  in  diplegia  appear  to 
differ  from  those  of  hemiplegia — they  are  somewhat  more  marked  in  the 


CEREBRAL  PALSIES  OF  CHILDREN. 


1275 


lower  limbs.  This  gives  the  child  a  characteristic  gait,  if  he  is  still  able 
to  walk.  The  limbs  are  usually  adducted  and  extended,  and  the  feet  may 
be  crossed  and  held  in  the  position  of 
equino-varus.  The  deep  reflexes  are 
exaggerated;  sensation  is  unim- 
paired; and  the  upper  limbs  share  in 
the  rigidity.  In  these  cases  of  double 
hemiplegia  there  may  be  imbecility 
or  idiocy.  Epilepsy  and  athetosis 
may  complicate  the  case;  speech 
defects  are  common;  and  strabis- 
mus and  nystagmus  are  sometimes 
seen.  The  condition  depends  on  a 
lesion  which  involves  both  hemi- 
spheres, and  the  destruction  of  brain 
tissue  is  sometimes  great. 

Paraplegia  of  cerebral  origin 
has  been  described  only  in  recent 
years,  and  its  pathology  is  still  a  mat- 
ter of  some  obscurity.  Some  authors 
claim  that  it  depends  upon  a  limited 
brain  lesion,  in  which  the  leg  areas 
alone  are  involved,  while  others 
attribute  it  to  a  primary  lateral 
sclerosis.  It  is  practically  identical 
with  the  spastic  paralysis  of  the 
legs  as  seen  in  diplegia,  but  the 
arms  are  not  involved.  There  may 
be  epilepsy,  athetosis,  and  idiocy, 
just  as  in  the  other  forms  of  cere- 
bral palsy  in  children.  Paralysis  of 
the  bladder  and  bowel  is  not  a  necessary  part  of  the  symptom-complex, 
as  in  spinal  paraplegia,  but  incontinence  may  result  from  the  mental  defects. 


Fig.  371.  —  Spastic    diplegia;      athetosis. —  Lloyd. 


Fio.  372. — Spastic  diplegia;  epilepsy;  idiocy. —  Lloyd. 


Monoplegia, 
palsy  in  children. 


either  brachial  or    crural,    is    a   rare   form    of    cerebral 
In  this  form  one  arm  or  one  leg  alone  is  involved. 


1276 


MEDICAL  DIAGNOSIS. 


In  this  connection  brief  mention  may  be  made  of  Little'' s  disease.  The 
affection  is  in  fact  a  form  of  cerebral  palsy,  in  which  the  motor-conducting 
paths  from  the  brain  are  injured,  diseased,  or  undeveloped.  Hence  its 
clinical  form  is  that  of  a  diplegia  or  a  paraplegia,  according  to  the  extent 
of  the  injury.  It  occurs  especially  in  children  who  are  prematurely  born. 
Some  writers  seem  inclined  to  limit  the  term  to  mild  cases  in  which  the 
cerebral  faculties  are  not  much  involved,  convulsions  are  absent,  and  the 
tendency   to  improvement  is  marked,  but  there  seems  to    be    no    good 

reason   for   retaining    it    as    a    desig- 
nation for  a  distinct  disease.^ 

Sachs  has  described  a  condition 
which  he  calls  amaurotic  family 
idiocy,  in  which  the  child,  soon  after 
birth,  becomes  weak  and  lethargic; 
blindness,  due  to  degenerative  changes 
in  the  optic  nerves,  ensues;  and  spas- 
tic paralysis  with  increased  tendon 
reflexes  may  be  added.  In  some 
cases  nystagmus,  strabismus,  and 
deafness  are  noted.  There  are  no 
convulsions,  but  there  is  well-marked 
idiocy;  and  death  occurs  in  early 
childhood.  Several  cases  have  been 
observed  in  one  family.  The  condition 
is  one  of  failure  of  development 
(agenesis)  of  the  nerve-centres;  its 
causation  is  obscure. 

Diagnosis. — The  diagnosis  is,  as 
a  rule,  not  difficult.  The  spastic 
paralysis,  usually  hemiplegic  or  diple- 
gic  in  type,  with  exaggerated  reflexes,, 
absence  of  muscular  atrophy  and 
electrical  changes,  and  the  associated 
mental  defects,  often  with  athetosis 
and  epilepsy,  distinguish  these  cases 
clearly  from  diseases  of  the  spinal  cord,  especially  anterior  poliomyelitis. 
Gross  lesion  of  the  brain,  such  as  tumor,  might  simulate  these  cases,  but 
the  history  and  course  are  different,  and  optic  neuritis  is  often  present  in 
the  case  of  tumor. 

Paraplegia  of  cerebral  origin  may  simulate  a  spinal  paraplegia,  but 
in  the  latter  there  are  no  true  cerebral  symptoms,  such  as  idiocy  and 
epilepsy,  and  the  bladder  and  bowel  are  almost  always  paralyzed.  In 
case  the  lumbar  cord  is  involved  the  paralysis  is  flaccid,  with  atrophy, 
lost  knee-jerks,  and  even  the  reactions  of  degeneration.  The  historj^  and 
course  are  also  different.  Infantile  paralysis,  due  to  acute  anterior  polio- 
myelitis, is  usually  confined  to  one  limb;  muscular  atrophy  occurs  with  lost 
knee-jerk  and  reactions  of  degeneration,  and  there  are  no  cerebral  symptoms. 


Fig.  373. — Attitude  in  cerebral  palsy;    paraplegic 
type. — Young. 


1  For  an  excellent  account  of  Little's  disease  see  Brissaud's  Lecons  siir  les  Maladies  Nerveuses 
Paris,  1895,  p.  108. 


HYDROCEPHALUS 


1277 


Obstetrical  paralysis,  especially  of  the  brachial  plexus,  could  hardly 
be  confounded  with  a  cerebral  palsy.  The  paralysis  is  flaccid,  the  muscles 
waste,  the  deep  reflexes  are  lost,  electrical  changes  are  present,  and  cere- 
bral symptoms  are  wanting. 

The  spastic  rigidity  of  rickets  and  of  tetany  is  distinguished  by  the 
associated  symptoms  of  those  diseases,  the  history,  and  the  etiology. 


VIII.  HYDROCEPHALUS. 

Pathology. — The  lateral  ventricles  are  enormously  distended;  the 
ependyma  thickened;  and  the  foramen  of  Monro  or  the  aqueduct  of  Sylvius, 
or  both,  are  possibly  occluded.  The  brain  may  be  so  stretched  as  to  be 
little  more  than  a  shell,  the  convo- 
lutions thin  and  flattened,  and  the 
sulci  almost  obliterated.  The  basal 
ganglia,  the  mid-brain,  pons,  medulla 
oblongata,  and  cerebellum  are  some- 
times compressed  and  only  partly 
developed.  The  choroid  plexus  may 
be  thickened  and  congested.  The 
bones  of  the  skull  are  thin  and  trans- 
lucent, and  usually  the  sutures  and 
fontanelles  are  widely  distended,  the 
former  as  much  even  as  an  inch. 
The  essential  elements,  or  neurons, 
of  the  cortex  suffer  greatly,  and  the 
optic  tracts  and  cranial  nerves  may 
be  degenerated. 

Etiology.  —  The  causation  is 
obscure.  Some  observers  attribute 
the  disease  to  occlusion  of  one  or 
other  of  the  natural  foramina,  such 
as  the  foramen  of  Monro,  the  aqueduct  of  Sylvius,  or  the  foramen  of 
Magendie.  Not  enough  attention  has  been  paid  to  the  state  of  the  choroid 
plexus  and  veins  of  Galen.  Recently  much  has  been  written  by  Lees,  Barlow, 
and  others  about  a  posterior  basic  meningitis,  which  causes  occlusion  of 
the  foramen  of  Magendie,  with  consequent  distention  of  the  ventricles. 

Symptoms.  —  Besides  the  distention  of  the  skull  there  are  seen 
various  defects  of  development  of  the  brain  and  nervous  system.  There 
may  be  mental  impairment,  ranging  from  slight  imbecility  to  complete 
idiocy.  In  rare  cases,  however,  there  is  preserved  quite  a  remarkable 
mental  integrity. 

The  motor  symptoms  are  often  prominent;  there  is  hemiplegia, 
diplegia,  or  monoplegia;  the  muscles  are  usually  spastic,  even  contrac- 
tured,  and  the  deep  reflexes  are  exaggerated.  The  eyes  may  be  deflected 
downward,  and  there  may  be  various  forms  of  oculomotor  palsy,  with 
nystagmus.  Other  symptoms  more  or  less  common  are  convulsions,  pain, 
as  shown  by  the  "hydrocephalic  cry"  (but  this  is  more  common  in  acute 
tuberculous  meningitis),  blindness,  and  incontinence.    In  extreme  cases  the 


Fig.  374. — Hydrocephalus. — Lloyd. 


1278  MEDICAL  DIAGNOSIS. 

child  is  bed-ridden  from  inability  to  hold  up  the  enormously  distended 
head.    Occasionally  hydrocephalus  is  associated  with  spina  bifida. 

Diagnosis. — This  presents  no  difficulty  in  the  advanced  cases;  the 
child's  appearance  is  enough.  In  early  stages,  however,  the  diagnosis 
must  rest  on  the  child's  evident  failure  properly  to  develop,  and  on  the 
gradual  enlargement  of  the  head.  Hydrocephalus  sometimes  begins  before 
birth,  and  the  skull  may  be  greatly  distended,  causing  grave  dystocia. 

IX.  INTRACRANIAL  ANEURISMS. 

The  larger  aneurisms  which  develop  on  the  main  intracranial  arteries, 
particularly  at  the  base,  will  be  discussed.  The  arteries  usually  involved 
are  those  that  form  the  circle  of  Willis,  and  their  branches,  especially  the 
middle  cerebral.  The  internal  carotid,  cerebellar,  and  basilar  arteries  also 
are  sometimes  affected. 

Pathology. — Diseases  affecting  the  coats  of  the  arteries,  especially 
atheroma  and  syphilis,  are  the  determining  causes.  Trauma  also  acts  in 
this  way.  Emboli  from  vegetating  endocarditis  may  be  a  cause.  The 
aneurism  is  either  fusiform  or  sacculated;  it  is  likely  to  increase  rapidly, 
and  it  eventually  bursts  with  fatal  effect. 

Symptoms. — The  aneurism  acts  by  compression  like  a  brain  tumor. 
Some  authors  describe  a  thrill  or  murmur  audible  on  the  skull  or  over  the 
great  vessels.  The  patient  sometimes  has  a  subjective  sense  of  pulsation. 
Headache,  vertigo,  vomiting,  and  affections  of  consciousness  occur.  In 
some  cases  the  aneurism  is  latent  until  rupture  occurs,  while  in  other 
ases  the  symptoms  are  paroxysmal,  from  successive  small  bleedings. 
Aneurism  of  the  internal  carotid  may  compress  the  optic  nerve  or  optic 
tract,  the  nerves  of  the  eyeball,  and  the  first  division  of  the  fifth  nerve, 
and  as  it  increases  may  even  cause  hemiplegia,  and,  if  it  is  on  the 
left  side,  aphasia.  Starr  observed  a  case  of  left  third  nerve  paralysis  with 
right  hemiplegia.  The  optic  chiasm  may  be  compressed  by  aneurism  of 
the  carotid  and  especially  of  the  anterior  communicating  artery.  Various 
affections  of  the  retinal  and  visual  fields  thus  result,  and  bilateral  tem- 
poral hemianopsia  has  been  reported.  Aneurism  of  the  anterior  cerebral 
causes  symptoms  similar  to  those  of  the  preceding,  except  when  it  is  far 
to  the  front,  when  it  may  involve  no  cranial  nerves  and  cause  only 
obscure  compression  symptoms  in  the  frontal  lobes.  Aneurism  of  the 
middle  cerebral,  especially  if  well  within  the  Sylvian  fissure,  causes  hemi- 
plegia; possibly  hemiansesthesia  and  hemianopsia;  and,  on  the  left  side, 
aphasia.  The  third  nerve  may  be  compressed.  There  may  be  loss  of  smell 
on  the  affected  side  in  the  case  of  aneurism  of  any  one  of  these  arteries 
near  the  olfactory  nerve.  Aneurism  of  the  posterior  communicating  artery 
may  involve  the  optic  tract  and  the  third  and  sixth  nerves;  and  if  it 
grow  very  large,  it  may  compress  the  peduncle,  causing  hemiplegia. 
Aneurism  of  the  posterior  cerebral  may  compress  the  peduncle  and 
the  third  and  sixth  nerves,  causing  hemiplegia  alternans;  and  if  it  should 
involve  the  occipital  lobes  it  might  cause  various  affections  of  the  visual 
fields.  Aneurisms  of  the  basilar  and  vertebral  arteries  cause  pontile  and 
bulbar  symptoms.     The  most  -striking  is  the  compression  bulbar  palsy 


TUMORS  OF  THE  BRAIN.  1279 

sometimes  seen.  If  the  pons  alone  is  involved  there  may  or  may  not  be 
unilateral  symptoms,  such  as  hemiplegia  alternans — paralysis  of  the  sixth 
and  seventh  nerves  on  one  side  with  opposite  hemiplegia.  If  the  medulla 
oblongata  is  involved  the  bulbar  symptoms  are  dysarthria,  dysphagia, 
paralysis  of  the  tongue  and  lips,  and  sometimes  respiratory  symptoms, 
especially  when  the  head  is  thrown  forward. 

Diagnosis. — Intracranial  aneurism  simulates  a  brain  tumor,  and  the 
distinction  between  it  and  a  neoplasm  cannot  always  be  made.  A  mur- 
mur, having  the  cardiac  rhythm  controlled  by  pressure  on  the  carotid,  is 
suggestive  of  aneurism,  but  even  this  sign  is  not  reliable,  for  such  a  mur- 
mur has  been  heard  in  other  lesions.  Starr  claims  to  have  heard  a  loud 
double  murmur  over  the  Sylvian  region  in  a  case  of  extensive  softening. 
Murmurs  in  the  head  have  also  been  heard  in  cases  of  tumor  (when  the 
growth  is  near  a  large  artery),  in  anaemia,  in  hydrocephalus,  in  exophthal- 
mic goitre,  and  in  several  cases  of  loud  endocardial  murmurs,  which  I  have 
observed.  There  are  therefore  no  positive  rules  for  diagnosis.  The  history 
and  course  may  be  the  same  in  aneurism  as  in  tumor  of  the  brain.  Mills 
calls  attention  to  pulsating  exophthalmus  as  a  sign  of  aneurism  of  the 
internal  carotid. 

X.  TUMORS  OF  THE  BRAIN. 

Under  this  term  are  included  all  new  growths  within  the  cranium, 
whether  within  the  brain,  in  the  membranes,  or  springing  from  the  bones 
of  the  skull.  These  tumors  are  comparatively  rare,  but  in  any  large 
neurological  clinic  several  of  them  are  likely  to  be  seen  in  the  course  of 
a  year. 

Pathology. — Intracranial  tumors  are  of  various  kinds.  In  a  series 
of  100  cases,  analyzed  by  Mills  and  Lloyd,  16  were  gliomata,  15  sarco- 
mata, 13  gummata,  13  tuberculous,  7  carcinomata,  16  unclassified,  and  the 
remainder  of  various  forms.  An  area  of  congestion,  inflammation,  soft- 
ening, or  hemorrhage  is  sometimes  seen  about  the  tumor;  more  rarely 
suppuration.  The  cerebrospinal  fluid  may  be  increased,  and  in  some  cases 
the  ventricles  are  distended,  this  depending  on  the  seat  of  the  neoplasm. 
The  tumor  may  be  encapsulated,  especially  if  it  be  a  meningeal  growth,  in 
which  case  it  is  sometimes  easily  shelled  out.  If  the  tumor  is  within  the 
substance  of  the  brain,  as,  for  instance,  in  one  of  the  cerebral  hemispheres, 
this  may  appear  swollen,  and  even  slightly  flattened  and  discolored  from 
pressure.  Occasionally  the  cranial  nerves  are  pressed  upon  or  stretched 
over  the  surface  of  tumors  at  the  base.  In  some  cases  the  new  growth 
closely  resembles  brain  tissue.  Tumors  of  the  brain  are  sometimes  multiple, 
and  in  the  case  of  carcinomata  they  may  be  metastatic. 

Symptoms. — The  onset  of  a  tumor  is  usually  insidious,  and  the  course 
gradual  and  even  slow.     The  symptoms  are  general  and  local. 

The  general  symptoms  are  such  as  are  common  to  all  kinds  of  brain 
tumors,  and  indicate  in  a  more  or  less  distinctive  Avay  the  presence  of  an 
intracranial  lesion.  These  symptoms  are  headache,  vertigo,  vomiting, 
convulsions,  paralysis,  ataxia,  sensory  changes,  optic  neuritis,  and  affec- 
tions of  consciousness.  Headache  is  a  very  common  symptom  of  brain 
tumor.     In  the  early  stages   it   may   be  slight,  increasing   later  to   great 


1280  MEDICAL  DIAGNOSIS. 

intensity.  Sometimes  it  is  paroxysmal;  sometimes,  but  rarely,  it  is 
absent  (in  5  out  of  the  100  tabulated  cases);  occasionally  it  is  localized. 
It  is  not  easily  controlled  by  drugs.  Vertigo,  with  which  we  may  include 
affections  of  equilibration,  forced  movements,  and  ataxia,  is  seen  in  many 
cases.  Some  of  these  symptoms,  such  as  affections  of  equilibration  and 
forced  movements,  are  highly  characteristic  of  cerebellar  tumor;  but 
vertigo  is  not  confined  to  subtentorial  growths.  Vomiting  is  usually  of  the 
propulsive  kind,  irrespective  of  food  in  the  stomach;  in  other  words,  of 
the  type  known  as  cerebral.  It  is  by  no  means  constant,  but  when 
associated  with  other  general  symptoms  it  is  highly  suggestive.  It  may 
be  unaccompanied  with  nausea.  Convulsions  occur  in  many  cases;  they 
are  either  general  or  focal.  The  former  are  seen  in  practically  all  kinds 
of  cases;  the  latter  are  indicative,  as  a  rule,  of  irritation  of  the  motor 
centres  in  the  cortex.  By  focal  convulsion  we  mean  one  commencing  in 
or  confined  to  one  or  a  few  groups  of  muscles.  Paralysis  in  some  form  is 
usually  present,  and  it  may  or  may  not  be  an  early  symptom.  It  is 
more  appropriately  discussed  among  the  local  symptoms,  as  may  also 
be  said  of  the  sensory  changes.  Optic  neuritis  is  a  frequent  symptom,  but 
it  occurs  also  in  other  conditions,  especially  in  brain  abscess,  purulent 
encephalitis,  and  brain  syphilis.  In  brain  tumor  it  occurs  in  at  least  80 
per  cent,  according  to  Gowers,  Bramwell,  and  others.  From  another 
view-point  Oppenheim  claims  that  of  all  cases  of  choked  disk  90  per  cent, 
are  due  to  tumor  of  the  brain.  Affections  of  consciousness  range  all  the 
way  from  slight  stupor  to  profound  coma.  The  emotions  may  be  affected, 
and  hysterical  symptoms  are  sometimes  seen. 

The  local  symptoms  are  such  as  indicate  the  site  of  the  tumor. 
The  most  important  of  these  symptoms  are  the  various  forms  of 
paralj^sis.  Thus  hemiplegia  indicates  that  either  the  motor  cortex  or  the 
descending  motor  tracts  are  involved.  A  monoplegia,  as  of  the  leg,  arm, 
or  face,  is  especially  indicative  of  a  lesion  of  the  respective  centre  in  the 
pre-Rolandic  area.  Aphasia  points  to  involvement  of  the  left  cerebrum, 
in  one  or  other  speech  centre,  according  to  the  t3^pe  of  the  aphasia.  Paraly- 
sis of  the  various  cranial  nerves,  especially  the  third,  fourth,  fifth,  sixth, 
seventh,  eighth,  and  twelfth,  is  often  of  definite  localizing  value,  as  will 
be  shown  presently.  An  ataxic  form  of  paralysis  is  sometimes  seen  in 
lesions  of  the  superior  parietal  lobule.  Affections  of  sensation  may  take 
the  form  of  hemianesthesia,  hemianopsia,  astereognosis,  or  localized 
anaesthesia,  and  will  be  considered  with  the  focal  diagnosis.  Focal 
convulsions,  of  the  type  known  as  Jacksonian  epilepsy,  indicate 
usually  a  lesion  in  the  respective  motor  centres.  When  associated  with 
focal  paralysis  they  are  especially  typical  of  a  focal  lesion  in  the  motor 
area.  It  must  be  borne  in  mind  that  a  convulsion  may  have  a  focal  type 
at  the  beginning,  passing  later  into  a  general  convulsion;  in  such  cases  a 
focal  origin  of  the  convulsion  is  usually  indicated,  hence  such  fits  have 
diagnostic  value. 

The  focal  diagnosis  for  tumors  at  various  sites  in  the  brain  is  briefly 
indicated  as  follows: 

Tumors  of  the  frontal  lobe  may  give  few  if  any  localizing  symptoms 
unless  they  involve  the  motor  area.     The  mental  changes  are  sometimes 


TUMORS  OF  THE  BRAIN. 


1281 


Fig.  375. — Paralysis  of  the  sixth  nerve  of  both 
sides  and  of  tlie  right  seventh  nerve,  in  a  case  of 
pontile  tumor. — Lloyd. 


characteristic,  and  may  consist  of  alterations  of  character,  lack  of  power 

of  attention,  and  especially  retarded  cerebration.      If  the  motor  area  is 

involved,  a  tumor  in  the  upper  part 

of  the  pre-central  gyrus,  or  on  the 

mesial  aspect  of  that  region,  causes 

paralysis  of  the  opposite  leg;  in  the 

middle  part  of  the  gyrus,  paralysis 

of  the  arm;  and  in  the  lower  part, 

paralysis  of  the  face.    On  the  left  side 

a  tumor  involving  the  posterior  part 

of    the    third    frontal    convolution 

causes   motor   aphasia. 

Tumors  of  the  parietal  lobe  may 

also  cause  focal  paralysis  and  con- 
vulsions by  pressure  on  the  pre-cen- 
tral gyrus;    and  if  located  on  the  left 

side  they  may  cause  motor  aphasia 

for  the  same  reason.     Affections  of 

the   superior   parietal  lobule    cause 

astereognosis  and  ataxic  paralysis  of 

the  opposite  leg  or  arm  or  both.     If 

the   posterior   part   of   the   internal 

capsule  is  involved  there  is  hemian- 

aesthesia,  and  possibly  hemianopsia,  on  the  opposite  side.     If  the  angular 

gyrus  is  involved  there  may  be  visual  aphasia  and  word-blindness.    Tumors 

of  the  occipital  lobe  cause  hemi- 
anopsia, possibly  also  hemianaes- 
thesia;  and  also  visual  aphasia, 
word -blindness,  and  object -blind- 
ness. Tumors  of  the  temporal  lobe 
may  cause  hemiplegia  and  hemian- 
sesthesia  by  pressure  on  the  internal 
capsule,  if  they  are  large  enough, 
but  the  most  typical  symptom,  if 
the  tumor  is  on  the  left  side  and 
involves  the  first  two  temporal  gyri, 
is  word -deafness  and  auditory 
aphasia.  Tumors  of  the  mfd-brain 
often  cause  a  hemiplegia  alternans, 
in  which  the  hemiplegia  is  on  the 
opposite  side,  while  paralysis  of  the 
oculomotor  nerve  is  on  the  side  of 
the  lesion — the  so-called  "  S3mdrome 
of  Weber."  Tumors  of  the  pons 
may  also  cause  a  hemiplegia  alter- 
nans,  in    which   with    an    opposite 

hemiplegia  there  is  paralysis  of  the  sixth  and  seventh  nerves,  possibly  also 

of  the  fifth  and  eighth  nerves,  on  the  side  of  the  tumor.     Sometimes  both 

sixth  nerves  are  involved.     These  cranial  nerve  paralyses  vary  somewhat 
81 


Fig.  37G. — Paralysis  of  the  seventh  nerve,  right 
side,  and  of  both  sixth  nerves.  Case  of  pontile 
tumor;  patient  attempting  to  close  her  eyes. — Lloyd. 


12S2 


MEDICAL  DIAGXOSIS. 


according  to  the  site  of  the  growth.  Thus  if  the  tumor  is  located  high  in  the 
pons,  above  the  decussation  of  the  motor  paths  for  these  cranial  nerves, 
the  hemiplegia  and  the  paralysis  of  the  nerv-es  are  both  on  the  opposite 
side.     A  favorite  site  for  these  tumors  is  in  the  cerebellopontile  angle. 

Tumors  of  the  cerebellum  give  a  Tvide  variety  of  symptoms,  the  most 
characteristic  being  loss  of  equilibration,  cerebellar  ataxia  (in  tumor  of 
the  vermis),  and  forced  movements  (in  tumor  of  the  peduncles,  especially 
the  middle  peduncle\  If  the  tumor  presses  upon  the  mid-brain,  pons,  or 
medulla  oblongata,  there  may  be  characteristic  paralysis  of  the  several 
cranial  nerves  which  have  their  nuclei  in  those  structures,  just  as  in  tumors 
of  those  parts,  and  even  hemiplegia.  The  knee-jerks  may  be  lost,  or  may 
even  go  and  come,  but  this  symptom  is  not  always  seen.  Tumors  of  the 
basal  ganglia  cause  hemiplegia,  hemianassthesia,  and  hemianopsia,  and  on 
the  left  side  aphasia   or  paraphasia.      Tumors   of   the  membranes  at  the 

base  of  the  brain,  according  to  their 
location,  cause  paralysis  of  the 
various  cranial  nerves,  especially  the 
third,  fourth,  fifth,  and  sixth.  Lloyd 
reported  a  case  of  total  unilateral 
ophthalmoplegia,  with  anaesthesia 
of  the  first  di^dsion  of  the  fifth 
nerve,  caused  by  a  sypliiloma  just 
behind  the  orbit.  Tumors  of  the 
medulla  oblongata  are  rare;  they 
cause  paralysis  of  the  twelfth  nerve 
and  of  the  motor  tracts,  and  diffi- 
culty in  swallowing  and  in  respira- 
tion. In  some  cases  brain  tumor  is 
latent,  especially  if  it  occupy  a 
so-called  silcrd  region  of  the  brain. 
Diagnosis.  —  The  above  brief 
sketch  sets  forth  the  principles  of 
local  diagnosis;  but  brain  tumors 
both   general    and   local,   and   these 


Fig.  3,  7.- — Tumor  of  the  cerebellum,  showingforced 
movement  to  one  side. — Llovd. 


cause  a  wide  varietv 


or    symptoms. 


must  be  interpreted  with  care.     A  successful  local  diagnosis  is  frequently 
possible,    and  is  often  made. 

Tumor  may  simulate  abscess,  but  the  history  and  course  are  usually 
different;  there  is  no  history  of  a  precedent  focus  of  suppuration,  there 
is  no  eAddence  of  sepsis,  the  evolution  is  more  gi-adual,  and  as  a  rule  the 
duration  is  longer.  Hemorrhage  is  not  likely  to  be  mistaken  for  tumor; 
the  onset  is  entirely  different.  It  is  sudden,  the  sj^mptoms  are  established 
quickly,  and  the  case  is  not  progressive.  Yet  tumor  in  the  motor  region, 
causing  hemiplegia,  has  been  mistaken  for  a  long-standing  parah^ic 
"stroke"  due  to  hemorrhage.  The  history,  the  presence  of  optic  neuritis 
and  of  headache  in  the  case  of  tumor  should  prevent  error.  Syphilis  of 
the  brain  may  possibly  simulate  brain  tumor,  especialh'  if  the  headache 
and  optic  neuritis  are  associated  with  focal  symptoms,  but  the  symptoms 
of  syphilis  often  pursue  an  irregular  course,  quite  unlike  the  steady  prog- 
ress of  a  tumor.     Nevertheless,  sypliilis  may  cause  a  gummatous  tumor. 


PARASITES  IX  THE  BRAIX  12S3 

In  truth,  tumor  of  the  brain  does  not  closely  simulate  any  other  lesion; 
the  onset,  the  course,  the  duration,  and  the  grouping  of  symptoms  are  all 
sufficient  as  a  rule  to  prevent  error.  It  is  well,  however,  in  this  connection 
not  to  overlook  those  curious  cases  in  which  hysterical  symptoms  have 
masked  the  symptoms  of  brain  tumor  and  led  to  error. 

XI.  PARASITES  IX  THE  BRAIX. 

The  commonest  is  the  Cysticercus  cellulosa?.  the  larval  form  of  the 
Taenia  solium,  or  pork  tape-worm.  Occasionally  the  echinococcus.  or 
hydatid,  is  observed. 

Pathology, — The  parasites  exist  as  cysts,  of  the  size  of  a  millet-seed 
to  that  of  a  grape  or  even  a  walnut.  They  may  be  found  in  the  sub- 
stance of  the  brain,  or  beneath  the  membranes,  or  floating  free  in  the 
ventricles.  The  last  is  the  most  common.  There  is  usually  an  ependymitis 
and  great  increase  of  the  ventricular  fluid.  The  parasites  are  found  in 
both  the  lateral  and  the  fourth  ventricle. 

Symptoms. — The  nature  of  the  disorder  may  be  obscure.  In  a  case 
observed  by  Lloyd  ^  in  the  Philadelphia  Hospital  the  earliest  symptoms  were 
apoplectiform  attacks,  followed  by  severe  headache,  hemiparesis.  ataxia,  dis- 
turbance of  equilibration,  exaggerated  knee-jerks,  incontinence  of  urine  and 
faeces,  drowsiness,  loss  of  power  of  attention,  speech  defects,  trismus,  and 
failing  vision.  There  were  no  convulsions  nor  optic  neuritis.  Death  occurred 
in  coma.  At  the  autopsy  eighteen  cysts,  some  as  large  as  a  chestnut,  clear 
and  satin-like,  were  found  floating  in  the  right  ventricle,  which  was  enor- 
mously distended.  One  small  cyst  was  found  adherent  in  the  fourth  ven- 
tricle.   There  was  ependymitis,  and  the  aqueduct  of  S^'lvius  w^as  occluded. 

The  patient  in  Lloyd's  case  insisted  that  when  he  moved  his  head  he 
could  feel  something  rolling  within  it. 

The  symptoms  are  not  the  same  in  all  cases;  much  depends  upon  the 
number,  size,  and  location  of  the  cysts.  Convulsions  are  not  uncommon, 
and  affections  of  consciousness  are  frequent.  Headache  is  a  constant 
symptom,  and  choked  disk  is  sometimes  observed.  A  cysticercus  has 
been  seen  in  the  eye.-    On  the  whole,  the  symptoms  are  irregular. 

Diagnosis. — The  diagnosis  is  most  difficult,  and  the  chances  are  that 
the  true  nature  of  the  case  will  not  be  discovered  until  the  autopsy.  This 
is  especialh'  so  in  America,  where  the  infection  is  rare. 

Because  of  the  irregularity  of  the  symptoms,  with  headache,  drowsi- 
ness, convulsions,  and  various  forms  of  paralysis,  the  case  may  easily  be 
mistaken  for  one  of  syphilis  of  the  brain;  also  for  brain  tumor.  There 
are  no  pathognomonic  signs,  and  in  any  case  the  diagnosis  must  be  prob- 
lematical. The  subjective  sense  of  an  object  rolling  in  the  head  is  the  most 
distinctive  sign  that  we  have  seen  noted.  It  is  quite  impossible,  as  a  rule, 
to  trace  the  origin  of  the  infection  in  the  character  of  the  patient's  diet. 
There  may  be  no  tape-worm  in  the  bowel,  for  autoinfection  is  not  common, 
the  eggs  being  usually  introduced  from  without.  If  cysts  are  found  under 
the  retina  or  skin  or  in  the  muscles,  the  presence  of  similar  growths  in  the 
brain  is  rendered  highly  probable. 

1  Philadelphia  Med.  Journal.  March  19.  1S9S. 

^Oliver,  Ophthalmoscopy,  in  Keatiug's  Cyclopaedia  of  the  Diseases  of  Childreu,  vol.  iv,  p.  238. 


1284  MEDICAL  DIAGNOSIS. 

XII.  SYPHILIS  OF  THE  BRAIN. 

Syphilis  in  the  spinal  cord  or  brain  begins  its  work,  as  a  rule,  upon 
the  arteries.  The  inner  and  sometimes  the  outer  coat  of  the  vessel 
becomes  infiltrated  and  thickened,  as  Heubner  has  pointed  out.  The 
inflammation  then  spreads  to  the  meninges,  and  there  results  an  exuda- 
tive meningitis,  which  still  further  involves  the  blood-vessels  and  even 
invades  the  brain  tissue  and  the  cranial  nerves. 

Pathology. — There  may  be  syphilis  of  the  convexity,  or  of  the  base, 
or  of  both.  At  the  base  we  often  see  the  most  typical  picture  of  thickened 
membranes  and  gummatous  infiltration.  There  is  usually  an  associated 
cerebritis,  especially  near  the  surface,  and  deeper  in  there  may  be  soften- 
ing or  hemorrhage  from  obstruction  of  the  arteries  or  from  rupture  of  their 
diseased  walls.  A  common  seat  for  this  form  of  meningitis  is  between  the 
cerebral  peduncles  and  at  the  anterior  perforated  space,  where  the 
arteries  run  up  to  supply  the  interior  of  the  brain,  especially  the  lenticu- 
lar nucleus  and  internal  capsule.  The  basilar  and  vertebral  arteries  may 
also  be  involved.  On  the  convexity  there  is  seen  sometimes  a  leptomen- 
ingitis or  a  pachymeningitis,  or  both.  Occasionally  the  gummatous  new 
growth  forms  a  veritable  tumor.  It  is  thus  understood  that  the  syphilitic 
process  causes  damage  to  the  brain  by  pressure,  by  inflammation,  by  scle- 
rosis, by  softening  and  hemorrhage,  and  by  involving  the  cranial  nerves. 
It  also  acts  by  elaborating  secondary  products — toxins. 

Symptoms. — These  may  be  exceedingly  irregular,  sometimes  advanc- 
ing quickly  and  then  receding,  or  remaining  for  a  long  time  stationary. 
From  the  character  of  the  lesions  it  is  evident  that  the  symptoms  may  be 
multiform  and  show  the  invasion  of  many  different  parts  of  the  brain. 

Of  general  symptoms  headache  is  common;  .  it  may  be  especially 
severe  at  night,  causing  insomnia.  There  may  be  vertigo  and  vomiting. 
Psychical  changes  are  observed.  There  are  drowsiness,  stupor,  confusion, 
dementia,  even  delirium  and  maniacal  excitement.  Convulsions,  either 
general  or  focal,  may  occur  in  brain  syphilis.  The  focal  convulsions  are 
usually  indicative  of  a  lesion  at  some  part  of  the  motor  area.  When  the 
motor  area  is  invaded,  as  by  a  small  patch  of  infiltration  or  sclerosis, 
there  is  focal  paralysis  as  well  as  focal  epilepsy.  The  cranial .  nerves  at 
the  base  of  the  brain  are  often  involved.  Optic  neuritis  is  seen,  some- 
times as  an  early  symptom.  Primary  optic  atrophy  is  not  so  common. 
The  third  nerve,  one  or  all  of  its  roots,  is  peculiarly  exposed  in  the  inter- 
peduncular space  to  the  action  of  the  poison;  next  to  it  in  frequency 
the  sixth  nerve,  one  or  both.  Ricord  had  a  saying  that  syphilis  puts  its 
sign  manual  on  the  third  nerve.  Because  of  the  involvement  of  the 
arteries,  softening  or  hemorrhage  results,  especially  in  the  lenticular 
nucleus  and  internal  capsule,  causing  hemiplegia,  hemiansesthesia,  and 
aphasia. 

The  mid-brain  may  be  involved,  as  shown  by  ophthalmoplegia  and 
even  by  an  alternate  hemiplegia,  in  which  the  third  nerve  is  involved  on 
the  side  of  the  lesion,  with  hemiplegia  of  the  opposite  side.  Pontile  and 
bulbar  symptoms  result  when  the  basilar  artery  is  affected.  There  may 
be  sixth  or  seventh  nerve  palsy  on  one  side,  with  hemiplegia  on  the  opposite 


GENERAL  PARESIS.  12S5 

side.  Combined  facial  and  trigeminal  paralysis  due  to  pontile  syphilis  has 
been  noted.  An  apoplectic  bulbar  palsy,  due  to  arterial  disease,  some- 
times specific,  has  been  described. 

Syphilitic  tumors  occur  in  various  regions  of  the  brain,  and  act  like 
other  tumors. 

The  symptoms  of  brain  syphilis  are  often  controlled  by  specific  treat- 
ment, especially  in  the  early  stages,  before  destruction  of  tissue  has  occurred. 
-  In  some  cases  there  are  associated  spinal  symptoms — cerebrospinal 
syphilis. 

Diagnosis. — The  mode  of  onset  and  progress  may  suggest  syphilis. 
The  symptoms  are  often  insidious,  advancing  irregularly,  receding,  then 
again  advancing.  This  is  seen  in  syphilitic  hemiplegia.  There  may  be 
slight  apoplectiform  attacks,  then  slight  hemiparesis,  then  improvement, 
then  a  more  grave  attack,  and  so  on.  This  can  readily  be  understood 
from  the  nature  of  the  syphilitic  meningitis  and  endarteritis,  interfering 
with  circulation.  The  third  nerve  palsy  is  also  sometimes  irregular;  only 
one  or  two  branches  may  be  involved  at  first,  then  later  the  whole  nerve, 
due  to  the  gradual  involvement  of  the  several  roots  of  this  nerve  in  the 
interpeduncular  space.  The  history  of  the  case  is  often  clear,  but  some- 
times it  is  not  reliable.  The  multiformity  of  symptoms  is  often  charac- 
teristic, and  the  presence  of  spinal  lesions  is  generally  conclusive.  It  may 
be  difficult  to  distinguish  syphilis  in  some  cases  from  brain  tumor,  and 
often  impossible  to  say  whether  a  tumor  is  syphilitic  or  not.  Brain 
tumors,  as  a  rule,  are  more  focal  and  constant  in  their  symptomatology, 
and  more  regularly  progressive.  The  therapeutic  test  should  always  be 
made.  Tuberculous  meningitis  has  a  more  rapid  course  than  syphilitic 
meningitis;  it  is  not  amenable  to  drugs,  and  is  uniformly  fatal.  There 
is  also  fever  and  slowing  of  the  pulse,  and  the  disease  is  commonly  seen  in 
children,  whereas  the  syphilitic  form  is  more  common  in  adults.  A  febrile 
reaction  is  sometimes,  though  rarely,  seen  in  brain  syphilis.  The  hemi- 
plegia of  syphilis  cannot  always  be  easily  distinguished  from  hemiplegia 
due  to  other  causes.  If  there  is  a  clear  history  of  syphilis,  no  endocardial 
lesion  to  cause  embolism,  and  the  accident  occurs  in  a  young  adult; 
and  if,  especially,  there  be  headache,  involvement  of  one  or  other  cranial 
nerve,  particularly  the  third,  and  the  symptoms  are  of  rather  irregular 
onset  and  course,  the  evidence  is  in  favor  of  syphilis. 

XIII.  GENERAL  PARESIS. 

General  paresis  is  a  degenerative  disease  of  the  brain  cortex,  medul- 
lary tracts,  and  nerves.  Syphilis  and  over-strain,  especially  business 
worry,  are  probably  active  but  not  exclusive  causes.  The  disease  occurs 
more  frequently  in  men  than  in  women;  and  in  the  white  than  in  the 
colored  races.  The  French  attach  much  importance  to  alcoholism.  It  is 
more  common  in  civilized  countries  and  among  the  better  classes,  but 
Krafft-Ebing's  statement  that  it  is  always  due  to  "  civilization  and 
syphilization"  is   probably   more   resonant  than   correct. 

Pathology. — There  is  a  destructive  process  in  the  tissues  of  the  brain. 
This  process  shows  itself  in  the  small  vessels  of  the  membranes,  leading  to 


1286  MEDICAL  DIAGNOSIS. 

congestion,  obstruction  of  the  circulation  and  the  lymph  stream,  morbid 
increase  of  the  neuroglia,  hardening  and  atrophy  of  the  cortex,  thickening 
of  the  membranes,  minute  hemorrhages,  extravasation  of  the  cerebro- 
spinal fluid,  distention  of  the  ventricles,  and  impaired  nutrition  and 
destruction  of  the  neurons  in  the  brain   cortex.^ 

Symptoms. — General  paresis  is  usually  divided  into  four  stages. 

In  the  first  stage  the  prodromes  appear,  such  as  change  of  character, 
spells  of  irritability  or  even  of  depression,  inattention  to  business,  erratic 
conduct,  and  moral  lapses.  Insomnia,  or  its  opposite,  somnolence,  may 
occur.     Alcoholic  and  sexual  excesses  are  common. 

In  the  second  stage  the  period  of  grandiose  delusions  sets. in.  The 
patient  has  most  extravagant  ideas  of  his  wealth,  of  his  personal  impor- 
tance, even  of  his  sexual  prowess.  He  becomes  talkative,  boastful,  and 
slightly  demented.  Along  with  these  mental  changes  appear  physical 
changes.  There  is  tremor  of  the  muscles  of  the  face,  tongue,  hands,  and 
limbs;  speech  becomes  drawling,  stammering,  or  staccato;  the  hand- 
writing is  unsteady,  and  words  are  dropped  or  run  together  just  as  in 
speech.  The  gait  is  weakened  and  incoordinate,  with  increased  knee- 
jerks  as  a  rule.  There  may  be  myosis,  or  irregularity  and  inequality  of 
the  pupils,  and  sometimes  the  Argyll-Robertson  symptom,  in  which  the 
light  reflex  is  lost  while  the  movement  on  accommodation  remains.  There 
may  also  be  optic  atrophy. 

In  the  third  stage  the  disease  assumes  a  more  chronic  aspect,  and 
dementia  is  more  advanced.  In  this  stage  especially  we  see  crises  of 
epilepsy,  apoplexy,  hemiplegia,  or  maniacal  excitement.  The  paralytic 
symptoms  increase. 

In  the  fourth  stage  the  patient  is  in  terminal  dementia,  paralyzed, 
bedridden,  almost  or  quite  speechless,  with  incontinence  of  urine  and 
faeces — a  total  wreck,  until  death  ends  the  scene  in  exhaustion  or  in  an 
epileptic  or  apoplectic  crisis. 

In  rare  cases  arthropathies  form,  especially  when  the  disease  is  asso- 
ciated with  posterior  sclerosis  of  the  spinal  cord. 

In  some  cases  remissions  occur,  of  quite  long  duration,  but  the  hopes 
raised  by  them  are  fallacious,  for  the  disease  is  fatal. 

Diagnosis. — This  may  present  some  difficulty  in  the  early  stages,  as 
between  this  disease  and  disseminated  syphilis  of  the  brain.  But  in  the 
latter  there  is  not  seen  the  characteristic  psychosis,  with  grandiose 
delusions,  and  the  disease  does  not  present  the  regular  evolution  that 
is  seen  in  general  paresis.  Still,  the  diagnosis  is  not  always  easy.  The 
therapeutic  test  may  help  to  solve  the  problem,  but  it  must  be  borne  in  mind 
that  general  paretics  do  not  bear  well  the  heroic  antisyphilitic  drugging. 
Striking  examples  of  cerebral  lues,  resembling  the  early  stages  of  general 
paresis,  sometimes  make  good  recoveries  under  a  judicious  treatment. 
These  are  probably  the  kind  of  cases  that  are  reported  as  cures  of  general 
paresis.     The  Argyll-Robertson  pupil  would  point  to  the  latter  disease. 

There  is  a  pseudoparesis  induced  by  alcohol  and  promoted  by  morphia, 
cocaine,  etc.,  which  closely  resembles  the  genuine  disease,  especially  in 

1  Bevan  Lewis,  Mental  Diseases,  2d  edit.,  p.  548;  Berkley,  Mental  Diseases,  p.  197.  These  two 
works  give  the  best  accounts  of  the  morbid  anatomy  of  general  paresis. 


SENILE  DEGENERATION. 


1287 


the  tremor  and  speech  defects,  but  recovery  occurs  promptly  on  the 
withdrawal  of  the  poison.  The  history  in  these  cases  is  suggestive,  and 
they  do  not  present  quite  such  a  typical  expansive  psychosis  as  in 
general  paresis;  the  mental  condition  is  usually  one  of  enfeeblement 
with   hallucinatory  delirium,   which,  however,  may  be  rather   grandiose. 

The  distinction  between  neuras- 
thenia and  the  early  stages  of  paresis 
is  not  difficult. 

Multiple  sclerosis  differs  from 
general  paresis  in  the  history  of  the 
case,  in  the  nystagmus  and  intention 
tremor,  and  in  the  absence  of  the 
expansive  psychosis. 


XIV.   SENILE   DEGENERA- 
TION. 

The  fundamental  change  in  the 
central  nervous  system  in  old  age  is 
probably  atheroma  of  the  blood- 
vessels. It  is  a  trite  saying  that  a 
man's  life  is  only  as  long  as  the  life 
of  his  arteries.  Some  of  the  effects 
of  this  arterial  degeneration  have 
already  been  discussed  in  the  chap- 
ters on  cerebral  hemorrhage  and  soft- 
ening. There  are  other  conditions, 
however,  so  identified  with  senility 
that  they  merit  especial,  though  brief, 
attention.  Whether  or  not  they  all 
depend  on  changes  in  the  blood-ves- 
sels may  still  be  an  open  question. 

Cerebral  Symptoms. — The 
most  conspicuous  of  these  are 
undoubtedly  the  mental  changes 
which  occur  in  old  age.  There  is 
loss  of  memory  and  failure  of  the 
mental  powers  so  familiar  to  all. 
such  as  senile  melancholia,  delusional  insanity,  maniacal  episodes,  and 
dementia,  belong  rather  to  psychiatry  than  to  clinical  medicine. 

The  early  symptoms  of  atheroma  of  the  cerebral  arteries  are  not  easily 
recognized.  Among  them  are  tinnitus,  vertigo,  throbbing  or  fulness  in 
the  head,  transient  attacks  of  mental  confusion,  slight  paresis,  aphasia, 
and  headache.  The  throbbing  or  beating  in  the  head  is  sometimes  almost 
enough  to  suggest  aneurism,  especially  when  accompanied  by  headache.  It 
may  even  depend  in  some  cases  on  slight  aneurismal  dilatations.  We  must 
not  overlook  in  these  cases  associated  disorders  in  the  heart  and  kidneys. 

Senile  Epilepsy. — The  onset  of  epilepsy  in  old  age  is  occasionally 
observed.    It  is  doubtless  helped  on  in  some  cases  by  alcoholism.     The 


Fig.  378. — Arthropathy  in  general  paresis. — Lloyd, 
Philadelphia  Hospital  Reports,  vol.  ii. 


The  various  psychoses  of  the  aged, 


1288  MEDICAL  DIAGNOSIS. 

prime  cause  is  probably  degenerative  change  in  the  brain  cortex.  The 
epileptic  seizure  in  senile  patients  is  practically  like  that  seen  in  ordinary 
epilepsy.     It  is  necessary  to  exclude  uraemia. 

Senile  Tremor. — In  some  old  persons  a  very  pronounced  tremor  is 
seen.  It  usually  begins  as  a  fine  movement  in  the  hands,  most  marked  on 
exertion.  Later  it  may  spread,  especially  to  the  neck,  causing  a  shaking 
of  the  head.  In  advanced  stages  it  is  even  present  during  rest,  but  it 
disappears  during  sleep.  It  is  not  accompanied  with  the  muscular  rigidity 
and  the  characteristic  attitude,  expression,  and  gait  of  paralysis  agitans, 
although  intermediate  cases  are  seen,  and  the  two  conditions  have  some 
points  of  contact. 

Senile  Paraplegia. — A  spastic  paresis  of  the  legs,  more  rarely  of 
the  arms  also,  occurs  in  the  aged.  There  may,  or  may  not,  be  anaesthesia 
and  weakness  of  the  sphincters.  The  cases  usually  resemble  primary 
lateral  sclerosis,  without  loss  of  sensation  or  involvement  of  the  bladder 
and  bowel.  This  condition  may  depend  on  primary  changes  in  the  cord, 
especially  in  the  lateral  tracts,  or  it  is  possibly  due  to  small  foci  of 
softening  in  the  motor  regions  of  the  brain.  These  patients  often,  have 
well' marked  mental  deterioration. 

Alcoholism  and  Drug  Habits  in  the  Aged. — Evil  habits  creep 
on  insidiously  in  some  old  people  who  may  always  have  led  strictly  tem- 
perate lives.  Bevan  Lewis  calls  attention  to  the  frightful  impetus  which 
the  excessive  use  of  alcohol  lends  to  the  retrograde  changes  which  natu- 
rally occur  in  the  brain  in  old  age.  The  opium  habit  may  be  formed  by 
the  aged. 

XV.  ACUTE  DELIRIUM. 

This  disease  was  first  described  by  Luther  Bell,  an  American  alienist, 
and  is  sometimes  called  from  him  Bell's  mania.^  It  is  also  called  typho- 
mania  and  delirium  grave. 

Pathology. — The  disease  is  probably  an  acute  infection,  and  may 
be  caused  by  a  variety  of  germs.  Bacteriological  studies  have  not  led 
to  uniform  results.  Berkley  says  that  in  a  malady  which  may  be  caused 
by  so  many  agents,  a  sole  cause  is  not  to  be  expected. 

Symptoms. — The  onset  is  usually  abrupt  and  the  course  very  rapid. 
Delirium  sets  in  acutely  and  advances  quickly  to  stupor  and  coma.  The 
tongue  becomes  dry  and  brown,  and  sordes  form.  The  pulse  is  rapid  and 
compressible.  There  are  muscular  unsteadiness,  tremor,  and  incoordination. 
The  temperature  rises  but  pursues  no  regular  course.  There  is  aversion 
to  food,  and  the  vital  powers  soon  fail.  Death  may  occur  in  a  few  days. 
Cases  of  longer  duration  are  seen  to  follow  the  puerperium,  and  are 
probably  due  to  sepsis;   but  in  the  typical  cases  no  cause  can  be  made  out. 

Diagnosis. — The  diagnosis  rests  upon  the  abrupt  onset,  the  rapid 
course,  and  the  tendency  to  speedy  death  without  obvious  cause.  Bac- 
teriological studies  should  be  made.  Perhaps  with  our  increasing  knowl- 
edge of  microbian  pathology  the  nature  of  these  cases  will  be  made  clear. 
The  possibility  of  poisoning  by  alcohol,  syphilis,  lead,    or  malaria   must 

I  Bell  described  the  disease  at  a  meeting  of  the  Association  of  Superintendents  of  American 
Asylums,  in  1849. 


MULTIPLE  SCLEROSIS.  1289 

not  be  ignored.  Fulminating  attacks  of  typhoid  fever,  measles,  and 
scarlatina  may  simulate  delirium  grave,  but  can  usually  be  recognized  by 
the  associated  symptoms.     Uraemia  must  also  be  excluded. 

XVI.  MULTIPLE  SCLEROSIS. 

This  disease,  also  called  insular,  or  disseminated,  sclerosis,  is  marked 
by  foci  of  degeneration  scattered  through  the  brain  and  spinal  cord. 

Pathology. — The  foci  vary  in  size  from  that  of  a  small  bird-shot  to 
that  of  a  pea  or  a  chestnut,  and  there  may  be  even  larger  areas  involved. 
They  are  difTerent  in  color  from,  and  harder  in  consistence  than,  the  brain 
tissue.  Histologically  they  consist  of  hardened  connective  tissue  and 
infiltrated  blood-vessels,  with  degenerated  nerve-fibres,  although  many 
fibres  are  seen  intact,  penetrating  the  diseased  tissue — a  fact  which  is 
supposed  to  explain  one  of  the  chief  symptoms,  the  intention  tremor.  The 
cause  of  multiple  sclerosis  is  not  known;  it  is  not  believed  to  be  syphilis, 
although  diffuse  syphilitic  lesions  sometimes  cause  a  state  which  clinically 
is  not  very  unlike  multiple  sclerosis.  The  fact  that  the  disease  sometimes 
follows  the  infectious  diseases,  such  as  smallpox,  typhoid  fever,  etc.,  does 
not  explain  its  causation.  The  same  may  be  said  of  its  appearance  in 
metal  workers. 

Symptoms. — The  affection  is  one  of  early  adult  life;  it  rarely  appears 
after  the  thirtieth  year,  and  it  is  not  uncommon  in  young  women. 

There  are  three  symptoms  which  especially  distinguish  insular  scle- 
rosis— intention  tremor,   scanning  speech,   and   nystagmus. 

The  intention  tremor  is  an  early  symptom.  As  its  name  implies,  it 
appears  on  voluntary  motion;  the  arm,  for  instance,  showing  wide  jerky 
tremors  when  the  patient  attempts  to  use  it,  as  for  carrying  a  glass  of 
water  to  the  lips.  The  motion  is  then  so  violent  that  often  a  large  part 
of  the  water  is  spilled.  The  tremor  is  coarse,  with  wide  amplitude  and  few 
vibrations  to  the  second.  While  the  patient  is  at  rest,  it  is  absent.  The 
tremor  extends  to  the  face,  tongue,  and  limbs,  causing  other  symptoms, 
especially  scanning  speech  and  an  unsteady  gait. 

The  speech  is  usually  scanning  rather  than  staccato,  although  in  all 
cases  the  words  are  uttered  slowly,  and  sometimes  with  pauses  between 
them.  In  a  few  rare  cases  bulbar  symptoms  have  been  seen,  such  as  paraly- 
sis and  wasting  of  the  tongue.     Pseudobulbar  palsy  has  also  been  noted. 

The  nystagmus  is  usually  a  prominent  symptom,  and  is  most  marked 
when  the  patient  turns  the  eyeballs  to  one  side  —  lateral  nystagmus. 
Sometimes  a  rotary  nystagmus  is  seen,  in  which  the  eyeballs  are  rolled 
on  their  axes.  Even  when  the  eyes  are  fixed  straight  ahead  slight  oscilla- 
tions are  sometimes  seen. 

The  gait  is  usually  spastic,  and  the  deep  reflexes  are  exaggerated  in 
consequence  of  involvement  of  the  lateral  tracts  in  the  insular  foci  at 
various  levels.  Abolition  of  the  cremasteric  reflex  is  claimed  by  Collins. 
The  bladder  and  bowel  are  not  paralyzed;  if  there  are  exceptions  to  this 
rule,  they  must  be  very  rare. 

In  advanced  stages  the  mental  faculties  may  suffer,  and  crises  of  an 
apoplectiform  kind  may  be  seen.     Optic  atrophy  is  present  in  some  cases. 


1290  MEDICAL  DIAGNOSIS. 

Gowers  claims  that  even  when  the  optic  nerve  is  involved  in  a  patch  of 
sclerosis  many  fibres  pass  through  unharmed  and  a  fair  degree  of  vision  is 
retained;  but  the  visual  fields  are  variously  affected.  One  optic  nerve 
may  be  more  injured  than  the  other.  Uhthoff,  who  analyzed  100  cases 
of  multiple  sclerosis,  found  the  optic  nerves  affected  in  40.  He  also  found 
paralysis  in  one  or  other  of  the  ocular  muscles  in  17  of  his  cases.  Involve- 
ment of  the  pupils  was  rare.  Muscular  atrophy  sometimes  occurs,  and  a 
slight  ataxia. 

Sensory  symptoms  are  usually  remarkable  for  their  absence.  Pain  is 
sometimes  felt,  and  various  but  slight  modes  of  anaesthesia  are  sometimes 
present  and  are  most  likely  to  be  found  in  the  distal  parts  of  the  limbs. 

The  course  of  multiple  sclerosis  is  chronic;  remissions  occur,  and  even 
slight  improvement,  but  the  disease  is  incurable. 

Diagnosis. — The  diagnosis  is  easily  made  from  the  association  of  the 
three  cardinal  symptoms.  Nystagmus  and  scanning  speech  are  seen  in 
Friedreich's  disease,  but  they  are  then  associated  with  ataxia  and  lost 
knee-jerks,  and  the  disease  is  usually  a  famihal  one.  In  disseminated 
syphilis  the  course  is  more  rapid,  the  mind  more  involved,  the  evolution 
of  symptoms  is  not  characteristic,  and  scanning  speech  and  nystagmus 
are  not  seen  as  a  rule.  General  paresis  shows  scanning  speech,  tremor, 
and  ocular  changes,  but  the  expansive  psychosis,  the  history,  the  evolu- 
tion, the  more  marked  tremor  of  the  facial  muscles,  all  serve  to  distinguish 
it.  The  cremasteric  reflex  is  likely  to  be  preserved,  but  we  do  not  insist 
here  upon  this  sign  as  distinctive. 

Multiple  sclerosis  may  be  simulated  by  hysteria,  in  which,  however, 
symptoms  that  can  only  be  accounted  for  by  organic  lesions,  such  as 
nystagmus  and  optic  atrophy,  are  never  found.  Cases  of  hysterical  pseu- 
dosclerosis are  usually  of  traumatic  origin.  The  differential  diagnosis  is 
most  important.  Other  hj'sterical  stigmata  are  not  always  present.  Some- 
what similar  cases  follow  exposure  to  mercury  or  lead. 

XVII.  DISEASES  OF  THE  MID-BRAIN. 

The  mid-brain  is  composed  in  part  of  the  cerebral  peduncles,  which 
contain  the  motor  tracts  from  the  cerebrum;  its  dorsal  part  consists  of  the 
corpora  quadrigemina,  and  it  is  penetrated  by  the  aqueduct  of  Sylvius, 
underneath  which  are  located  the  nuclei  of  the  third  and  fourth  nerves. 
The  sensory  tract,  or  fillet,  runs  up  just  behind  each  peduncle. 

Pathology. — Tumors  are  sometimes  observed  in  this  region,  and  more 
rarely  hemorrhage  and  softening.  Wernicke  has  described  an  acute 
destructive  process  located  in  the  gray  matter  about  the  aqueduct,  which 
he  has  named  superior  jyolio encephalitis.  The  meninges  in  the  inter- 
peduncular space  are  not  infrequently  the  seat  of  syphilitic  meningitis. 

Symptoms. — Tumors  of  the  mid-brain  are  usually  unilateral,  and 
cause  hemiplegia  alternans,  in  which  there  is  an  opposite  hemiplegia, 
with  or  without  hemiansesthesia,  associated  with  paralysis  of  the  third 
nerve  on  the  side  of  the  lesion.  Other  symptoms  of  tumor  are  usually 
present,  such  as  optic  neuritis,  headache,  vertigo,  vomiting,  changes  in 
consciousness,  and  more  rarely  convulsions.     A  somewhat  similar  train 


NUCLEAR  OPHTHALMOPLEGIA.  1291 

of  symptoms  may  be  caused  by  cerebellar  tumors,  if  these  make  pressure 
on  the  mid-brain;  but  in  cerebellar  tumors  there  is  likely  to  be  in  addition 
some  disorder  of  equilibration.  A  meningeal  tumor  in  the  interpeduncular 
space  may  paralyze  both  third  nerves. 

In  Wernicke's  acute  superior  polioencephalitis  there  is  a  destructive 
process  in  the  mid-brain,  and  sometimes  in  the  gray  matter  of  the  third 
ventricle.  The  floor  of  the  aqueduct  of  Sylvius,  hence  the  oculomotor 
nuclei,  and  even  the  peduncles,  are  involved.  The  symptoms  are  paralysis 
of  the  third  and  fourth  nerves,  nystagmus,  optic  neuritis,  and  rapid  pros- 
tration, sometimes  with  ataxia,  dysarthria,  and  even  paralysis  of  the  face 
and  extremities.     Death  is  common  in  from  eight  to  fourteen  days. 

Hemorrhage  and  softening  in  the  mid-brain  are  rare.  The  symptoms 
are  those  of  a  focal  lesion,  such  as  ophthalmoplegia  of  various  kinds,  accord- 
ing to  the  nuclei  involved,  hemiplegia  alternans,  etc. 

Diagnosis. — This  rests  upon  the  grouping  of  symptoms  as  described 
above.  The  most  characteristic  is  the  hemiplegia  alternans,  in  which  the 
third  nerve  is  paralyzed  on  the  side  of  the  lesion  and  the  hemiplegia  is  on 
the  opposite  side.  In  Wernicke's  disease  the  association  of  symptoms  and 
the  rapidly  acute  course,  often  with  fatal  ending,  are  characteristic.  The 
disease  is  to  be  distinguished  from  bulbar  palsy  by  the  history  and  course 
and  especially  by  the  different  cranial  nerves  involved.  In  the  mid-brain 
lesion  the  eyes  are  paralyzed;   in  the  bulbar  lesion,  the  tongue  and  lips. 

Interpeduncular  syphilitic  meningitis  is  distinguished  by  the  head- 
ache, the  third  nerve  palsy,  the  irregular  course,  the  absence  usually  of 
hemiplegia,  and  the  history.  There  may,  however,  be  hemiplegia  if  either 
peduncle  is  softened  by  syphilitic  endarteritis.  Complete  paralysis  of  both 
third  nerves  is  not  common;  in  fact,  the  third  nerve  palsy  may  change 
from  time  to  time,  and  it  is  usually  unilateral. 

XVIII.  NUCLEAR  OPHTHALMOPLEGIA. 

By  this  term  is  meant  an  affection  in  which  the  muscles  of  the  eye- 
balls and  upper  lids  are  paralyzed  by  reason  of  disease  of  the  nuclei  of 
their  motor  nerves.  The  disease  is  often  chronic  and  selective,  for  it  picks 
out  gradually  the  nuclei  of  the  third  and  fourth  nerves,  which  are  in  the 
mid-brain,  and  those  of  the  sixth  nerves,  which  are  in  the  pons,  some 
distance  away.  Consequently  it  is  neither  a  purely  mid-brain  nor  a  purely 
pontile  disease. 

Hutchinson  was  one  of  the  first  to  describe  a  pure  nuclear  ophthal- 
moplegia. Later  Wernicke  described  an  acute  destructive  process  invad- 
ing the  floor  of  the  aqueduct  of  Sylvius  and  neighboring  parts  in  the 
mid-brain,  which  he  called  superior  polioencephalitis  to  distinguish  it  from 
bulbar  disease,  which  he  called  inferior  polioencephalitis;  but  cases  of  this 
affection  often  present  other  than  purely  nuclear  ophthalmoplegic  sjmip- 
toms,  as,  for  instance,  optic  neuritis,  nystagmus,  facial  paresis,  dysarthria, 
ataxia,  and  even  hemiplegia;  in  other  words,  it  is  not  a  purely  nuclear 
disease.  It  is  best  to  limit  the  description,  therefore,  to  the  nuclear  disease, 
a  sufficient  number  of  cases  of  which  have  now  been  reported  to  entitle  it 
to  distinction  as  a  substantive  affection. 


1292 


MEDICAL  DIAGNOSIS. 


Pathology. — The  disease  process  has  some  resemblance  to  the  chronic 

or  subacute  forms  of  anterior  poliomyehtis,  inasmuch  as  the  multipolar 
ganglion  cells  are  gradually  destroyed.  From  this  form  there  are  all 
grades,  apparently,  up  to  the  highly  acute  types  in  which  the  process 
is  more  wide-spread  and  the  case  may  end  fatally  in  a  few  days. 

Symptoms.  —  Brissaud  has  proposed  a  useful  classification  of  the 
ophthalmoplegias  as  follows:  The  affection  is  total  if  all  the  muscles  of  the 
eyes,  both  exterior  and  interior,  are  involved;  'partial,  if  only  some  muscles 
are  paralyzed;  complete,  if  the  paralysis  in  the  affected  muscles  is  absolute; 
and  incomplete,  if  the  affected  muscles  are  not  absolutely  paralyzed,  but 
only  paretic.  Hutchinson  describes  an  ophthalmoplegia  externa  in  which 
the  interior  muscles,  that  is,  the  iris  and  ciliary  muscle,  escape;  and  the 
opposite  form  is  the  ophthalmoplegia  interna  in  which  only  the  iris  and 

ciliary  muscle  are  paralyzed.  This 
is  possible,  because  the  nuclei  for 
the  iris  and  ciliary  body  lie  some 
distance  anterior  to  the  other  nuclei. 
Finally,  ophthalmoplegia  may  be 
either  unilateral  or  bilateral,  but  the 
unilateral  cases  are  never  nuclear, 
as  will  be  explained  later.  All  these 
nuclei,  except  the  sixth,  lie  under- 
neath the  aqueduct  of  Sylvius ; 
those  for  the  iris  and  ciliary  body, 
however,  lie  somewhat  farther  for- 
ward, even  in  the  walls  of  the 
third  ventricle. 

In  a  case,  studied  by  Lloyd,  the 
patient,  a  woman  aged  35,  noticed 
first  external  strabismus  in  the  right 
e5^e,  then  ptosis,  then  extel-nal  stra- 
bismus in  the  left  eye,  and  finally,  after  some  months,  loss  of  all  ocular  move- 
ments except  in  the  left  external  rectus.  This  patient  had  headache  and 
abolished  knee-jerks,  but  no  fulgurant  pains  and  no  ataxia.  There  was  pos- 
sibly some  beginning  optic  atrophy.  No  history  of  syphilis  was  obtainable. 
In  most  of  the  described  cases  this  gradual  progress  has  been  noted, 
significaht  of  a  slowly  progressive  nuclear  disease.  First  one  ocular  muscle 
and  then  another,  in  one  eye  and  then  in  the  other,  becomes  paralyzed 
until  all,  or  nearly  all,  are  involved.  Various  forms  of  strabismus  occur, 
until  the  eyeballs  become  motionless  and  ptosis  is  complete.  It  is 
occasionally  seen  in  young  persons,  even  in  children,  and  Mobius  called 
it  then  ''infantile  nuclear  atrophy." 

Diagnosis. — Syphilitic  meningitis  between  the  cerebral  peduncles 
may  involve  the  roots  of  the  third  nerves,  and  may  possibly,  but  not 
probably,  extend  to  the  sixth.  Headache  is  present,  and  possibly  optic 
neuritis,  but  the  resemblance  to  nuclear  disease  may  be  striking.  Syph- 
ilis, however,  would  hardly  give  the  picture  of  gradual  and  persistent 
progress,  without  remission,  with  first  one  muscle  and  then  another  in 
each   eye   becoming    paralyzed.      Syphilis    of    the    third    nerve    is   often 


riG.379. — Nuclear  ophthalmoplegia. — Philadelphia 
Hospital — Lloyd. 


NUCLEAR  OPHTHALMOPLEGIA. 


1293 


unilateral.  Moreover,  in  interpeduncular  syphilis  the  paralysis  is  confined 
to  the  third  nerve;    the  fourth  and  sixth  escape. 

Tumor  of  the  mid-brain  does  not  invade  the  nuclei  alone;  it  usually 
causes  paralysis  of  the  limbs,  sometimes  a  hemiplegia  alternans,  that  is, 
paralysis  of  the  third  nerve  on  the  side  of  the  lesion  with  opposite  hemi- 
plegia; also  optic  neuritis,  headache,  and  pressure  symptoms.  This  may 
be  true,  also,  of  extensive  syphilitic  disease. 

Wernicke's  acute  superior  polioencephalitis  is  known  bj'  its  history, 
its  rapid  course,  its  invasion  of  other  than  nuclear  territory,  and  its 
consequent  wider  range  of  symptoms. 

Nuclear  ophthalmoplegia,  rarely  or  never  total,  occurs  in  locomotor 
ataxia,  but  it  is  not  usually  an  early  symptom,  and  it  is  associated  with 
true  tabetic  symptoms,  such  as  ataxia,  fulgurant  pains,  optic  atrophy, 
lost  knee-jerks,  etc.    The  commonest 
form  is  bilateral  ptosis.     Some 
observers    claim,    however,    that    a 
chronic  progressive  ophthalmoplegia 
is  sometimes    a    precursor    of    tabes 
dorsalis,  combined  sclerosis,  multiple 
sclerosis,  or  even   progressive  mus- 
cular  atrophy.      Hence    a   cautious 
diagno&is  is  called  for,  since  it  may 
take  months  or  even  years  to  deter- 
mine the  question. 

Unilateral  ophthalmoplegia, 
total  and  complete,  is  never  nuclear, 
since  nuclear  disease  is  always  bilat- 
eral. The  one-sided  cases  are  usually 
caused  by  some  local  lesion  at  the 
base  of  the  brain.  The  first  division 
of  the  fifth  nerve  is  likely  to  be 
involved  in  these  basilar  cases ;  hence 
there  is  anaesthesia  of  the  conjunc- 
tiva and  brow  on  one  side;  and  if  the 

second  and  third  divisions  of  the  fifth  nerve  are  involved,  the  anaesthesia 
extends  over  one-half  of  the  face  and  tongue.  These  cases  should  not  be 
mistaken  for  isolated  paralysis  of  individual  nerves,  in  which  the  loss  of 
power  is  confined  to  the  nerve  affected.  The  third  or  the  sixth  nerve  on 
one  side  is  occasionally  paralyzed  by  trauma. 

Paralysis  of  Associated  Movements  of  the  Eyes. — These  are 
the  lateral,  the  upward,  and  the  downward  movements,  and  the  move- 
ment of  convergence.  The  evidence  is  in  favor  of  a  centre  in  the 
brain  cortex  for  associated  ocular  movements.  Griinbaum  and  Sher- 
rington found  a  centre  for  lateral  movements  of  the  head  and  eyes  in 
the  frontal  lobe  somewhat  apart  from  the  rest  of  the  motor  area,  and 
Ferrier  has  shown  from  many  recorded  instances  that  conjugate  deviation 
of  the  head  and  eyes  is  caused  by  a  lesion  in  the  posterior  end  of  the  middle 
frontal  gyrus.  Perinaud,  Mott,  and  others  hold  that  this  ocular  centre  is 
subdivided  for  the  various  associated  movements;    thus,  one  part  is  for 


Fig.  380. — Nuclear  ophthalmoplegia.  Upper 
lids  supported  in  order  to  show  the  position  of  the 
eyeballs. — Philadelphia  Hospital — Lloyd . 


1294 


MEDICAL  DIAGNOSIS. 


the  lateral,  another  for  the  upward,  and  still  another  for  the  downward 
movements.  As  a  fact,  however,  it  is  the  conjugate  lateral  movement 
which  is  usually  affected,  and  this  is  seen  in  a  variety  of  lesions,  as,  for 
instance,  in  large  cerebral  hemorrhage,  and  in  thrombic  and  embolic 
softening.  Any  lesion  which  affects  this  centre  directly  or  cuts  off  its 
underlying  connections  may  cause  conjugate  lateral  deviation  of  the 
head  and  eyes.  The  patient  looks  toward  the  side  of  the  lesion  when  the 
paralysis  is  complete;  but  if  the  lesion  is  an  irritative  one,  as  in  focal  or 
one-sided  epilepsy,  he  looks  away  frojn  the  lesion.  The  lateral  deviation 
of  the  eyes  that  is  caused  by  a  cerebral  lesion  is  usually  temporary,  and  it 
is  associated  with  lateral  deviation  of  the  head.     It  is  thus  distinguished 

from  the  lateral  deviation  of  the 
eyes  which  is  sometimes  seen  in 
lesions  in  the  pons,  located  in  the 
posterior  longitudinal  bundle,  by 
which  the  nuclei  of  the  third, 
fourth,  and  sixth  nerves  are  joined. 
In  these  pontile  cases  the  paralysis 
is  not  transient,  it  is  not  likely  to 
be  associated  with  deviation  of  the 
head,  it  may  be  accompanied  with 
other  pontile  symptoms,  and  the 
deviation  is  sometimes,  but  not 
always,  away  from  the  side  of 
the  lesion. 

Paralysis  of  the  associated 
upward  movements  of  the  eyes  is 
sometimes  seen,  and  is  sometimes 
accompanied  with  paralysis  of 
convergence.  The  associated 
downward  movements  may  be 
paralyzed,  but  this  isolated  paral- 
ysis is  rare;  it  is  usually  associated 
with  paralysis  of  the  upward  move- 
ments. The  lesion  in  these  cases  is  located  on  or  near  the  floor  of  the 
aqueduct  of  Sylvius,  and  it  may  be  a  tumor,  a  syphilitic  inflammation,  or 
a  spot  of  softening.  It  is  possible,  however,  that  paralysis  of  associated 
upward  or  downward  movements  may  be  caused  by  a  lesion  cutting  off 
the  cortical  centres  from  the  nuclei  in  the  mid-brain.  Wernicke  has 
called  this  condition  pseudo-ophthalmoplegia,  and  Lloyd  has  recently 
reported  a  case  of  pseudobulbar  palsy,  due  to  bilateral  lesions  in  the  len- 
ticular nuclei,  in  which  there  was  loss  of  power  in  the  associated  upward 
movement  of  the  eyes. 

Marie  claims  that  paralysis  of  associated  ocular  movements  ma}''  be 
caused  by  hysteria;  but  in  such  a  case  the  affection  would  more  likely  be 
a  spasm  of  the  opposing  muscles  than  a  true  paralysis.  Thus  a  spasm 
of  both  superior  recti  muscles,  pulling  both  eyes  upward,  would  present 
the  appearance  of  a  paralysis  of  the  inferior  recti  and  the  superior 
oblique  muscles,  whose  function  it  is  to  pull  the  eyes  downward.     The 


Fig.  381.- 


-A  case  of  unilateral  ophthalmoplegia.- 
Lloyd. 


DISEASES  OF  THE  CEREBELLUM.  1295 

patient  would  probably  present  other  hysterical  symptoms.  Gilles  de  la 
Tourette  thinks  that  hysterical  paralysis  of  any  of  the  eye  muscles  is  rare, 
and  that  the  real  affection  is  a  spasm  or  contraction  of  the  opposing 
muscles.  There  is,  for  instance,  an  hysterical  blepharospasm  which  may 
simulate  a  bilateral  ptosis. 

The  muscles  of  accommodation  (ciliary)  and  of  convergence  (internal 
rectus)  usually  act  together,  and  in  both  eyes  at  the  same  time.  Thus 
vision  is  accommodated  for  near  objects.  But  the  conjoint  action  of  the 
two  internal  recti  for  convergence  may  be  interfered  with,  and  convergence 
may  be  paralyzed  while  these  two  muscles  continue  to  act  in  other  asso- 
ciated movements.  Perlia  has  described  a  special  nucleus  for  convergence 
beneath  the  middle  line  of  the  aqueduct  of  Sylvius — called  Perlia's  central 
nucleus.  A  destructive  lesion  at  this  point  presumably  causes  isolated 
paralysis  of  convergence;  that  is,  the  internal  recti  muscles  fail  to  turn 
the  eyeballs  inward  in  attempts  at  convergence,  but  they  may  act  properly 
in  associated  lateral  movements  to  the  right  or  left. 

In  determining  these  various  paralyses  of  associated  movements- it 
must  be  borne  in  mind  that  the  eyeballs  roll  away  from  the  paralyzed 
muscles:  thus,  if  the  upward  movement  is  paralyzed  the  eyeballs  roll  down- 
ward, and  vice  versa.  If  there  is  right  conjugate  lateral  deviation,  the  mus- 
cles paralyzed  are  the  left  external  rectus  and  the  right  internal  rectus. 

XIX.  DISEASES  OF  THE  CEREBELLUM. 

Tumor,  abscess,  and  other  focal  lesions  of  the  cerebellum  have  been 
considered  under  a  previous  heading.  Besides  tumor  and  abscess  there 
are  occasionally  seen  softening  and  terminal  cysts  in  the  cerebellum,  due 
to  occlusion  of  the  blood-vessels,  as  in  syphilis  and  atheroma.  Exten- 
sive softening  of  one  cerebellar  hemisphere  may  occur  with  little  or  no 
evidence  of  cerebellar  disease.  Atrophy  and  sclerosis  of  the  cerebellum 
are  also  seen  in  cases  of  arrest  of  development,  and  in  the  cerebellar  form 
of  hereditary  ataxia. 

Symptoms. — In  gross  lesions  of  the  cerebellum  incoordination  and 
forced  movements  are  often  seen.  There  may  be  wide  staggering  and 
swaying,  the  patient  standing  with  the  legs  far  apart,  or  there  may  be 
reeling  and  even  rotary  movements.  These  symptoms  are  attributed  to 
lesions  of  the  middle  lobe.  Forced  movements  are  supposed  to  depend 
rather  on  lesion  of  the  middle  cerebellar  peduncles.  They  may  be  so 
aggravated  that  the  patient  cannot  even  sit  upright  in  bed,  but  is  forced 
to  one  side.  Paralysis  of  the  oculomotor  nuclei  is  sometimes  caused  by 
pressure  on  the  mid-brain;  and  pontile  symptoms,  such  as  paralysis  of  the 
fifth,  sixth,  seventh,  and  eighth  nerves,  and  even  hemiplegia,  are  also 
caused  by  gross  lesions  of  the  cerebellum  pressing  on  the  pons.  Optic 
neuritis  or  atrophy  is  common,  and  headache,  vomiting,  and  vertigo  are 
seen  just  as  in  other  intracranial  affections.  When  one  cerebral  hemi- 
sphere is  alone  affected  there  may  be  few  if  any  symptoms,  but  this  is 
not  a  universal  rule.  The  knee-jerks  are  variously  affected.  In  some 
cases  of  tumor  or  abscess  they  disappear,  and  even  return  again,  or  they 
are  merely  exaggerated  or  diminished,  as  the  case  may  be,  or  they  are 


1296  MEDICAL  DIAGNOSIS. 

not  the  same  on  both  sides.  The  functions  of  the  cerebellum  are  still 
obscure,  but  they  evidently  are  largely  concerned  with  equilibration,  as 
is  proved  by  the  diseases  of  the  organ. 

Cerebellar  hereditary  ataxia  is  an  affection  nearly  allied  to  the 
spinal  hereditary  ataxia  of  Friedreich,  but  there  are  well-marked  differ- 
ences between  the  two.  It  develops  according  to  most  authors  rather 
later  in  life  but  has  in  some  cases  dated  from  a  very  early  period,  if  indeed 
it  were  not  congenital.  In  addition  to  ataxia  there  are  speech  defects, 
not  mere  scanning  but  rather  an  incoordinate  and  explosive  type  of 
speech;  exaggerated  knee-jerks;  and  optic  atrophy.  Nystagmus  is  occa- 
sionally seen.  The  disease  may  be  familial,  as  in  a  remarkable  series  of 
cases  reported  by  Sanger  Brown.  Lloyd  is  convinced  that  there  are  differ- 
ent types  of  cerebellar  ataxia;  that  not  all  are  necessarily  familial  or 
hereditary;  and  that  optic  atrophy  is  not  always  present.  The  most 
typical  symptoms  seem  to  be  the  ataxia,  which  is  not  always  so  extreme 
as  in  Friedreich's  disease,  and  the  incoordinate  explosive  speech.  The 
knee-jerks  are  probably  preserved  or  even  increased  in  most  cases.  Some 
of  these  cases  may  be  due  to  injury  at  birth.  Some  form  of  atrophy  of  the 
cerebellum  has  usually  been  found  after  death,  but  again  the  findings 
have  been  practically  negative.  The  cerebellar  tracts  in  the  cord  were 
involved  in  one  of  Brown's  cases. 

Diagnosis. — The  diagnosis  between  Friedreich's  ataxia  and  the  cere- 
bellar hereditary  ataxia  rests  upon  the  difference  in  the  speech  defects, 
and  upon  the  preservation  or  even  increase  of  the  knee-jerks,  and  possibly 
the  presence  of  optic  atrophy  in  the  latter  form.  In  chorea  there  is  not  a 
true  ataxia  but  rather  involuntary  irregular  movements,  and  an  absence 
of  the  characteristic  speech.  Optic  atrophy  is  not  seen.  The  history 
and  evolution  are  also  different,  chorea  having  a  much  more  abrupt 
onset  and  a  more  acute  course,  with  a  tendency  to  recover.  In  insular 
sclerosis  there  is  intention  tremor  and  spastic  gait,  but  the  nystagmus 
and  affections  of  speech  may  cause  some  resemblance,  and  the  distinction 
should  be  made  with  care. 

XX.  DISEASES  OF  THE  PONS. 

The  pons  is  well  named,  for  it  is  a  bridge  by  way  of  which  many  nerve- 
tracts  take  their  course.  It  is  also  the  seat  of  the  nuclei  of  several  impor- 
tant cranial  nerves,  namely,  the  fifth,  sixth  and  seventh.  The  pyramidal 
or  motor  tracts  from  the  brain  pass  down  through  the  anterior  parts  of 
the  pons,  and  the  great  sensory  tract,  known  as  the  median  and  lateral 
fillet,  passes  upward  through  the  deeper  portion.  The  transverse  fibres 
of  the  pons  connect  the  hemispheres  of  the  cerebellum  with  the  opposite 
cerebral  hemispheres,  and  other  important  cerebellar  connections  are 
probably  made  through  the  middle  peduncles;  and  finally  the  cochlear 
nerve,  or  nerve  of  hearing,  enters  the  lower  outer  part  of  the  pons,  and  it, 
as  well  as  the  auditory  tract  to  the  posterior  quadrigeminal  bodies,  passes 
through  the  mid-region  of  this  great  bridge. 

Pathology. — Tumors,  hemorrhage,  softening,  and  meningitis  are  the 
chief  lesions  here,  as  in  other  regions  of  the  brain. 


DISEASES  OF  THE  PONS. 


1297 


Symptoms. — In  such  a  complicated  structure  the  symptoms  vary 
widely;  one  of  the  most  characteristic  symptoms  is  the  hemiplegia  alter- 
nans,  in  which  there  is  an  opposite  hemiplegia  with  paralysis  of  the 
sixth  nerve  causing  internal  strabismus,  and  of  the  seventh  nerve  causing 
facial  paralysis  on  the  side  of  the  lesion;  in  some  cases  the  fifth  is 
also  involved,  also  the  eighth.  The  sixth  nerves,  which  pass  out  near  the 
median  line,  may  both  be  involved  even  in  a  lesion  which  is  mainl}^  uni- 
lateral. The  above  symptom-complex  points  to  a  lesion  in  the  lower  and 
anterior  half  of  the  pons,  and  if  it  is  a  tumor  it  is  most  likely  to  be  menin- 
geal and  located  in  the  cerebellopontile  angle.  Mills  has  reported  a  case 
of  limited  softening  in  the  lower  ventral  part  of  the  pons  near  the  median 
line,  in  which  paralysis  of  the  left  sixth  and  paresis  of  the  right  sixth  nerve 
were  associated  with  left  hemiplegia.  There  apparently  was  no  facial  palsy. 
The  facial  nerve  may  exhibit  remarkable  resisting  power,  as  in  a  case 
observed  by  Lloyd,  in  which  the  seventh  nerve  was  bent  over  the  surface 
of  a  tumor  in  this  region,  and  yet  there  had  been  no  paralysis  of  the  face. 
In  some  cases  both  roots  of  the  auditory  nerve  are  not  simultaneously 
involved;  as  one  of  these  roots  subserves  hearing  (the  cochlear  nerve)  and 
the  other  probably  subserves  equilibration  (the  vestibular  nerve),  it  is 
well  to  test  these  two  functions  separately. 

If  the  lesion  is  high  in  the  pons,  above  the  level  where  the  motor  tracts 
for  the  sixth  and  seventh  nerves  decussate,  the  paralysis  of  these  nerves  will 
be  on  the  side  opposite  the  lesion  and  on  the  same  side  as  the  hemiplegia. 

Involvement  of  the  fifth  nerve 
causes  anaesthesia  of  one  side  of  the 
brow,  face,  and  tongue  (in  whole  or 
in  part,  according  to  the  extent  of 
the  involvement),  the  eyeball  of  the 
affected  side,  and  paralysis  of  the 
muscles  of  mastication  —  the  tem- 
poral, masseter,  and  pterygoids.  A 
neuroparalytic  ophthalmia  may 
result  and  totally  destroy  the  eye. 

Superficial  or  meningeal  lesions, 
unless  they  make  deep  pressure,  are 
not  likely  to  involve  the  sensory 
tract  (the  fillet),  which  lies  deeply 
within;  nevertheless  in  all  cases  of 
suspected  pontile  lesion  the  limbs 
should  be  carefully  tested  for  anaes- 
thesia, including  the  tactile,  the 
thermal,    and   the   pain  senses. 

Deep  lesions  of  the  pons  may 
cause  headache,  vertigo,  hemiplegia, 
hemiansesthesia,  dysarthria,  paraly- 
sis of  the  tongue  (not  nuclear),  con- 
vergent strabismus  or  even  lateral  deviation  of  the  eyes,  inability  to 
swallow,  and  intense  emotionalism,  with  involuntary  spasmodic  laughter  in 
some  cases.  Rotation  of  the  head  to  one  side  has  been  noted;  also  }irofuse 
82 


Fig.  382. — Woman  with  deviation  of  the  eyes 
toward  the  right,  of  tlie  head  toward  the  left. 
Case  of  hemiplegia  alternans  inferioris  encephahti- 
di.s  pontis  (crossed  lieiniplegia  from  inferior  enceph- 
ahtis  of  the  pous). — Oppenheim. 


1298  MEDICAL  DIAGNOSIS. 

sweating,  vasomotor  symptoms,  and  even  epistaxis.  Conjugate  deviation 
of  the  head  and  eyes  is  said  to  be  caused  sometimes  by  a  lesion  high 
in  the  pons.  Deviation  of  the  eyes  is  away  from  the  side  of  the  lesion  if 
this  is  in  the  posterior  longitudinal  fasciculus;  and  cases  have  been 
reported  in  which  the  eyes  were  rolled  to  one  side  and  the  head  to  the 
other  in  the  hemiplegia  alternans. 

The  symptom-complex  described  as  pseudobulbar  palsy  is  probably 
caused  in  some  cases  by  a  pontile  lesion. 

Diagnosis. — This  is  made  from  the  pecuhar  grouping  of  symptoms 
as  given  above.  A  question  may  arise  as  to  the  nature  of  the  lesion,  whether 
it  be  a  tumor,  a  hemorrhage,  a  softening,  or  a  syphilitic  meningitis.  Tumor 
is  usually  slow  in  onset  and  gradual  in  its  course;  hemorrhage  and  softening 
abrupt  in  onset  and  not  progressive;  syphilitic  meningitis  may  not  be  easily 
distinguishable  from  tumor,  but  irregularity  in  the  development  and  course 
of  the  symptoms,,  as  well  as  a  luetic  history,  points  to  specific  disease. 

XXI.  BULBAR  PALSY. 

In  the  account  of  progressive  muscular  atrophy  and  amyotrophic 
lateral  sclerosis  the  degeneration  of  the  ganglion  cells  in  the  anterior,  or 
motor,  horns  of  the  spinal  cord,  which  is  characteristic  of  these  diseases,  is 
described.  We  have  now  to  describe  a  disease  which  depends  upon  a 
similar  degeneration  of  motor  gangHon  cells,  but  these  cells  are  located 
higher  in  the  medullary  gray  matter  and  preside  over  special  functions; 
they  are  the  motor  neurons  which  arise  in  the  bulb,  or  medulla  oblongata, 
and  especially  in  the  nuclei  of  the  ninth  (glossopharyngeal),  tenth  (pneu- 
mogastric),  and  twelfth  (hypoglossal)  nerves.  This  disease  is  known  as 
bulbar  palsy,  or  labio-glosso-pharyngeal  paralysis. 

Pathology. — There  is  found  a  degeneration  of  the  large  multipolar 
cells  in  the  nuclei  of  origin  of  the  ninth,  tenth,  and  twelfth  nerves  in  the 
medulla,  and  possibly  of  the  seventh  nerve  in  the  pons.  Thus  in  the  nucleus 
ambiguus,  which  contains  the  motor  cell-bodies  of  the  ninth  nerve,  these 
multipolar  cells  are  found  greatly  changed;  they  have  shrunken  in  size, 
present  evidence  of  chromatolysis  and  displacement  of  the  nuclei,  and  the 
nerve-fibrils  are  diminished  in  number.  In  advanced  or  severe  cases  it  is 
evident  that  many  cell-bodies  have  entirely  disappeared.  The  same  changes 
are  found  in  the  nucleus  of  the  twelfth  nerve,  which  is  entirely  a  motor 
nerve.  In  the  case  of  the  ninth,  which  is  a  mixed  nerve,  the  sensory  ganglia 
(the  jugular  and  petrous)  are  not  involved.  The  diseased  cells,  however, 
are  not  confined  to  the  regions  just  mentioned,  but  are  found  in  that 
rather  extensive  mass  of  gray  matter  in  the  bulb  from  which  arise  motor 
fibres  not  only  for  the  ninth  but  also  for  the  tenth  (pneumogastric)  and 
even  the  spinal  accessory.  In  some  cases  the  roots  of  the  bulbar  nerves 
are  degenerated,  and  occasionally  some  degeneration  is  observed  in  the 
pyramidal  tracts  of  the  cord.  This  sclerosis  of  the  motor  columns  marks 
the  connection  of  this  disease  with  progressive  muscular  atrophy  and 
amyotrophic  lateral  sclerosis,  for  that  there  is"  some  relationship  is  evident 
not  only  from  the  similarity  of  the  degeneration  in  the  motor  nuclei,  but 
from  the  fact  that  bulbar  palsy  may  precede  or  compHcate  either  of  these 
two  diseases,  especially  the  latter. 


BULBAR  PALSY. 


1299 


Symptoms. — The  initial  symptoms  usually  are  disorders  of  speech* 
The  articulation  becomes  imperfect,  especially  for  labials  and  Unguals, 
due  to  beginning  paresis  of  the  lips  and  tongue.  Nasal  speech  occurs,  and 
finally  a  very  distressing  dysarthria,  in  which  the  patient  finds  it  almost 
impossible  to  make  himself  understood.  The  attempt  at  speech  is  fatigu- 
ing, and  finally  may  be  almost  abandoned.  Deglutition  in  turn  becomes 
impaired.  The  patient  can  manage  the  bolus  of  food  only  wath  difficulty, 
especially  in  passing  it  back  into  the  pharynx.  There  may  be  regurgita- 
tion of  fluids  through  the  nose,  or  out  between  the  paralyzed  lips,  and 
attacks  of  strangling,  coughing,  and 
vomiting  result.  Mastication  also  is 
somewhat  impaired.  Phonation  is 
altered,  and  becomes  monotonous. 
Respiration  may  also  be  embar- 
rassed. The  loss  of  power  in  the 
lips  causes  inability  to  whistle  or  to 
show  the  teeth.  The  lower  part  of 
the  face  becomes  immobile  and  ex- 
pressionless; the  lips  are  flaccid  and 
partially  open,  and  drooling  or  drib- 
bling of  saliva  results.  The  tongue 
becomes  so  palsied  that  it  cannot 
be  protruded,  but  lies  almost  or 
quite  motionless  in  the  mouth.  The 
paralysis  is  atrophic;  hence  all  the 
affected  muscles  waste  and  lose  tone. 
The  tongue  is  flabby,  wasted,  and 
fissured.  The  lips  are  thin  and  life- 
less. The  pharyngeal  reflex  may  be 
abolished,  but  sensation  is  not 
involved.  The  velum  palati  hangs 
flaccid,  and  the  laryngoscope  may 
reveal  paralysis  of  the  adductors  of 
the  vocal  cords.  As  a  rule,  the  muscles  of  the  upper  part  of  the  face 
and  of  the  eyes  are  not  involved. 

Occasionally  there  is  evidence  of  lateral  sclerosis,  as  exaggerated 
knee-jerks  and  some  spasticity  of  the  gait.  This  indicates,  as  already 
said,  the  kinship  of  this  disease  to  amyotrophic  lateral  sclerosis. 

The  electrical  reactions  may  be  partially  altered,  but  true  reactions 
of  degeneration  are  seldom  seen.  This  is  for  the  same  reason  that  holds 
in  progressive  muscular  atrophy;  as  long  as  any  muscle  fibres  remain  in 
connection  with  the  gradually  wasting  nuclei  they  react  to  the  current. 

The  onset  of  bulbar  paralysis  is  usually  insidious,  the  course  is 
slow  and  chronic,  and  the  disease  is  incurable.  Acute  cases,  with  rapidly 
developing  symptoms,  have  been  reported,  but  they  are  rare. 

Diagnosis. — There  is  not  much  possibility  of  confusing  true  bulbar 
paralysis  with  any  other  disease.  Diphtheritic  paralysis  has  been  mis- 
taken for  it,  but  in  that  disease  there  is  no  paralysis  of  the  tongue  and  lips, 
and  the  history  and  course  are  different.     The  mistake  is  most  likely  to 


Fig.  383. — Atrophy  of  tongue  due  to  partial  bulbar 
paralysis. — Lloyti. 


1300 


MEDICAL  DIAGNOSIS. 


occur  from  regarding  the  paralysis  of  the  velum  palati  and  the  dysphagia 
as  evidences  of  an  acute  onset  of  bulbar  paralysis;  but  the  history  of  sore 
throat,  the  paralysis  of  accommodation,  and  the  evidences  of  a  multiple 
neuritis  are  usually  sufficient  to  identify  postdiphtheritic  paralysis. 

The  distinction  between  true  bulbar  paralysis  and  myasthenia  gravis 
presents  some  difficulty,  but  the  subject  is  discussed  in  connection  with 
the  latter  disease. 

Organic  disease,  such  as  tumor  of  the  pons  or  medulla,  may  simulate 
bulbar  paralysis — may,  in  fact,  cause  a  bulbar  palsy — but  other  evidences 
will  be  present  of  gross  organic  disease,  such  as  are  described  under  the 
head  of  Tumors  of  the  Brain. 

There  is  an  apoplectic  bulbar  palsy  due  to  hemorrhage  or  vascular 
disease  in  the  bulb  and  pons.  It  may  simulate  atrophic  bulbar  paralysis, 
but  its  sudden  onset,  often  with  apoplectiform  symptoms,  is  characteristic. 
In  some  non-fatal  cases  there  may  even  be  a  tendency  for  some  of  the 
earlier  symptoms  to  improve. 

An  acute  disease  of  the  gray  matter  of  the  bulb,  analogous  to  the  acute 
anterior  poliomyelitis  of  children,  has  been  reported  by  Wernicke  and  others 
— the  so-called  acute  polioencephalitis  inferior.  The  history  and  nature  of 
the  attack  are  usually  sufficient  to  distinguish  it.  The  symptoms  are  those 
of  bulbar  palsy  of  rapid  onset.  Wernicke  associates  this  disease  with  a 
_  _       _     similar  affection  of  the  nuclei  in  the 

;  ]     mid-brain,  causing  ophthalmoplegia 

— the  acute  polioencephalitis  superior. 

XXII.  PSEUDOBULBAR 
PALSY. 

The  term  pseudobulbar  palsy 
applies  to  a  labio-glosso-pharyngeal 
paralysis  which  is  of  cerebral,  not  of 
nuclear,  origin.  To  -understand  it 
we  must  bear  in  mind  that  there  are 
centres  in  the  motor  cortex  of  the 
brain  for  the  hps,  the  tongue,  the 
muscles  of  mastication,  the  pharynx, 
and  the  larynx,  and  that  these  cen- 
tres are  connected  with  the  nuclei  of 
the  facial,  the  motor  branch  of  the 
fifth,  the  hypoglossal,  the  pneumo- 
gastric,  and  the  glossopharyngeal 
nerves  by  the  motor  conducting 
paths,  which  run  down  through  the 
internal  capsule,  cerebral  peduncle, 
and  pons.  These  nuclei  are  located  in  the  pons  and  medulla  oblongata. 
Hence  a  lesion  which  interrupts  these  motor  tracts  from  the  brain  causes 
bulbar  or  pontobulbar  symptoms:  there  is  paralysis  of  the  lips,  tongue, 
and  the  muscles  of  mastication,  of  deglutition,  and  possibly  of  phonation. 
Symptoms. — A  few  such  cases  have  been  reported,  and  the  accompany- 
ing illustrations  represent  two  such  patients  from  the  service  of  J.  Hendrie 


Fig.  384. — Pseudobulbar  palsy,  showing  paral 
ysis  of  the  lips,  tongue,  and  lower  jaw,  from  lesion; 
in  the  lenticular  nuclei. — Lloyd. 


PSEUDOBULBAR  PALSY. 


1301 


Fig.  385.- 


Pseudobulbar  palsy;  involuntary  laufjli- 
ter. — Lloyd. 


Lloyd  in  the  Philadelphia  Hospital.    The  nature  and  location  of  the  lesions 

in  such  cases  are  not  always  clear.    As  the  symptoms  are  usually  bilateral, 

it  is  not  easy  to  interpret  them  as 

due  to  a  unilateral  lesion.    Sometimes  ■       ' 

the  symptoms  in  their  entirety  occur 

only    after   sudden   apoplectiform 

attacks,   and  the   inference  is  that 

bilateral    vascular    lesions,   such    as 

could    be    caused    by    atheroma   or 

syphilis,  are  the  cause.     In  one  of 

Lloyd's  cases  bilateral  lesions  were 

found  in  the   lenticular  nuclei. 

There   may   be    hemiplegic   or 

diplegic    symptoms,    not    always 

well  marked. 

The  muscles  of  the  tongue  and 

lips  and  of  mastication  and  degluti- 
tion may  be  completely  paralyzed. 

In  one  of  the  cases  here  depicted  the 

tongue  was  motionless,  the  mouth 

hung  open  because  of  paralysis  of 

the  temporal  and  masseter  muscles, 

the    lips   were    paralyzed,    and    the 

patient   could   only   swallow  by 

thrusting  the  bolus  of  food  far  back  into    his  pharynx  with  his  finger. 
The  paralysis  is  central,  as  shown  by  the  absence  of  muscular  atrophy, 

of  fibrillation,  and  of  the  reactions  of  degeneration.     A  peculiar  symptom 

is  spasmodic  involuntary  laughter  or 
crying.  It  is  well  shown  in  tile  cuts. 
Brissaud  thought  that  this  indicated 
lesions  of  the  optic  thalami. 

•  Cerebral  symptoms  sometimes 
occur  in  these  patients,  such  as  apha- 
sia, dysarthria,  dementia,  hemianop- 
sia, etc.  There  is  also  seen  in  rare 
cases  conjugate  paralysis  of  the 
eyes;  in  one  of  the  above  cases  there 
was  paralysis  of  the  upward  move- 
ment of  both  eyes. 

Among  other  symptoms  rarely 
seen  are  optic  neuritis  or  atrophy, 
and  respiratory  troubles.  Anses- 
thesia  is  not  commonly  observed. 
There  has  been  more  speculation 
than  actual  post-mortem  o])servation 

fjjout  the  seat  of  the  lesion;   and  Oppenheim,  who  reviews  the  subject,  comes 

to  no  very  definite  conclusion.     Brissaud  places  the  lesion,  or  lesions,  in  the 

posterior  part  of  the  optic  thalami;  ^  this  was  not  so  in  Lloyd's  recent  case. 

1  Legons  sur  les  Maladies  Nerveuses,  Paris,  1895,  p.  440. 


Fig.  386. — Involuntary  laughter  in  a  case  of  pseu 
dobulbar  palsy. — Lloyd. 


1302 


MEDICAL  DIAGNOSIS. 


Diagnosis. — The  disease  is  distinguished  from  true  bulbar  palsy  by 
the  abrupt  onset,  the  central  character  of  the  symptoms, — the  absence  of 
atrophy,  of  fibrillation,  and  of  electrical  changes, — by  the  associated 
cerebral  symptoms,  and  by  the  history. 


DISEASES  OF  THE  CRANIAL  NERVES. 

The  cranial  or  cerebral  nerves  comprise  twelve  pairs  ot  symmetri- 
cally arranged  nerve-trunks  which  are  immediately  connected  with  the 
brain  and  pass  through  various  foramina  at  the  base  of  the  skull  to  be 
distributed,  with  the  exception  of  the  tenth  pair,  to  the  structures  of 
the  head  and  neck. 

These  pairs  of  nerves  are  numbered  according  to  the  order  in  which 
they  penetrate  the  dura  from  before  backward  from  the  first  to  the  twelfth. 
They  have.,  moreover,  received  designations  descriptive  of  their  functions 
or  distribution.  Some  of  them  are  wholly  motor;  others  convey  impulses 
of  special  sense;  while  certain  of  them  transmit  impulses  of  common  sen- 
sation and  motion. 

THE  CRANIAL  XERVES. 


I 

II 
III 

IV 

v 

VI 

vn 


VIII 

IX 

X 


XI 

xn 


Olfactory 

Optic 

Oculomotor 

Trochlear 

Trigeminal 

AbdnceBt 

Facial 

Auditory, 

( a)  Cochlear  division  . 

(b)  Vestibular  division 
Glossopharyngeal 


Pneumogastric  or  vagus . 


Spinal  accessory. 
Hypoglossal 


Function. 


Special  sense  of  smell. 

Special  sense  of  sight. 

Motor  to  eye  muscles  and  levator  palpebrse  superioris. 

Motor  to  superior  oblique  muscle. 

Common  sensation  to  structures  of  head. 

Motor  to  muscles  of  mastication. 

Motor  to  external  rectus  muscle. 

Motor  to  muscles  of  head  (scalp  and  face)  and  neck  (platysma). 

Probably  secretory  to  submaxillary  and  sublingual  glands. 

Sensory  "(taste)  toanterior  two-thirds  of  tongue. 

Hearing. 

Equilibration. 

Special  sense  of  taste. 

Common  sensation  to  part  of  tongue  and  to  pharynx  and  middle  ear. 

Motor  to  some  muscles  of  pharynx. 

Common  sensation  to  part  of  tongue,  pharynx,  oesophagus,  stomach, 
and  respiratory  organs. 

Motor  (in  conjunction  with  bulbar  part  of  spinal  accessory)  to  mus- 
cles of  pharynx,  cesophagus,  stomach  and  intestine,  and  respiratory 
organs :  inhibitory  impulses  to  heart. 

Spinal  part :  Motor  to  sternomastoid  and  trapezius  muscles. 

Motor  to  muscles  of  tongue. 


Modern  knowledge  concerning  the  relative  position  of  the  cell-bodies 
of  motor  and  sensory  neurons  renders  necessary  a  readjustment  of  the 
former  views  concerning  the  superficial  and  deep  origin  of  the  cranial 
nerves  and  their  course  from  the  brain  to  parts  outside  the  skull.  Only  the 
motor  fibres  of  the  cranial  nerves  arise  from  nerve-cells  within  the  cere- 
brospinal axis,  while  the  fibres  which  transmit  sensory  impulses  have 
their  origin  from  cell-bodies  forming  ganglia  situated  outside  of  the  central 
nervous  system  and  in  the  course  of  the  nerve- trunks.  The  term  "  deep 
origin"  as  indicating  cell-groups  constituting  nuclei  within  the  brain  and 
''superficial  origin"  as  indicating  the  point  of  attachment  to  the  surface 
of  the  brain  can  only  be  properly  employed  in  regard  to  motor  nerves  and 
the  fibres  of  motor  and  sensory  nerves  which  convey  motor  impulses. 


DISEASES  OF  THE  CRANIAL  NERVES.  1303 

The  cell-groups  with  which  the  terminal  arborizations  of  the  sensory  fibres 
come  into  relation  within  the  cerebral  substance  are  not  nuclei  of  origin 
but  of  termination — nuclei  of  reception.  The  impulses  which  they  receive 
are  transmitted  to  various  parts  of  the  brain  by  neurons  of  the  second, 
third,  or  even  higher  order.  The  motor  nerves  then  have  their  deep  origin 
within  the  substance  of  the  brain,  their  superficial  origin  at  the  point  of 
their  attachment  to  the  surface  of  the  brain,  and  their  exit  from  the  skull 
by  the  various  foramina.  The  sensory  nerves  have  their  origin  in  their 
respective  ganglia,  their  entrance  into  the  skull  by  way  of  certain  foramina, 
their  points  of  attachment  to  the  brain,  and  their  nuclei  of  reception. 
Finally,  the  nerves  of  common  sensation  and  motion,  viewed  from  the 
standpoint  of  the  direction  of  the  impulses  which  they  convey,  whether 
the}'-  be  afferent  or  efferent,  contain  fibres  which  enter  the  brain  and  fibres 
which  make  their  exit  by  way  of  the  respective  foramina. 

Every  cranial  nerve  is  directly  or  indirectly  in  relation  with  groups 
of  neurons  in  the  cerebral  cortex.  These  groups  constitute  the  higher 
cortical  centres,  the  location  of  which  in  the  case  of  many  of  the  nerves 
has  been  more  or  less  accurately  determined. 

I.  FIRST  NERVE. 

The  term  olfactory  nerve,  formerly  employed  to  designate  the  olfac- 
tory bulb  and  tract  as  well  as  the  filaments,  is  now  employed  to  describe 
the  paths  of  conduction  represented  by  a  number  of  minute  filaments 
which  connect  the  perceptive  elements  situated  within  the  Schneiderian 
mucous  membrane  with  the  olfactory  lobe.  In  man  the  olfactory  bulb 
and  tract  with  its  roots  represent  as  rudimentary  structures  the  more 
developed  olfactory  lobe  of  animals  in  which  the  sense  of  smell  is  keen. 
The  true  olfactory  nerves,  which  number  about  twenty,  are  the  axons  of 
the  neurons — the  olfactory  cells — which  are  situated  in  the  olfactory 
area.  This  space  is  limited  in  extent,  .comprising  on  the  outer  nasal 
wall  less  than  the  mesial  surface  of  the  superior  turbinate  bone  and  a 
slightly  more  extended  distribution  upon  the  upper  part  of  the  nasal 
septum.  These  filaments  pass  upAvard  by  way  of  openings  in  the  crib- 
riform plate  of  the  ethmoid  bone  and  enter  the  olfactory  bulb  by  its 
under  surface. 

Lesions  of  the  nasal  mucous  membrane  involving  the  olfactory  area  or 
the  upper  turbinate  bone  or  the  adjacent  part  of  the  septum,  are  attended 
with  impairment  or  loss  of  the  sense  of  smell.  Lesions  of  the  uncinate 
gyrus  may  also  cause  loss  of  smell  upon  one  or  both  sides.  The  conduction 
path  may  also  be  destroyed  in  fractures  of  the  base  of  the  skull  in  the 
anterior  fossa,  involving  the  cribriform  plate.  Irritative  lesions  cause- 
perversion  of  the  sense  of  smell — parosmia;  destructive  lesions  partial  or 
complete  loss — anosmia.  Hallucinations  of  the  olfactory  sense  may  be 
symptomatic  of  hysteria,  insanity,  or  tabes,  and  constitute  one  of  the 
various  forms  of  aura  in  epilepsy. 

The  sense  of  smell  may  be  tested  by  presenting  to  each  nostril  in 
turn  bottles  containing  familiar  aromatic  substances,  as  the  oils  of  clove, 
peppermint,  or  asafa^tida. 


1304  MEDICAL  DIAGNOSIS. 

II.   SECOND  NERVE. 

The  ganglion  cells  among  the  rods  and  cones  of  the  retina  are  the 
beginnings  of  the  optic  nerve;  its  apparent  origin  at  the  papilla  is  simply 
the  point  where  the  axons  from  these  retinal  cell-bodies,  coming  together, 
form  the  trunk  of  the  nerve. 

The  ophthalmoscope  is  of  special  value  in  neurologic  diagnosis  because 
it  lays  bare,  in  the  papilla,  a  great  nerve  close  to  the  brain.  Of  the  lesions 
thus  directly  revealed,  papilhtis  or  optic  neuritis  is  usually  a  symptom  of 
intracranial  pressure  or  inflammation.  When  attended  with  much  swell- 
ing it  becomes  "  choked  disk,"  since  the  optic  foramen,  unyielding,  squeezes 
the  swollen  fibres.  For  the  same  reason  optic  neuritis  is  prone  to  pass  into 
optic  atrophy;  but  the  latter  is  often  primary,  as  in  tabes,  the  optic  nerve 
being,  hke  other  sensory  roots,  hable  to  degeneration  in  this  disease. 

For  the  consideration  of  vision  in  neurology,  the  retina  is  divided  into 
lateral  halves.  The  fibres  from  the  right  half-retinas  (nasal  half  of  left 
retina,  temporal  half  of  right)  run  together  at  the  chiasm  to  form  the  right 
optic  tract.  Their  arrangement  is  like  that  of  the  lines  for  driving  a  team 
of  horses,  the  right  line  (as  the  optic  tract)  dividing  to  go  to  the  right 
side  of  each  horse's  head  (as  to  the  right  half  of  each  retina)  and,  mutatis 
mutandis,  the  same  applies  to  the  left  half-retinas.  The  partial  decussa- 
tion at  the  chiasm,  then,  is  a  device  to  make  the  two  eyes,  like  a  team  of 
horses,  act  as  one  (binocular  vision). 

The  optic  tract  passing  back  winds  around  the  brain-stem  (crus)  to 
enter  it  dorsally  after  the  manner  of  spinal  sensory  roots.  It  meets  here  its 
superior  cell-bodies  in  three  structures,  the  pregeminum,  the  pregeniculum, 
and  the  pulvinar,  which  constitute  the  ''primary  optic  centres."  From 
these  cell-bodies,  axons  (the  optic  radiations)  arise  to  pass  into  the 
posterior  part  of  the  internal  capsule  and  outside  the  posterior  horn  of  the 
lateral  ventricle  to  the  cortical  optic  centre  in  the  cuneus,  or,  more  exactly, 
in  the  region  bordering  the  calcarine  fissure.  Lesion  at  any  point  in  this 
path  from  the  chiasm  to  the  occipital  cortex  affects  the  half-retinas  of  the 
same  side.  Thus  it  appears  that  physiologically  there  is  no  cross-way  in 
the  optic  path  within  the  brain;  yet  just  as  an  object  touching  the  left 
side  of  the  body  is  felt  in  the  right  half  of  the  cerebrum  through  a  cross- 
ing within  the  brain-stem,  so  an  object  on  the  left  (in  the  left  half-field  of 
vision)  is  seen  by  the  right  half  of  the  cerebrum  through  a  crossing,  not  of 
nerve-fibres  but  of  rays  of  light  within  the  eyeballs  (vitreous  chambers) ;  and 
as  lesion  of  the  right  touch-path  (fillet)  causes  left  hemiansesthesia,  so  lesion 
of  the  right  optic  path,  by  affecting  the  right  half-retinas,  causes  blindness 
of  the  left  half-fields,  called  left  hemianopsia.  The  varieties  of  hemianopsia 
•  are  named  by  the  fields  which  are  darkened,  not  by  the  blind  part  of  the 
retina.  Tumor  of  the  pituitary  body  by  pressure  at  the  chiasm  destroying 
the  inner  fibres  of  each  nerve  from  the  nasal  half  of  each  retina  causes 
temporal  hemianopsia.     More  severe  pressure  may  cause  total  blindness. 

The  optic  tract  may  be  pressed  upon  by  tumor  at  the  base,  some- 
times growing  from  the  temporal  lobe.  There  is  hemianopsia,  with 
Wernicke's  sign  and  general  symptoms  of  brain  tumor.  The  primary 
optic  centres  may  be  the  seat  of  a  tumor  or  they  may  be  pressed  upon 
bv  a  tumor  of  the  middle  lobe  (vermis)  of  the  cerebellum. 


DISEASES  OF  THE  CRANIAL  NERVES. 


1305 


The  optic  radiations  may  be  involved  in  tumor,  hemorrhage,  or  soft- 
ening at  the  hind  part  of  the  internal   capsule,   adding    hemianopsia    to 
the  symptoms  of  capsular  lesion;    or  one  of  these  lesions  may   implicate 
the  radiations  farther  back  in 
the  subcortex,  when   hemian- 
opsia  may  exist    alone;    or    a 
lesion  in  the  angular  gyrus  may 
invade  the  radiations  beneath, 
adding    hemianopsia    to    the 
cortical    symptoms    of    mind- 
blindness,  etc. 

Lesions  in  the  vicinity  of 
the  calcarine  fissure  cause 
hemianopsia;  occasional!}' 
they  are  bilateral,  causing 
double  hemianopsia  which 
amounts  to  total  blindness 
(amaurosis).  The  half-retinas 
are,  as  it  were,  mapped  out 
upon  the  cuneus,  so  that,  half 
of  it  being  destroyed,  there  is 
blindness  in  a  quarter  of  the 
opposite  fields  (quadrantic 
hemianopsia).  Color  appears 
to  be  separately  represented. 
On  the  outer  surface  of  the 
cerebrum,  in  the  angular  gyrus, 
apparently,  is  a  higher  centre 
for  visual  concepts.  "With 
lesion  there  the  patient  has 
mind  -  blindness,  including 
word-blindness. 

The  mid-brain,  receiving 
the  great  sensory  eye-nerve 
(optic),  sends  back  to  the  eye 
its  chief  motor  nerve  (third 
or  motor  ocuH).  These  two 
nerves  are  the  limbs  of  the 
reflex- arc  through  which  the 
pupils  react  to  light;  and  lesion 
of  either  may  cause  among 
other  symptoms  impairment 
of  the  light  reflex. 

Wernicke's  "  hemianopic 
pupillary  inaction"  is  a  sign  of  lesion  at  the  base  of  the  brain  (see  p.  373). 

The  third  nerve  nuclei  just  beneath  the  anterior  gemina  are  connected 
with  these  bodies,  or  with  the  optic  tract  in  front  of  them,  by  collateral 
fibres  to  complete  the  light  reflex  arc,  and  lesion  (usually  tabetic  or  paretic 
degeneration)  of  these  collaterals  may  impair  the  light  reflex  alone,  causing 


occ:  i  ^^ 

CUNEUS. 

Fig.  387. — Diagram  of  visual  system.  Modified  from 
Vialet.  OP.  T.,  optic  tract ;  INT.  CAP.,  internal  capsule  ; 
OP.  R.,  optic  radiation;  THO.,  optic  thalamus  ;  EXT.  GEN., 
external  geniculate  body;  C.  QU.,  corpora  quadrigemina ; 
MS.,  motor  speech  centre;  AS.  auditory  speech  centre; 
VS.,  visual  speech  centre. 

Lesions  at  the  points  indicated  by  the  figures  in  the  dia- 
gram cause  the  following  morbid  conditions  :  1,  blindness 
of    the    corresponding   eye;     2,    bitemporal    hemianopsia; 

3,  nasal     hemianopsia;     3,   and   3',    binasal    hemianopsia; 

4,  right  lateral  homonymous  hemianopsia  with  Wernicke's 
hemianopic  pupillary  inaction  sign;  .5,  left  lateral  homon- 
ymous hemianopsia  with  normal  pupillary  reflexes  ;  6,  right 
lateral  homonymous  hemianopsia  with  normal  pupillary 
reflexes;  7,  amblyopia  'especially  on  the  side  opposite  the 
lesion)  ;    8,  on  the  left  side,  word-blindness. 


1306  MEDICAL  DIAGNOSIS. 

reflex  iridoplegia  without  other  eye-symptoms.  Loss  of  the  hght-reaction 
of  the  iris  with  the  preservation  of  the  reaction  in  convergence  and  accom- 
modation is  called  the  Argyll-Robertson  pupil.  It  occurs  in  tabes  and  in 
paresis. 

OPTIC    NEURITIS— PAPILLITIS. 

Inflammation  of  the  optic  nerve,  visible  with  the  ophthalmoscope. 
When  the  swelling  causes  bulging  of  the  nerve-head  to  the  extent  of  two 
diopters  or  more  it  is  called  choked  disk.  An  affection  of  the  nerve 
back  of  the  eyeball,  causing  peculiar  symptoms,  is  called  retrobulbar 
neuritis.  Sclerosis  of  the  nerve,  seen  in  the  papilla,  is  optic  atrophy. 
Ordinarily,  as  the  sequel  of  optic  neuritis,  it  is  consecutive  atrophy;  when 
a  part  of  the  degeneration  in  tabes,  etc.,  it  is  primary;  when  a  symptom 
of  brain  disease,  like  tumor,  secondary  optic  atrophy. 

Impairment  of  vision  and  of  the  iris-reflex  to  light,  both  in  varying 
degree,  with  ophthalmoscopic  changes  in  the  disk,  indicate  disease  of  the 
optic  nerve.  The  field  of  vision  is  contracted,  sometimes  irregularly.  The 
diagnosis  rests  mainly  upon  ophthalmoscopic  examination;  the  prognosis 
upon  the  cause  of  the  condition.     In  general  it  is  grave. 

III.  THIRD,  FOURTH,  AND  SIXTH  NERVES  (MOTOR 
NERVES   OF   THE   EYE). 

Supplying  the  internal  muscles  of  the  eyeball,  except  the  dilator  fibres 
of  the  iris,  and  the  external  muscles,  except  the  external  rectus  and  the 
superior  oblique,  the  third  nerve  is  the  most  important  motor  nerve  of 
the  eye,  whence  its  name,  motor  oculi. 

As  cortical  centres  control  movements,  not  muscles  or  nerves,  the  third 
nerve  with  its  opposite  actions  is  not  totally  affected  in  cerebral  palsies. 
When  in  a  case  of  head  injury  one  pupil  is  dilated  and  immobile,  this 
(Hutchinson  pupil)  is  said  to  be  pathognomonic  of  extradural  hemorrhage. 

The  internal  rectus,  supplied  by  the  third  nerve,  when  paralyzed,  per- 
mits the  eyeball  to  turn  outward  (divergent  strabismus);  there  is  double 
vision  with  the  secondary  image  on  the  opposite  side  (crossed  diplopia). 
The  inferior  rectus  being  paralyzed,  the  eyeball  fails  to  move  down- 
ward and  to  some  extent  outward;  of  the  double  vision,  the  secondary 
image  is  below.  The  superior  rectus  paralyzed,  the  eyeball  does  not  move 
upward,  nor  perfectly  outward;  the  secondary  image  is  above.  To  look 
with  this  eye  the  head  is  thrown  back.  The  inferior  oblique  is  opposite,  in 
action  and  in  the  effects  of  paralysis,  to  the  inferior  rectus.  The  superior 
oblique,  supplied  by  a  separate  nerve,  the  fourth  or  trochlear,  is  often 
paralyzed;  the  effects  are  opposite  to  those  of  paralysis  of  the  superior 
rectus.  The  fourth  nucleus,  under  the  posterior  geminum,  is  a  continua- 
tion of  the  third.  The  sixth  nucleus,  in  the  lower  part  of  the  pons,  is  another 
link  in  the  chain  of  gray  matter  for  the  ocular  muscles.  The  external 
rectus,  supplied  by  the  sixth  or  abducent  nerve,  is  more  often  affected 
alone  than  any  other  ocular  muscle.  When  the  entire  third  nerve  is  para- 
lyzed the  eyehd  droops  (ptosis),  the  eye  turns  outward  by  the  action  of 
the  sixth  nerve,  and  slightly  downward   by  the  action  of  the  fourth,  the 


DISEASES  OF  THE  CRANIAL  NERVES. 


1307 


pupil  is  larger  than  its  fellow  and  fails  to  react  to  light  or  in  accomniotla- 
tion.  Lesions  of  the  trunk  of  the  nerve  are  generally  unilateral;  the}-  may 
affect  the  extra-ocular  muscles,  while  sparing  the  iris-movements  and 
accommodation.  The  third  nerve- trunk  in  the  orbit  may  be  injured,  as 
by  a  blow  on  the  temple,  or  compressed  by  an  orbital  growth.  It  may 
be  the  seat  of  neuritis,  from  rheumatism,  alcoholism,  or  diphtheria,  or 
of  degeneration  in  tabes.  Within  the  skull  it  may  be  implicated  in  menin- 
gitis or  compressed  by  tumor  or  aneurism.  In  its  course  through  the  crus 
it  may  be  compressed  by  tumor,  or  suddenly  paralyzed  by  hemorrhage, 
embolism,  or  thrombosis,  commonly  associated,  by  implication  of  the 
motor  pathway,  with  hemiplegia  of  the  opposite  side  (Weber's  syndrome). 
In  the  cortex  there  is  no  representation  of  the  third  nerve  as  a  whole,  but 
of  the  various  movements  governed  by  it.  In  traumatism  of  the  con- 
vexity on  one  side  inducing  extradural  hemorrhage,  the  pupil  of  this  side 
may  be  dilated  and  immobile  (Hutchinson  pupil).  Lesions,  as  apoplexy, 
affecting  the  motor  pathway  within  the  cerebrum  often  cause  conjugate 
deviation  of  the  eyes,  with  the  head  ordinarily  toward  the  side  of  the 
lesion.  Finally,  syphilitic  disease,  either  gumma,  meningitis,  or  neuritis, 
often  selects  the  third  nerve.  The  palsy  of  myasthenia  gravis  is  often  in 
the  domain  of  the  third  nerve  (recurring  palsy — ophthalmic  migraine). 
Nuclear  Ocular  Palsies. — (See  p.  1291.) 

IV.  FIFTH  NERVE. 

The  fifth  or  trifacial  is  the  great  nerve  of  common  sensation  for  the 
head.     Its  motor  branch,  for  mastication,  is  subsidiary.    The  surfaces  sup- 


Ophthalmic- 


Maxillary 


Oplithalmic 


.    ,.     Occipitalis 
Ljf^!*^ininor 


Fig.  388. — Showing  distribution  of  cutaneous  brandies  of  trigeminal  and  cervical  spinal  nerves. —  Piersol. 

plied  by  its  three  Ijranches,  namely,  the  ophthalmic  and  the  superioi'  and 
inferior  maxillary  nerves,  are   shown    in   the  accompanying  illustrations. 


1308 


MEDICAL  DIAGNOSIS. 


Supra-troehlear 
1.V 

1.V 
jfaealUV 


Entering  the  cranium — the  first  branch  by  the  sphenoidal  fissure,  the 
second  by  the  foramen  ovale,  the  third  by  the  foramen  rotundum — the 
branches  unite  in  the  Gasserian  ganghon,  thence  to  enter  the  side  of 
the  pons,  midway  between  its  upper  and  lower  borders.  At  this  level, 
in  the  back  of  the  pons  is  the  main  nucleus  of  the  fifth,  but  a  chain  of 
gray  matter  and  connecting  fibres  (mid-brain  root)  extending  alongside  the 
aqueduct  of  Sylvius  forms  the  motor  root,  which  leaves  the  pons  just 
above  the  sensory  root  and  passes  under  the  Gasserian  ganglion,  and  a 
similar  chain  descending  at  the  side  of  the  medulla  conveys  sensory 
impulses  down  to  the  cervical  cord. 

Diseases  of  the  Fifth  Cranial  Nerve. — Branches  of  the  fifth  may  be 
the  seat  of  neuralgia,  from  cold  or  from  dental  affections;    they  may  be 

damaged  by  wounds.  Sclerosis  of 
the  Gasserian  ganglion  may  be  the 
cause  of  facial  hemiatrophy;  it  is 
the  usual  cause  of  trifacial  neuralgia 
or  tic  douloureux,  and  may  be  the 
seat  of  irritation,  giving  rise  to 
herpes  zoster  of  the  face.  Hemor- 
rhage, tumors,,  or  other  lesions  within 
the  pons,  paralyzing  the  fifth,  cause 
anaesthesia  of  various  areas  of  the 
face.  Meningitis,  syphilitic  lesions, 
tumors  beneath  the  pons  often  im- 
plicate the  roots  of  the  fifth. 

Symptoms. — Disease  of  the  fifth 
nerve  may  cause  first  neuralgic  pain, 
but  the  chief  effect  is  anaesthesia  in 
the  distribution  of  one  or  more  of 
its  branches  to  the  middle  line  of 
the  face.  A  touch  upon  the  con- 
junctiva is  not  felt,  and  does  not 
excite  the  flow  of  tears.  Fumes  in  the  nostril  have  no  effect,  and  on  the 
tongue,  especially  its  anterior  two-thirds,  substances  whose  taste-qualities 
are  allied  to  touch  are  not  recognized.  The  salivary  secretion  fails,  the 
mucous  membranes  are  dry,  and  from  slight  injury  ulcers  may  form  upon 
them,  particularly  over  the  cornda,  which  becomes  clouded,  opaque,  and 
may  perforate,  leading  to  panophthalmia  (neuroparalytic  ophthalmia). 
The  motor  portion  of  the  fifth  being  paralyzed,  the  jaws  are  not  closed 
so  firmly  on  the  affected  side,  and  in  opening  deviate  toward  that  side. 
The  weaker  action  of  the  temporal  and  masseter  can  be  felt  by  the  fingers. 
Diagnosis. — Anaesthesia  of  half  the  face,  including  the  mucous  mem- 
branes, when  it  exists  alone  points  to  lesion  of  the  Gasserian  ganglion  or 
of  the  nerve-trunk  between  this  and  the  pons.  Anaesthesia  corresponding 
to  one  branch  of  the  fifth  may  be  due  to  lesion  at  any  point  in  the  course 
of  the  branch.  When  the  fifth  nerve  and  the  cranial  nerves  next  in  order— 
the  sixth  or  seventh,  fourth,  or  third — are  affected  together,  the  lesion  is 
at  the  base  of  the  brain  involving  the  roots  of  these  nerves.  Anaesthesia 
of  one  side  of  the  face  and  of  the  arm  and  leg  of  the  same  side  (hemian- 


FiG.  389.  —  Normal  distribution  of  the  fifth 
nerve  to  the  face.  1.  V,  ophthalmic  division;  S.  V, 
superior  maxillary;  3.  V,  inferior  maxillary.  The 
names  on  the  different  areas  indicate  the  branches 
supplying  them.     (Flower.) — Posey  and  Spiller. 


DISEASES  OF  THE  CRANIAL  NERVES.  1309 

sesthesia)  points  to  lesion  in  the  posterior  third  of  the  posterior  limb  of  the 
internal  capsule;  but  of  the  face  on  one  side  and  of  the  arm  and  leg  opposite 
(crossed  anaesthesia)  lesion  in  the  pons,  on  the  side  of  the  facial  anaesthesia. 
With  the  latter  there  may  be  loss  of  the  associated  movement  of  the  eyes 
to  this  side  and  there  may  be  a  corresponding  crossed  motor  paralysis. 

Differential  Diagnosis. — Hysterical  hemianaesthesia  is  not  associ- 
ated with  dryness  of  the  mucous  membranes;  the  tears  flow  on  irritation  of 
the  conjunctiva  and  the  special  senses  are  afTected  on  the  anaesthetic  side. 

Tic  Douloureux.  —  This  is  an  aggravated  and  persistent  form  of 
neuralgia  in  the  trigeminal  nerve. 

Pathology. — The  disease  has  often  been  described  as  idiopathic,  but 
recent  observations,  especially  by  Horsley,  Rose,  Putnam,  Spiller,  and 
others,  have  tended  to  show  that  there  are  degenerative  or  sclerotic  proc- 
esses in  the  nerve-fibres  and  in  the  Gasserian  ganglion.  The  tendency  for 
the  disease  to  pass  slowly  but  surely  from  one  branch  to  the  other,  even 
after  the  branch  first  affected  has  been  excised,  seems  to  indicate  that  the 
process  spreads  from  one  group  of  neuron  cells  to  the  others  in  the  Gas- 
serian ganglion  in  somewhat  the  same  way  as  the  motor  neurons  of  the 
anterior  horns  of  the  spinal  cord  are  involved  in  progressive  muscular 
atrophy.     The  essential  causes  of  this  process  are  obscure. 

Symptoms.  —  The  chief  and  usually  the  only  symptom  is  pain. 
Lachrymation,  flushing  of  the  face,  and  spasmodic  movements  of  the  facial 
muscles  are  occasionally  seen.  Herpes  has  been  observed  in  some  cases, 
but  it  is  doubtful  whether  it  belongs  to  the  disease  proper. 

The  pain  is  intense,  atrocious,  even  agonizing.  It  sometimes  occurs 
in  paroxysms  or  exacerbations,  but  in  many  cases  there  is  more  or  less 
constant  suffering.  The  paroxysms  are  usually  spontaneous,  but  they 
can  also  be  excited  by  trifling  causes,  such  as  movements  of  the  face, 
attempts  at  talking  or  eating,  or  even  a  draught  of  qold  air.  It  is  character- 
istic of  tic  douloureux  to  begin  in  one  division,  or  even  in  one  branch,  of 
the  fifth  nerve,  and  then  to  spread  in  time  to  other  branches.  The  progress 
is  usually  slow  and  chronic.  Many  cases  -are  operated  on,  but  excision  of 
the  offending  branch,  while  often  giving  relief  for  longer  or  shorter  periods, 
seldom  effects  a  radical  cure,  the  pain  returning  in  another  branch. 

Spasm  of  the  facial  muscles  is  seen  in  some  cases  and  even  consti- 
tutes a  special  type  of  the  disease  (the  so-called  convulsive  or  epileptiform 
tic),  but  it  is  not  common.  The  pains  in  these  cases  are  usually  paroxysmal 
and  severe;  they  occur  with  lightning-like  quickness,  and  the  facial  mus- 
cles are  thrown  into  twitchings  and  spasmodic  movements.  The  taking 
of  food  is  sometimes  seriously  interfered  with  by  the  pain. 

Paralysis  and  anaesthesia  are  not  seen  in  tic  douloureux.  Inhibition 
of  movement  is  caused  by  the  pain  and  the  fear  of  pain,  but  neither 
the  facial  nor  the  masticatory  muscles  (the  latter  of  which  are  supplied 
by  the  motor  branch  of  the  fifth  nerve)  are  truly  paralyzed.  Anaes- 
thesia in  the  territory  of  the  fifth  nerve  is  also  absent  as  an  almost 
universal  rule;  a  few  exceptions  have  been  noted,  but  they  properly 
raise  a  question  whether  the  case  is  typical.  Neurotrophic  disorder  of 
the  eye,  as  seen  in  organic  disease  of  the  fifth  nerve,  is  also  not  observed. 
The  affection  is  unilateral. 


1310  MEDICAL  DIAGNOSIS. 

Diagnosis. — The  disease  is  unmistakable.  The  gradual  establishment 
of  severe  pain  in  one  branch  of  the  fifth  nerve,  its  progress  in  time  to  other 
branches,  its  intractability,  and  the  facial  spasms  (when  they  occur)  are 
easily  recognized.  The  only  doubt  that  may  arise  is  with  reference  to  the 
causation  and  pathology. 

Organic  lesions  of  the  fifth  nerve,  such  as  occur  from  tumors,  meningitis, 
etc.,  may  cause  pain,  but  usually  they  also  cause  anaesthesia  of  the  face, 
brow,  eye,  and  tongue,  and  paralysis  of  the  masticatory  muscles,  and  the 
pain  is  not  always  intense  or  strictly  limited  to  a  branch  of  the  trigeminus. 
Moreover,  in  such  cases  the  symptoms  are  seldom  confined  to  the  fifth  nerve. 

The  term  "epileptiform,"  as  applied  to  the  type  in  which  facial 
spasms  occur,  is  a  misnomer.     The  disease  has  no  relation  to  epilepsy. 

Masticating  Spasm. — Tonic  spasm  in  the  domain  of  the  motor 
fifth  occurs  as  trismus  or  "lockjaw"  in  tetanus;  occasionally  in  tetany, 
in  hysteria,  and  reflexly  in  dental  affections,  like  caries  of  a  molar.  Clonic 
spasm,  noticeable  in  a  chill  and  in  the  epileptic  convulsion,  occurs  rarely 
as  an  isolated  affection  called  "chattering  teeth." 

V.  SEVENTH  NERVE. 

The  seventh  or  facial  nerve,  arising  from  the  nucleus  ambiguus,  passes 
behind  and  over  the  sixth  nucleus  and  out  at  the  side  of  the  pons  near  its 
lower  border.  With  the  eighth  it  enters  the  internal  auditory  meatus, 
then  alone  passes  in  the  Fallopian  canal  close  to  the  tympanum,  and  finally, 
through  the  stylomastoid  foramen,  emerges  upon  the  face. 

Paralysis  of  the  facial  muscles  may  be  supranuclear  or  central  as  the 
result  of  lesion  of  the  centre  in  the  lower  Rolandic  cortex,  or  of  the  fibres 
from  this  centre  passing  down  through  the  brain,  commonly  as  a  part  of 
hemiplegia;  or  nuclear  in  consequence  of  lesion  of  the  nucleus  in  the  pons; 
or  infranuclear  from  lesion  of  the  nerve-trunk  at  any  point.  The  ordinary 
form  of  facial  palsy  is  "peripheral"  from  neuritis  in  the  Fallopian  canal, 
and  is  called  Bell's  palsy.  Hemorrhage  or  softening  in  the  pons,  damaging 
one  facial  nucleus,  may  paralyze  the  face  on  that  side  and  affect  the  adja- 
cent motor  pathway,  the  arm  and  leg  of  the  other  side  (crossed  paralysis). 
The  seventh  nerve  may  also  be  paralyzed  in  that  rare  form  of  tetanus 
known  as  cephalic  tetanus. 

At  its  emergence  from  the  pons  the  seventh  nerve  may  be  implicated 
in  meningitis,  or  compressed  by  a  new  growth,  which  may  also  involve  the 
sixth  and  eighth  nerves.  Within  the  Fallopian  canal  the  seventh  nerve 
may  be  encroached  upon  by  caries  of  the  temporal  bone  from  middle-ear 
disease.     It  may  be  damaged  in  operations. 

Bell's  Palsy. — This  affection  is  ascribed  to  neuritis  from  exposure. 
The  nerve  swells  in  its  bony  case  and  is  compressed.  The  corresponding 
half  of  the  face  is  rapidly  paralyzed. 

Symptoms. — The  lines  of  expression  are  smoothed  out;  the  mouth 
droops  on  that  side,  and  the  lower  eyelid  sags  and  lets  the  tears  run  down. 
In  "showing  the  teeth,"  the  mouth  and  cheek  are  dragged  toward  the 
sound  side;  in  looking  up.  the  forehead  does  not  wrinkle  on  the  affected 
side;  and  in  the  attempt  to  close  the  eye,  the  lids  remain  apart. 


DISEASES  OF  THE  CRANIAL  NERVES.  1311 

The  palate  moves  sj^mmetrically  and  the  tongue  is  protruded  in  the 
middle  line,  though  by  the  distortion  of  the  mouth  it  appears  to  deviate. 
Liquid,  in  drinking,  or  saliva  runs  from  the  corner  of  the  mouth,  and  in 
chewing  the  food  gathers  in  the  cheek.  The  sense  of  taste  on  the  front  of 
the  tongue,  supplied  by  the  chorda  tympani,  is  impaired  in  some  cases,  as 
this  nerve  accompanies  the  facial  within  the  Fallopian  canal  for  a  short  dis- 
tance. The  reaction  of  degeneration  occurs  typically  in  facial  palsy. 
Both  nerve  and  muscle  show  diminishing  irritability  to  faradism  after  a 
few  days,  while  to  galvanism  the  muscle  contracts  excessivel}",  and  in  the 
serial  order  of  the  reaction  of  degeneration.  Bell's  palsy  is  rarely  sudden, 
but  usually  rapid,  developing  in  a  few  hours  or  days.  It  lasts  ordinarily 
two  or  three  months.  In  severe  cases,  after  four  or  five  months,  contrac- 
tures of  the  affected  muscles  deepen  the  lines  of  expression,  so  that  the 
face  appears  normal  or  the  sound  side  looks  weaker. 

Diagnosis. — In  recent  cases  the  condition  is  obvious.  In  older  ones 
the  muscular  contracture  and  overaction  may  conceal  it;  but  strong 
movements  in  showing  the  teeth  or  closing  the  eyes  will  show  the  difference 
of  the  two  sides.  Cerebral  (supranuclear)  paralysis  of  the  facial  is  usually 
a  part  of  hemiplegia.  In  this  form  the  upper  half  of  the  face  (orbicularis 
palpebrse,  frontalis,  and  corrugator  supercilii)  regains  power  in  a  few  clays, 
through  its  bilateral  innervation  from  the  cortex;  and  even  the  lower  half 
moves  fairly  with  emotion,  as  in  quiet  smiling.  In  the  cerebral  form  the 
supra-orbital  reflex  is  preserved.  Lesion  at  the  base  of  the  brain  is  indicated 
by  concomitant  paralysis  of  adjacent  nerves,  particularly  the  sixth  and 
eighth.  Deafness  with  facial  palsy  may  result  from  tumor  also  involving 
the  eighth  nerve.  In  peripheral  (nerve-trunk)  palsies  the  entire  half  of 
the  face  is  affected  for  all  movements,  voluntary  or  emotional,  and  the 
electrical  reaction  shows  degeneration. 

Prognosis. — Early  return  of  power  though  slight  is  a  good  sign.  Toward 
the  end  of  the  second  week  of  paralysis  an  electrical  examination  gives  valu- 
able information.  If  at  this  time  the  faradic  irritability  is  simply  lessened, 
the  paralysis  will  disappear  in  about  two  months;  if  lost,  the  outlook  is 
bad,  though  some  return  of  power  is  possible  after  several  months.  With 
the  loss  of  faradic  irritability  occur  the  true  reactions  of  degeneration  to 
the  galvanic  current. 

Facial  Spasm. — As  a  symptom  this  occurs  in  epilepsy  and  chorea,  in 
facial  paralysis,  in  cerebral  palsies  as  a  part  of  athetosis,  and  as  habit 
spasm.  The  habitual  occurrence  of  spasm  in  one  or  several  muscle-groups 
of  the  face  is  called  convulsive  tic.  The  orbicularis  palpebrse  and  the  zygo- 
matics are  its  most  frequent  seat.  Convulsive  tic  is  a  disease  of  later  middle 
life  (forty-five  to  sixty)  more  frequent  in  women.  Prolonged  anxiety  is  a 
factor;  also,  reflexly,  a  great  variety  of  painful  affections,  as  caries  of  a  tooth. 

Symptoms. — In  the  usual  form  of  convulsive  tic  the  eye  is  squeezed 
shut  and  the  angle  of  the  mouth  drawn  out  and  up  momentarily  at  inter- 
vals. It  is  generally  made  worse  by  disturbing  emotions.  The  spasm 
may  be  more  extensive,  involving  other  muscles  of  the  face,  mouth, 
neck,  or  arms,  and  especially  in  the  platysma,  which  stands  out  on  the  side 
of  the  neck.  In  severe  cases  the  spasm  occurs  in  numerous  quick  jerks 
or  frequently  repeated  contractions  in  the  course  of  two  or  three  minutes. 


1312  MEDICAL  DIAGNOSIS. 

Convulsive  tic,  usually  slight  at  first,  increases  gradually  in  the  intensity 
and  frequency  of  the  spasm,  and  in  the  extent  of  the  musculature  involved. 
It  is  likely  to  continue  indefinitely,  but  sometimes  ceases  after  years. 
Intermissions  of  several  months  may  happen. 

Diagnosis. — Facial  spasm  is  unmistakable.  The  spasm  may  be  symp- 
tomatic of  some  gross  disease.  True  convulsive  tic  is  idiopathic.  Sources 
of  reflex  irritation  in  the  teeth,  eyes,  etc.,  must  be  investigated.  Intra- 
cranial disease,  causing  facial  spasm,  may  be  tumor  or  other  lesion  of  the 
face  centre  in  the  cortex,  or  of  the  root  of  the  seventh  nerve  beneath  the 
pons.  From  such  a  cause  the  affected  muscles  often  will  be  found  paretic, 
or  will  become  paralyzed. 

VI.  EIGHTH  NERVE. 

The  auditory  nerve  is  physiologically  two  nerves — the  cochlear  for 
hearing,  the  vestibular  for  equilibration.  From  the  distributions  in  the 
internal  ear  (the  cochlea  and  the  semicircular  canals)  the  two  parts, 
united  as  the  eighth  nerve,  pass  from  the  internal  auditory  meatus  into 
the  side  of  the  pons.  Here  the  two  parts  of  the  nerve,  again  separating, 
embrace  the  inferior  cerebellar  peduncle,  the  cochlear  on  its  outer  side, 
the  vestibular  on  the  inner,  to  connect  with  various  nuclei  in  the  pons 
and  thence  to  seek  different  central  goals.  The  cochlear  fibres  pass  up  in 
the  lateral  fillet,  and  by  way  of  the  postgeminum  and  postgeniculum  reach 
the  auditory  centre  in  the  first  temporal  convolution.  The  vestibular 
fibres  pass  to  the  middle  lobe  of  the  cerebellum. 

Deafness. — Total  deafness  from  birth  or  early  childhood,  depriving 
the  child  of  speech,  constitutes  deaf-mutism.  Acquired  deafness  fre- 
quently depends  on  disease  of  the  labyrinth;  but  this  is  often  secondary 
to  middle-ear  disease,  particularly  of  the  chronic  catarrhal  variety,  or  to 
meningitis  by  extension  through  one  of  the  foramina.  Basal  fracture 
often  enters  the  internal  ear;  The  eighth  nerve  at  its  junction  with  the 
pons  may  be  involved  in  meningitis,  aneurism,  or  tumor,  particularly 
fibroma  of  the  nerve  sheath.  Degenerative  disease,  as  tabes,  may  attack 
the  eighth  nerve.  Pontine  lesions  rarely  affect  this  nerve;  but  at  the 
level  of  the  posterior  geminum,  in  the  hinder  part  of  the  internal  capsule 
or  in  the  first  temporal  convolution,  the  auditory  pathway  may  be  dam- 
aged by  tumor,  hemorrhage,  softening,  etc.,  causing  deafness  of  the  oppo- 
site ear.     Impaired  hearing  may  be  functional,  as  in  hysteria. 

Symptoms.  —  If  no  objective  signs  of  obstruction  of  the  external 
meatus  or  disease  of  the  middle  ear  are  present,  deafness  may  be  ascribed 
to  conditions  which  affect  the  reception  of  sound  in  the  labyrinth  or  its 
conduction  by  the  auditory  nerve,  or  to  lesions  involving  the  central  audi- 
tory tract.  This  is  especially  the  case  when  the  deafness  is  unilateral. 
When  the  sound  of  a  tuning-fork  held  against  the  mastoid  process — bone 
conduction — has  ceased  to  be  heard  but  is  again  perceived  when  the 
instrument  is  •  moved  to  a  position  opposite  the  external  meatus — aerial 
conduction — labyrinthine  disease  may  be  suspected.  When  in  unilateral 
deafness  the  sound  of  a  tuning-fork  in  contact  with  the  vertex  at  the 
middle  line  is  perceived  more  distinctly  on  the  side  of  the  deaf  ear,  the 


DISEASES  OF  THE  CRANIAL  NERVES.  1313 

fault  of  hearing  is  due  to  the  conducting  apparatus;  when  it  is  heard 
more  distinctly  or  only  in  the  sound  ear  the  deafness  is  caused  by  laby- 
rinthine disease.  In  the  latter  condition  there  is  an  interval  varying  from 
one  to  several  seconds  between  the  time  at  which  the  patient  ceases  to 
hear  the  sound  and  the  examiner  ceases  to  feel  the  vibrations  of  the  fork. 
There  are  no  direct  means  by  which  deafness  arising  from  lesion  of  the 
auditory  nerve  in  its  course  can,  in  the  absence  of  the  signs  of  involvement 
of  adjacent  structures,  be  distinguished  from  that  caused  by  disease  of  the 
auditory  centres. 

The  locality  of  the  eighth  nerve-root,  spoken  of  as  the  pontocerebellar 
angle,  is  a  favorite  seat  of  tumor  (fibroma)  which  grows  from  the  sheath 
of  this  nerve.  This  is  recognized  by  its  pressure-effects,  paralysis  of  the 
facial  and  external  rectus  on  the  same  side,  deafness,  vertigo,  and  inco- 
ordination, the  latter  partly  of  cerebellar  origin.  Deafness  from  a  higher 
seat,  the  quadrigeminal  region,  or  the  internal  capsule  (posterior  extremity) 
is  usually  associated  with  hemianopsia,  and  sometimes  with  other  disturb- 
ances on  the  same  side.  Cortical  deafness  is  likely  to  be  of  special  char- 
acter (word-deafness,  etc.)  related  to  aphasia.  Sudden  deafness  indicates 
a  vascular  lesion,  especially  hemorrhage,  most  frequently  in  the  internal 
ear.     Hysterical  deafness  may  be  recognized  by  the  associated  symptoms. 

Auditory  Irritation. — Uncomfortable  acuteness  of  hearing  (hyper- 
acusis)  is  ordinarily  hysterical,  though  observed  occasionally  in  facial 
palsy.  Tinnitus  aurium  embraces  simple  subjective  noises,  as  ringing, 
hissing,  and  roaring,  referred  either  to  the  ear  or  to  some  part  of  the  head. 
More  elaborate  sounds,  as  words  seemingly  spoken  in  the  ears,  in  other 
parts  of  the  body,  or  at  a  distance,  are  called  auditory  hallucinations. 
Tinnitus  is  a  common  symptom  in  the  various  diseases  of  the  internal  ear, 
as  well  as  of  the  middle  ear  and  external  meatus.  Tinnitus  may  arise 
especially  in  elderly  persons,  without  definite  cause.  It  is  common  in 
neurasthenia.  In  some  cases  it  has  a  pulsating  character,  and  is  then 
referred  to  vasomotor  disturbance  in  the  internal  ear.  Head  injuries, 
sudden  loud  noises,  and,  above  all,  the  habitual  subjection  to  noise  (as  in 
boiler-makers)  dispose  to  it.  Tinnitus  is  commonly  associated  with  partial 
deafness,  but  may  be  accompanied  by  hyperacusis. 

Diagnosis. — Irritation  of  the  cortical  centre  (first  temporal  convolu- 
tion) is  a  cause  of  hallucinations  of  hearing,  not  of  simple  tinnitus.  Tinnitus 
due  to  irritation  of  the  eighth  nerve-trunk  is  known  by  the  associated 
symptoms.     Disease  of  the  internal  ear  is  the  commonest  cause. 

Prognosis. — In  a  case  of  organic  origin  the  prognosis  is  that  of  the 
primary  disease.  In  functional  disease,  like  neurasthenia,  the  symptom 
subsides  as  the  patient  improves.  In  some  instances  tinnitus  is  stubbornly 
persistent. 

Meniere's  Disease. — An  affection  characterized  by  noises  in  the  ear, 
sudden  attacks  of  vertigo  with  nausea  and  vomiting,  and  nervous  deafness, 
which  in  many  cases  is  progressive.  The  attacks  are  often  apoplectiform, 
with  momentary  loss  of  consciousness. 

This  disease  was  first  described  by  Meniere  in  1861.    The  term  should 
be  restricted  to  the  affection  characterized  by  the  complexus  of  symptoms 
about  to  be  described. 
83 


1314  MEDICAL  DIAGNOSIS. 

Etiology. — Age  plays  an  important  part  in  the  predisposition.  The 
affection  is  very  rare  in  early  life.  In  a  large  proportion  of  the  cases  the 
attacks  first  show  themselves  between  forty-five  and  fifty-five,  but  they 
may  come  on  much  later.  Men  suffer  more  frequently  than  women. 
Nothing  is  known  of  the  exciting  causes. 

Symptoms.  —  The  disease  is  paroxysmal,  the  attacks  occurring  at 
irregular  intervals,  and  very  often  in  series,  several  of  which  may  take  place 
in  one  day  or  on  successive  days.  Such  series  or  single  attacks  may  be 
separated  by  intervals  of  weeks  or  even  months.  The  attack  begins  sud- 
denly with  tinnitus  aurium  and  subjective  or  objective  vertigo  of  such 
intensity  that  the  patient,  in  order  to  prevent  himself  from  falling,  is  obliged 
immediately  to  catch  some  support  or  to  sit  or  lie  down.  If  loss  of  con- 
sciousness occurs  it  is  momentary.  Occasionally  ocular  symptoms  accom- 
pany the  attack.  These  consist  of  diplopia  or  nystagmus.  Forced  move- 
ments may  occur,  and  in  the  intervals  of  frequent  attacks  there  is  an 
impairment  of  equilibrium,  so  that  the  patient  walks  with  difficulty.  The 
attack  is  usually  of  short  duration.  As  the  vertigo  passes  off  the  patient 
is  pale,  breaks  into  a  profuse  sweat,  suffers  from  nausea,  or  there  may  be 
actual  vomiting.  As  a  rule,  there  is  no  disease  of  the  middle  ear.  When 
it  is  present  the  association  is  accidental.  The  deafness,  which  is  nervous, 
usually  affects  one  ear  only.  It  is  progressive  but  never  complete.  When 
deafness  becomes  complete  the  vertigo  ceases,  the  end  organs  of  the  nerve 
being  destroyed. 

Three  principal  theories  have  been  suggested  to  account  for  the  phe- 
nomena of  Meniere's  disease:  1.  That  the  symptoms  are  due  to  lesions 
of  the  labyrinth.  There  is  progressive  degeneration  of  the  nerve  or  its 
end  organs.  2.  That  the  disease  is  a  vasomotor  neurosis  of  the  vessels  of 
the  labyrinth.  3.  That  the  primary  trouble  consists  in  an  affection  of  the 
centres  for  hearing  and  equilibration.  Of  these  the  first  is  at  present 
generally  accepted. 

Diagnosis. — The  direct  diagnosis  of  Meniere's  disease  rests  upon  the 
paroxysmal  vertigo,  the  apoplectiform  seizure,  the  occurrence  of  tinnitus, 
nausea,  and  vomiting,  and  the  progressive  nervous  deafness.  The  differen- 
tial diagnosis  between  the  vertigo  which  is  so  prominent  a  symptom  and 
other  forms  of  vertigo  depends  upon  the  association  of  the  foregoing  symp- 
toms, the  paroxysmal  nature  of  the  attack,  and  the  absence  of  other 
pathological  states  usually  attended  with  vertigo. 

Prognosis. — This  is  uncertain.  A  small  proportion  of  the  cases  termi- 
nate, after  a  variable  duration,  in  complete  recovery,  with  total  loss  of 
hearing  in  the  affected  side.  More  commonly  the  disease  proves  persistent 
and  intractable,  and,  with  periods  of  exacerbation  and  improvement  for 
which  no  explanation  is  to  be  found,  continues  throughout  life.  In  rare 
instances  the  symptoms  are  so  severe  that  the  patients  become  bed-ndden. 

VII.  NINTH  NERVE. 

The  ninth,  tenth,  and  eleventh  nuclei  form  a  continuous  chain  of  gray 
matter,  and  the  nerves  a  continuous  hne  of  fibres  springing  from  the 
side   of  the   medulla,  in   the   order   of    their   numbering.     The   ninth   or 


DISEASES  OF  THE  CRANIAL  NERVES.  1315 

glossopharyngeal,  mainly  sensory,  supplies  the  back  of  the  tongue,  the 
soft  palate,  tonsils,  and  adjacent  pharynx,  with  the  Eustachian  tube 
and  middle  ear.  The  muscles  of  the  upper  pharynx  are  probably  governed 
by  the  ninth. 

Tumors  or  meningitis  affect  the  ninth  usually  in  company  with  other 
nerves.  Swallowing  is  embarrassed  by  lesions  of  the  nerve-trunk  or,  as  in 
glosso-labio-laryngeal  paralysis,  by  degeneration  of  its  nucleus. 

VIII.  TENTH  NERVE. 

The  tenth  nerve,  termed  the  pneumogastric  or  vagus,  arises  in  the 
medulla  by  a  line  of  nuclei  and  fibres  continued  downward  from  those  of 
the  ninth.  It  is  the  chief  of  the  "bulbar"  nerves  in  the  variety  and 
importance  of  its  functions,  supplying  motor  fibres  to  the  muscles  of  the 
pharynx,  oesophagus,  stomach,  and  intestines,  and  to  those  of  the  larynx, 
trachea,  and  bronchi;  sensory  fibres  to  the  dura  mater,  external  ear, 
pharynx,  oesophagus,  stomach,  larynx,  trachea,  bronchi,  and  the  peri- 
cardium; and  spinal  fibres  to  the  heart,  liver,  spleen,  pancreas,  kidneys, 
suprarenal  bodies,  and  intestinal  blood-vessels.  The  "respiratory  centre" 
and  "cardiac  centre"  are  thus  contained  in  the  vagus  nucleus,  though  for 
these  vital  functions,  as  for  vasomotor  regulation  and  for  the  movements 
of  the  stomach  and  intestines,  the  sympathetic  acts  in  connection  with 
this  nerve. 

The  tenth  nucleus  may  be  implicated  in  softening,  hemorrhage,  or 
tumor  of  the  medulla,  usually  with  adjacent  nuclei,  inducing  paralytic 
effects  in  combination  known  as  "bulbar  symp'toms."  Degeneration  of 
the  tenth  nucleus  in  glosso-labio-laryngeal  paralysis  (chronic  bulbar  palsy) 
and  its  inflammatory  destruction  in  acute  bulbar  palsy  are  responsible 
for  the  impaired  phonation,  difficult  swallowing  (mainly),  and  embarrassed 
cardiac  and  respiratory  action.  In  cerebral  disease,  particularly  bilateral 
softening  in  the  neighborhood  of  the  internal  capsules,  these  symptoms  are 
due  to  the  destruction  of  the  motor  fibres  destined  to  these  nuclei  (pseudo- 
bulbar paralysis).  The  root  of  the  vagus  may  be  the  source  of  these  symp- 
toms in  like  combination  from  basilar  meningitis,  tumor,  or  aneurism  of 
the  vertebral  artery. 

In  the  neck  the  nerve-trunk  accompanying  the  carotid,  or  lower  down 
winding  over  the  subclavian,  may  be  compressed  by  an  aneurism  or  tumor, 
or  damaged  in  operation.  This  nerve  is  involved  in  toxic  or  infectious 
neuritis  more  frequently  than  is  ordinarily  thought.  The  affection  of  the 
pneumogastric  nucleus  or  trunk  may  be  of  a  degree  to  induce  irritative 
symptoms  (slowness  of  the  heart's  action,  spasm  of  the  larynx,  and 
vomiting),  or  paralytic  symptoms  (paralysis  of  the  larynx,  embarrassed 
respiration,  and  rapid  pulse). 

The  inferior  or  recurrent  laryngeal  nerve,  branching  from  the  tenth  at 
the  base  of  the  neck,  winds  around  the  great  vessels — the  aorta  on  the  left, 
the  subclavian  on  the  right  side — and  ascends  back  of  the  trachea  to  the 
larynx,  of  which  it  supplies  the  most  important  muscles. 


1316 


MEDICAL  DIAGNOSIS. 


IX.  ELEVENTH  NERVE. 

The  accessory  fibres  of  the.  spinal  accessory  join  the  vagus  nerve,  of 
which  they  form  mainly  the  recurrent  laryngeal  branch.  The  spinal  por- 
tion, composed  of  several  motor  roots  of  the  cervical  cord,  forms  part  of 
the  cervical  plexus  and  supplies  the  sternomastoid  and  the  upper  portion 
of  the  trapezius  muscle.  Spasm  of  these  muscles  causes  torticollis. 
Paralysis  of  the  muscles  suppHed  by  the  spinal  accessory  results  from 
degeneration  of  the  cervical  gray  matter  in  progressive  muscular  atrophy, 
from  lesion  of  the  trunk,  in  meningitis  or  brain  tumor,  and  from  wounds, 
tumors,  vertebral  disease,  etc.,  in  the  neck.  Paralysis  of  the  sternomastoid 
alone  may  result  from  a  wound  of  this  muscle,  severing  the  nerve-trunk 
within  it.  In  paralysis  of  one  spinal  accessory,  the  head  cannot  be  turned 
to  the  other  side,  the  sternomastoid  and  the  upper  border  of  the  trapezius 
are  relaxed  and  in  time  wasted,  and  all  movements  about  the  shoulder,  as 
raising  the  arm,  are  embarrassed.  When  this  paralysis  is  bilateral  the 
head  falls  backward  or  forward,  according  as  the  sternomastoid  or  the 
trapezius  is  more  affected. 

Bilateral  paralysis  of  the  spinal  accessory  is  conspicuous  in  menin- 
gitis, especially  the  tuberculous  form  of  childhood,  and  in  progressive 
muscular  atrophy.  Lesion  of  the  nerve  at  the  base  of  the  brain, 
including  the  accessory  part  (laryngeal  fibres),  paralyzes  the  vocal  cords, 

and  is  likely  at  the  same  time  to 
implicate  the  hypoglossal  or  the  glosso- 
pharyngeal and  paralyze  the  tongue 
or  the  palate. 

Torticollis  or  Wry=neck — Acces= 
sory  Spasm. — True  torticollis  is  a  devi- 
ation of  the  head  due  to  abnormal  action 
of  the  muscles  supplied  by  this  nerve. 
It  may  be  a  fixed  deformity — congenital 
wry-neck — or  due  to  spasm — spasmodic 
wry -neck.  In  congenital  torticollis 
there  is  atrophy  of  neck  muscles,  prin- 
cipally the  sternomastoid,  in  conse- 
quence of  prenatal  poliomyelitis  or  of 
injury  to  the  muscles  during  labor. 
Contraction  of  the  sternomastoid  tilts 
the  head  toward  the  affected  side  and 
at  the  same  time  rotates  the  face 
toward  the  opposite  side.  The  muscle 
stands  out  rigid. 

Spasmodic  torticollis  is  of  the 
nature  of  facial  tic,  and  like  it  may  be 
either  tonic  or  clonic.  The  position  of 
the  head  ordinarily  is  governed  by  the  sternomastoid,  but  in  some  cases 
there  is  backward  tilting  in  consequence  of  contraction  of  the  trapezius. 
When  the  affection  is  bilateral  the  trapezii  draw  the  head  backward, — 
retrocollic    spasm, — aided    by    both    sternomastoids,    and    the    frontales 


Pig.  390. — Torticollis    (Jochimsthal). — Young. 


DISEASES  OF  THE  CRANIAL  NERVES.  1317 

muscles  in  association  raise  the  eyebrows.  Spasmodic  torticollis  appears 
usually  in  middle  life,  is  more  frequent  in  women,  and  has  been  ascribed 
to  a  variety  of  causes.  Its  source  in  typical  cases  is  probably  cortical. 
It  may  be  ushered  in  by  pain  and  stiffness  about  the  neck,  but  as  a  rule 
the  spasm  sets  in  gradually.  It  generally  centres  in  the  sternomastoid 
and  may  be  confined  to  it,  but  the  trapezius  of  the  same  side  and  the 
splenius  of  the  other  are  commonly  associated  with  the  sternomastoid 
in  spasm.  The  head  is  tilted  sidewise  and  slightly  backward  and  twisted 
to  the  other  side,  more  frequently  the  left. 

In  bilateral  (retrocolhc)  spasm  the  face  is  turned  upward  and  the  eye- 
brows raised  synchronously.  Ordinarily  with  the  tonic  variety  of  torticollis, 
as  it  becomes  intense,  clonic  spasms  are  associated.  The  intensity  varies, 
and  intermissions  are  frequent.  The  affection  may  involve  various  muscles 
of  the  arm  or  face.     The  affected  neck  muscles  hypertrophy  in  time. 

The  diagnosis  is  obvious.  The  rotation  of  the  head  to  one  side  and  its 
sHght  inclination  to  the  other  side,  on  which  the  sternomastoid  muscle 
stands  out  prominently,  especially  when  this  position  is  emphasized  by 
clonic  jerkings,  cannot  be  mistaken.  So-called  rheumatic  torticollis, 
*' stiff-neck,"  is  marked  by  its  acute  appearance,  often  after  exposure,  with 
lameness  and  tenderness  of  the  neck  muscles.  "False  torticollis"  is  an 
unnatural  position  of  the  head  from  gross  disease  in  the  neck,  most  fre- 
quently of  vertebrae,  as  Pott's  disease  and  spondylitis  deformans.  In  these 
conditions  the  sternomastoid  is  prominent  on  the  side  to  which  the  head  is 
turned.  Hysl^erical  torticollis  occurs  in  younger  persons  with  other  signs 
of  hysteria.    True  torticollis  is  more  common  in  middle  life. 

Congenital  torticollis  may  be  relieved  by  operation.  Spasmodic  tor- 
ticollis is  chronic  and  intractable.  Often  after  increasing  for  years  it 
becomes  stationary.  There  are  cases  in  which  remissions  are  frequent 
and  intermissions  occur,  sometimes  lasting  many  months.  The  disease 
is  of  no  consequence  beyond  annoyance  and  embarrassment.  Patients 
sometimes  complain  of  fatigue  or  pain  in  the  affected  muscles. 

X.  TWELFTH  NERVE. 

The  hypoglossal  nerve,  governing  the  muscles  attached  to  the  hyoid 
bone,  controls  the  movements  of  the  tongue.  Within  the  cranium  and 
in  the  upper  part  of  the  neck  it  is  near  the  pneumogastric  and  spinal  acces- 
sory nerves,  with  which  it  often  is  associated  in  disease,  and  the  lips  have 
some  nuclear  connection  of  movement  with  the  tongue.  In  bulbar  paraly- 
sis, acute  and  chronic,  the  hypoglossal  nuclei  are  a  focus  of  the  disease; 
and  they  occasionally  are  degenerated  in  tabes  and  paresis.  In  hemiplegia 
the  cerebral — supranuclear — fibres  for  the  tongue  are  commonly  included 
in  the  lesion  between  the  lower  part  of  the  motor  cortex  and  the  hypo- 
glossal nucleus  in  the  medulla.  The  roots  in  the  medulla  may  be  damaged 
by  hemorrhage  or  by  tumor,  which  usually  implicates  the  main  pathway 
to  the  opposite  arm  and  leg;  or  the  roots  emerging  from  the  medulla  may 
be  involved,  often  with  the  tenth  and  eleventh,  in  meningitis,  syphilis,  or 
tumor.  In  the  upper  part  of  the  neck  various  gross  diseases  or  wounds 
may  injure  the  hypoglossal  trunk  with  the  spinal  accessory. 


1318  MEDICAL  DIAGNOSIS. 

Paralysis  of  the  tongue  without  sensory  disturbance  is  the  effect  of 
hypoglossal  lesion.  When  this  is  bilateral  the  tongue  is  motionless.  When 
paralyzed  on  one  side  the  tongue^  protruded,  curves  toward  the  affected 
side,  speech  is  thick,  and  chewing  is  awkward.  The  affected  half  in  time 
wastes,  shows  fibrillary  tremors,  and  is  puckered  with  transverse  folds. 
When  the  lesion  is  nuclear,  as  in  bulbar  palsy,  the  lips  share  in  the  atrophy; 
when  it  is  cerebral  the  tongue  shows  no  trophic  change.  Associated 
particularly  with  double  hemiplegia,  paralysis  of  the  tongue,  with  other 
bulbar  symptoms,   constitutes  ''pseudobulbar  paralysis." 

Paralysis  of  the  tongue  from  cerebral  disease  is  commonly  a  part  of 
hemiplegia.  Nuclear  palsy  is  generally  bilateral  and  a  part  of  "bulbar 
palsy,"  recognizable  by  its  combination  of  paralyses  with  atrophy,  in 
particular  of  the  tongue.  The  similar  combination  of  palsies  in  pseudo- 
bulbar paralysis  is  not  associated  with  atrophy  nor  with  evidence  of  hemi- 
plegia weakness.-  Paralysis  of  one-half  of  the  tongue  and  of  the  opposite 
arm  and  leg — a  form  of  crossed  paralysis — indicates  a  lesion  of  the  medulla 
at  the  level  of  the  hypoglossal  nucleus  on  the  side  on  which  the  tongue  is 
paralyzed  and  wasted.  Paralysis  of  half  the  tongue,  usually  with  atrophy, 
and  associated  by  implication  of  the  spinal  accessory,  with  paralysis  of 
the  palate  and  vocal  cord  on  the  same  side  (Hughlings  Jackson),  points 
to  lesion  of  the  nerve  within  the  skull  or  in  the  upper  part  of  the  neck. 
The  prognosis  depends  on  the  seat  and  character  of  the  lesion.  As  a  rule, 
it  is  unfavorable;  the  likelihood  of  improvement  is  slight,  even  in  the 
syphilitic  cases.  # 

Spasm  of  the  tongue  is  an  incident  of  the  epileptic  convulsion  and  of 
chorea.     It  occurs  ailso  as  a  rare  phenomenon  in  hysteria. 


DISEASES  OF  THE  SPINAL  CORD. 

I.  SPINAL  MENINGITIS. 

Two  varieties  are  usually  mentioned — leptomeningitis,  inflammation 
of  the  pia  and  arachnoid,  and  pachymeningitis,  inflammation  of  the  dura. 
Syphilis  causes  a  meningomyelitis  in  which  both  membranes  may  be 
involved.  Tuberculous  meningitis  of  the  cord  is  very  rare,  unless  asso- 
ciated with  the  same  affection  of  the  brain.  A  meningomyelitis  is  caused 
by  spinal  caries,  and  in  these  cases  the  cord  as  well  as  the  membranes 
is  involved.  Cerebrospinal  fever  is  an  acute  infectious  disease  which 
involves  the  membranes  of  both  the  brain  and  cord.  There  is  an  affec- 
tion called  hypertrophic  pachymeningitis,  especially  of  the  cervical  region, 
in  which  the  dura  is  much  thickened  and  the  cord  more  or  less  involved;  it 
is  sometimes  caused  by  trauma,  but  in  many  cases  the  causation  is  not 
clear.  Purulent  meningitis  of  septic  origin  is  common;  sometimes  such 
an  infection  extends  from  the  membranes  of  the  brain,  as  after  an  otitis 
media;  or  from  the  pelvis,  as  in  the  puerperium.'  A  pneumococcus 
infection  occurs. 

Pathology. — The  membranes  are  congested,  thickened,  and  some- 
times covered  with  a  fibrinous  or  purulent  exudate.     The  nerve-roots  are 


MYELITIS.  1319 

often  implicated,  and  the  cord  itself  may  be  involved  in  various  degrees. 
The  offending  microbe  can  often  be  isolated  after  a  lumbar  puncture. 

Symptoms. — Irritation  of  the  nerve-roots  is  an  early  symptom;  hence 
there  are  pain,  stiffness  of  the  back,  opisthotonos,  contractures  of  muscles, 
and  even  slight  clonic  spasms.  Kernig's  sign  is  usualty  present.  Later  in 
the  case  there  may  be  pressure  symptoms,  as  paralysis  and  anaesthesia. 
In  very  acute  cases  there  may  be  chill  and  fever. 

Pachymeningitis  cervicalis  hypertrophica  is  an  affection  almost  sui 
generis,  especially  as  caused  by  trauma.  It  may  closely  resemble  syrin- 
gomyeha.  There  is  flaccid  atrophic  paralysis  of  the  shoulders  and  arms, 
spastic  paralysis  of  the  lower  limbs,  and,  in  some  cases,  the  disso- 
ciation symptom,  that  is,  abolition  of  the  pain  and  thermal  senses  with 
preservation  of  the  tactile  sense.  There  may  also  be  pain  and  stiffness 
about  the  neck. 

Diagnosis. — It  is  scarcely  possible  to  distinguish  a- pure  meningitis 
from  a  meningomyelitis;  the  symptoms  of  disease  of  the  membranes  are 
likely  to  be  associated  with  some  evidence  of  implication  of  the  cord. 
Where  symptoms  of  irritation  predominate,  as  pain,  stiffness,  hyperses- 
thesia,  etc.,  we  may  suspect  that  the  membranes  are  the  more  concerned. 
Later,  when  paralysis  and  anaesthesia  with  incontinence  appear,  we  inter- 
pret these  symptoms  to  mean  that  the  cord  is  involved.  The  eccentric 
pains,  felt  at  points  in  the  chest  or  abdomen,  may  suggest  some  deep- 
seated  visceral  disease,  but  the  diagnosis  can  usually  be  made  from  the 
associated  symptoms.  The  determination  of  syphiHs  as  a  cause  of  men- 
ingitis is  always  of  first  importance.  The  history  of  the  case  may  point 
that  way,  but  it  is  not  always  to  be  reHed  on,  especially  when  it  is 
negative. 

II.  MYELITIS.   • 

This  term  should  be  restricted  to  true  inflammation  of  the  spinal 
cord.  In  the  past,  however,  it  has  been  loosely  used  for  a  variety  of 
lesions,  such  as  softening  and  the  destructive  effects  of  trauma.  When 
the  term  is  properly  restricted  it  will  be  found  that  genuine  myelitis 
is  not  a  common  affection. 

Etiology. — This  disease  is  doubtless  due  in  every  case  to  some  form 
of  infection  or  toxaemia.  The  old  ideas  that  it  was  caused  by  exposure 
to  cold,  to  worry,  to  sexual  excesses,  and  other  such  far-fetched  notions 
are  no  longer  credible.  At  most,  cold  can  act  but  as  a  predisposing  cause. 
It  is  even  doubtful  whether  alcohol  causes  myehtis.  *  SyphiHs  undoubtedly 
causes  a  meningomyelitis,  but  this  is  such  a  distinct  affection  that  it  is 
treated  under  a  separate  heading.  Among  the  causes  assigned  are  the 
infectious  diseases,  such  as  septic  infection,  varicella,  gonorrhoea,  and 
measles.  It  is  claimed  that  malaria  may  cause  it.  Typhoid  fever  and 
smallpox  may  cause  multiple  neuritis,  which  might  be  mistaken  for  myeli- 
tis by  a  careless  observer.  In  fact,  these  two  latter  diseases  must  be  care- 
fully distinguished.  A  destructive  myehtis  may  be  caused  by  spinal  caries 
of  tuberculous  origin,  but  otherwise  tubercle  does  not  often  attack  the 
cord.  Injury  may  cause  extensive  lesions  in  the  spinal  cord,  and  these 
may  become  secondarily  infected,  but  they  are  not  primarily  inflamma- 


1320  MEDICAL  DIAGNOSIS. 

tory,  nor  do  they  become  so  in  every  case.  Cancer  of  the  vertebra  may 
also  cause  myelitis.  There  are  also  special  forms  of  myelitis,  such  as  the 
anterior  poliomyelitis,  or  inflammation  of  the  anterior  horns  of  the  gray 
matter,  but  these  affections  are  described  apart.  Finally,  cases  occur  in 
which  acute  transverse  softening  is  found  post  mortem,  suggesting  the 
idea  of  acute  infection,  but  the  cause  is  obscure.  In  fact,  not  a  few  cases 
of  myehtis,  and  myelitic  softening,  cannot  be  satisfactorily  accounted-  for. 

The  spinal  membranes  are  often  involved  in  cases  of  myelitis,  so  that 
in  effect  the  condition  is  one  of  meningomyelitis,  and  the  cause,  whatever 
it  be,  may  act  primarily  on  the  membranes. 

Pathology. — This  disease  may  be  transverse,  focal,  disseminated,  or 
diffused.  In  transverse  myelitis  the  lesion  implicates  the  whole  thickness 
of  the  cord,  but  it  may  be  comparatively  limited  in  its  upward  and  down- 
ward extent;  in  fact,  not  more  than  one,  two,  or  three  segments  may  be 
involved.  Focal  myelitis,  described  by  some  authors,  is  much  more  rare; 
as  the  name  imphes,  the  lesion  is  discrete;  and  in  the  disseminated  variety 
there  are  more  than  one  such  lesion  scattered  in  various  places  in  the  cord. 
Diffused  myelitis  is  merely  that  variety  in  which  the  inflammatory  process 
is  more  widely  and  continuously  extended.  The  inflamed  area  may  be 
variously  discolored;  in  some  cases  it  is  congested  and  bright  red  or  pink, 
in  others  rather  yellowish,  in  others  white.  Its  consistence  varies,  but 
it  is  usually  softer  than  the  normal  cord,  and  it  may  be  so  soft  as  to 
flow  out  under  the  knife.  This  is  the  condition  often  called  "white"  or 
"red"  or  "yellow"  softening.  The  color  is  merely  due  to  the  elements  of 
the  blood  contained  in  the  softened  area.  The  tissue  is  usually  necrotic, 
but  it  is  not  necessarily  purulent.  Pus-cells  may,  however,  be  found.  The 
membranes  may  or  may  not  be  involved,  congested,  and  thickened,  and 
there  are  cellular  infiltration  and  thickenin    oi  the  blood-vessels. 

Symptoms. — It  is  best  to  describe  the  symptoms  of  myehtis  according 
to  the  level  at  which  the  lesion  is  located. 

If  the  lesion  is  in  the  cervical  region,  all  the  functions  of  the  cord  below 
that  point  may  be  partly  or  entirely  involved.  There  will  be  spastic  paral- 
ysis in  the  lower  limbs,  exaggerated  knee-jerks  and  other  reflexes,  ankle 
clonus,  and  Babinski's  reflex;  incontinence  of  urine  and  faeces,  if  the 
lesion  is  transverse  or  even  extensive;  anaesthesia  to  all  modes  of  sensa- 
tion; possibly  bed-sores;  in  the  upper  limbs  also  spastic  paralysis, 
unless  the  anterior  horns  of  gray  matter  in  the  cervical  enlargement  are 
involved,  in  which  case  there  may  be,  especially  in  chronic  cases,  extensive 
muscular  atrophy,  even  with  fibrillation,  in  the  shoulders,  arms,  and 
hands,  with  flaccid  paralysis.  Anaesthesia  is  also  more  or  less  complete 
in  the  trunk,  arms,  and  hands,  and  the  muscles  of  respiration  may  be 
involved.  If  the  lesion  extends  to  or  above  the  fourth  segment  there 
is  danger  of  death  from  involvement  of  the  phrenic  nerve.  There  may  be 
a  girdle  sense  in  the  neck  or  upper  part  of  the  chest.  As  a  rule,  pain  is  not 
an  urgent  symptom,  unless  the  membranes  and  nerve-roots  are  implicated. 
The  pupils  may  be  dilated  or  contracted,  according  as  the  oculopupillary 
centre  is  irritated  or  paralyzed.  A  total  transverse  lesion  abolishes 
all  functions  below  its  level,  but  such  a  lesion  in  the  neck  is  seldom 
compatible  with  prolonged  life. 


MYELITIS.  1321 

In  the  dorsal  region  the  lesion  causes  symptoms  in  the  trunk  and 
lower  limbs  only.  There  is  likely  to  be  a  spastic  paraplegia,  sometimes 
with  contractures,  exaggerated  reflexes  and  clonus,  Babinski's  sign,  incon- 
tinence of  urine  and  faeces,  anaesthesia  to  all  modes  of  sensation,  and  a 
girdle  sense  about  the  trunk,  or  pain  radiating  through  the  chest  or  abdo- 
men, according  to  the  exact  level  of  the  inflammation.  There  may  be  a 
zone  of  hyperaesthesia  marking  the  upper  limits  of  the  lesion  and  caused 
by  irritation  of  the  membranes  or  nerve-roots.  Bed-sores  of  an  aggra- 
vated type  may  form.  If  the  lesion  is  totally  transverse  these  symptoms 
are  absolute;  if,  however,  the  lesion  involves  only  certain  structures  of  the 
cord,  the  symptoms  may  vary  within  wide  limits.  Thus,  motion  may  be 
more  involved  than  sensation;  control  of  the  bladder  may  not  be  entirely 
lost;  the  patient  may  be  able  to  walk  with  a  weak  and  spastic  gait;  and 
pain  may  not  be  urgent.  In  spinal  caries  the  paralysis  is  often  more  motor 
than  sensory,  due  to  the  bone  lesion  being  located  in  front  of  the  cord. 

In  the  lumbar  region  myelitis  causes  an  atrophic  or  flaccid  paralysis 
of  the  lower  limbs,  due  to  the  fact  that  the  anterior  horns  of  gray  matter 
are  involved.  There  is  also  paralysis  of  the  bladder  and  rectum  in  grave 
cases,  bed-sores,  pain  in  the  legs,  loss  of  sensation  in  the  lower  trunk  and 
lower  limbs,  and  abohshed  knee-jerks.  But  here  as  elsewhere  the  symp- 
toms will  vary  somewhat  with  the  extent  of  the  lesion. 

The  course  of  myelitis  may  be  acute  or  exceedingly  chronic.  The  patient 
may  recover  up  to  a  certain  point,  and  then  remain  more  or  less  perma- 
nently crippled.  Entire  recovery  is  rare.  A  fatal  result  is  not  uncommon. 
In  the  myelitis  of  Pott's  disease  a  good  recovery  is  sometimes  obtained. 

Diagnosis. — Myehtis  is  to  be  distinguished  especially  from  locomotor 
ataxia,  syringomyelia,  and  multiple  neuritis.  It  may  also  closely  resemble 
some  forms  of  syphihs  of  the  cord.  When  it  is  due  to  trauma  or  spinal 
caries  the  cause  is  usually  apparent. 

From  locomotor  ataxia  it  is  distinguished  by  the  mode  of  onset,  which 
is  usually  much  more  abrupt.  There  is  absence  of  the  fulgurant  pains, 
the  peculiar  ataxic  gait,  the  swaying  with  closed  eyes,  the  abolished  knee- 
jerks  (unless  in  lumbar  myehtis,  in  which  case,  however,  there  is  flaccid 
paralysis  and  muscular  atrophy  in  the  lower  limbs,  very  different  from 
tabes).  There  is  also  absence  of  the  Argyll-Robertson  pupil,  with  optic 
atrophy;  and  the  paralysis  of  the  bladder  and  bowel  is  much  more  com- 
jDlete  and  of  earlier  onset  than  in  locomotor  ataxia. 

In  sj^ringomyelia  the  symptom-complex  is  quite  different  from  ordi- 
nary myelitis.  There  is  especially  the  dissociation  symptom,  in  which 
the  temperature  and  pain  senses  are  abolished  without  impairment  of  tac- 
tile sensation;  also  scohosis,  arthropathies,  and  vasomotor  changes.  The 
onset  is  also  more  gradual  than  in  myelitis;  the  bladder  and  bowel  are  not 
so  likely  to  be  involved.  Still,  some  cases  of  traumatic  meningomj-elitis  of 
the  cervical  cord  closely  resemble  syringomyelia,  and  are  distinguishable 
only  with  care.     The  history  of  trauma  in  these  cases  is  significant. 

In  multiple  neuritis  the  symptoms  are  distinctly-  peripheral.  The 
nerve-trunks  are  involved,  and  are  often  painful  on  pressure.  The  mus- 
cular masses,  especially  the  calf,  are  exquisitely  sensitive.  The  paralysis 
is  flaccid,  and  the  muscles  waste.     The  reactions  of  degeneration  may  be 


1322  MEDICAL  DIAGNOSIS. 

present.  The  deep  reflexes  are  abolished.  The  anaesthesia,  while  present 
in  varying  degrees,  is  not  always  seen  in  such  extensive  areas  as  in  myelitis. 
The  bladder  and  bowel,  as  a  rule,  are  not  involved.  There  may  be  mental 
symptoms — the  so-called  Korsakoff's  psychosis — and  there  is  a  history 
of  exposure  to  alcohol,  to  lead,  to  arsenic,  or  to  diphtheria. 

It  is  often  difficult  to  say  whether  or  not  a  myelitis  is  due  to  syphiKs, 
but  in  some  forms  of  syphilis  of  the  cord  the  type  is  quite  distinct.  In 
some  cases  of  cord-syphilis,  but  not  by  any  means  in  all,  there  may  be,  or 
may  have  been,  some  involvement  of  the  cerebrum  or  cranial  nerves. 
Lumbar  puncture  may  throw  some  light  on  the  causation  and  pathology 
of  myelitis. 

The  constitutional  reaction  in  myelitis  at  the  beginning  is*not  marked, 
except  in  the  acute  anterior  poliomyelitis  of  children.  There  may,  how- 
ever, be  some  fever  and  weakness  of  the  pulse.  In  advanced  cases,  with 
bed-sores  and  incontinence  of  urine,  symptoms  of  sepsis  may  occur.  Infec- 
tion of  the  bladder  is  always  a  grave  complication.  It  may  be  due  to 
the  use  of  the  catheter. 

III.  ANTERIOR  POLIOMYELITIS. 

Inflammation  of  the  anterior  horns  of  gray  matter  in  the  spinal  cord 
may  occur  as  an  acute  or  a  subacute  disease.  The  acute  form  is  usually 
a  disorder  of  childhood,  although  adults  are  not  entirely  exempt.  In 
children  it  is  called  infantile  paralysis.  The  subacute  form  is  rare,  and  is 
usually  seen  in  adults.  The  disease  known  as  progressive  muscular  atrophy, 
or  chronic  anterior  poliomyelitis,  is  also  a  disorder  of  adults,  but  its  inflam- 
matory nature  may  be  doubted.  It  is  a  slowly  progressive  degeneration 
of  the  ganglion  cells  in  the  anterior  horns. 

The  cause  of  acute  and  subacute  anterior  poliomyelitis  is  now  gener- 
ally believed  to  be  an  infection  or  toxaemia.  Infantile  paralysis  has  been 
known  to  prevail  as  an  epidemic,  as  in  the  instance  reported  by  Medion, 
in  which  44  cases  occurred  within  a  few  weeks  in  one  town  in  Sweden. 
Epidemics  have  been  observed  in  the  United  States.  A  series  of  126  cases 
occurred  in  Rutland,  Vt.,  in  1894.  An  epidemic,  or  very  prevalent  type, 
of  the  disease  occurred  in  New  York  City  in  the  summer  and  autumn  of 
1907,  and  the  affection  was  rather  more  common  than  usual  in  other  parts 
of  the  United  States.  Isolated  cases  sometimes  follow  the  infectious 
diseases,  as  measles,  scarlet  fever,  whooping-cough,  and  diphtheria. 

Pathology. — In  the  early  stage  there  is  hyperaemia  of  the  horns  and 
some  congestion  of  the  cord;  the  ganglion  cells  are  swollen  and  indistinct; 
the  vessels  are  engorged,  and  white  cells  are  seen  migrated  from  them. 
Later  the  ganglion  cells  are  atrophied  or  even  entirely  destroyed;  the 
nerve  fibrils  are  obliterated,  and  the  horns  are  reduced  in  size.  The 
disease  may  be  located  in  either  the  cervical  or  lumbar  enlargement.  In 
the  subacute  form  the  lesions  may  be  found  more  extensively  spread;  the 
anterior  horns  in  many  parts  of  the  cord  are  involved,  and  in  some  cases 
the  neighboring  white  matter  is  invaded. 

Symptoms.  —  Infantile  paralysis  begins  rather  abruptly,  and  with 
constitutional  reaction.     There  is  fever;    sometimes  moderate  stupor  and 


ANTERIOR  POLIOMYELITIS.  1323 

deUrium;  and  convulsions  may  occur.  Some  daj^s  may  eLipse  before  the  true 
nature  of  the  disease  is  recognized,  and  then  it  is  found  that  the  child  is 
paralj^zed  in  one  or  more  limbs.  This  paralysis  is  flaccid,  with  abolished 
reflexes.  Pain  is  not  prominent,  as  a  rule,  and  may  even  be  entirely 
absent;  but  in  rare  cases  it  may  be  severe  and  rheumatoid  in  character 
in  the  early  stages.  The  initial  palsy  may  involve  the  whole  limb,  but  as 
time  passes  a  partial  recovery  takes  place,  until  finally  the  paralysis  is 
located,  and  remains  stationary,  in  a  few  muscles  or  a  group  of  muscles. 
There  is  no  anaesthesia  in  the  paralyzed  part.  The  bladder  and  bowel  are 
not  involved.  Infantile  palsy  is  a  common  cause  of  club-foot,  the  type 
of  deformity  depending  upon  the  group  of  muscles  paralyzed.  The  reac- 
tions of  degeneration  are  present,  and  the  muscles  do  not  show  fibrillation. 
In  the  arm  the  muscles  oftenest  damaged  are  the  deltoid,  biceps,  bra- 
chialis  anticus,  and  supinator  longus.  Deformity  of  the  hand  is  not  com- 
mon. The  paralyzed  limb  does  not  grow  normalh',  but  remains  partially 
stunted  and  even  shortened. 

In  the  recent  epidemic  in  Nev\'  York  bulbar  symptoms  were  some- 
times seen,  even  in  mild  cases  in  which  recovery  ensued.  Meningeal 
symptoms,  such  as  pain,  rhachialgia,  and  rigidity,  were  marked,  and 
sometimes  there  was  photophobia.  Nothing  was  found  in  the  cerebro- 
spinal fluid  or  in  the  blood  to  show  the  cause,  although  the  disease 
had  some  resemblance  to  epidemic  cerebrospinal  meningitis.  According 
to  Harbitz  and  Scheel,  the  brain  and  bulb  were  often  involved  in  epi- 
demics in  Norway. 

The  subacute  form  of  this  disease  is  a  much  more  grave  affection.  It 
was  described  by  Duchenne,  who  recognized  an  ascending  and  a  descend- 
ing type.  In  the  former  the  disease  begins  in  the  lower  extremities,  and 
later  invades  the  upper  limbs;  in  the  latter  the  course  is  the  reverse;  but 
some  of  Duchenne's  cases  may  have  been  instances  of  Landry's  disease. 
The  paralysis  in  genuine  cases  is  characteristic  of  a  lesion  of  the  anterior 
horn;  the  muscles  become  atrophied,  and  they  may  show  fibrillation. 
Bramwell  points  out  that  the  paralysis  precedes  the  atrophy,  that  the 
reflexes  are  abolished,  and  the  reactions  of  degeneration  are  present.  In 
cases  in  which  recovery  occurs  there  may  be  permanent  parah'sis  in  some 
muscles.  Sensory  and  bladder  symptoms  are  wanting.  Bulbar  symptoms 
have  been  reported.     The  disease  is  rare. 

Diagnosis. — Infantile  paralysis  in  its  initial  stage  may  be  mistaken 
for  an  acute  febrile  infection,  or,  if  a  fit  occurs,  for  infantile  convul- 
sions; and  the  paralysis  may  be  overlooked  for  several  days,  especially 
in  very  young  children.  After  the  paralysis  is  noted  the  disease  is  not 
likely  to  be  mistaken.  The  flaccid  palsy,  the  abolished  reflexes,  the  onset 
of  wasting,  all  coming  on  after  the  symptoms  of  an  acute  infection, 
without  anaesthesia,  and  limited  to  one  limb  or  part  of  one  limb,  are 
unmistakable.  The  disease  may  also  resemble  multiple  neuritis,  which  is 
sometimes  seen  in  children;  but  multiple  neuritis  is  more  wide-spread  and 
symmetrical,  pain  in  the  affected  limbs  is  more  common,  the  cause  may 
be  traced  in  some  poison,  and  complete  recovery  may  occur. 

The  subacute  form  in  adults  bears  a  resemblance  to  multiple  neuritis, 
but  the  fibrillation  in  the  muscles,  and  the  absence  of  sensory  symptoms 


1324  MEDICAL  DIAGNOSIS. 

and  of  pain  on  pressure  over  nerve-trunks  and  muscles,  serve  to  distinguish 
it.  The  reactions  of  degeneration  may  not  be  so  promptly  estabhshed  as 
in  multiple  neuritis. 

The  resemblance  of  the  subacute  form  to  Landry's  paralysis  may  be 
close;  but  the  latter  is  a  more  acute  affection,  and  the  tendency  to  a 
fatal  ending  is  more  marked.  Fibrillation  is  not  seen  in  Landry's  disease, 
but  neither  is  it  reported  in  all  cases  of  subacute  inflammation  of  the 
anterior  gray  horns.    The  two  affections  have  not  a  little  in  common. 

In  myasthenia  gravis  there  is  the  rapid  exhaustion  on  exertion,  and 
the  affected  muscles  do  not  atrophy  or  show  fibrillation.  In  all  these  three 
affections,  namely,  subacute  anterior  pohomyelitis,  Landry's  paralysis, 
and  myasthenia  gravis,  the  exact  causation  and  pathology  are  not  yet 
clearly  understood;  they  seem  to  depend  on  a  poisoning  of  the  motor 
neurons,  or,  in  the  case  of  myasthenia  gravis,  on  some  affection  of  the 
muscular  fibres,  and  the  motor  symptoms  are  not  altogether  dissimilar. 

IV.  ACUTE  ASCENDING  PARALYSIS. 

This  disease  was  first  described  by  Landry  in  1859,  and  is  usually 
called  by  his  name.  It  was  for  a  long  time  depicted  as  a  disease  without 
a  pathology,  but  the  more  refined  methods  of  recent  days  have  tended 
to  make  it  out  an  affection  of  the  peripheral  motor  neurons. 

Pathology. — We  cannot  claim  that  the  pathology  of  Landry's  paraly- 
sis is  satisfactorily  established.  Some  observers,  as  Bailey  and  Ewing, 
have  found  changes  in  the  ganghon  cells  in  the  anterior  horns  of  gray 
matter  and  in  the  bulb.  Among  these  changes  are  chromatolysis  and 
swelhng  of  the  axis-cyhnder;  also  foci  of  inflammation  and  capillary  hem- 
orrhages in  the  cord  and  medulla  oblongata.  Changes  have  also  been 
found  in  the  peripheral  nerves.    The  cause  is  unknown. 

Symptoms. — The  disease  usually  begins  as  a  flaccid  paralysis  in  the 
lower  Hmbs,  and  extends  upward,  involving  the  muscles  of  the  trunk,  the 
arms,  and  finally  the  bulb.  Anaesthesia  is  not  present,  although  there 
may  be  some  shght  dulness  or  retardation  of  sensation.  The  muscles  do 
not  waste  perceptibly,  but  in  rapidly  fatal  cases  there  is  not  time.  The 
electrical  reactions  may  be  preserved.  There  is  no  incontinence,  as  a  rule, 
although  exceptions  occur.  In  some  cases  the  initial  symptoms  are  in  the 
bulb  and  upper  extremities — the  descending  type.  The  mind  is  not 
affected.  Fever  is  not  common,  although  some  rise  in  temperature  is 
occasionally  noted.  There  may  be  hyperidrosis.  The  course  of  the  disease 
is  sometimes  very  rapid.  Death  results  from  exhaustion  and  asphyxia. 
A  few  recoveries  have  been  claimed. 

Diagnosis. — Landry's  paralysis  resembles  a  rapidly  fatal  multiple 
neuritis  more  than  anything  else,  and  if  the  pathology  be  proved  to  be 
a  toxic  affection  of  the  motor  neurons,  it  is  almost  identical  with  neuritis, 
except  that  the  usual  sensory  symptoms  are  almost  altogether  wanting. 
It  is  not  hkely  to  be  confounded  with  any  other  disease,  unless  it  be  with 
myasthenia  gravis,  in  which  the  history  and  course  are  different  and  the 
exhaustion  symptom  is  marked.  It  is  possible,  however,  that  in  myas- 
thenia gravis  there  may  be  some  involvement  of  the  motor  neurons. 


PROGRESSIVE  MUSCULAR  ATROPHY.  1325 

V.  PROGRESSIVE  MUSCULAR  ATROPHY. 

This  is  a  degenerative  process  in  the  spinal  cord,  usually  chronic, 
which  affects  chiefly  the  anterior  horns  of  gray  matter,  especially  in 
the  cervical  region.  This  is  the  disease  called,  from  its  anatomy,  chronic 
anterior  poliomyelitis;  and  from  its  clinical  form,  progressive  muscular 
atrophy. 

Pathology. — Chronic  anterior  poliomyehtis  is  a  destructive  process 
which  invades  the  anterior  horns  of  gray  matter.  Whether  it  is  an 
inflammatory  process  may  well  be  doubted.  It  has  the  appearance  under 
the  microscope  of  being  a  degeneration  of  the  motor  neurons.  Thus  the 
large  ganglionic  cells  are  shrunken  or  even  destroyed,  the  interlacing 
nerve  fiibrils  of  the  anterior  horns  are  obliterated,  and  these  horns  are 
smaller  than  normal.  Thus  far  the  anatomical  picture  is  simple.  But 
there  are  cases  in  which  this  identical  process  is  found,  and  in  which  is 
seen  in  addition  a  degeneration  of  the  lateral,  or  crossed,  pyramidal 
tracts.  Where  this  association  exists  the  clinical  form  differs,  for  in  addi- 
tion to  muscular  atrophy  there  is  seen  a  spastic  paralysis  with  exaggerated 
reflexes.  This  latter  affection  has  been  given  a  distinct  name — amyo- 
trophic lateral  sclerosis — and  is  described  in  most  text-books  as  a  distinct 
disease.  Some  neurologists  believe  these  two  so-called  diseases  are  merely 
different  forms  of  the  same  pathological  process.  They  may  be  right,  but 
for  convenience'  sake  and  to  conform  to  custom  the  two  affections  will 
here  be  described  separately.  It  is  to  be  remembered  in  any  case  that 
these  two  clinical  forms  represent  disease  of  the  motor  neurons:  in 
anterior  poliomyelitis  it  is  the  neurons  of  the  lower  order  which  are 
affected,  whereas  in  amyotrophic  lateral  sclerosis  not  only  the  neurons 
of  the  lower,  but  also  those  of  the  upper  order  are  involved.^ 

Symptoms. — The  disease  usually  begins  with  wasting  of  the  muscles 
of  the  hands,  especially  of  the  thenar  and  hypothenar  groups,  and  the  inter- 
ossei.  Later  the  muscles  of  the  forearms  become  involved,  then  those  of 
the  upper  arms  and  shoulders.  This  is  called  the  Aran-Duchenne  type. 
Other  forms  appear,  as,  for  instance,  early  wasting  of  the  deltoids,  supra- 
and  infraspinati,  and  biceps — the  upper  arm  type.  In  some  rather  rare 
or  advanced  cases  the  muscles  of  the  lower  limbs  are  involved.  The 
neck  and  trunk  muscles  may  also  waste.  Various  deformities  occur,  such 
as  the  claw  hand,  or  ''main  en  griffe, "  in  which  the  proximal  phalanges 
are  over-extended  and  the  distal  phalanges  are  flexed;  and  the  so-called 
monkey  hand,  or  "Affenhand"  of  the  Germans,  the  ''main  de  singe"  of 
the  French,  which  is  caused  by  overaction  of  the  long  extensor  of  the 
thumb,  causing  the  metacarpal  bone  to  be  displaced  backward  and  to  lie 
in  the  same  plane  as  the  metacarpal  bones  of  the  fingers.  In  the  lower 
limbs  various  forms  of  club-foot  result.  As  the  wasting  progresses,  loss 
of  power  occurs,  until  in  advanced  cases  the  wasted  arms  hang  powerless 
at  the  sides.  In  the  pure  forms,  that  is,  in  cases  in  which  the  lateral  tracts 
are  not  involved,  there  is  no  spastic  paralysis,  and  the  reflexes,  either  of 
the  arms  or  legs,  are  not  increased.     In  advanced  cases  the  reflexes  in  the 

1 R.  T.  Williamson:    "Amyotrophic  Lateral  Sclerosis  and  Progressive  Muscular  Atrophy  "  Edinburgh 

Med.  Journal,  April,  1907,  p.  304. 


1326  MEDICAL  DIAGNOSIS. 

affected  muscles  may  be  much  diminished  or  even  lost;  but  this  is  not 
invariable,  for  even  in  very  much  wasted  muscles  a  sharp  tap  will  some- 
times elicit  a  slight  response.  The  affected  muscles  are  the  seat  of  fibrillary 
twitchings.  The  complete  reactions  of  degeneration  are  not  present, 
although  some  modal  change  and  partial  reaction  may  be  seen  in  advanced 
cases.  There  is  no  anaesthesia  of  any  kind,  nor  are  the  bladder  and  bowel 
affected.  Scoliosis  does  not  occur.  In  cases  in  which  the  neck  muscles 
are  greatly  wasted  there  may  be  head-drop,  but  this  symptom  occurs 
more  frequently  in  amyotrophic  lateral  sclerosis.  As  a  rule,  there  are  no 
bulbar  or  oculomotor  symptoms.  The  disease  may  be  very  chronic,  lasting 
for  many  years.  Some  aberrant  forms  are  seen,  but  the  above  are  the 
most  common  types.  The  disease,  as  a  rule,  begins  in  adult  life.  It  is 
progressive  and  incurable. 

Diagnosis.  —  The  distinction  has  already  been  made  clear  between 
this  affection  and  amyotrophic  lateral  sclerosis.  In  the  latter  disease  there 
is  spastic  paralysis  in  addition  to  the  muscular  atrophy,  and  this  spasticity 
with  exaggerated  reflexes  is  seen  in  the  wasted  arm  muscles  as  well  as  in 
the  lower  limbs,  in  which  there  may  be  little  or  no  wasting.  In  pure  cases 
of  progressive  muscular  atrophy  there  is  no  real  spasticity  in  the  affected 
muscles  and  no  spastic  paralysis  of  the  lower  limbs.  It  must  be  acknowl- 
edged, however,  that  the  dividing  hne  between  the  two  diseases  is  not 
always  sharply  defined.  In  progressive  muscular  atrophy  increased  reflexes 
with  some  spasticity  of  the  limbs  are  sometimes  observed. 

The  disease  may  resemble  syringomyelia,  but  is  to  be  distinguished 
by  the  absence  of  the  dissociation  sensory  syndrome,  and  of  the  trophic 
lesions,  arthropathies,  and  scoliosis. 

From  pachymeningitis  of  the  cervical  cord  it  is  to  be  distinguished 
also  by  the  absence  of  sensory  symptoms  and  of  pressure  palsies  of  the  cord. 

From  multiple  neuritis  it  is  distinguished  by  its  history  and  course, 
the  absence  of  sensory  symptoms,  the  distribution  of  the  muscular  atrophy, 
the  absence  of  reactions  of  degeneration,  the  fibrillary  twitchings,  and  the 
preserved  or  even  increased  reflexes. 

The  various  muscular  dystrophies  often  resemble  progressive  muscular 
atrophy  of  spinal  origin.  They  usually  begin  in  childhood,  however,  and 
the  muscles  do  not  present  fibrillary  tremors,  nor  are  the  reflexes  preserved. 
They  are  sometimes  hereditary  and  more  than  one  case  may  occur  in  a 
family.  Several  types  are  recognized  and  will  be  described  under  their 
appropriate  headings. 

In  some  cases  of  myelitis  there  are  muscular  atrophies  and  spastic 
paralysis,  but  the  onset  is  more  rapid  and  the  course  of  the  disease  more 
acute;  sensory  symptoms  are  present,  and  there  is  paralysis  of  the  bladder 
and  rectum. 

In  the  advanced  stages  of  locomotor  ataxia  there  is  sometimes  seen 
extensive  muscular  atrophy,  but  the  history  of  the  case,  the  fulgurant 
pains,  the  ataxia,  the  aboHshed  knee-jerks,  the  atony  of  the  bladder,  the 
optic  atrophy,  the  Argjdl-Robertson  pupil  all  serve  to  distinguish  tabes. 

So,  also,  in  Friedreich's  ataxia  there  may  be  some  degree  of  muscular 
atrophy  in  later  stages  of  the  disease,  but  the  history  and  the  typical  symp- 
toms, as  ataxia,  nystagmus,  and  the  affection  of  speech,  will  prevent  error. 


AMYOTROPHIC  LATERAL  SCLEROSIS. 


1327 


VI.  AMYOTROPHIC  LATERAL  SCLEROSIS. 

Amyotrophic  lateral  sclerosis  may  be  said  to  be  a  progressive  mus- 
cular atrophy  plus  a  lateral  sclerosis.  The  two  affections  may  be  syn- 
dromes of  one  and  the  same  pathological  process,  depending  for  their 
differences  upon  a  mere  difference  in  the  distribution  of  the  lesions  in  the 
cord.  Amyotrophic  lateral  sclerosis  was  first  described  by  Charcot,  and  is 
sometimes  called  by  his  name. 

Pathology. — The  lateral  tracts  are  sclerosed,  sometimes  throughout 
their  entire  length  in  the  cord,  the  process  stopping  in  the  medulla;  and 
Alfred   W.   Campbell    has   traced    the    degeneration  as  far  as  the  brain 
cortex,  where  it  is  seen  especially  in 
the   large    Betz    cells    in    the   motor 
region — that  is,  the  ascending  frontal 
convolution   and   paracentral   lobule. 
The    degeneration    of    the     anterior 
horns  in  the  cervical  region  is  marked, 
and   sometimes   the   gray   matter   in 
the   medulla   oblongata  is    involved. 

Symptoms. — The  disease  begins 
as  a  muscular  atrophy,  most  marked 
at  first  in  the  hands,  but  gradually 
including  the  arms,  shoulders,  neck, 
and  even  the  trunk.  In  this  respect 
its  appearance  is  like  progressive 
muscular  atrophy.  The  essential 
muscles  of  the  hands  are  much 
involved,  and  ''claw  hand"  or  ''mon- 
key hand"  may  develop;  the  arms 
become  so  powerless  that  they  hang 
useless  at  the  sides;  the  muscles  of 
the  neck  atrophy  and  permit  the 
head  to  fall  forward  on  the  chest,  and 
when  the  patient  raises  the  head  it  goes  up  into  place  with  a  quick  jerk 
somewhat  like  the  closing  of  a  blade  of  a  penknife;  in  rare  cases  bulbar 
symptoms  occur,  the  patient  having  difficulty  in  swallowing  and  the  voice 
having  a  nasal  twang.  Fibrillary  twitchings  are  present.  The  muscular 
atrophy  seldom  invades  the  lower  limbs. 

Along  with  the  atrophy  appear  the  evidences  of  sclerosis  of  the  lateral 
tracts.  Even  in  the  wasting  muscles  there  is  hypertonus,  and  the  reflexes 
are  increased.  The  paretic  arms  may  be  slightly  spastic.  The  biceps- 
jerks,  triceps-jerks,  and  wrist-jerks  are  exaggerated.  The  spastic  paresis 
of  the  lower  limbs  is  very  marked;  the  patient  walks  with  a  feeble  but 
.spastic  gait,  the  feet  dragging  the  floor.  The  reflexes  are  all  exaggerated, 
such  as  the  knee-jerks  and  ankle  clonus,  and  there  is  seen  the  plantar 
extensor  reflex  of  the  great  toe — the  Babinski  reflex.  There  is  no  anaes- 
thesia, nor  any  paralysis  of  the  bladder  or  bowel. 

Diagnosis. — The  rules  for  differential  diagnosis  are  practically^  the 
same  as  in  the  case  of  progressive  muscular  atrophy,  and  have  already 
been  given  under  the  head  of  that  disease. 


Fig.  391. 


Amyotrophic  lateral  sclerosis,  showing 
head-d  rop . — Lloyd . 


1328  MEDICAL  DIAGNOSIS. 

It  is  not  always  easy  to  distinguish  these  two  diseases  from  each  other, 
for  in  truth  they  shade  into  each  other  and  may  practically  be  only  vari- 
ants of  the  same  morbid  process.  Dejerine  claims  that  bulbar  symptoms 
do  not  occur  in  true  progressive  muscular  atrophy,  and  that  they  are  indic- 
ative of  amyotrophic  lateral  sclerosis.  The  latter  disease  runs  a  more 
rapid  course  than  the  former.  The  increase  of  the  deep  reflexes,  the  spastic 
gait,  and  the  paralysis  of  the  muscles  before  the  onset  of  atrophy  are  in 
favor  of  amyotrophic  lateral  sclerosis. 

VII.  PRIMARY  LATERAL  SCLEROSIS. 

Some  authors,  as  Charcot,  Erb,  and  Dreschfeld,  have  described  a 
sclerosis  of  the  lateral  tracts  which  appears  to  be  primary,  that  is,  it  does 
not  depend  upon  a  focal  lesion,  and  is  not  associated  with  degeneration 
of  other  structures  or  tracts  of  the  cord. 

Symptoms. — The  symptoms  are  the  same  as  those  already  described 
for  amyotrophic  lateral  sclerosis,  minus  the  muscular  atrophy.  There 
is  spastic  paralysis  of  the  legs,  with  "  clasp-knife  rigidity,"  in  which  the 
limb,  when  passively  extended,  resists,  then  suddenly  yields,  as  in  the 
closing  of  the  blade  of  a  knife.  The  arms  are  sometimes  involved.  The 
deep  reflexes  are  all  exaggerated.  There  is  no  anaesthesia,  nor  paralysis 
of  the  bladder  or  bowel. 

Diagnosis.— It  is  particularly  necessary  to  eliminate  every  focal  lesion 
from  which  lateral  sclerosis  could  occur  as  a  descending  degeneration,  and 
every  disease  of  other  structures  than  the  lateral  tracts.  The  affection  is 
rare,  and  thus  far  partakes  rather  of  the  nature  of  a  pathological  curiosity. 
Mills  has  described  an  ascending  hemiplegia  which  goes  by  his  name,  and 
which  has  its  origin  in  the  cord;  the  lateral  tract  of  one  side  is  especially 
involved.  It  is  probably  distinct  from  the  affection  here  described.  Spinal 
syphilis  may  simulate  this  disease,  especially  when  the  specific  lesion  is 
confined  to  the  lateral  aspects  of  the  cord.  It  may  also  be  simulated  in 
the  early  stages  of  multiple  sclerosis. 

It  is  to  be  distinguished  from  some  degenerative  brain  and  cord 
affections;  as  that  described  by  Striimpell,  in  which  spastic  paralysis 
occurred  in  several  members  of  the  same  family;  and  from  spastic  diplegia 
in  children,  the  result  of  focal  lesions  in  the  brain,  in  which  cases  there  is 
likely  to  be  mental  defect. 

VIII.  LOCOMOTOR  ATAXIA. 

This  disease,  also  called  tabes  dorsalis,  is  characterized  by  a  degenera- 
tion of  the  posterior  columns  of  the  spinal  cord.  It  has  been  recognized 
only  within  comparatively  recent  years,  and  was  first  described  clinically 
about  1840  by  Romberg,  who,  however,  did  not  recognize  its  morbid 
anatomy.  Todd,  of  England,  and  Cruveilhier,  of  France,  were  among  the 
first  to  associate  it  with  disease  of  the  posterior  columns. 

Pathology. — There  has  been  much  discussion  as  to  the  exact  seat  of 
the  initial  lesion  in  tabes.  Vulpian,  Charcot,  and  others  held  that  it  was 
primarily  an  inflammation  of  the  posterior  nerve-roots.     Others,  as  Marie, 


LOCOMOTOR  ATAXIA.  1329 

Marinesco,  and  Wollenburg,  contend  that  the  gangHon  cells  in  the  posterior 
gangha  are  the  first  involved.  Leyden  and  Goldschneider  hold  that  the 
starting-point  is  in  the  peripheral  sensory  nerve  endings;  while  still 
others,  as  Nageotte,.  Redlich,  and  Obersteiner,  believe  that  the  disease 
begins  as  a  meningitis,  affecting  especially  the  posterior  nerve-roots.  Fer- 
rier  concludes  that  none  of  these  theories  is  satisfactory,  but  that  the 
essential  lesion  of  tabes  is  a  dystrophy,  similar  to  that  induced  by  certain 
toxic  agents,  affecting  the  sensory  protoneuron  as  a  whole.  The  disease, 
however,  is  not  confined  to  the  spinal  protoneuron,  but  may  affect  the 
optic,  the  sympathetic,  and  certain  motor  neurons. 

When  fully  established  locomotor  ataxia  shows  a  degeneration  espe- 
cially marked  in  Goll's  columns  in  the  cervical  region,  in  Burdach's  columns 
more  or  less  marked  at  various  levels  of  the  cord,  and  in  the  lumbar 
region  in  the  areas  known  as  the  handelettes  externes  of  Pierret.  There 
is  a  rare  cervical  type  in  which  the  columns  of  Goll  in  the  neck  entirely 
escape.  There  is  also  optic  degeneration,  and  in  advanced  cases  mus- 
cular atrophy.  The  posterior  nerve-roots  are  degenerated,  and  there  is 
leptomeningitis.  Syphilis  is  assigned  by  many  as  the  invariable  cause 
of  tabes. 

Symptoms. — Locomotor  ataxia  is  known  by  an  ataxic  gait,  loss  of 
static  equilibrium,  abolished  knee-jerks,  crises  and  fulgurant  pains,  sensory 
changes,  atony  of  the  bladder,  loss  of  sexual  power,  optic  atrophy,  and 
the  Argyll-Robertson  pupil.  Other  but  rare  symptoms  are  muscular 
atrophy,  arthropathies,  and  trophic  lesions. 

The  ataxic  gait  of  tabes  is  its  most  conspicuous  symptom.  It  is  not 
due  to  paralysis  but  to  incoordination.  There  may  be  full  motor  power, 
even  an  excessive  use  of  power,  but  the  muscles  do  not  act  in  harmony 
with  the  will.  The  patient  walks  with  the  feet  well  apart;  the  foot  is 
lifted  high  from  the  ground,,  thrown  out  widely,  and  brought  down  with  a 
stamp,  the  heel  striking  the  floor  first.  It  is  evident  that  the  patient  feels 
the  unreliability  of  his  gait,  for  he  watches  the  floor^  and  aids  his  progress 
by  the  use  of  his  eyes.  Hence  he  walks  with  especial  difficulty  in  the  dark 
and  in  coming  downstairs.  He  may  not  be  able  to  walk  at  all  with  his 
eyes  closed.  The  ataxia  may  also  be  marked  in  the  arms  and  hands,  as 
in  touching  the  tip  of  the  nose  with  the  forefinger  (with  closed  eyes),  unbut- 
toning his  coat,  etc.  It  is  also  seen  when  the  patient^  is  lying  down  and 
attempts  to  move  his  legs.  It  is  often  an  early  symptom,  but  may  be 
preceded  by  fulgurant  pains  and  changes  in  the  pupils. 

The  loss  of  static  equilibrium  is  seen  when  the  patient  attempts  to 
stand  without  support  and  with  his  feet  close  together;  but  it  is  much 
increased  when  he  closes  his  eyes.  He  then  sways  violently  and  in  some 
cases  would  even  fall.     This  is  the  Romberg  symptom. 

The  knee-jerks  are  abolished  early  in  tabes.  This  is  one  of  the  most 
constant  symptoms,  and  is  the  Westphal  sign.  The  other  deep  reflexes 
are  also  lost. 

The  fulgurant  pains  are  usually  an  early  symptom.  They  are  light- 
ning-like and  severe,  and  felt  most  in  the  lower  limbs.  They  may  prevent 
sleep,  and  are  most  urgent  in  their  demand  for  relief.  They  are  usually 
paroxysmal,  and  may  remit  for  days  and  even  weeks.  Closely  associated 
84 


1330  MEDICAL  DIAGNOSIS. 

with  these  pains  are  the  girdle  sense  and  various  crises.  The  former  is 
felt  as  a  band  tied  about  the  waist  or  abdomen,  or  about  the  chest,  or 
even  about  one  limb.  The  crises  are  bouts  of  pain  felt  in  various  parts 
of  the  body,  especially  in  the  epigastric  region,  hut  sometimes  in  the  thorax, 
the  larynx,  or  even  the  rectum.  They  may  simulate  some  disorder  of  one 
or  other  internal  organ.  The  laryngeal  crises  cause  a  sense  of  strangling 
and  excite  cough.  According  to  Semon  the  essential  cause  is  a  paralysis 
of  the  abductors  of  the  vocal  cords,  and  the  attacks  may  begin  with  a 
sense  of  tickling,  or  even  pain  in  the  throat,  followed  quickly  by  a  sense 
of  suffocation;  among  accessory  symptoms  are  dizziness,  mental  confusion, 
and  even  loss  of  consciousness  with  convulsive  movements,  but  the  attacks 
are  in  no  sense  epileptic.  Involuntary  passage  of  urine  and  faeces  is  occa- 
sionally present. 

There  are  various  disorders  of  sensation.  Tactile  anaesthesia  is  not 
always  present,  or  it  may  be  present  in  only  limited  areas;  in  other  cases, 
especially  in  the  advanced  stages,  it  may  be  extensive.  There  may  be 
paraesthesia,  or  altered  sense.  Thus,  the  patient  may  have  abnormal 
feelings  in  the  soles  of  the  feet,  causing  him  to  feel  as  though  he  were  walk- 
ing on  some  soft  substance,  as  velvet  or  mud.  There  may  also  be  numb- 
ness, or  formication,  or  a  sense  of  cold.  Alteration  of  the  thermal  sense, 
however,  is  not  usually  marked.  Analgesia  is  common:  the  patient  has 
lost  the  sense  of  pain,  particularly  in  the  legs;  pinching  or  sticking  with 
a  pin  is  not  felt  as  pain.  There  is  often  loss  of  muscular  sense  and  sense 
of  position;  also  of  the  sense  of  pressure  and  sense  of  active  and  passive 
motion;  and  some  writers  attach  great  importance  to  these  changes  in 
deep  sensibility  as  the  fundamental  cause  of  the  ataxia. 

Some  loss  of  power  in  the  bladder  is  often  an  early  symptom;  at 
first  there  is  difficulty  in  extrusion,  later  there  may  be  retention  or  even 
incontinence.  Loss  of  sexual  power  is  not  uncommon;  occasionally,  in  the 
early  stages,  there  is  sexual  excitement. 

Optic  atrophy  is  frequent  in  tabes,  but  its  exact  frequency  is  a  subject 
of  some  debate.  Gowers,  in  70  cases  of  posterior  sclerosis,  found  only  9 
with  this  condition;  Voight  in  52  cases  found  9;  and  Erb  in  56  cases 
found  7.  Optic  atrophy  may  appear  early,  sometimes  before  the  onset  of 
ataxia.  It  is  primary;  that  is,  it  is  not  dependent  on  a  preceding  neuritis. 
It  may  progress  to  complete  blindness,  but  its  progress  is  often  slow. 
Changes  in  the  pupils  are  likely  to  be  early  symptoms  of  tabes.  The 
sympathetic  reflex  from  irritating  the  skin  of  the  neck  is  often  lost.  There 
may  be  myosis,  sometimes  extreme;  the  pupils  are  contracted.  Some- 
times they  are  unequal,  and  even  irregular  in  outline.  Later  in  the  disease 
they  may  be  widely  dilated.  But  the  commonest  change  is  the  Argyll- 
Robertson  pupil. 

The  exterior  muscles  also  of  the  eyes  are  sometimes  involved. 
Thus,  there  may  be  ptosis  of  one  or  of  both  upper  lids.  Other 
paralyses  of  the  third  nerve  and  of  the  sixth  are  also  seen,  but  are 
not  so  common. 

Among  the  rarer  symptoms  of  tabes  are  arthropathies.  These  may 
affect  the  knee,  ankle,  hip,  elbow,  or  shoulder.  A  very  typical  form  is 
that  seen  in  the  knee.     The  joint  is  the  seat  of  a  painless  swelling;    there 


LOCOMOTOR  ATAXIA. 


1331 


is  denudation  of  the  artic-ular  surfaces,  grating,  effusion  of  fluid,  osteo- 
phytes, and  deformity.  The  joint  is  relaxed,  allowing  the  knee  to  be  over- 
extended, or  bent  backward.  The  whole  leg  may  be  enlarged  and  brawny. 
In  the  shoulder  and  hip  an  atrophic  form  of  arthropathy  is  seen;  there  is 
preternatural  mobility.  Sometimes  painless  fractures  occur.  A  condition 
known  as  hypotonia  exists:  the  joints  may  allow  a  much  wider  range  of 
motion  than  normal.  Thus,  when  the  patient  lies  upon  his  back,  the  whole 
lower  limb,  straightened  at  the  knee,  may  be  so  extended  that,  in  extreme 
cases,  the  foot  may  even  rest  alongside  the  neck. 

Of  trophic  lesions  one  of  the  most  characteristic  is  the  mal  perforans, 
or  perforating  ulcer.  This  forms  on  the  ball  of  the  foot  or  great  toe;  it  is 
deep,  painless,  and  obstinate  in  healing. 

Muscular  atrophy  is  seen  in  some 
advanced  cases  of  posterior  sclerosis, 
and  may  be  extreme  and  accompanied 
with  loss  of  power.  It  is  probably 
dependent  on  involvement  of  the  ante- 
rior nerve-roots  or  anterior  horns,  or 
on  a  peripheral  neuritis. 

The  course  of  tabes  is  usually 
chronic.  It  is  a  disease  of  long,  dura- 
tion, often  extending  over  many 
years.  In  the  advanced  stages  the 
patient  becomes  a  wreck;  unable  to 
leave  his  chair,  or  even  his  bed,  the 
victim  of  painful  crises,  partially  or 
entirely  blind,  with  incontinence  of 
urine  and  possibly  with  one  or  more 
arthropathies. 

There  is  a  sensory  type  of  tabes. 
This  is  marked  by  early  optic  atro- 
phy, proceeding  to  complete  blind- 
ness, associated  with  severe  lancinating 
pains  and  crises,  with  lost  knee-jerks, 
but  without  impairment  of  gait.  This  form  may  persist  for  many  years, 
finally  developing  ataxia.  Buzzard  reported  a  case  which  preserved 
this  type  for  fifteen  years,  and  Gowers  mentions  one  in  which  optic 
atrophy  had  existed  for  twenty  years  before  the  onset  of  incoordination. 
This  type  is  peculiarly  liable  to  arthropathies. 

Locomotor  ataxia  sometimes  coexists  with  general  paresis.  It  may 
precede  that  disease,  as  is  the  more  common  way,  or  in  some  cases 
it  may  follow  it. 

There  is  a  juvenile  tabes,  which  is  the  result  of  hereditary  syphilis. 
The  disease,  however,  is  usually  one  of  adult  Hfe,  the  initial  symptoms 
generally  showing  themselves  between  the  ages  of  30  and  40  years.  It 
is  not  limited  to  any  race  or  country,  but  is  seen  wherever  syphilis  abounds; 
and  the  statement,  at  one  time  current,  that  locomotor  ataxia  does  not 
occur  in  the  negro  race,  is  erroneous.  It  is  not  so  common  among  women 
in  any  race  as  among  men. 


Fig.   392. — Arthropathy  of   the   left   ankle- 
joint  in  locomotor  ataxia.— Lloyd. 


1332  MEDICAL  DIAGNOSIS. 

Diagnosis. — Locomotor  ataxia  is  to  be  distinguished  from  multiple 
neuritis  by  the  f  ulgurant  pains,  the  crises,  the  pupillary  changes,  the  bladder 
symptoms,  and  the  absence  of  true  paralysis  with  atrophy  and  the  reac- 
tions of  degeneration.  There  is  a  pseudotabes  due  to  multiple  neuritis, 
in  which  ataxia  is  marked,  but  the  history  of  the  case  (as  exposure 
to  lead  or  alcohol),  the  flaccid  paralysis,  with  atrophy  and  electrical 
changes,  the  painful  nerve-trunks  and  muscles,  which  differ  from  the 
lancinating  pains  of  true  tabes,  as  well  as  the  absence  of  the  optic  atrophy 
and  pupillary  changes,  serve  to  distinguish  it.  It  is  true  that  muscular 
atrophy  with  loss  of  power  may  occur  in  advanced  stages  of  tabes,  but  the 
other  tabetic  symptoms  and  the  history  of  the  case  should  prevent  error. 

From  syringomyelia,  in  which  there  sometimes  occurs  an  ataxic  type, 
tabes  is  distinguished  by  the  absence  of  the  dissociation  syndrome,  of  the 
scoliosis,  of  the  spastic  paralysis  in  the  legs  with  exaggerated  knee-jerks,  and 
of  the  muscular  atrophy  in  the  shoulders  and  arms.  Arthropathies  occur 
in  both  diseases.     Optic  atrophy  is  seldom  if  ever  seen  in  syringomyelia. 

Progressive  muscular  atrophy  is  hardly  to  be  confounded  with  tabes. 
The  muscular  atrophy,  often  with  preserved  or  even  exaggerated  reflexes, 
and  the  absence  of  ataxia,  crises,  optic  atrophy,  and  the  Argyll-Robertson 
pupil,  are  sufficient  to  distinguish  the  one  from  the  other.  The  same  may 
be  said  of  amyotrophic  lateral  sclerosis. 

From  multiple  sclerosis  tabes  is  distinguished  by  the  ataxia,  which  is 
not  the  same  as  the  intention  tremor  of  the  former  disease,  in  which  the 
movement  is  jerky,  tremulous,  and  very  marked  only  on  voluntary  motion. 
Moreover,  in  multiple  sclerosis  there  is  usually  a  spastic  gait  with  exagger- 
ated reflexes,  and  an  absence  of  f ulgurant  pains  and  crises;  nystagmus 
and  scanning  speech  are  observed;  optic  atrophy  may  be  present,  but 
only  rarely;   the  Argyll-Robertson  pupil  is  not  seen. 

The  painful  crises  of  tabes,  occurring  in  the  chest  or  abdomen,  may 
simulate  disease  of  spme  internal  organ,  as  angina  pectoris,  or  gastric 
ulcer,  or  some  affection  of  the  bowel.  The  resemblance  is  only  superficial, 
and  the  coexistence  of  other  tabetic  symptoms  points  to  the  correct  diag- 
nosis. The  laryngeal  crises  sometimes  simulate  laryngismus  stridulus, 
especially  in  the  crowing  inspiration  at  the  end  of  the  attack,  and  even 
epilepsy,  when  consciousness  is  lost  and  spasmodic  movements  occur; 
but  the  diagnosis  is  to  be  made  from  the  associated  tabetic  symptoms  in 
the  pupils,  the  gait,  and  the  reflexes. 

In  various  forms  of  myelitis  there  may  be  a  girdle  sense,  and  in 
inflammation  of  the  lumbar  cord  loss  of  the  knee-jerks;  but  usually  the 
knee-jerks  are  exaggerated,  and  the  optic  and  pupillary  symptoms  are 
wanting.  There  is  spastic  paralysis  in  the  legs,  sometimes  incontinence 
of  urine  and  faeces  early  in  the  case,  and  the  general  history  is  different. 
Crises  and  fulgurant  pains  are  wanting.  Anaesthesia,  clearly  delimited 
at  its  upper  margin,  is  often  present.  In  the  meningomyelitis  of  syphihs 
we  sometimes  see  an  ataxic  paraplegia,  in  which  the  incoordination  is  l^ery 
similar  to  that  of  tabes;  but  it  is  associated  with  a  spastic  state  of  the 
lower  limbs  and  exaggerated  knee-jerks. 

Tabes  may  coexist  with,  or  lead  up  to,  general  paresis,  but  the  peculiar 
mental  symptoms  serve  to  distinguish  these  diseases. 


ATAXIC  PARAPLEGIA.  .  1333 

IX.  ATAXIC  PARAPLEGIA. 

This  is  a  syndrome  caused  by  a  combined  sclerosis  of  the  lateral  and 
posterior  columns  of  the  spinal  cord. 

Pathology. — There  is  a  posterior  sclerosis  very  much  as  in  locomotor 
ataxia,  and  in  addition  a  sclerosis  of  the  lateral  columns  of  the  cord,  but 
more  especially  of  the  crossed  pyramidal  tracts.  Occasionally  the  direct  cere- 
bellar tracts  are  also  involved;  but  it  is  rather  rare  for  other  parts  of  the 
anterolateral  columns  to  be  invaded,  as,  for  instance,  Gowers's  tracts  or  the 
direct  pyramidal  tracts.  The  disease  seems  to  be  a  system  disease,  con- 
fining itself  to  certain  definite  tracts,  and  not  a  diffused  myelitis.  There 
is  a  form  of  syphilitic  meningomyelitis,  however,  which  closely  resembles 
combined  sclerosis  both  clinically  and  anatomically:  in  this  form,  the 
inflammation  is  located  in  the  lateral  and  posterior  aspects  of  the  cord; 
but  the  membranes  are  involved  first  and  the  posterior  and  lateral  columns 
are  affected  secondarily. 

Symptoms. — Because  of  its  morbid  anatomy  it  is  easy  to  understand 
that  ataxic  paraplegia  partakes  of  the  nature  both  of  locomotor  ataxia 
and  spastic  or  primary  lateral  sclerosis.  This  idea,  however,  requires  some 
qualification,  for  those  two  diseases  cause  some  contrary  symptoms,  such 
as  lost  knee-jerks  by  the  one  and  exaggerated  knee-jerks  by  the  other, 
and  the  two  symptoms  cannot  coexist  in  the  same  person.  As  usually 
seen,  the  share  of  the  disease  contributed  by  the  posterior  sclerosis  is  the 
ataxia.  There  may  be  some  other  tabetic  symptoms,  as  lancinating 
pains,  sensory  changes,  and  optic  atrophy,  but  they  are  rare.  Except  for 
the  ataxia  the  disease  takes  its  form  largely  from  the  sclerosis  of  the 
lateral  tracts.  There  is  a  spastic  gait,  with  exaggerated  reflexes,  and 
these  with  the  ataxia  produce  a  rather  confusing  picture. 

There  is  a  type  of  the  disease  in  w^hich  the  tabetic  symptoms  pre- 
dominate, and  there  is  then  seen  the  ataxia  with  lost  knee-jerks,  fulgurant 
pains,  and  bladder  weakness,  combined  with  some  loss  of  power  due  to  the 
lateral  sclerosis.  According  to  Oppenheim  this  predominance  of  the  ataxia 
and  other  symptoms  of  posterior  sclerosis  is  likely  to  appear  in  the  more, 
advanced  stages. 

Some  authors  claim  that  the  muscle  tonus  is  lowered,  or  at  least  not 
increased.  This  may  be  so  in  cases  in  which  the  posterior  columns  are  the: 
more  involved;  but  in  many  cases,  and  especially  in  advanced  stages,, 
there  is  increased  tonus  along  with  the  spastic  paraplegia.  The  type  of 
the  case,  whether  more  ataxic  or  more  paraplegic  and  spastic,  will  depend 
upon  which  region  of  the  cord  is  more  affected. 

Diagnosis. — The  disease  is  not  likely  to  be  mistaken  for  any  other. 
The  combination  of  ataxia  with  a  spastic  gait  is  distinctive.  Multiple 
sclerosis  may  be  simulated  by  ataxic  paraplegia,  but  in  multiple  sclero- 
sis there  is  not  a  true  ataxia,  but  rather  an  intention  tremor,  with 
nystagmus  and  speech  defects.  From  some  forms  of  spinal  syphilis  the 
distinction  is  not  always  easy.  Diffused  myelitis  may  also  resemble  com- 
bined sclerosis,  but  the  symptoms  are  not  so  characteristic  of  a  system 
disease.  The  ataxia  closely  resembles  that  of  tabes  dorsalis,  but  the 
spastic  paraplegia,  with  exaggerated  knee-jerks,  marks  the  difference. 


1334  MEDICAL  DIAGXOSIS. 

X.  HEREDITARY  ATAXIA. 

This  affection,  also  called  Friedreich's  disease,  is  a  family  rather  than 
an  hereditary  disorder.  It  is  often  seen  in  several  brothers  or  sisters,  but 
is  seldom  directly  herechtary.  It  is  due  to  degeneration  of  several  tracts 
of  the  spinal  cord,  especially  the  posterior  columns,  but  the  lateral  tracts, 
and  sometimes  the  direct  cerebellar  tracts  and  Clarke's  columns,  may  also 
be  involved.  The  affection  of  the  posterior  columns  seems  to  give  the 
disease  most  of  its  individuality. 

Symptoms. — The  patient  has  an  ataxic  or  staggering  gait,  in  v,-hich 
he  keeps  his  feet  far  apart  and  sways  his  body  violently.  The  gait  is  not 
identical  with  that  of  locomotor  ataxia;  the  stamping  is  not  so  marked, 
the  swaying  of  the  body  is  more  conspicuous,  and  the  jDrogTession  has 
something  in  it  that  even  suggests  a  cerebellar  lesion.  There  may  also 
be  violent  ataxic  movements  while  sitting  or  even  reclining.  The  swajang 
is  not  particularly  increased  by  closing  the  eyes.  Later  there  are  ataxic 
movements  in  the  arms.  The  knee-jerks  are  abolished.  Anaesthesia  is 
not  present,  unless  in  the  advanced  stages,  and  then  not  alwa3's.  True 
paralysis  of  the  legs  occurs  also  in  advanced  stages,  and  there  may  even 
be  marked  muscular  atrophy.  ScoKosis  sometimes  occurs  and  a  form  of 
club-foot  with  characteristic  over-extension  of  the  gi'eat  toe.  In  some 
cases  a  Babinski  reflex  has  been  seen.  The  fulgurant  pains  and  crises  of 
true  tabes  are  not  seen,  nor  is  there  paralysis  of  the  bladder.  Especially 
characteristic  are  the  nj'stagmus  and  speech  defects.  The  former  is  usually 
of  the  lateral  variety.  The  speech  is  slow,  labored,  staccato,  or  scanning. 
Optic  atrophy  and  ophthalmoplegias  do  not  occur.  The  disease  begins 
in  childhood,  as  a  rule,  although  in  a  few  cases  it  has  not  appeared  untU 
early  adult  life.  It  is  an  incurable  affection,  and  steadily,  but  sometimes 
slowly,  progi-essive. 

Diagnosis.  —  From  locomotor  ataxia  Friedreich's  ataxia  is  distin- 
guished by  its  early  onset,  its  family  association,  its  freedom  from  crises 
and  bladder  atony,  its 'exemption  from  optic  atrophy  and  ophthalmople- 
gias, its  nystagmus,  and  its  speech  defects. 

Multiple  sclerosis  may  simulate  this  disease,  but  it  is  rare  in  early 
childhood.  It  presents  spastic  paralysis  with  exaggerated  knee-jerks, 
intention  tremor,  sometimes  an  optic  atrophy,  and  it  is  not  seen  as  a 
family  affection. 

In  cerebellar  ataxia  there  may  be  exaggerated  knee-jerks,  optic  atro- 
phv.  ataxic  speech,  and  a  more  distinct  cerebellar  gait  than  in  Friedreich's 
disease.     Still  these  two  affections  have  much  in  common. 

The  ataxic  movements  in  this  disease  may  simulate  chorea  and  various 
kinds  of  tremors;  but  the  association  with  the  other  symptoms  is  usually 
enough  to  prevent  error.  These  movements  have  not  the  rh}i:hm  of  trem- 
ors, and  they  are  not  of  the  involimtary  nature  of  choreic  jerldngs.  In 
chorea  the  movements  persist  while  the  patient  is  at  rest;  in  Friedreich's 
disease  thev  are  seen  only  dining  voluntary  motion. 


SYRINGOMYELIA. 


1335 


XI.  SYRINGOMYELIA. 

This  term  is  applied  to  a  process  in  the  cord  which  results  in  the  for- 
mation of  a  cavity.  This  process  is  a  gliomatosis^  or  proliferation  of  a 
gliomatous  tissue  which  breaks  down  in  the  centre.  It  is  not  a  mere  dila- 
tation of  the  central  canal  of  the  cord,  for  this  canal  may  not  be  included 
in  the  cavity,  as  was  first  pointed  out  by  Simon  in  1875.  Dilatation  of 
the  central  canal  may  result  from  other  conditions,  and  is  then  properly 
called  hydromyelia. 

Pathology.  —  The  overgrowth  of  gliomatous  tissue  is  usually  most 
marked  in  the  gray  matter.  When  this  tissue  breaks  down,  the  resulting 
cavity  is  of  greater  or  less  extent.     It  may  extend  across  the  cord  almost 


Fin.  393. — Syringomyelia  in  the  cervical  region. — Lloy 


symmetrically  on  either  side;  in  other  cases  it  tends  to  follow  one  or  other 
horn  of  gray  matter.  The  resulting  injury  to  the  structures  of  the  cord 
may  be  extensive.  The  anterior  horns  are  involved,  the  lateral  tracts 
below  the  lesion  are  degenerated,  and  the  posterior  horns  may  be  almost 
cut  off  from  the  rest  of  the  cord;  but  the  posterior  columns  may  largely 
escape.  The  location  of  the  central  canal  is  usually  marked  by  a  collection 
of  ependymal  cells  on  the  anterior  border  of  the  cavity.  The  walls  of  the 
cavity  are  sometimes  lined  with  a  sort  of  membrane  formed  from  glioma- 
tous tissue.  The  lesion  may  be  largely  located  in  the  cervical  region,  the 
cavity  extending  upward  and  downward  in  various  shapes  and  to  various 
levels.  In  a  few  cases  the  dorsal  cord  is  most  involved;  in  others,  the 
lumbar  cord.  The  cord  at  the  seat  of  lesion  is  often  flattened  and  ribbon-like. 


1336 


MEDICAL  DIAGNOSIS. 


Symptoms.  —  There  is  degeneration  of  the  anterior  horns.  If  the 
cavity  is  in  the  cervical  cord,  there  results  extensive  muscular  atrophy 
of  the  shoulders  and  arms  with  a  flaccid  paralysis  and  fibrillary  tremors. 
Occasionally,  however,  the  type  of  paralysis  in  the  wasted  limb  is  spastic, 
and  the  reactions  of  degeneration  are  wanting.  The  degeneration  of  the 
lateral  tracts  causes  a  spastic  paralysis  of  the  lower  Hmbs,  with  exaggerated 
knee-jerks.     The  paralysis  in  rare  instances  is  hemiplegic,   and  in  some 

cases  ataxia  has  been  seen.  The  sensory 
symptoms  are  most  characteristic:  they 
constitute  the  so-called  dissociation  S}^- 
drome.  There  is  loss  of  the  sense  of  heat, 
cold,  and  pain,  with  preservation  of  the 
tactile  sense.  The  location  of  this  syn- 
drome depends  upon  the  seat  and  extent 
of  the  lesion:  it  may  be  most  marked  on 
the  trunk,  but  it  is  also  seen  on  the 
extremities.  It  may  also  be  more  marked 
on  one  side,  and  it  occurs  in  areas  of  va- 
rious extent.  Occasionally  some  areas  of 
tactile  anaesthesia  are  also  found.  Trophic 
lesions  occur.  Maculae  appear  on  the  skin 
of  the  legs;  the  toe-nails  are  enlarged  and 
thickened,  with  transverse  ridges.  In  the 
tj^pe  known  as  Morvan's  disease  there  are 
painless  destructive  lesions  of  the  fingers. 
Scoliosis  is  not  uncommon;  and  occasion- 
ally an  arthropathy  of  one  or  other  joint 
is  seen  just  as  in  locomotor  ataxia.  Among 
the  rarer  symptoms  are  paralysis  of  the 
muscles  of  respiration,  bulbar  and  oculo- 
motor symptoms,  paralysis  of  the  vocal 
cords,  nystagmus,  painless  fractures,  and 
various  skin  eruptions,  such  as  urticaria 
and  pemphigus.  Bladder  symptoms  are 
usually  not  present. 

Diagnosis.  —  Syringomyelia  is  to  be 
distinguished  especially  from  progressive 
muscular  atrophy  and  amyotrophic  lateral 
sclerosis.  To  both  diseases  it  bears  a 
resemblance  because  of  the  muscular  atrophy  of  the  shoulders  and  arms 
and  the  spastic  paralysis  in  the  legs;  but  it  differs  from  both  in  its  dis- 
sociation sensory  syndrome  and  in  its  trophic  lesions.  The  disease  known 
as  pachymeningitis  hypertrophica  of  the  cervical  cord  sometimes  bears  a 
striking  resemblance  to  syringomyelia,  even  in  its  sensory  symptoms. 
There  may  be  the  same  loss  of  sense  for  pain,  heat,  and  cold,  with  pres- 
ervation of  tactile  sense;  muscular  atrophy  of  the  shoulders  and  arms; 
and  spastic  paralysis  of  the  legs;  but  in  the  former  disease  there  is  often 
a  history  of  trauma,  and  in  some  cases  the  stiffness  and  deformity  fol- 
lowing upon  fracture  of  the  vertebrae  are  seen. 


Fig.  394. —  Syringomyelia,  showing 
scoliosis,  muscular  atrophy  of  the  shoul- 
der, and  arthropathy  of  the  ankle. — 
Lloyd. 


SYPHILIS  OF  SPINAL  CORD  AND  MEMBRANES.         1337 

Morvan's  disease  is  a  form  of  syringomyelia  in  which  there  are  painless 
destructive  whitlows  of  the  fingers  (the  panaris  analgesique  of  French 
writers).  Morvan  claimed  that  the  disease  is  distinguished,  however,  from 
syringomyelia,  by  the  predominance  of  trophic  lesions  and  the  loss  of 
tactile  sense;  but  there  may  be  the  same  muscular  atrophy,  scoliosis,  and 
even  arthropathy,  and  the  two  affections  are  probably  closely  allied. 
This  type  so  much  resembles  some  forms  of  lepros}"  that  Zambaco  and 
others  have  even  claimed  that  syringomj^elia  is  a  form  of  leprosy — a  curi- 
ous instance  of  confusing  a  resemblance  with  an  identity.  There  is  no 
central  gliomatosis  in  leprosy,  and  there  are  many  distijictions,  too 
numerous  to  mention  here,  which  are  described  under  that  disease.  The 
anaesthetic  form  of  leprosy  is  dependent  on  a  neuritis,  not  a  cord  lesion. 

Charcot  pointed  out  that  one  of  the  trophic  lesions  of  syringomyelia 
is  an  enlargement  of  the  hand  closelj^  resembhng  acromegalia.  In  his 
case  the  change  was  limited  to  one  hand,  and  was  symptomatic  of  glioma- 
tosis. In  some  cases  the  parah'sis  is  largely  unilateral,  resembling  hemi- 
plegia of   cerebral    origin;    but  the  other  cord   symptoms  distinguish  it. 

Dejerine  contends  that  Friedreich's  ataxia  is  due  to  a  gliomatous 
change  in  the  cord;  and  in  a  series  of  12  autopsies  in  Griffith's  collection 
of  cases  cavities  were  found  in  three.  Doubtless  in  rare  cases  in  which 
the  posterior  columns  are  much  involved  and  ataxia  results,  the  resem- 
blance of  syringomyelia  to  hereditary  ataxia  is  manifest,  but  the  sensory 
and  trophic  lesions  of  the  one,  and  the  speech  defects  and  nystagmus  of 
the  other,  serve  to  distinguish  them.  Thus  in  syringomyelia  the  knee- 
jerks  are  exaggerated,  except  in  the  rare  tabetic  form;  in  Friedreich's 
ataxia  they  are  abolished,  while  in  the  latter  there  are  speech  defects 
w^hich  are  not  seen  in  the  former,  as  well  as  a  familial  history  in  many 
cases.  Nystagmus  is  most  rare  in  syringomyelia,  while  it  is  common 
in  Friedreich's  disease.  Finally,  the  dissociation  symptom,  muscular 
atrophy,  arthropathies  and  other  trophic  lesions  are  all  suggestive  of 
syringomyelia;    which  disease,  moreover,  rarel}'  begins  in  early  youth. 

In  the  rare  cases  in  which  ataxia  occurs,  especially  if  there  should  be 
a  spinal  arthropathy  and  lost  knee-jerks,  the  resemblance  to  locomotor 
ataxia  may  be  striking,  but  the  sensory  symptoms,  the  muscular  atroph}?-, 
the  scoliosis,  and  the  other  trophic  lesions  would  establish  the  diagnosis. 
The  knee-jerks  are  not  always  lost  in  the  ataxic  form. 

XII.  SYPHILIS  OF  THE  SPINAL  CORD 
AND  MEMBRANES. 

Syphilis  may  confine  its  ravages  entirely  to  the  spinal  cord  and 
membranes,  or  it  may  affect  both  the  spinal  contents  and  the  brain.  The 
diffused  cerebrospinal  syphilis  is  usually  more  conspicuous  for  its  brain 
symptoms,  but  evidences  of  involvement  of  the  cord  can  often  be 
found  on  close  inspection. 

Pathology.— The  essential  lesion  of  syphihs  of  the  nervous  system  is 
an  initial  endarteritis.  The  membranes,  however,  are  soon  involved,  and 
the  resulting  meningitis  then  spreads  to  the  contiguous  nervous  structures. 
It  is  highly  characteristic  of  the  syphilitic  inflammation  to  become  exuda- 


1338  MEDICAL  DIAGNOSIS. 

tive;  there  then  results  a  thickening  of  the  membranes,  a  plastic  exudate, 
and  very  often  a  gummatous  neoplasm.  In  some  forms  the  resulting 
meningomyelitis  presents  but  little  exudation  and  practically  no  gumma. 
Thickening  and  even  obstruction  of  blood-vessels  may  occur,  leading  to 
various  degrees  of  necrosis  or  softening.  In  the  spinal  cord  the  lesion 
may  be  largely  confined  to  the  membranes,  especially  the  pia,  with  only  a 
limited  area  of  peripheral  myelitis  underneath.  This  condition  is  especially 
seen  about  the  lateral  or  posterolateral  columns.  In  other  cases  the  disease 
process  is  more  diffused,  without  reference  to  the  various  tracts  and 
systems  of  the  cord,  thus  causing  various  bizarre  combinations,  and 
symptoms  of  disseminated  myelitis. 

Symptoms. — Because  of  its  irregular  distribution  and  various  degrees, 
the  syphilitic  process  gives  rise  to  manifold  and  irregular  symptoms. 
In  some  cases  there  is  merely  a  meningomyelitis,  more  or  less  circum- 
scribed, with  some  resulting  softening.  The  symptoms  are  then  practically 
the  same  as  have  already  been  described  under  the  head  of  myelitis.  In 
the  more  diffused  or  disseminated  form,  the  symptoms  are  irregular.  Irri- 
tation of  the  nerve-roots  is  common,  with  resulting  pains,  girdle  sense,  and 
stiff  back.  There  may  be  spastic  paraplegia,  impairment  of  the  nerve 
supply  to  the  bladder,  and  various  forms  of  anaesthesia.  Sometimes  there 
is  muscular  atrophy,  and  even  monoplegia.  As  a  rule,  spinal  syphilis 
does  not  cause  a  so-called  "system-disease."  Exceptions  to  this  rule 
occur,  however,  especially  in  the  form  described  by  Erb  and  sometimes 
called  by  his  name.  In  Erb's  paralysis  the  lesion  is  a  meningomyelitis 
of  the  lateral  aspects  of  the  cord.  There  results  a  spastic  paralysis  of 
the  legs,  with  exaggerated  knee-jerks,  low  muscle  tension,  that  is,  without 
contractures;  with  weakness  of  the  bladder,  and  usually  no  involvement 
of  sensation.  In  some  cases,  however,  the  lesion  includes  the  posterior 
aspects  of  the  cord,  and  there  is  then  added  an  ataxia,  possibly  with 
some  alterations  of  sensation.  This  condition  closely  resembles  ataxic 
paraplegia. 

Another  form  of  spinal  syphilis  is  seen  in  the  gummatous  tumor.  This 
may  be  located  at  almost  any  level  of  the  cord,  or  sometimes  in  the  cauda 
equina.  Its  symptomatology  will  depend  upon  its  location  and  extent, 
the  same  as  in  any  other  tumor  of  the  spinal  cord. 

The  clinical  picture  of  spinal  syphilis  varies;  there  may  be  reces- 
sions and  improvement;  at  other  times,  an  irregular  advance  with 
remissions.  Pure  "system-diseases"  are  rare,  except  in  Erb's  type; 
and  the  affection  may  especially  change  under  specific  treatment.  In 
some  cases  there  may  be  cerebral  symptoms,  and  involvement  of  one 
or  more  cranial  nerves. 

Sj^philis  is  now  believed  by  many  neurologists  to  be  the  sole  cause  of 
locomotor  ataxia.  The  lesion  in  tabes,  however,  does  not  always  present 
the  type  of  an  exudative  meningomyelitis,  but  it  is  rather  a  parenchymatous 
change,  a  dystrophy  confined  to  the  sensory  protoneuron.  Nevertheless 
there  are  some  pathologists,  as  Nageotte  and  others,  who  believe  that 
even  in  locomotor  ataxia  the  initial  lesion  is  a  meningitis  affecting  the 
posterior  nerve-roots.  However  that  may  be,  tabes  dorsalis  is  usually 
described  as  a  distinct  disease. 


TUMORS  OF  THE  SPINAL  CORD.  1339 

Diagnosis. — From  ordinary  myelitis  it  is  not  always  easy  to  distin- 
guish syphilis  of  the  spinal  cord;  in  fact,  the  syphilitic  lesion  may  consist 
largely  of  a  meningomyelitis.  Syphilis  is  hkely  to  cause  an  irregular 
distribution  of  symptoms,  but  this  fact  is  not  of  as  much  diagnostic 
importance  as  some  writers  contend.  There  are  cases  of  myelitis,  or 
meningomyelitis,  with  or  without  softening,  in  which  it  is  not  possible  to 
make  a  differential  diagnosis.  The  problem  is  simplified  in  cases  in  which 
there  is  a  clear  history  of  syphilitic  infection.  The  therapeutic  test  is  not 
always  determinative,  although  sometimes  helpful.  In  cases  in  which 
there  is  some  associated  cerebral  syphilis  the  diagnosis  is  more  evident. 

The  same  difficulty  occurs  in  cases  of  Erb's  palsy,  for  this  affection 
closely  resembles  primary  lateral  sclerosis  (the  so-called  primary  spastic 
paraplegia),  except  that  in  the  former  the  bladder  is  often  involved, 
slight  sensory  changes  occur,  and  the  muscle  tone  is  not  increased.  In 
Erb's  palsy  there  may  also  be  irritative  symptoms,  as  pain  and  the  girdle 
sense,  due  to  involvement  of  the  posterior  nerve-roots.  This  is  particu- 
larly so  in  cases  in  which  the  lesion  spreads  to  and  upon  the  posterior 
columns.  We  then  see  a  condition  of  ataxic  paraplegia,  which  is  prac- 
tically indistinguishable  from  the  combined  sclerosis  which  some  authors 
describe  as  a  system  disease  of  non-syphilitic  origin.  These  fine  problems 
in  diagnosis  cannot  always  be  satisfactorily  solved,  but  in  all  such  cases 
the  history  of  syphilis  in  the  patient  should  be  carefully  sought;  and 
whether  this  is  found  or  not,  the  antisyphilitic  treatment  should  be  given 
a  fair  trial. 

Some  authors  attempt  to  make  a  distinction  between  locomotor 
ataxia  and  syphilitic  leptomeningitis  extending  to  the  posterior  columns. 
In  the  latter  disease  there  are  sensory  symptoms  ■  and  ataxia  closely 
resembling  these  symptoms  in  tabes,  but  the  other  distinctive  tabetic 
symptoms,  such  as  optic  atrophy,  Argyll-Robertson  pupil,  crises,  and 
arthropathies,  are   wanting. 

•  * 

XIII.  TUMORS  OF  THE  SPINAL  CORD. 

We  include  here  not  only  tumors  of  the  cord  proper  but  also  tumors 
of  the  membranes,  for  the  distinction  between  them  is  not  clinically  pos- 
sible. We  also  include  tumors  of  the  vertebrae,  for  although  these  are 
sometimes  distinguishable  at  the  bedside  from  intraspinal  growths,  their 
clinical  features  are  similar.  Tumors  of  the  spinal  cord  proper  aj-e  rare; 
those  springing  from  the  membranes  are  the  more  common.  In  50  cases 
collected  by  Mills  and  Lloyd,  the  largest  number  were  sarcomata, 
gliomata,  or  gummata.  In  nearly  one-half  of  these  cases  the  tumor  was 
in  the  cervical  region;  the  dorsal  region  was  involved  next  in  frequency, 
and  then  the  lumbar  region.  The  cauda  equina  was  also  involved  in  a 
few  cases. 

Symptoms. — In  most  cases  the  symptoms  indicate  irritation  early 
of  the  nerve-roots  and  membranes,  and  later  pressure  on  the  cord.  Hence 
pain  is  often  an  early  or  initial  symptom;  it  may  be  intense,  neuralgic, 
persisting  for  a  long  time  in  one  region,  and  may  radiate  or  be  located  far 
from  the  cord  (eccentric  pain).     It  may  be  associated  with  hypersesthesia, 


1340  MEDICAL  DIAGNOSIS. 

hyperalgesia,  parsesthesia,  or  even  anaesthesia,  and  there  may  be  a  subjec- 
tive sense  of  numbness  in  some  localized  part,  and  even  a  girdle  sense. 
With  the  pain  there  may  be  some  stiffness  of  the  spine,  and  contracture 
of  some  or  other  muscle  groups.  As  the  case  progresses  the  symptoms  of 
pressure  show  themselves;  there  is  paralysis  of  one  or  other  limb  or  group 
of  muscles,  and  anaesthesia  is  more  marked  and  more  extensive.  There 
may  be  anaesthesia  dolorosa,  that  is,  absence  of  sensation  to  objective 
tests,  with  the  presence  of  pain  in  the  affected  part.  Paralysis  of  the 
bladder  and  bowel  may  eventually  come  on.  In  fact,  we  see  the  symptoms 
of  either  a  partially  transverse  or  even  (in  advanced  cases)  a  totally  trans- 
verse lesion.  The  distribution  of  these  symptoms  will,  of  course,  vary 
according  to  the  seat  of  the  lesion.  In  a  very  advanced  stage  there  will 
be  total  paralysis  below  the  seat  of  lesion,  contractures,  deviation  of  the 
spine,  anaesthesia,  incontinence,  bed-sores,  cystitis,  alteration  in  the  re- 
flexes, dyspnoea,  tachycardia  or  bradycardia,  in  cervical  cases  dysphagia, 
and  even  bulbar  and  ophthalmic  symptoms.  In  some  cases  there  is  pain 
on  pressure  or  palpation  over  the  site  of  the  tumor,  and  pain  on  twisting 
or  bending  the  spine. 

Diagnosis. — The  mode  of  onset  is  often  suggestive.  The  initial  symp- 
toms are  likely  to  be  irritative,  hence  pain.  This  pain  may  be  eccentric  and 
localized  in  the  distribution  of  one  or  of  a  few  nerves.  Paresis  begins  also 
as  a  localized  symptom;  it  may  at  first  be  more  marked  in  one  limb  or 
even  in  one  group  of  muscles.  Later  the  symptoms  are  more  suggestive 
of  compression  of  the  cord,  as  anaesthesia,  paraplegia,  incontinence,  and 
bed-sores.  In  some  cases  the  symptoms  are  markedly  unilateral,  causing 
the  so-called   Brown-Sequard  paralysis,  or  an   approach  to  it. 

From  syphilis  of  the  cord  it  is  not  always  possible  to  distinguish  tumor. 
In  fact  syphihs  may  cause  a  gummatous  tumor.  The  mode  of  onset  is 
more  suggestive  of  a  neoplasm.  The  therapeutic  test  with  the  iodides  is 
not  reliable.  The  progress  of  the  disease  in  tumor  is  rather  more  per- 
sistent and  hopeless  than  in  most  cases  of  syphilitic  meningomyelitis. 

From  myelitis  and  acute  softening  the  distinction  is  often  to  be  made 
by  the  more  abrupt  onset  of  these  affections.  The  symptoms  of  a  trans- 
verse lesion  are  much  sooner  established  than  in  tumor;  and  the  initial 
pain,  so  marked  in  case  of  neoplasm,  may  be  wanting.  Unilateral  symp- 
toms are  not  common  in  myelitis  and  softening.  In  hemorrhage  the 
onset  is  sudden,  often  caused  by  trauma,  and  the  disease  reaches  its 
acme  in  a  short  time.  In  spinal  caries  the  bone  lesion  can  usually  be 
detected  by  inspection.  The  X-ray  may  demonstrate  the  lesion.  In  very 
early  cases,  before  deformity  appears,  it  may  be  possible  to  elicit  pain  by 
jarring  the  spine,  and  there  may  be  stiffness  of  the  back,  and  pain  on 
passive  movements  of  the  trunk. 

In  traumatism  the  case  can  usually  be  distinguished  by  the  history. 
Still,  it  is  well  to  recall  that  tumor  may  follow  trauma.  Aneurism  of 
the  aorta  may  erode  the  spine  and  cause  symptoms,  first  of  irritation  and 
later  of  pressure.  It  is  only  to  be  detected  by  exploration  and  by  the 
methods  of  physical  diagnosis.  Cancer  of  the  vertebrae  usually  causes 
very  urgent  symptoms,  especially  of  initial  pain,  and  later  of  pressure  on 
the  cord  or  nerve-roots.     The  nature  of  the  lesion  may  remain  for  some  time 


INJURIES  TO  THE  SPINAL  CORD.  1341 

obscure;  or  there  may  be  the  history  of  precedent  cancer.  The  symptoms 
soon   become  extremely  aggravated,   and  the  patient  becomes   cachectic. 

In  neuritis  there  is  soreness  of  the  nerve-trunks,  with  paralysis  of 
motion  or  of  sensation,  or  of  both,  in  areas  supplied  by  the  individual 
nerves.  In  early  stages  motion  is  more  likely  to  be  impaired  than  sensa- 
tion. Muscular  atrophy  occurs.  Compression  symptoms,  and  involve- 
ment of  the  bladder  and  rectum,  are  wanting.  Still,  the  distinction  is  not 
always  easy  between  neuritis  and  intraspinal  tumor,  especially  if  the  new 
growth  affects  chiefly  the  nerve-roots,  as  in  the  cauda  equina. 

The  eccentric  or  localized  pain  of  tumor,  especially  in  the  early  stage, 
may  closely  simulate  a  mere  neuralgia,  or  even  a  disease  of  some  internal 
organ,  as  in  the  chest  or  abdomen.  The  differential  diagnosis  must  depend 
on  the  association  of  the  symptoms;  for  instance,  of  other  symptoms  of  cord- 
lesion,  on  the  one  hand,  or  of  disease  of  the  suspected  viscus,  on  the  other. 

The  local  or  regional  diagnosis  is  to  be  made  as  in  cases  of  myelitis  or 
trauma. 

XIV.  INJURIES  TO  THE  SPINAL  CORD. 

The  spinal  cord  is  subject  to  injury  by  blows,  falls,  crushings,  stab- 
wounds,  and  gun-shot  wounds.  The  commonest  injuries  are  those  which 
also  cause  fracture  and  dislocation  of  the  vertebrae.  It  is  not  essential, 
however,  that  there  should  be  a  fracture  or  dislocation  of  vertebrae,  as 
fatal  injury  has  been  done  to  the  cord  by  falls,  without  visible  injury  to 
the  bones.  Gun-shot  wounds  are  common,  and  a  few  instances  are  on 
record  of  the  cord  being  injured  or  partly  severed  by  a  stab  with  a  knife 
or  stiletto.  The  commonest  seat  of  injuries  to  the  cord  is  in  the  neck; 
next  in  the  dorsal  region.  The  lumbar  region,  being  more  massive  and 
better  protected  by  large  muscles,  is  not  so  often  involved.  It  has  been 
supposed  in  some  cases  that  a  vertebra  may  be  partly  dislocated  and 
then  spring  back  into  place,  thus  causing  a  crushing  of  the  cord.  Fracture 
is  not  always  associated  with  dislocation,  nor  vice  versa. 

The  lesion  in  most  of  these  cases  is  severe.  The  cord  is  either  partly 
disintegrated,  or  entirely  so  in  its  transverse  diameter.  It  is  softened  and 
necrosed,  and  may  be  the  seat  of  hemorrhage.  There  may  also  be  hemor- 
rhage within  the  spinal  membranes.  In  long-standing  cases  in  which  there 
have  been  attempts  at  repair,  there  is  much  scar  tissue,  together  with 
degeneration  of  various  tracts  in  the  cord. 

Symptoms. — The  symptoms  depend  upon  the  seat  of  the  lesion. 

Injury  to  the  cervical  region  causes  a  characteristic  symptom-group, 
which  varies  according  to  the  extent  of  the  injury.  There  is  a  spastic 
paralysis  of  the  legs,  more  or  less  complete,  with  paralysis  of  the  bladder 
and  rectum.  The  knee-jerks  are,  as  a  rule,  increased,  although  in  totally 
transverse  lesions  the  knee-jerks  may  be  abolished  at  first.  Later,  if 
the  patient  survives,  they  may  return  and  become  exaggerated.  This 
is  also  true  of  the  other  deep  reflexes.  Contractures  of  the  leg  muscles 
often  supervene,  and  bed-sores  may  form  very  rapidly  about  the  buttocks 
or  on  the  sacrum.  The  arms  are  totally  or  only  partly  paralyzed,  accord- 
ing as  the  cervical  enlargement  and  the  roots  of  the  brachial  plexus  are 
or  are  not  totally  involved.    In  some  cases  the  arms  lie  paralyzed  and 


1342 


MEDICAL  DIAGNOSIS. 


flaccid  at  the  side;  in  other  cases  some  power  is  retained,  especially 
power  of  flexion  of  the  arm  at  the  elbow,  and  contractures  supervene. 
Wasting  of  the  muscles  of  the  shoulders,  arms,  and  hands  is  likely  to  set 
in  if  the  cervical  enlargement  is  injured.  Sensation  may  be  entirely 
abohshed  below  the  line  of  injury.    If  the  lesion  is  low  in  the  neck  the 

anaesthesia  may  not 
involve  the  shoulders  and 
outer  aspects  of  the  upper 
arms.  Pain  on  moving 
the  neck  may  be  severe. 
If  the  injury  extends 
above  the  fourth  cervical 
segment  the  phrenic  nerve 
may  be  paralyzed  and 
cause  death.  The  pupil- 
lary centre  in  the  cord  may 
be  injured,  with  conse- 
quent contraction  of  the 
pupil;  if  it  is  only  irri- 
tated the  pupil  is  dilated. 
In  some  cases  of  injury 
to  the  cervical  cord  the 
clinical  picture  closely 
resembles  syringomyelia. 
There  is  atrophic  paral- 
ysis of  the  shoulders,  arms 
and  hands,  spastic  paral- 
ysis of  the  legs,  with  the 
dissociationsensory  symp- 
toms as  seen  in  syringo- 
myelia. In  such  cases 
there  is  usually  deformity 
of  the  cervical  spine  from 
the  old  injury,  and  sub- 
sequent ankylosis. 

Injury  to  the  dorsal 
region  causes  spastic  para- 
plegia and  all  the  other 
symptoms  as  described 
above  except  those  in  the  upper  extremities.  The  anaesthesia  when 
present  gives  a  valuable  clue  to  the  uppermost  limit  of  the  injury.  There 
may  be  a  zone  of  hyperaesthesia  at  the  extreme  upper  limit,  due  to 
irritation  of  the  nerve-roots;  and  pain  may  radiate  through  the  trunk 
at  this  level  for  the  same  reason. 

Injury  to  the  lumbar  region  also  causes  paralysis  of  the  legs,  bladder, 
and  rectum,  but  if  the  lumbar  enlargement  is  involved  the  paralysis  of  the 
legs  is  flaccid,  with  abplished  knee-jerks,  wasting  of  the  muscles,  and  elec- 
trical changes.  Anaesthesia  may  be  present  on  the  buttocks,  genitalia, 
perineum,  thighs,  and  legs.     Pain  in  the  legs  may  also  be  present. 


Fig.  395.- 


-Trauma  of  the  cervical  region  of  the  spinal  cord,  simu- 
lating syringomyelia. — Lloyd. 


HEMORRHAGE  IN  SPINAL  CORD  AND  MEMBRANES.    1343 

A  unilateral  lesion  of  the  cord  may  cause  the  so-called  Brown-Sequard 
syndrome:  there  is  paralysis  of  motion  on  the  side  of  the  lesion  and  loss 
of  sensation  on  the  opposite  side,  but  this  sensory  loss  is  in  the  tempera- 
ture and  pain  sense  rather  than  in  the  tactile  sense.  If,  however,  the  pos- 
terior column  of  one  side  is  affected  there  is  tactile  anaesthesia  also,  but  it 
is  on  the  side  of  the  lesion. 

Diagnosis. — To  determine  the  exact  seat  of  the  lesion  the  practitioner 
should  study  the  uppermost  limits  of  the  anaesthesia,  and  the  muscle-groups 
involved,  and  compare  them  with  a  chart  and  table  of  the  spinal  segments. 
In  this  way  an  exact  local  diagnosis  may  be  reached  (pp.  313-314). 

The  history  of  the  case  is  usually  sufficient  to  establish  the  clinical 
diagnosis.  It  is  not  always  possible  to  say  whether  the  lesion  is  a  mere 
hemorrhage  in  the  substance  of  the  cord,  or  in  the  membranes,  or  whether 
it  is  a  crush  of  the  cord.  Practically  the  distinction  is  not  of  much  impor- 
tance so  far  as  the  welfare  of  the  patient  is  concerned.  It  is  more  important 
to  ascertain,  if  possible,  whether  the  cord  is  merely  affected  by  pressure, 
or  whether  it  is  actually  crushed,  especially  when  surgical  intervention  is 
contemplated.  But  this  is  seldom  possible  before  operation.  The  reason 
why  laminectomy  is  so  seldom  beneficial  in  these  cases  is  that  the  cord  has 
been  damaged  beyond  the  power  of  surgery  to  repair.  Clinically  these 
cases  closely  resemble  myelitis;  and  in  some  of  them  secondary  inflam- 
mation may  be  present.  Abolition  of  the  knee-jerks  may  indicate  a  total 
transverse  lesion  and  is  usually  of  grave  import. 


XV.  HEMORRHAGE  IN  THE  SPINAL  CORD 
AND  MEMBRANES. 

Hemorrhage  in  the  spinal  cord,  or  hsematomyelia,  is  usually  the  result 
of  injury.  It  may  be  associated  with  a  crush  of  the  cord  due  to  vio- 
lence, or  with  fracture  or  dislocation  of  the  vertebrae.  In  a  few  cases  of 
injury,  however,  the  hemorrhage 
may  be  the  only  lesion.  Thus 
cases  have  been  reported  of  great 
violence,  as  a  fall  down  a  long 
flight  of  stairs,  in  which  the  bones 
were  uninjured,  and  even  the 
membranes  escaped,  and  yet  a 
small  and  rapidly  fatal  hemor- 
rhage was  found  in  the  substance 
of  the  cord.  The  hemorrhage  may 
be  in  the  gray  matter,  or  close  to 
it,  and  may  cause  extensive 
destruction  of  the  spinal  medulla. 
It  may  be  so  small  as  not  to  be 
apparent  until  the  cord  is  sec- 
tioned, or  it  may  cause  an  appear- 
ance of  pallor  or  slight  swelling  on  the  surface.  In  some  cases  the 
blood  breaks  through  to  the  surface  and  is  present  in  the  meninges. 
Minute  capillary  hemorrhages  may  be  the  starting-point  for  necrotic  soft- 


FiG.  396. — Hsematomyelia. — Lloyd. 


1344  MEDICAL  DIAGNOSIS. 

ening.  Van  Gieson  has  found  long  slender  columns  of  necrosis  in  the 
"Cord,  causing  narrow  cavities,  which  he  thinks  may  be  due  to  traumatic 
hemorrhage.  They  extend  for  long  distances  both  above  and  below  the 
main  lesion.     Meningeal  hemorrhage  may  also  occur  from  trauma. 

Spontaneous,  or  non-traumatic,  hemorrhage  in  the  spinal  cord  is  rare. 
The  primary  lesion  is  probably  vascular,  due  to  some  weakness  or  disease 
of  the  blood-vessels.  It  is  remarkable  that  such  vascular  lesions,  which 
are  so  common  in  the  brain,  are  apparently  so  uncommon  in  the  spinal 
cord.  It  has  been  doubted  by  competent  pathologists  whether  arterio- 
sclerosis, as  well  as  thrombosis  and  embolism,  occurs  in  the  cord;  but 
there  is  not  sufficient  ground  for  dogmatic  statements  in  the  negative. 
It  seems  more  probable  that  some  cases  of  hemorrhage  and  hemorrhagic 
softening  in  the  cord  may  be  due  to  such  lesions. 

Symptoms. — The  symptoms  come  on  rapidly,  even  suddenly,  and 
may  cause  profound  shock;  but  even  in  the  traumatic  cases  this  rule  is 
not  absolute,  for  hours  may  elapse  before  all  the  symptoms  are  estab- 
lished. This  is  probably  due  to  the  fact  that  a  small  hemorrhage,  once 
started,  continues  for  some  time  to  progress,  with  gradually  increasing 
effect.  Especially  in  meningeal  hemorrhage  this  gradual  onset  is  seen, 
and  perhaps  more  so  in  the  lower  part  of  the  spinal  canal,  where  the 
Cauda  equina  is  involved.  Many  hours  have  been  known  to  elapse  before 
the  paralysis  was  complete.  In  such  a  case  presumably  the  blood  gradu- 
ally settles  and  clots  in  the  lower  part  of  the  spinal  canal.  There  may  be 
complete  paralysis  of  all  the  muscles  below  the  level  of  the  lesion.  If  the 
lesion  is  in  the  neck,  the  muscles  of  the  chest  may  be  paralyzed.  The 
respiration  is  then  diaphragmatic  and  irregular. 

All  modes  of  sensation  may  be  absolutely  lost  below  the  level  of  the 
lesion.  These  symptoms,  however,  vary.  Some  hours  may  elapse  before 
they  are  fully  established,  and  later,  even  in  unfavorable  cases,  sensation 
has  been  known  to  return  in  part.  Thus  the  patient  may  have  a  return 
of  tactile  sense  in  some  limited  area;  or  of  pain  sense,  or  thermic  sense, 
or  sense  of  position,  one  or  all.  The  bladder  and  rectum  may  be  para- 
lyzed, and  priapism  may  occur. 

The  reflexes,  especially  the  knee-jerks,  may  be  retained  and  soon 
become  exaggerated.  If  the  lesion  is  totally  transverse,  the  knee-jerks 
are  likely  to  be  abolished,  although  they  may  return  in  time.  Occasion- 
ally they  are  not  lost  until  after  some  days.  Total  abolition  of  the 
knee-jerks,  therefore,  in  a  hemorrhage  above  the  lumbar  enlargement  is 
not  a  favorable  sign,  for  it  indicates  an  extensive  lesion.  If  the  hemor- 
rhage is  in  the  lumbar  enlargement  the  knee-jerks  will  probably  also  be 
abolished,  but  this  is  from  interference  with  the  reflex  centres  in  the  cord; 
hence  it  is  not  necessarily  so  ominous  a  symptom.  The  ciliary  reflex 
from  irritation  of  the  skin  of  the  neck  may  be  absent  in  cases  of  hemor- 
rhage in  the  cervical  region;  hence  there  may  be  spastic  myosis.  If  this 
centre  is  only  irritated  there  is  symptomatic  mydriasis  in  one  or  both  eyes. 

Pain  may  be  an  urgent  symptom.  In  Kindred's  case,  in  which  the 
hemorrhage  was  in  the  fourth  dorsal  segment,  there  was  an  initial  agonizing 
pain  simulating  angina  pectoris.  Pain  may  persist,  and  it  may  even  be  felt 
far  below  the  level  of  the  lesion,  if  this  is  not  totally  transverse;  this  probably 


SOFTENING  OF  THE  SPINAL  CORD.  1345 

because  free  blood  escapes  in  the  meninges  and  causes  pressure  and  irritation 
at  lower  levels.     The  girdle  or  ''cincture"  feeling  is  present  in  some  cases. 

In  brief,  the  symptoms  of  hsematomyelia,  whether  traumatic  or  non- 
traumatic, are  those  of  a  complete  or  almost  complete  transverse  lesion 
of  the  cord.  Abolition  of  the  knee-jerks  may  be  seen.  The  locahzing 
symptoms  depend  upon  the  exact  level  at  which  the  lesion  occurs,  and 
they  have  already  been  described  under  the  head  of  myelitis. 

The  course  of  severe  cases  is  usually  rapid.  In  Kindred's  case  of  spon- 
taneous hemorrhage  death  came  in  six  hours.  If  the  lesion  is  totally 
transverse,  with  abolished  knee-jerks  and  rapidly  forming  bed-sores,  the 
prognosis  is  highly  unfavorable.  If  the  lesion  is  high  in  the  neck  death 
may  come  from  paralysis  of  the  phrenic  nerve. 

High  temperature  and  excessive  sweating  are  seen  toward  the  end 
in  fatal  cases.  In  a  case  recorded  by  Lloyd  moist  skin  was  noted  above, 
and  dry  skin  below,  the  line  of  anaesthesia  toward  the  end. 

In  hemorrhage  in  the  membranes,  when  the  cord  itself  is  not  involved 
and  not  much  pressed  upon,  the  outlook  is  more  favorable,  although  per- 
manent crippling  in  some  form  is  not  unusual.  Pain  is  often  a  prominent 
symptom,  and  the  anaesthesia  and  pain  may  follow  individual  nerve-trunks. 
In  the  legs,  if  the  cauda  equina  is  involved,  there  is  a  flaccid  paralysis  with 
muscular  atrophy  and  abolished  reflexes,  somewhat  like  a  multiple  neuritis, 
but  with  paralysis  of  the  bladder  and  bowel. 

Diagnosis. — In  traumatic  cases  the  diagnosis  is  not  difficult,  except 
to  distinguish  hemorrhage  from  crush,  and  this  is  often  not  possible,  nor 
is  it  of  great  practical  importance.  The  history  of  the  case  points  unerringly 
to  a  grave  lesion  of  the  cord.  It  is  important  to  distinguish  fracture, 
and  this  can  be  done  only  by  a  careful  surgical  examination,  aided  by 
the  X-rays.  Haematomyelia  is  not  Hkely  to  be  mistaken  for  a  disease  of 
any  internal  organ,  and  yet  in  dorsal  hemorrhage  the  initial  symptoms 
have  simulated  angina  pectoris.  But  the  speedy  onset  of  paralysis,  anaes- 
thesia, priapism,  and  incontinence  would  distinguish  the  cord  lesion.  So, 
too,  of  pain  from  lumbar  hemorrhage  simulating  disease  of  abdominal 
viscera.  The  supreme  difficulty  in  non-traumatic  cases  is  to  distinguish 
haematomyelia  from  transverse  myelitis,  acute  white  softening,  and 
pachymeningitis.  The  sudden  onset  and  rapid  course  serve  better  than 
all  other  symptoms  to  distinguish  hemorrhage  from  any  of  these  condi- 
tions; but  the  diagnosis  in  non-traumatic  cases  may  remain  obscure. 
The  extreme  rarity  of  spontaneous  haematomyelia  must  not  be  overlooked 
in  coming  to  a  conclusion.  Softening  and  hemorrhage  being  due  often 
to  the  same  causes,  and  being  part  of  the  same  pathological  process,  a 
dogmatic  diagnosis  between  them  may  sometimes  not  be  practicable. 

The  exact  seat,  or  level,  of  the  lesion  is  to  be  determined  as  in 
injury  or  myelitis. 

XVI.  SOFTENING  OF  THE  SPINAL  CORD. 

Acute  softening  of  the  cord  is  often  confused  with  myelitis,  and  indeed 
in  some  cases  it  may  be  impossible  to   distinguish  between  them  at  the 
bedside.     The    subject   has    already   been   discussed   under   the    head    of 
85 


1346  MEDICAL  DIAGNOSIS. 

myelitis.  The  latter  term  properly  indicates  an  inflammation,  and  this  in 
turn  is  due  to  some  infection;  whereas  softening  may  presumably  be 
caused  by  a  vascular  lesion,  such  as  embolus  or  thrombus.  Nevertheless, 
softening  is  sometimes  secondary  to  inflammation;  and  it  also  results 
from  trauma.  Weiss  has  recorded  a  case  of  softening  of  the  cord  occur- 
ring suddenly  in  a  boy  who  had  mitral  disease.  Gowers  refers  to  a  sim- 
ilar case.  The  inference  is  that  cardiac  emboli  were  the  causes  of  the 
softening.  The  symptoms  are  so  similar  to  those  which  occur  in  myelitis 
that  it  is  not  necessary  to  describe  them  again.  The  onset  of  the  disease, 
however,  may  be  more  abrupt. 

XVII.  THE  CAISSON  DISEASE. 

The  caisson  is  a  large  compartment,  inverted,  in  which  a  constant 
supply  of  compressed  air  is  maintained  in  order  to  counteract  the  pressure 
of  the  water  from  without,  thus  allowing  men  to  work  upon  the  founda- 
tions of  piers.  The  caisson  disease  is  an  affection,  largely  of  the  central 
nervous  system,  and  especially  of  the  spinal  cord,  caused  by  working  in 
the  compressed  air  of  these  compartments.  The  highest  pressure  attained 
at  the  St.  Louis  bridge  was  50  lbs.  to  the  square  inch,  the  normal  pressure 
of  the  atmosphere  being  15  lbs.  By  some  observers  the  mischief  is  attrib- 
uted to  the  emerging  from  the  compressed  air  while  the  system  is  over- 
heated and  fatigued  with  the  hard  labor. 

Pathology.  —  Van  Rensselaer  studied  the  cord  in  a  case  of  this 
disease  and  found  extensive  changes.  A  disseminated  necrotic  area  was 
found  in  the  dorsal  region,  with  ascending  degeneration  in  the  columns 
of  Goll  and  in  the  direct  cerebellar  tract,  and  descending  degeneration  in 
the  pyramidal  tracts,  respectively  above  and  below  the  mid-dorsal  lesion. 
The  necrosis  seemed  to  be  confined  to  the  white  substance,  the  gray 
matter  not  being  involved.  Possibly  with  the  more  refined  methods 
now  used,  this  entire  exemption  of  the  cells  of  the  gray  matter  might 
not  be  found.  No  hemorrhages  were  seen.  The  fanciful  theory  that 
air-bubbles  or  air-emboh  cause  the  softening  need  not  be  discussed  here. 
Brooks  has  recently  studied  the  blood-pressure  in  75  workmen  before, 
during,  and  after  working  in  the  caisson,  and  found  no  marked  change 
in   arterial  pressure. 

Symptoms. — The  initial  symptoms  do  not  appear  until  after  the 
workman  emerges  into  the  outer  air.  Some  minutes,  even  hours,  may 
elapse.  There  is  usually  severe  epigastric  pain,  with  vomiting,  then  very 
severe  pain  in  the  back  and  lumbar  region,  along  the  spine,  and  shooting 
down  the  legs.  Smith  described  these  pains  as  of  a  tearing  character  and 
intolerable.  Anaesthesia  shows  itself  promptly,  often  of  the  type  known 
as  "anaesthesia  dolorosa,"  and  advances  with  the  motor  symptoms.  The 
paralysis  is  usually  in  the  form  of  a  paraplegia,  although  in  some  cases 
the  arms  also  have  been  involved.  The  bladder  and  rectum  are  commonly 
paralyzed.     Bed-sores  form. 

Brain  symptoms  are  seen  in  the  more  severe  cases,  and  especially  in 
fatal  cases.  There  are  headache  and  vertigo,  and  in  fatal  cases  uncon- 
sciousness supervenes   before  death.     Pelton  describes  a  comatose  type, 


AFFECTIONS  OF  THE  CAUDA  EQUINA.  1347 

which  may  appear  suddenly,  with  cyanosis,  and  is  usually  fatal.  The 
duration  in  mild  cases  is  from  a  few  hours  to  six  or  eight  days.  In  severe; 
cases  death  ma}^  result  in  a  few  days. 

The  viscera  are  not,  as  a  rule,  seriously  involved.  There  may  be 
bronchial  irritation  and  cough.  The  urine  has  usually  a  high  specific 
gravity.  Perforation  of  the  ear  drum  and  catarrh  of  the  middle  ear  have 
been  observed. 

Diagnosis.  —  The  import  of  severe  spinal  symptoms,  such  as  para- 
plegia, anaesthesia,  and  incontinence,  in  a  caisson  worker  soon  after 
quitting  work  is  unmistakable.  The  disease,  as  described  by  most  ob- 
servers, is  of  spinal  or  central  origin,  as  proved  also  by  such  autopsies  as 
the  one  made  by  Van  Rensselaer,  and  is  not  a  mere  peripheral  neuritis, 
due  to  carbonic  acid  poisoning,  as  others  have  contended.  Still,  it  is  not 
unlikely  that  the  peripheral  neurons  may  be  found  involved  in  some  cases. 
An  affection  similar  in  every  way  to  the  caisson  disease  occurs  in  divers. 

XVIII.  AFFECTIONS  OF  THE  CAUDA  EQUINA. 

The  Cauda  equina  is  the  leash  of  nerve-roots  lying  in  the  lower  end 
of  the  spinal  canal.  These  are  the  nerve-roots  that  come  off  from  the 
lumbar  and  sacral  segments.  The  spinal  cord  ends  about  opposite  the 
second  lumbar  vertebra;  consequently  the  nerve-roots  from  its  lower 
segments  have  to  traverse  comparatively  long  distances  before  uniting 
to  form  the  lower  spinal  nerves  at  or  about  their  respective  foramina 
of  exit  from  the  spinal  canal.  These  prolonged  nerve-roots  are  the 
Cauda  equina. 

Pathology. — The  cauda  equina  maybe  the  seat  of  injury  or  disease. 
The  injuries  are  similar  to  those  that  cause  damage  to  the  cord  itself. 
Thus  there  may  be  fracture  or  dislocation  of  the  vertebrae,  rupture  of  the 
membranes,  or  traumatic  hemorrhage,  sometimes  with  secondary  inflam- 
mation. Fractures  and  dislocations  of  the  lower  parts  of  the  spine  are 
not  so  common  as  in  the  dorsal  and  cervical  regions,  for  the  parts  are 
massive  and  protected  by  large  muscles;  nevertheless  they  sometimes 
occur.  But  a  traumatic  meningeal  hemorrhage  may  settle  from  still 
higher  levels  and  press  upon  the  strands  of  the  cauda  equina.  Septic 
meningitis  may  occur  in  the  lower  part  of  the  spinal  canal,  sometimes 
during  the  puerperium,  or  from  other  causes,  such  as  a  sloughing  bed- 
sore. Syphilitic  meningitis  may  also  occur,  and  syphilitic  tumor,  or 
gumma,  is  not  so  very  uncommon.  Other  varieties  of  tumor  may  also  be 
seen.  It  is  well  to  bear  in  mind  that  although  the  cauda  equina,  being 
composed  of  nerve-fibres,  is  anatomically  a  part  of  the  peripheral  nervous 
system,  nevertheless,  being  contained  within  the  spinal  canal  and  enclosed 
within  the  spinal  meninges,  it  has  practically  some  points  of  resemblance 
to  central  structures. 

Symptoms. — Pain  is  a  common  symptom  in  meningitis  or  neuritis 
of  the  cauda  equina,  and  is  due  to  involvement  of  the  sensory  roots. 
It  may  be  felt  in  the  lower  part  of  the  abdomen  or  pelvis,  or  it  may 
be  transmitted  to  the  legs  and  feet.  It  is  sometimes  lancinating  or 
neuralgic,  or  burning  as  in  neuritis,  and  may  be  associated  with  glossy  skin 


1348  MEDICAL  DIAGNOSIS. 

and  cutaneous  hypersesthesia.  Anaesthesia  may  also  occur;  it  may  be 
variously  distributed,  and  is  sometimes  segmental  in  type,  especially 
when  the  lesion  is  localized,  as  in  the  case  of  hemorrhage,  and  involves 
only  the  lower  parts  of  the  leash  of  nerves.  This  is  explained  by  the 
fact  that  each  succeeding  pair  of  nerves  from  below  upward  represents 
a  distinct  segment  of  the  cord. 

The  paralysis  is  peripheral  in  type;,  that  is,  it  is  of  the  flaccid  variety, 
with  atrophy  of  the  muscles  and  changes  in  the  electrical  reactions.  The 
knee-jerks  are  abolished,  unless  the  roots  from  the  upper  lumbar  segments 
escape.  This  type  of  paralysis  is  due  to  the  fact  that  the  strands  of  the 
Cauda  equina  belong  anatomically  to  the  peripheral  nervous  system. 

In  a  few  cases  the  knee-jerks  are  exaggerated,  as  when  the  lesion 
extends  gradually  from  below  upward  and  acts  as  an  irritant  to  the  roots 
from  the  upper  lumbar  segments.  The  distribution  of  the  paralysis  varies. 
In  some  cases  muscular  groups  only  are  involved,  as  the  peronei,  sural, 
hamstring,  etc.,  thus  indicating  a  segmental  type. 

The  bladder  and  bowel  may  be  paralyzed,  and  priapism  or  even  normal 
erections  do  not  occur  as  a  rule.  Bed-sores  are  not  uncommon.  In  some 
cases  painful  contractures  are  present  in  the  legs. 

Tumors  of  the  cauda  equina  cause  a  great  variety  of  symptoms.  All 
depends  upon  the  level  at  which  the  tumor  is  located  and  its  extent.  Pain 
is  an  early  symptom,  possibly  felt  low  in  the  back,  in  the  pelvis,  or  in  the 
legs.  Later,  pressure  symptoms  develop,  and  consist  of  various  forms  of 
paralysis,  usually  of  the  peripheral  type.  The  symptoms  thus  gradually 
extend  as  from  a  centre.     The  bladder  and  bowel  may  be  affected. 

Diagnosis.  —  The  diseases  from  which  these  affections  have  to  be 
differentiated  are  myelitis,  multiple  neuritis,  and  locomotor  ataxia.  In 
traumatic  cases  the  history  is  usually  sufficient  to  distinguish  them.  From 
myelitis  the  peculiar  segmental  distribution  of  the  symptoms,  the 
flaccid  atrophic  paralysis,  the  reactions  of  degeneration,  and  the  lost 
knee-jerks  suffice  to  make  clear  the  difference.  .It  must  be  admitted, 
however,  that  in  myelitis  involving  the  lumbar  enlargement  all  these 
symptoms  might  be  present,  and  in  such  a  case  an  exact  diagnosis  may 
not  be  practicable. 

■  Inflammation  of  the  cauda  equina  may  closely  simulate  multiple 
neuritis,  but  multiple  neuritis  is  seldom  confined  to  the  legs,  and  the  blad- 
der and  bowel  are,  as  a  rule  practically  without  exception,  not  involved. 
In  the  cases  of  alcoholic  multiple  neuritis  in  which  the  lower  Hmbs 
alone  are  paralyzed,  the  exemption  of  the  bladder  and  bowel  would  serve 
to  point  out  the  difference.  The  pains,  too,  are  of  a  different  kind  in  mul- 
tiple neuritis,  being  more  local  and  peripheral,  and  felt  most  acutely  on 
pressure  on  the  nerves  and  muscles. 

Disease  of  the  cauda  equina  resembles  locomotor  ataxia  only  remotely, 
and  chiefly  in  the  pain  and  lost  knee-jerks.  There  are  no  true  tabetic 
symptoms,  as  ataxia,  pupillary  changes,  and  optic  atrophy;  and  even  the 
pain  is  not  like  the  paroxysmal  fulgurant  pain  of  tabes.  Moreover  in  tabes 
we  do  not  see  distinct  segmental  anaesthesia,  and  the  muscles,  at  least  in 
the  early  stages,  are  not  paralyzed  and  degenerated. 

Tumor  of  the  cauda  equina  is  discussed  with  tumors  of  the  spinal  cord. 


DISEASES  OF  THE  SPINAL  NERVES.  1349 

XIX.  SPINA  BIFIDA. 

Spina  bifida  is  a  developmental  defect,  caused  by  failure  of  the  verte- 
bral ai'ches  (which  grow  from  the  mesoblastic  somites  in  the  embryo)  to 
coalesce  behind  the  spinal  cord  and  between  it  and  the  skin  of  the  back. 
SeA'eral  varieties  of  deformity  result  according  to  the  tissues  involved 
(see  p.  16). 

Spina  bifida  is  sometimes  associated  with  other  developmental  defects, 
especially  hydrocephalus. 

This  condition  usually  presents  no  difficulty  in  diagnosis,  although  the 
defect  is  not  always  detected  at  once  in  the  new-born  child.  The  small 
tumor  on  the  back  tends  to  grow,  and  in  time  may  become  very  large.  The 
important  point  is  to  determine  the  variety  of  the  bifid  spine.  In  menin- 
gomyelocele the  spinal  cord  and  nerves  are  involved,  and  paraplegic  symp- 
toms are  always  present.  This  distinction  is  important,  especially  from  a 
surgical  stand-point,  for  any  operation  for  the  excision  or  obliteration  of 
the  sac  in  this  variety,  even  if  successful,  must  inevitably  leave  the  child 
a  more  or  less  hopeless  cripple.  In  simple  meningocele  the  results  may  be 
better,  as  the  cord  is  not  involved. 

The  tumor  is  usually  in  the  lumbar,  lumbosacral,  or  sacral  region. 
It  is  infrequent  in  the  cervical  and  upper  dorsal  regions. 

Spina  bifida  requires  to  be  distinguished  from  certain  other  embryo- 
logical  defects,  such  as  congenital  tumors  in  the  sacrococcygeal  region, 
dermoid  cysts,  and  teratomata,  but  these  fall  within  the  purview  of  surgery. 

DISEASES  OF  THE  SPINAL  NERVES. 

I.  MULTIPLE  NEURITIS. 

This  disease,  also  called  peripheral  neuritis  or  polyneuritis,  is,  as  its 
name  indicates,  an  inflammation,  more  or  less  wide-spread,  of  the  nerves. 

Etiology.  —  Multiple  neuritis  is  caused  by  a  great  variety  of  poisons, 
the  most  common  being  alcohol,  lead,  arsenic,  mercury,  and  some  of  the 
infectious  diseases,  especially  diphtheria.  Cases  also  occur  after  typhoid 
fever,  and  more  rarely  after  smallpox;  also  in  diabetes.  Beriberi  is  a  form 
of  multiple  neuritis,  the  exact  causation  of  which  is  still  undetermined. 
Among  the  rarer  causes  of  polyneuritis  are  carbon  monoxide  and  carbon 
bisulphide.  Phosphorus  may  also  cause  neuritis,  and  in  ergotism  there  is 
involvement  of  the  sensory  and  motor  nerves.  The  anaesthetic  form  of 
leprosy  is  due  to  a  neuritis. 

Pathology.  —  There  are  two  forms  usually  described  —  the  paren- 
chymatous and  the  interstitial.  Whatever  may  be  the  cause  of  multiple 
neuritis,  its  essential  morbid  anatomy  is  much  the  same,  and  sometimes 
the  cases  partake  of  both  forms.  There  are  segmentation  of  the  mj^elin, 
proliferation  of  the  nuclei  of  the  sheath  of  Schwann,  and  destruction  of 
the  axis-cylinder.  In  many  cases  there  are  also  some  overgrowth  of  the 
connective  tissue  and  alterations  in  the  blood-vessels.  In  the  purely 
parenchymatous  form  there  is  destruction  of  the  neuron,  even  including 
its  cell-body;    but  according  to  Berkley,  in  experimental  poisoning  with 


1350  MEDICAL  DIAGNOSIS. 

alcohol,  the  earliest  changes  appear  to  be  in  the  blood-vessels  of  the  nervous 
system.  The  seat  of  the  most  active  changes  is  usually  in  the  peripherj'- 
of  the  nerves.  As  the  cord  is  approached  the  disease  process  diminishes. 
At  the  present  time,  however,  the  tendency  is  to  find  some  evidence  of 
degeneration  even  in  the  cord,  due  doubtless  to  the  peripheral  neurons 
being  implicated  as  far  as  their  course  in  the  spinal  medulla  —  as,  for 
instance,   in  the  posterior  columns. 

Symptoms.  —  The  most  common  form  of  multiple  neuritis  is  that 
which  is  caused  by  alcohol.  This  may  be  taken  as  a  type,  although  some 
of  the  other  forms,  notably  that  caused  by  diphtheria,  differ  from  it  in 
certain  particulars,  as  will  be  pointed  out. 

In  alcoholic  neuritis  the  earliest  symptom  is  usually  pain.  This 
pain  is  felt  especially  in  the  nerve-trunks  and  in  the  muscular  masses, 
such  as  the  calves  of  the  legs.  It  is  commonly  of  an  intense  burning  char- 
acter, and  is  so  urgent  that  for  a  while  it  may  mask  the  other  symptoms. 
When  fully  developed  this  pain  is  quite  unmistakable;  it  is  increased 
by  pressure  and  by  handling  the  parts;   and  the  patient,  especially  if  a 


y^* —  -, 


Fig.  397. — Alcoholic  multiple  neuritis,  showing  wrist-  and  foot-drop. — Lloyd. 

woman,  will  cry  out  and  even  weep  when  the  limbs,  and  particularly  the 
legs,  are  handled.  The  toes  and  soles  of  the  feet  may  be  exquisitely  sen- 
sitive, and  sometimes  exhibit  some  erythema.  This  is  the  state  known  as 
causalgia.  The  pain  is  increased  on  voluntary  motion,  and  is  usually 
worse  in  the  legs  and  feet;  but  it  may  not  be  absent  in  the  upper  limbs. 
Pain  is  not  present  in  all  cases.  Other  sensory  symptoms  are  parsesthesia 
and  various  grades  of  anaesthesia.  The  thermal  sense  may  be  affected 
in  advanced  cases,  and  the  electrical  sensibility  may  be  impaired,  especially 
to  mild  currents;  but  strong  currents,  particularly  if  they  cause  muscular 
contraction,  are  most  painful. 

Of  motor  symptoms  the  commonest  are  cramps,  tremors,  paralysis, 
contractures,  and  ataxia.  Cramps  occur  early,  but  the}'"  are  not  seen  in 
all  cases.  Tremors  are  occasionally  seen  in  the  weakened  muscles,  and 
are  especially  common  in  the  alcoholic  cases.  Paralysis  is  the  most 
common  motor  symptom.  This  is  of  the  flaccid  or  peripheral  type;  the 
muscles  waste  and  become  flabby,  and  complete  reactions  of  degeneration 
are  seen.  The  distribution  of  this  paralysis  is  characteristic;  it  invades 
all  four  limbs,  and  is  most  marked  in  the  extensor  muscles;  hence  there 
are  wrist-drop  and  foot-drop.  It  is  also  most  marked  in  the  distal  muscles; 
that  is,  in  the  muscles  furthest  from  the  trunk;    hence  the  forearms  and 


DISEASES  OF  THE  SPINAL  NERVES. 


1351 


hands,  and  legs  and  feet,  are  more  paralyzed  than  the  upper  arms  and 
thighs.  The  trunk  muscles,  however,  do  not  escape,  and  the  external 
muscles  of  respiration  may  be  seriously  involved.  There  is  also  tachy- 
cardia. The  bladder  and  bowel  are  not  paralyzed,  as  a  rule,  although  a 
few  doubtful  cases  are  recorded.  In  the  alcoholic  cases  the  cranial  nerves, 
except  the  vagus,  are  not  often  affected.  Paralysis  of  the  abducens  nerve 
and  optic  neuritis  have  been  observed. 

Muscular  contractures  are  not  uncommon  in  advanced  cases;  they 
are  most  marked  in  the  flexor  muscles,  which  are  the  least  paralyzed. 
These  contractures  hold  the  limbs,  especially  the  legs,  in  a  semiflexed 
position;  they  are  hard  to  overcome,  and  greatly  retard  recovery. 

Ataxia  is  seen  occasionally, 
giving  rise  to  'pseudotabes.  The 
incoordination  is  not  unlike  that  of 
locomotor  ataxia.  It  occurs  in  the 
alcoholic  cases  and  in  those  caused 
by  lead. 

The  reflexes  are  usually  abol- 
ished. This  is  true  especially  of  the 
deep,  or  tendon,  reflexes.  The  knee- 
jerks,  as  a  rule,  are  lost  early;  in 
some  cases,  however,  they  may 
persist  much  diminished.  Some 
observers  claim  that  the  deep  reflexes 
are  exaggerated;  but  such  exceptions 
are  extremely  rare,  and  they  are  diffi- 
cult to  explain  except  on  the  theory 
of  irritation  of  the  sensory  neurons. 
The  superficial,  or  skin,  reflexes  are- 
not  so  promptly  or  uniformly  lost, 
and  in  cases  in  which  there  is  marked 
hyperaesthesia  they  may  even  be 
very  active;  but  in  advanced  cases, 
particularly  when  there  is  anaes- 
thesia, these  reflexes  are  abolished. 

Of  trophic  lesions  the  commonest  is  atrophy  of  the  muscles.  Oildema 
of  the  paralyzed  legs  is  sometimes  seen,  and  occasionally  erythema,  as 
of  the  soles  of  the  feet.  Ulcers  and  skin  lesions  are  very  uncommon;  but 
trophic  bed-sores,  especially  about  the  malleoli,  have  been  observed  in 
the  post-typhoid  cases.  Glossy  skin  may  be  entirely  absent.  Profuse 
sweating  is  seen  in  some  cases. 

In  severe  cases  the  weakness  of  the  heart  muscle  maybe  the  determining 
cause  of  death.  Paralysis  of  the  external  respiratory  muscles  constitutes 
an  additional  source  of  danger.      The  phrenic  nerve  is  not  often  involved. 

In  some  of  the  alcoholic  cases  a  characteristic  psychosis  occurs.  It 
is  characterized  by  a  wandering  delirium,  with  hallucinations  of  sight  and 
hearing,  confusion  of  identity  of  time,  place,  and  persons,  and  a  tend- 
ency to  fabulation.  Atypical  cases  of  alcohohc  multiple  neuritis  occur. 
Occasionally,  the  patient  has  little  if  any  pain,  while  the  motor  paralysis 


Fig.  398. — Alcoholic  polyneuritis,  with  marked  mus- 
cular atrophy  and  wrist-drop. — Singleton  Smith. 


1352 


MEDICAL  DIAGNOSIS. 


may  be  extreme.  This  motor  type  may  or  may  not  be  associated  with 
great  ataxia,  and  constitutes  a  form  of  -pseudotabes.  It  does  not  follow, 
however,  that  in  all  cases  of  pseudotabes  there  is  an  absence  of  pain. 
Another  rather  rare  form  is  that  in  which  the  paralysis  is  confined  to  the 
lower  limbs.  The  usual  pain  and  sore  muscles  in  the  calves  are  present, 
but  there  is  an  absence  of  bladder  and  rectal  troubles,  such  as  occur 
in  cord  lesions.    The  knee-jerks  are  lost. 

In  lead  neuritis  the  clinical  picture  is  somewhat  different.  The 
distribution  of  the  paralysis  is  usually  much  less  extensive;  as,  for 
instance,  in  the  cases  in  which  the  extensors   of  the   forearms  are  alone 

__  involved.  In  some  rare  cases,  how- 
ever, there  is  a  more  wide-spread 
paralysis,  and  the  upper  arms, 
shoulders,  and  even  the  lower  limbs 
are  affected.  There  is  a  form  of 
lead  palsy  closely  resembling  pro- 
gressive muscular  atrophy.  The 
pseudotabes  may  also  occur,  but 
as  a  rule  sensation  is  not  much 
involved  in  lead  cases,  and  pain  is 
rarely  observed. 

Postdiphtheritic  paralysis  (q. 
V. — diphtheria) . 

The  two  most  specialized  forms 
of  multiple  neuritis  are  beriberi  and 
the  ancesthetic  variety  of  leprosy  (q. 
V. — beriberi;  leprosy). 

In  diabetes  mellitus  neuralgic 
pains  of  a  severe  type  sometimes 
occur,  and  occasionally  angesthesia, 
especially  of  the  legs,  and  along 
with  this  may  occur  some  paralysis, 
and  atrophy  of  the  muscles,  with 
[  X;  ■^•i.™        }    lost  knee-jerks. 

HHHfe  x\  The    forms    of    multiple    neu- 

i^^^^^   ''^\\  J  ^'^^^^     ^^^     ^^     arsenic,     mercury, 

L-  "-   '■'  '    typhoid    fever,    smallpox,    and 

most  other  infectious  diseases  show 
nothing  very  distinctive. 
Diagnosis. — The  disease  with  which  multiple  neuritis  is  most  likely 
to  be  confused  is  locomotor  ataxia,  and  this  is  true  especially  of  the  ataxic 
type  of  polyneuritis.  But  polyneuritis  differs  from  tabes  in  its  mode  of 
onset,  which  is  usually  much  more  brusque;  in  its  history,  which  usually 
points  to  the  poison  or  infection  which  causes  it;  in  the  pain,  which  is 
constant,  burning,  and  neuralgic,  and  much  increased  by  pressure,  while 
in  tabes  the  pains  are  lancinating,  paroxysmal,  and  not  affected  by  pres- 
sure, unless  sometimes,  indeed,  they  are  relieved  by  it;  in  the  paralysis 
and  muscular  atrophy,  which  are  late  phenomena  in  tabes  and  often 
absent  even  late  in  the  disease;    in  the  reactions  of  degeneration;   in  the 


Fig.  399. — Peripheral  neuritis,  with  foot-drop  of  right 
side,  after  enteric  fever. — Pennsylvania  Hospital. 


DISEASES  OF  THE  SPINAL  NERVES.  1353 

gait,  which  is  high-stepping  in  neuritis,  with  foot-drop,  the  toe  grazing  the 
ground  (the  so-called  "turkey-gobbler  walk"),  due  to  paralysis  of  the 
extensor  muscles,  while  in  tabes  it  is  incoordinate,  the  foot  being  flung 
far  out  and  the  heels  striking  the  ground  first — a  distinction  which  is 
seen  even  in  pseudotabes  of  neuritic  origin.  Moreover,  in  locomotor 
ataxia  there  are  the  true  tabetic  phenomena,  such  as  optic  atrophy,  Argyll- 
Robertson  pupil,  atony  of  the  bladder,  sexual  impotence,  and  arthropa- 
thies, which  are  not  seen  in  polyneuritis,  although  in  the  form  due  to 
lead,  optic  neuritis  and  atrophy  sometimes  occur.  In  both  diseases  the 
knee-jerks  are  abolished,  and  the  loss  of  static  equilibrium  may  be  seen 
in  the  pseudotabes  as  well  as  in  the  true  tabes.  Sensory  changes  are 
somewhat  similar  in  the  two  diseases,  except  that  deep  sensibility  (the 
sense  of  position,  of  pressure,  and  of  voluntary  and  passive  motion)  is 
more  likely  to  be  abolished  in  tabes,  while  the  sup'erficial  sensibility 
(tactile  sense  especially)  is  preserved.  But  these  modes  of  sensation  are 
sometimes  affected  also  in  multiple  neuritis. 

Various  forms  of  myelitis  simulate  multiple  neuritis.  In  the  sub- 
acute and  chronic  anterior  poliomyelitis  there  is  a  flaccid  paralysis  with 
muscular  atrophy,  but  pain  is  not  conspicuous  and  may  be  entirely  want- 
ing, and  fibrillation  of  the  muscles  is  seen.  Sometimes  the  tendon  reflexes 
are  not  entirely  lost.  The  reactions  of  degeneration  are  not  complete; 
and  finally  the  history  and  evolution  are  different.  Transverse  myelitis 
is  marked  by  spastic  paraplegia,  with  exaggerated  knee-jerks,  and  incon- 
tinence. When  the  lumbar  enlargement  is  involved  there  may  be  flaccid 
paralysis,  but  the  bladder  and  bowel  are  paralyzed,  and  the  symptoms 
are  confined  to  the  lower  limbs-. 

In  the  myopathies  the  evolution  of  the  disease  is  extremely  slow; 
pain  is  not  conspicuous,  or  it  is  even  wanting,,  anaesthesia  is  usually  absent, 
and  the  history  of  the  case  is  different.  The  neuritic  form  of  the  myop- 
a.thies  has  more  in  common  with  neuritis,  and  may  even  depend  upon  a 
slow  neuritis,  but  the  course  is  extremely  slow,  the  disease  is  sometimes 
familial,  and  the  history  is  different.  Some  of  these  forms  begin  in  child- 
hood, whereas  multiple  neuritis  is  usually,  but  not  always,  a  disease  of 
adult  life.  A  few  cases  of  alcoholic  multiple  neuritis  have  been  reported 
in  children. 

Hysteria  may  simulate  multiple  neuritis,  but  only  superficially,  and 
more  particularly  in  chronic  cases,  with  anorexia  and  wasting  and  con- 
tractures of  muscles.  But  there  are  no  true  reactions  of  degeneration; 
the  tendon  reflexes  are  preserved  or  even  increased;  hysterical  stigmata 
are  present;    and  the  history  is  characteristic. 

II.  THE  CERVICAL  NERVES  AND  CERVICAL  PLEXUS. 

The  cervical  plexus  is  formed  from  the  four  upper  cervical  nerves. 
These  nerves  after  issuing  from  the  spinal  canal  divide  into  anterior  and 
posterior  branches;  it  is  from  the  anterior  branches  alone  that  the  cer- 
vical plexus  is  formed.  The  posterior  branches  are  largely  sensory,  and 
the  largest  nerve  arising  from  these  is  the  great  occipital  nerve.  The  most 
important  branch  of  the  plexus  proper  is  the  phrenic  nerve. 


1354  MEDICAL  DIAGNOSIS. 

Pathology. — This  group  of  cervical  nerves  may  be  involved  in  dis- 
eases about  the  base  of  the  skull  and  the  upper  cervical  vertebrae.  Among 
these  especially  are  spinal  caries,  and,  very  rarely,  new  growths.  Fracture 
and  dislocation  of  these  vertebrae  occasionally  occur.  Pure  neuralgic 
affections  also  may  be  seated  in  these  nerve  branches. 

Symptoms." — Neuralgia  of  the  great  occipital  nerve,  which  is  dis- 
tributed to  the  occiput  as  high  as  the  vertex,  is  a  distressing  malady. 
There  are  painful  points,  especially  where  the  nerve  penetrates  the 
trapezius  muscle,  and  over  the  boss  of  the  parietal  bone.  The  pain  is 
usually  paroxysmal.  This  nerve  may  also  be  involved  in  dislocation  of 
the  atlas,  as  in  a  case  reported  by  Lloyd,  in  which  there  was  anaesthesia 
in  the  distribution  of  the  great  occipital  (see  Fig.  388).  This  is  explained 
by  the  fact  .that  the  nerve  is  a  branch  of  the  second  cervical  nerve  which 
issues  from  the  si5ine  between  the  atlas  and  the  axis.  In  spinal  caries  and 
new  growths  there  is  not  only  pain  but  also  stiffness  of  the  neck  muscles, 
and  this  may  also  be  seen  in  meningitis  in  the  posterior  basic  region  of 
the  brain.  In  some  cases  of  torticollis  it  is  probable  that  some  of  the 
motor  branches  of  the  plexus  are  involved. 

Diagnosis. — Care  is  required  especially  to  detect  if  possible  any  organic 
lesion,  as  new  growths,  spinal  caries,  fracture,  basal  meningitis,  etc. 

III.  THE  PHRENIC  NERVE. 

This  nerve  supplies  the  diaphragm.  It  arises  from  the  third  and 
fourth  cervical  nerves,  and  therefore  has  its  central  origin  in  the  third 
and  fourth  cervical  segments  of  the  spinal  cord.  It  receives  a  small  branch 
also  from  the  fifth  cervical.  In  the  neck  it  is  deeply  situated  and  passes 
between  the  subclavian  artery  and  subclavian  vein.  It  is  supplied  to  the 
under  surface  of  the  diaphragm. 

Pathology. — Owing  to  its  deep  situation  in  the  neck  and  chest  the 
phrenic  nerve  is  not  often  injured.  It  may  be  involved  in  blows  and  wounds 
of  the  neck  and  in  surgical  operations;  also  in  caries  of  the  cervical  spine, 
and  in  cervical  meningitis.  In  injuries  to  the  cervical  cord,  due  to  fracture 
or  dislocation  of  the  vertebrae,  this  nerve  is  sometimes  involved  in  its 
centres  of  origin.  This  complication  is  then  the  immediate  cause  of  death. 
In  some  of  the  cases  in  which  the  lesion  is  lower  in  the  cervical  cord, 
and  the  external  respiratory  muscles  are  paralyzed,  life  may  hang  upon 
the  phrenic  nerve,  the  respiration  being  entirely  diaphragmatic.  This 
nerve  is  said  also  to  be  involved  sometimes  in  alcohohc  multiple  neuritis 
and  in  diphtheritic  paralysis.     It  may  also  be  pressed  upon  by  tumors. 

Symptoms. — Paralysis  of  both  phrenic  nerves  causes  complete  paral- 
ysis of  the  diaphragm.  Respiration  is  entirely  by  the  external  respiratory 
muscles.  Dyspnoea  may  or  may  not  be  present.  Bronchitis  and  pneu- 
monia are  among  the  risks  in  these  cases. 

Diagnosis. — The  symptom  may  be  overlooked,  especially  if  only  one 
phrenic  nerve  is  affected.  On  close  inspection,  however,  it  is  seen  in  the 
latter  case  that  the  movement  of  the  diaphragm  on  the  affected  side  is 
impaired,  and  when  both  nerves  are  paralyzed  the  failure  of  the  diaphragm 
to  descend  is  evident.  Compensatory  action  of  the  external  respiratory 
muscles  causes  exaggeration  of  the  costal  type  of  respiration. 


DISEASES  OF  THE  SPINAL  NERVES.  1355 

IV.  THE  BRACHIAL  PLEXUS. 

The  brachial  plexus  is  formed  from  the  anterior  branches  of  the 
last  four  cervical  nerves  and  of  the  first  dorsal  nerve.  It  begins  close 
to  the  vertebrae  and  extends  to  just  beneath  the  clavicle,  where  it  gives 
origin  to  its  main  nerve-trunks.  These  trunks  go  to  form  the  cir- 
cumflex, musculospiral,  musculocutaneous,  median,  ulnar,  and  internal 
cutaneous  nerves.  Hence  the  brachial  plexus  supphes  with  motor 
and  sensory  filaments  the  shoulder  and  upper  limb.  These  various 
nerve-trunks,  however,  take  origin  from  the  brachial  plexus  in  such 
a  way  that  none  of  them  is  derived  entirely  from  any  one  spinal 
nerve-root. 

Pathology. — The  brachial  plexus  may  be  the  seat  of  severe  neuralgia, 
trauma,  inflammation,  and  neoplasm.  Neuralgic  affections  are  often  of 
obscure  nature;  they  may  be  caused  by  rheumatism  or  gout,  possibly 
also  by  exposure  and  by  slight  grades  of  inflammation.  Tumors  are 
rare;  aneurism  sometimes  acts  as  a  cause.  Trauma  may  cause  exten- 
sive lesions.  Fracture  of  the  clavicle  and  dislocation  of  the  head  of  the 
humerus,  especially  the  subcoracoid  form,  may  cause  injury  to  the  plexus. 
Spinal  caries  may  cause  irritation  of  the  nerve-roots. 

Symptoms.  —  In  neuralgia  usually  the  sensory  fibres  alone  are 
involved.  Painful  points  are  present,  as  where  the  nerve-trunks  are  most 
exposed  or  most  easily  subjected  to  pressure;  hence,  on  the  side  of  the 
vertebrae,  in  the  axilla,  and  on  the  musculospiral  nerve  in  the  upper 
arm,  and  on  the  ulnar  and  radial  nerves  in  the  forearm.  If  inflammation 
is  present  there  may  be  areas  of  parsesthesia  and  anaesthesia,  and  vaso- 
motor and  trophic  lesions.  In  these  cases  the  motor  fibres  also  suffer, 
parah'sis   resulting.      The   pain   is   sometimes   intense. 

In  traumatic  cases  the  pain  may  be  very  severe,  and  various  forms  of 
paraly.sis  i*esult  according  as  the  lesion  is  total  or  partial;  also  glossy  skin 
and  other  trophic  lesions,  such  as  muscular  atrophy;  also  contractures 
in  old-standing  cases.  In  organic  lesions  of  the  plexus  from  whatever 
cause  there  may  be  complete  or  almost  complete  brachial  monoplegia. 
All  voluntary  movements  are  lost  when  the  lesion  is  a  total  one,  and  the 
arm  then  hangs  inert  at  the  side.  The  shoulder  may  be  kept  slightly 
elevated  by  over-action  of  the  trapezius  muscle.  The  paralysis  is  flaccid, 
with  reactions  of  degeneration,  and  the  tendon-reflexes  are  lost.  The 
pain  may  be  severe,  paroxysmal,  ill-defined,  and  may  interfere  with 
sleep.  In  total  lesion  the  anaesthesia  involves  the  hand  and  forearm 
and  the  outer  aspect  of  the  upper  arm.  The  tip  of  the  shoulder  is  not 
involved,  as  it  is  supplied  by  the  cervical  plexus,  and  the  inner  aspect 
of  the  upper  arm  also  escapes,  as  it  is  supplied  by  the  first  three 
dorsal  nerves.  The  upper  arm  type,  according  to  Erb,  is  caused  by 
injury  to  the  fifth  and  sixth  cervical  roots;  the  lower  arm  type  by 
injury  to  the  seventh  and  eighth  cervical  and  dorsal  roots.  The  upper 
arm  type  causes  paralysis  of  the  deltoid,  biceps,  brachialis  anticus, 
supinator  longus,  and  possibly  the  infraspinatus,  supraspinatus,  and  serra- 
tus  magnus.  The  lower  arm  type  involves  more  the  muscles  of  the  lower 
arm  and  hand. 


1356  MEDICAL  DIAGNOSIS. 

Diagnosis.  —  The  diagnosis  is  easy,  and  is  made  from  the  peculiar 
distribution  of  the  symptoms.  Cases  vary  according  to  the  extent  and 
completeness  of  the  lesion.  The  cause  in  pure  brachial  neuralgia  may 
be  obscure;  and  careful  search  should  be  made  for  organic  lesions,  such 
as  neuromata,  aneurism,  and  vertebral  disease. 

V.  THE  ANTERIOR  THORACIC  NERVES. 

These  nerves  are  not  of  great  clinical  importance  except  as  pointers 
in  some  cases  of  injury  to  the  brachial  plexus.  They  are  two  in  number. 
The  external  nerve  is  a  branch  from  the  outer  cord  of  this  plexus  and 
supplies  the  pectoralis  major  muscle;  the  internal  nerve  arises  from  the 
inner  cord  and  supplies  both  the  pectoralis  major  and  minor  muscles. 
They  are  consequently  likely  to  be  involved  in  a  lesion  high  in  the 
plexus,  but  they  escape  in  a  lesion  as  low  as  the  retroclavicular  portion 
of  that  system  of  nerves.  Paralysis  of  the  two  pectoral  muscles  impairs 
the  use  of  the  arm;  but  the  incapacity  to  the  patient  is  not  as 
great  as  might  be  supposed.  Forced  adduction  of  the  arm  across  the 
chest  is   affected. 

There  are  a  few  cases  on  record  of  congenital  absence  of  the  two 
pectoral  muscles  on  one  side.  Whether  this  anomaly  depends  on  primary 
defect  of  the  two  nerves,  is  not  determined.  There  is  surprisingly  little 
embarrassment  to  the  patient,  and  in  one  case  the  individual  was  a 
laboring  man  who  had  found  no  inconvenience  from  his  defect. 

VI.  THE  POSTERIOR  THORACIC  NERVE. 

The  posterior,  or  long,  thoracic  nerve  (the  external  respiratory  nerve 
of  Bell)  arises  from  the  fifth  and  sixth  cervical  nerves.  It  passes  through 
the  middle  scalene  muscle  in  the  neck,  and  runs  upon  the  outer  surface 
of  the  serratus  magnus  muscle,  which  it  supplies  with  a  filament  at  each 
of  its  digitations.     It  supplies  no  other  muscle. 

Pathology.  —  This  nerve  is  most  exposed  to  injury  at  and  about 
the  point  where  it  penetrates  the  middle  scalenus  muscle  in  the  neck. 
Thus  it  has  been  injured  by  carrying  heavy  weights  on  the  shoulder; 
possibly  also  by  mere  muscular  exertion,  acting  directly  through  the 
middle  scalene  muscle.  Cases  have  occurred  thus  in  parturition.  It 
may  also  be  injured  by  blows  upon  the  chest  and  by  axillary  wounds. 
The  nerve  is  probably  also  involved  in  some  cases  of  alcoholic  multiple 
neuritis  in  which  disease  paralysis  of  the  external  respiratory  muscles 
is  not  uncommon.  Rare  cases  have  been  seen  to  follow  typhoid  fever 
and  diphtheria. 

Symptoms. — Paralysis  of  the  serratus  magnus  muscle  is  the  only 
result  of  injury  to  this  nerve.  This  paralysis  causes  an  excessive  mobility 
of  the  scapula,  which  stands  out  from  the  chest  wall,  giving  the  patient  a 
peculiar  "winged"  appearance.  This  is  best  shown  when  the  patient 
elevates  the  arm:  the  posterior  edge  of  the  scapula  then  flies  out  from 
the  chest  wall  and  rotates  its  inferior  angle  upward  and  outward,  while 
the  acromion   descends.     The  movement  of  the  arm  is   thus   somewhat 


DISEASES  OF  THE  SPINAL  NERVES.  1357 

embarras-secl,  as  it  is  deprived  of  the  basis  of  support  normally  given  by 
the  shoulder-blade.  The  chest  wall  on  the  affected  side  is  not  properly 
expanded  in  inspiration.  In  traumatic  cases  pain  may  be  felt  in  the 
neck.  The  affection  is  generally  unilateral,  but  bilateral  cases  have 
been  reported. 

Diagnosis. — The  paralysis  is  easily  recognized  by  the  pecuhar  ''  wing- 
ing "  of  the  scapula. 

VII.  THE  CIRCUMFLEX  NERVE. 

This  nerve  supplies  the  deltoid  and  teres  minor  muscles,  and  gives 
sensation  to  the  skin  over  the  lower  and  posterior  parts  of  the  deltoid. 
It  arises  from  the  posterior  trunk  of  the  brachial  plexus  in  common  with 
the  musculospiral  nerve,  and  in  order  to  reach  its  destination  it  winds 
around  the  neck  of  the  humerus — a  fact  of  great  cHnical  significance.  It 
enters  the  deltoid  from  the  under  surface. 

Pathology. — The  commonest  cause  of  injury  to  the  circumflex  nerve 
is  dislocation  of  the  head  of  the  humerus.  The  nerve  may  also  be  injured 
in  fractures  of  the  neck  of  the  humerus.  A  rare  instance  is  reported  by 
Raymond  of  injury  to  both  circumflex  nerves  by  pressure  during  sleep,  the 
patient  lying  on  his  back  with  the  arms  elevated  and  the  hands  clasped 
behind  the  neck.  One  or  both  nerves  may  be  injured  also  during  surgical 
anaesthesia.  This  nerve  is  not  usually  the  seat  of  spontaneous  or  primary 
neuritis,  although  it  may  be  affected  in  lead  poisoning  and  in  diabetes. 
It  lies  too  deep  to  be  often  injured  by  external  causes.  In  cases  of 
arthritis,  rheumatic  or  otherwise,  of  the  shoulder-joint  there  may  be  some 
wasting  and  paralysis  of  the  deltoid  muscle. 

Symptoms. — Paralysis  of  the  deltoid  muscle  is  shown  by  inability 
to  lift  the  arm  from  the  side  and  to  elevate .  and  hold  it  above  the 
head.  Loss  of  power  in  the  teres  minor  causes  inability  to  rotate  the 
head  of  the  humerus  outward.  As  these  two  muscles  take  part  in 
various  combined  movements  with  the  muscles  of  the  upper  arm  and 
shoulder,  their  paralysis  is  very  disabling.  The  anaesthesia,  occupying 
but  a  small  area,  may  readily  be  overlooked,  and  in  fact  cannot  in  some 
cases  be  found  even  by  careful  search. 

Diagnosis.  —  Paralysis  of  the  deltoid  and  teres  minor  muscles  is 
unmistakable  from  the  peculiar  disablement  of  the  arm.  The  greatest  risk 
of  error  is  in  cases  of  dislocation  of  the  shoulder-joint,  when  the  practi- 
tioner omits  to  prepare  the  patient's  mind  for  the  possibihty  of  this 
comphcation.  A  week  or  more  may  elapse  before  the  paralysis  is  recog- 
nized, especially  if  the  shoulder  has  been  kept  bandaged  and  pain  has 
prevented  movement  in  the  joint.  The  paralysis  is  of  the  flaccid  type, 
and  the  deltoid  muscle  may  waste  rapidly  and  give  the  reactions  of 
degeneration.  Cases  have  been  recorded  in  which  recovery  did  not  take 
place  for  fully  a  year. 

Arthritis  causes  immobility  of  the  shoulder-joint,  but  the  joint  is 
usually  ankylosed  and  the  scapula  moves  with  the  humerus.  In  some 
of  these  cases  there  is  more  or  less  atrophy  and  loss  of  power  in  the 
deltoid  muscle. 


1358  MEDICAL  DIAGNOSIS. 

VIII.  THE  MUSCULOSPIRAL  NERVE. 

This  nerve  is  the  largest  branch  of  the  brachial  plexus.  It  winds 
around  the  humerus  from  within,  behind,  to  the  outer  side  of  the  arm 
in  a  spiral  groove  beneath  the  triceps  muscle.  It  divides,  near  the 
external  condyle,  into  two  terminal  branches,  the  radial  and  the  posterior 
interosseous  nerves.  In  the  upper  arm  its  main  trunk  supplies  branches 
to  the  triceps,  anconeus,  extensor  carpi  radialis  longior,  supinator  longus, 
and  in  part  to  the  brachialis  anticus.  The  interosseous  branch,  below  the 
elbow,  supplies  the  extensor  muscles  of  the  wrist,  thumb,  and  fingers. 
The  musculospiral  nerve,  and  its  main  branch,  the  radial,  supply  sensa- 
tion to  the  posterior  aspect  of  the  arm,  the  anterior  aspect  of  the  lower 
part  of  the  arm,  and  the  back  part  of  the  forearm,  hand,  and  fingers, 
except  possibly  the  extreme  tips  of  the  thumb  and  first  three  fingers, 
which,  according  to  Richelot,  are  supplied  by  the  median  nerve. 

Pathology.- — The  musculospiral  nerve  may  be  injured  in  various 
ways.  It  is  exposed  to  pressure  during  sleep,  when  the  patient  Hes  with 
his  head  upon  his  arm;  this  is  particularly  so  in  the  sleep  of  alcoholic 
drunkenness.  The  nerve  is  injured  occasionally  by  the  pressure  of  the 
head  of  a  crutch.  Bilateral  palsy  may  be  caused  in  this  way.  It  is  also 
liable  to  gun-shot  and  other  wounds,  but  these  are  rare.  The  posterior 
interosseous  branch  in  the  forearm  is  particularly  vulnerable  to  lead 
poisoning,  the  well-known  wrist-drop  resulting.  The  musculospiral  nerve 
is  also  injured  sometimes  in  fracture  of  the  humerus,  in  dislocation  of  the 
elbow,  and  even  by  sudden  and  violent  muscular  action  of  the  arm. 

Symptoms.- — These  depend  upon  the  seat  of  the  injury.  If  the  main 
trunk  is  injured  high  in  the  upper  arm  all  the  muscles  supplied  by  the 
nerve  are  paralyzed,  including  the  triceps.  This  is  the  case  usually  in  the 
crutch  palsy.  In  the  case  of  pressure  during  sleep  the  triceps  usually 
escapes,  and  then  the  paralysis  is  only  in  the  supinator  longus  and  the 
extensors  of  the  wrist  and  fingers;  occasionally,  however,  the  supinator 
longus  escapes.  When  the  paralysis  is  complete  the  patient  cannot  supi- 
nate  the  hand,  nor  extend  the  hand  at  the  wrist,  nor  extend  the  fingers. 
The  resulting  wrist-drop  is  characteristic.  A  curious  result  is  seen  in. 
diminished  power  of  flexion  of  the  hand  and  fingers,  not  that  the  flexors  are 
truly  paralyzed,  but  according  to  a  physiological  law  that  when  the  antag- 
onistic muscles  are  paralyzed  the  protagonists  lose  some  of  their  power 
apparently  from  failure  of  a  basis  of  support.  This  is  shown  if  the  hand 
is  passively  over-extended,  for  then  the  power  of  the  grip  is  much  strength- 
ened. The  loss  of  power  of  supination  excites  an  effort  of  compensation 
in  the  patient,  in  which  he  rotates  the  humerus  outward  and  jjresses  the 
arm  strongly  against  the  side.  The  basal  phalanges  cannot  be  extended, 
but  the  other  phalanges,  being  extended  by  the  interossei,  which  are 
supplied  by  the  ulnar,  can  be  extended  rather  weakly,  but  best  if  the 
basal  phalanges  be  extended  passively.  As  a  rule,  however,  in  wrist-drop 
the  fingers  are  flexed  and  the  thumb  turned  in  and  depressed.  The  paralysis 
of  the  supinator  longus  and  brachialis  anticus  causes  some  loss  of  power  of 
flexion  of  the  forearm  on  the  arm,  but  the  latter  muscle  is  not  much 
involved,  as  it  does  not  receive  its  whole  supply  from  this  nerve.    In  lead 


DISEASES  OF  THE  SPINAL  NERVES.  1359 

palsy,  as  a  rule,  the  supinator  longus  escapes  and  may  stand  out  con- 
spicuously among  the  wasted  muscles.  The  extensor  of  the  metacarpal 
bone  of  the  thumb  may  also  escape.  The  muscles  most  involved  in  lead 
paralysis  are  the  extensors  of  the  wrist  and  fingers. 

Sensation  may  be  not  much  impaired  in  pressure  cases  and  in  lead 
palsy.  When  present  from  a  total  transverse  lesion,  anaesthesia  is  dis- 
tributed about  as  follows:  When  the  lesion  is  high  in  the  upper  arm  the 
loss  of  sensation  is  located  on  the  posterior  part  of  the  arm,  the  anterior 
aspect  of  the  lower  part  of  the  arm,  the  back  of  the  forearm,  especially 
on  the  radial  side,  and  the  back  of  the  hand  and  fingers,  except  the  tips 
of  the  thumb  and  the  first  three  fingers.  When  the  lesion  is  lower,  as  in 
pressure  cases,  loss  of  sensation,  if  present,  is  only  seen  below  the  elbow. 
As  in  all  peripheral  palsies  there  may  be  marked  atrophy  of  the  muscles, 
lost  tendon  reflexes,  and  reactions  of  degeneration. 

Diagnosis. — The  paralysis  is  so  characteristic  that  a  mistake  is  hardly 
possible.  Lead  palsy  is  bilateral,  although  occasionally  it  is  worse  on  one 
side  than  the  other;  it  is  to  be  distinguished  from  the  extensor  paralysis 
of  alcoholic  multiple  neuritis  by  the  history;  by  the  pains  and  the  wider 
extent  of  the  paralysis  in  alcoholic  cases;  and  by  the  escape  of  the  supi- 
nator longus  in  lead  cases.  Pressure  cases  and  traumatic  cases  generally 
are  unilateral.     The  history  is  usually  clear. 

IX.  THE  MEDIAN  NERVE. 

The  median  is  properly  called  the  fellow  of  the  ulnar  nerve,  as  both 
are  flexors  of  the  wrist,  hand,  and  fingers.  It  arises  from  the  brachial 
plexus  and  passes  down  by  the  side  of  the  brachial  artery.  All  its 
branches  are  given  off  in  the  forearm  and  hand.  It  supplies  all  the 
muscles  on  the  front  of  the  forearm  except  the  flexor  carpi  ulnaris  and 
the  inner  half  of  the  flexor  profundus  digitorum,  which  are  suppHed  by  the 
ulnar.  In  the  hand  it  supplies  the  abductor,  the  opponens,  and  the 
short  flexor  of  the  thumb;  also  the  first  two  lumbricales.  Its  functions 
therefore  are  largely  flexor  and  pronator.  It  also  gives  sensation  to  the 
radial  side  of  the  palm  and  to  the  palmar  surfaces  of  the  thumb,  fore 
and  middle  fingers,  and  the  radial  side  of  the  ring  finger.  According 
to  some  observers  it  also  supplies  the  dorsal  aspect  of  the  tips  of  these 
fingers  and  the  thumb. 

Pathology. — The  median  nerve  may  be  injured  in  many  ways.  It 
is  not  often  involved  by  pressure  during  sleep,  nor  is  it  injured  as  often 
as  the  ulnar. 

Symptoms. — One  of  the  most  characteristic  symptoms  of  paralysis 
of  the  median  nerve  is  inability  to  pronate  the  forearm;  this  cannot  be 
accomphshed  beyond  the  mid-position,  and  the  patient  supplements  the 
attempt  by  rotating  the  humerus  inward.  Another  characteristic  symp- 
tom is  inability  to  oppose  the  thumb  to  the  tips  of  the  fingers;  the  thumb, 
in  fact,  is  much  hampered  in  many  of  its  movements,  including  flexion 
and  abduction.  Still  other  symptoms  are  impaired  flexion  of  the  wrist, 
which  is  then  done  entirely  through  the  ulnar  nerve,  with  consequently 
marked  deviation  of  the  hand  toward  the  ulnar  side;    and  loss  of  flexion 


1360 


MEDICAL  DIAGNOSIS. 


of  the  phalanges,  except  the  distal  phalanges  of  the  ring  and  little  fingers, 
which  are  supplied  thi'ough  the  ulnar.  The  unopposed  extensor  action  of 
the  interossei  muscles  may  cause  a  subluxation  of  the  joints  between  the 
second  and  third  phalanges.  Anaesthesia  is  present  on  the  radial  side  of  the 
palm,  the  palmar  surfaces  of  the  thumb,  fore  and  middle  fingers,  the  radial 
side  of  the  ring  finger,  and  the  dorsal  tips  of  these  fingers  and  thumb. 
Trophic  lesions  are  very  common  in  injuries  of  the  median  nerve. 
Diagnosis. — This  is  usually  clear  from  the  history  of  the  case  and  the 
characteristic  distribution  of  the  symptoms.  The  loss  of  power  of  com- 
plete pronation,  the  awkward  flexion  of  the  wrist  with  deviation  of  the 
hand  to  the  ulnar  side,  the  disablement  of  the  thumb,  and  the  loss  of 
power  of  flexion  of  the  fingers,  together  with  the  classical  ansesthesia, 
are  determinative.     The  muscular  atrophy  and  reactions  of  degeneration 

help  to  distinguish  the  case 
from  one  of  cerebral  origin. 
The  trophic  lesions,  if  present, 
are  especially  significant, 

X.  THE  ULNAR 
NERVE. 

The  ulnar  nerve  is  one  of 
the  two  flexor  nerves  of  the 
wrist,  hand,  and  fingers.  It 
arises  from  the  brachial  plexus 
and  passes  down  the  inner  side 
of  the  upper  arm  in  close  prox- 
imity to  the  brachial  artery. 
At  the  elbow  it  passes  behind  the  internal  condyle,  where  it  can  readily  be 
felt  in  most  persons,  and  where  pressure  upon  it  causes  a  tingling  sensation. 
It  supphes  the  flexor  carpi  ulnaris,  part  of  the  flexor  profundus  digitorum, 
the  muscles  of  the  httle  finger,  the  interosseous  muscles,  two  of  the  lum- 
bricales,  the  adductor  pollicis,  and  one  head  of  the  flexor  brevis  pollicis. 
It  gives  sensation  to  the  ulnar  side  of  the  forearm  and  hand,  the  httle 
finger,  and  the  ulnar  side  of  the  ring  finger.  By  reason  of  its  distribu- 
tion this  nerve  presides  over  the  ulnar  flexion  of  the  wrist,  the  flexion 
in  part  of  the  fingers,  the  adduction  and  abduction  and  other  finer 
movements  of  the  fingers,  also  extension  of  the  second  and  third  phalanges 
and  flexion  of  the  first  phalanges,  and  the  movements  of  the  thumb 
toward  the  palm. 

Pathology. — This  nerve  is  much  exposed  to  injury,  as  by  wounds, 
pressure,  dislocation,  and  fractures.  It  may  also  be  involved  in  tumors 
and  malignant  growths,  and  in  surgical  operations.  Pressure  may  occur 
during  sleep,  especially  during  alcoholic  sleep  and  the  unconsciousness 
caused  by  ether  or  chloroform;   also  during  parturition. 

Symptoms.  —  Paralysis  of  the  ulnar  nerve  causes  a  charactei'istic 
disability.  Flexion  of  the  wrist  is  impaired,  and  on  attempts  at  flexion 
there  is  a  deviation  of  the  hand  toward  the  radial  side.  Flexion  of  the 
little  and  ring  finger  is  es^Decially  impaired,  and  the  little  finger  is  almost 


Fig.  400.- 


-Distribution   of   anaesthesia   in    paralysis  of 
the  median  nerv^e. 


DISEASES  OF  THE  SPINAL  NERVES.  1361 

entirely  paralyzed.  Adduction  of  the  thumb  is  lost,  hence  the  patient's 
inability  to  grasp  objects.  Flexion  of  the  first  phalanges  and  extension 
of  the  last  two  phalanges  are  impaired,  but  the  loss  of  flexion  is  less  in  the 
first  two  fingers  which  are  supplied  in  part  by  the  median  nerve.  The 
finer  movements  of  the  fingers  are  abolished.  In  long-standing  cases  a 
characteristic  deformity  results  which  is  called  the  "main-en-griffe"; 
the  first  phalanges  become  over-extended,  much  more  so  than  is  possible 
by  voluntary  power,  and  the  last  two  phalanges  are  strongly  flexecl.  This 
deformity,  however,  is  not  so  marked  as  in  cases  of  anterior  poliomyelitis, 
because  the  lumbricales  of  the  first  two  fingers  are  not  involved  in  ulnar 
paralysis,  being  supplied  by  the  median  nerve.  Muscular  atrophy  is 
usually  marked;  the  interosseous  spaces  are  hollowed  out,  the  palm  is 
wasted,  and  the  hypothenar  eminence  is  atrophied.  Anaesthesia  involves 
the  ulnar  side  of  the  arm  for  some  distance  above  the  wrist,  also  the  ulnar 
side  of  the  hand  on  both  the  palmar  and  dorsal  aspects,  the  whole  of  the 
little  finger,  and  the  ulnar  side  of  the  ring  finger. 

Diagnosis.— This  is  comparatively  easy,  because  of  the  characteristic 
disablement  and  deformity.  Some  care  may  be  necessary  in  cases  due 
to  pressure,  as  during  sleep,  or  parturition,  or  surgical  anaesthesia.  The 
history  of  the  case,  however,  is  usually  clear,  and  the  resulting  paralysis 
is  unmistakable.  In  a  case  occurring  during  the  delirium  of  typhoid  fever, 
the  paralysis  was  riot  detected  until  the  patient's  mind  became  clear  and 
he  himself  called  attention  to  the  loss  of  power.  In  irritative  injuries,  such 
as  gun-shot  wounds,  trophic  lesions  ma}^  result,  such  as  glossy  skin  and 
oedema,  and  these  may  be  accompanied  with  burning  pain  or  "causalgia." 

XI.  THE  INTERCOSTAL  NERVES. 

These  nerves  are  branches  of  the  twelve  dorsal  nerves.  The}^  are 
separate  from  each  other  in  the  sense  that  they  do  not  form  a  plexus. 
Each  nerve  runs  forward  in  an  intercostal  space,  and  for  part  of  its  course 
it  is  in  close  proximity  to  the  pleura. 

The  intercostal  nerves  may  be  variously  affected,  and  they  some- 
times furnish  important  indications  for  diagnosis.  This  is  especially  so 
in  diseases  of  the  spinal  cord.  Thus  a  spinal  meningitis  or  a  spinal  tumor 
may  irritate  the  roots  of  one  or  more  dorsal  nerves,  and  this  may  point 
to  the  location  of  the  lesion.  It  may  also  simulate  an  intercostal  neu- 
ralgia. The  same  is  true  of  spinal  caries.  In  all  such  organic  lesions 
the  diagnosis  is  to  be  made  by  a  study  of  other  attendant  symptoms. 
Aneurism  of  the  thoracic  aorta  may,  by  irritating  a  dorsal  nerve-root, 
simulate  disease  of  the  spinal  cord.  Herpes  zoster  frequently  attacks 
one  of  the  dorsal  roots,  its  point  of  attack  being  probably  the  posterior 
ganglion,  and  the  pain  and  characteristic  eruption  follow  closely  the  distri- 
bution of  the  nerve  affected.  Intercostal  neuralgia  is  to  be  distinguished 
from  pleurisy.  The  affection  known  as  mastodynia,  or  neuralgia  of  the 
breast,  is  often  a  puzzling  affection,  and  is  commonly  seen  in  neurotic  or 
hysterical  women.  Fracture  of  the  ribs  is  usually  attended  with  severe 
pain  in  the  intercostal  nerves,  and  the  diagnosis  may  require  great  care, 
especially  where  the  history  of  trauma  is  obscure. 

86 


1362  MEDICAL  DIAGNOSIS. 

XII.  THE  LUMBAR  PLEXUS. 

This  plexus  is  formed  from  the  twelfth  dorsal  and  the  first  four  lumbar 
nerves.  The  fifth  lumbar  nerve  does  not  enter  into  this  formation,  but 
after  receiving  a  branch  from  the  fourth,  goes,  as  the  lumbosacral  cord, 
to  help  form  the  sacral  plexus  deep  in  the  true  pelvis.  This  formation 
of  the  lumbosacral  cord  has  not  a  little  clinical  importance,  as  will  be 
shown  later.  The  principal  nerves  arising  from  the  lumbar  plexus  are 
the  iliohypogastric,  the  ilio-inguinal,  the  external  and  internal  inguinal, 
the  anterior  crural,  and  the  obturator.  The  iliohypogastric  nerve  supplies 
sensation  to  the  skin  of  the  gluteal  and  hypogastric  regions.  It  is  of  little 
clinical  importance.  The  ilio-inguinal  nerve  is  both  motor  and  sensory. 
It  supplies  the  internal  oblique  muscle.  It  passes  out  at  the  external 
abdominal  ring  and  is  distributed  to  the  skin  of  the  scrotum  in  the  male 
and  of  the  labium  in  the  female,  and  to  the  upper  inner  part  of  the  thigh. 
The  genitocrural  nerve  is  of  clinical  significance  as  supplying  the  crem- 
asteric muscle.  It  might  be  involved  in  psoas  abscess,  as  it  penetrates 
the  psoas  muscle.  The  external  inguinal  or  external  cutaneous  nerve  is 
the  sensory  nerve  of  the  outer  part  of  the  thigh  as  far  down  as  the  knee. 
Its  posterior  branch  supplies  the  outer  posterior  part  of  the  thigh  as  far 
as  the  middle  third.  The  anterior  crural  and  obturator  nerves,  because 
of  their  importance,  are  described  under  separate  headings.  From  the 
nature  of  their  origin  and  relations,  however,  they  are  often  involved  in 
lesions  of  the  lumbar  plexus. 

Pathology. — The  lumbar  plexus  is  less  frequently  the  seat  of  injuries 
and  disease  than  either  the  brachial  or  sacral  plexus.  Its  anatomical 
position,  deep  within  the  body,  explains  this  comparative  exemption. 
The  lumbar  plexus,  being  merely  a  continuation  of  the  nerves  which 
have  their  origins  just  within  the  spinal  canal,  is  closely  associated  with 
these  parts  in  its  pathology.  Falls  and  crushing  injuries  may  possibly 
involve  the  lumbar  plexus  as  well  as  the  intraspinal  nerve-roots. 
Tumors  within  the  body  may  also  cause  pressure  or  irritation.  Lumbar 
and  psoas  abscess  may  variously  affect  these  nerve-cords.  Finally,  par- 
turition may  do  injury  to  the  anterior  crural  and  the  obturator  nerves. 

Symptoms.  —  These  vary  widely  according  to  the  particular  nerve- 
cords  involved.  A  good  method  of  diagnosis  is  carefully  to  study  the 
motor,  sensory,  and  reflex  phenomena  seriatiw.,  and  then  by  grouping  these, 
to  arrive  at  a  conclusion  as  to  what  parts  of  the  plexus  are  involved. 

The  pain  caused  by  these  lesions  may  be  most  misleading.  Lydston 
has  reported  a  case  of  acute  lumbar  abscess  which,  by  irritating  some 
strands  of  the  lumbar  plexus,  simulated  nephritic  colic:  the  pain  was  in 
the  iliolumbar  region.  Psoas  abscess  may  cause  pain  and  paralysis 
in  the  anterior  crural  nerve,  which  passes  through  the  psoas  muscle. 
It  may  also  involve  the  genitocrural  nerve.  Referred  or  distal  pain  is 
sometimes  a  puzzling  symptom  from  this  cause,  such  as  pain  on  the 
inner  side  of  the  knee  and  down  the  inner  side  of  the  leg  following 
the  course  and  distribution  of  the  anterior  crural  and  its  long  saphenous 
branch.  The  knee  pain  due  to  hip-joint  disease  is  another  example, 
probably  due  to  irritation  of  the  obturator  nerve. 


DISEASES  OF  THE  SPINAL  NERVES.  1363 

The  motor  and  reflex  symptoms  depend  upon  the  nerves  imphcated. 
If  the  anterior  crural  is  involved  the  knee-jerk  is  lost  and  the  extensor 
muscles  of  the  thigh  and  leg  are  paralyzed.  The  cremasteric  reflex  may  be 
lost  by  involvement  of  the  genitocrural  nerve.  Paralysis  of  the  obtu- 
rator causes  loss  of  power  of  adduction  in  the  thigh.  Paralysis  of  the 
bowel  and  bladder  is  not  caused  by  involvement  of  the  lumbar  plexus. 

Diagnocis. — This  has  been  indicated  in  the  foregoing  description  of 
the  pathology  and  symptoms.  It  is  most  important  to  search  for  gross 
local  lesions,  such  as  abscess,  tumor,  and  vertebral  disease.  Injuries  to 
the  plexus  are  rare;    they  sometimes  occur  as  results  of  child-birth, 

XIII.  THE  ANTERIOR  CRURAL  NERVE. 

This  nerve  arises  from  the  lumbar  plexus  and  passes  out  of  the  pelvis 
beneath  Poupart's  ligament  on  the  outer  side  of  the  femoral  artery.  It 
supplies  the  muscles  on  the  anterior  of  the  thigh,  which  act  as  extensors 
of  the  leg;  within  the  pelvis  it  passes  through  the  psoas  muscle,  and  sup- 
plies the  iliacus.  It  gives  sensation  to  the  front  and  inner  surfaces  of  the 
thigh,  and  by  its  main  branch,  the  long  saphenous,  to  the  inner  side  of  the 
leg  and  foot  as  far  sometimes  as  the  great  toe. 

Pathology. — The  anterior  crural  may  be  involved  in  psoas  abscess, 
as  the  nerve  passes  through  the  fibres  of  the  psoas  muscle.  Other  deep- 
seated  abscesses  in  the  pelvis  might  also  affect  it,  but  lumbar  abscess  is 
more  likely  to  affect  other  and  higher  branches  of  the  lumbar  plexus. 
Injury  to  the  anterior  crural  nerve  is  rare.  Fullerton  reports  the  case  of 
a  dwarf  in  which  pressure  during  labor  caused  transient  injury  to  this 
nerve;  and  it  may  also  be  hurt  in  some  forms  of  dislocation  of  the  hip, 
but  only  rarely. 

Symptoms. — There  is  paralysis  of  the  quadriceps  extensor  muscle  with 
consequent  inability  to  extend  the  leg.  This  paralysis  is  flaccid,  with 
atrophy,  and  the  knee-jerk  is  abolished.  If  the  iliacus  muscle  is  involved 
within  the  pelvis,  there  is  inability  to  flex  the  thigh,  which  is  characteris- 
tically shown  by  the  patient  lifting  the  thigh  with  his  hands  when  asked 
to  cross  the  lame  leg  over  the  other.  This  movement  also  is  embarrassed 
by  the  paralysis  of  the  sartorius.  Pain  may  be  present  and  is  experienced 
from  Poupart's  ligament  to  the  inner  side  of  the  knee,  and  thence  down 
the  inner  side  of  the  leg  even  to  the  foot  and  great  toe.  In  psoas  abscess 
this  pain  is  sometimes  distal  and  is  relieved  by  flexing  the  thigh  on  the 
pelvis  with  the  knee  kept  bent.  Anaesthesia  involves  the  anterior  and 
internal  surfaces  of  the  thigh  and  the  inner  surface  of  the  leg  and  foot 
following  the  course  of  the  long  saphenous  branch. 

Diagnosis.  —  Psoas  abscess  may  simulate  crural  neuralgia.  The 
paralysis  of  the  nerve  is  readil}"  determined  by  the  characteristic  loss  of 
power  in  the  iliacus,  sartorius,  pectineus,  and  quadriceps  extensor  mus- 
cles, with  lost  knee-jerk,  and  by  the  distribution  of  the  anaesthesia  and 
pain.  Irritation  of  the  roots  of  this  nerve  might  be  caused  by  a  tumor  in 
or  near  the  spine,  or  by  disease  of  the  lumbar  vertebra.  It  may  also  be 
paralyzed  by  aneurism  of  the  femoral  artery.  Diabetes  has  been  known 
to  cause  paralysis  and  neuralgia  in  both  crural  nerves. 


1364  MEDICAL  DIAGNOSIS. 

XIV.  THE  OBTURATOR  NERVE. 

This  nerve,  after  rising  from  the  second,  third,  and  fourth  lumbar 
nerves,  and  penetrating  the  inner  fibres  of  the  psoas  muscle,  runs  along 
the  inner  and  lateral  wall  of  the  pelvis  to  the  obturator  foramen,  by  which 
it  emerges.  It  suppHes  the  obturator  externus  and  adductors  of  the  thigh, 
the  articulations  of  the  hip  and  knee,  and  the  skin  of  the  inner  side  of  the 
thigh,  and,  possibly  by  its  communication  with  the  long  saphenous  nerve, 
of  the  leg  also. 

Pathology.  —  Because  of  its  deep  position  injury  to  the  obturator 
nerve  is  rare.  Some  obstetricians  believe  that  it  is  sometimes  involved  in 
puerperal  cases,  as  by  the  forceps,  or  the  child's  head,  or  in  pelvic  inflam- 
mation. The  pain  in  the  knee  in  the  early  stages  of  hip-joint  disease  is 
usually  ascribed  to  irritation  of  the  obturator  nerve,  which  sends  fila- 
ments to  both  joints;  but  some  orthopaedists  explain  it  as  due  to  mus- 
cular spasm.  Obturator  hernia  and  pelvic  tumors  may  compress  the 
nerve,  and  it  may  be  irritated  by  psoas  abscess. 

Symptoms. — Paralysis  of  the  obturator  nerve  interferes  with  crossing 
the  affected  leg  over  its  fellow,  and  with  outward  rotation  of  the  thigh. 
The  anaesthesia  is  on  the  inner  side  of  the  thigh  and  perhaps  of  the  leg, 
but  it  may  not  be  marked. 

Diagnosis. — This  is  indicated  in  the  account  of  the  symptoms.  The 
knee  pain  in  hip-joint  disease  has  led  to  error.  In  an  obscure  case  it  is 
well  to  bear  in  mind  the  possibility  also  of  a  psoas  abscess. 

XV.  THE  SACRAL  PLEXUS. 

The  sacral  plexus  lies  deep  in  the  pelvis.  It  is  formed  from  the  lumbo- 
sacral cord,  which  arises  from  the  fourth  and  fifth  lumbar  segments,  and 
from  the  three  upper  sacral  nerves  and  a  part  of  the  fourth  sacral  nerve. 
It  gives  origin  to  four  main  nerves,  the  superior  gluteal,  pudic,  small 
sciatic,  and  great  sciatic. 

Pathology. — The  sacral  plexus  may  be  injured  by  tumors  within  the 
pelvis  and  diseases  of  the  womb,  ovaries,  or  rectum;  by  pressure  during 
labor;  by  wounds;   and  it  may  be  the  seat  of  neuritis. 

Symptoms. — These  vary  widely,  according  to  the  particular  nerve- 
cords  involved. 

Pain  is  a  common  symptom,  and  may  be  felt  about  the  buttock,  hip, 
perineum,  and  even  down  the  thigh  and  in  the  leg,  foot,  and  toes,  following 
the  course  of  the  great  or  small  sciatic  nerves.  Paralysis  of  various  muscles 
is  also  present,  and  this  paralysis  may  even  present  certain  types,  accord- 
ing to  the  nerves  involved.  The  bladder  and  bowel  may  be  paralyzed. 
For  a  proper  understanding  of  these  cases  it  is  best  to  describe  the  vari- 
ous types  of  the  affection. 

One  of  the  commonest  and  most  important  is  the  'peroneal  type. 
This  is  particularly  likely  to  occur  after  child-birth.  After  instrumental 
delivery,  or  even  after  normal  labor  in  rare  instances,  the  patient  has 
pain  in  the  foot  and  toes;  this  is  soon  followed  by  loss  of  power  in  the 
extensor  muscles  of  these  parts,  such  as  the  peronei,  the  tibialis  anticus, 


DISEASES  OF  THE  SPINAL  NERVES.  1365 

and  the  long  extensor  of  the  toes.  The  patient  in  walking  has  foot-drop 
and  lifts  the  foot  high,  the  toes  dragging  along  the  floor.  The  paralysis  is 
flaccid,  the  muscles  atrophy,  and  complete  reactions  of  degeneration  are 
seen.  The  knee-jerks  are  not  abolished.  Anaesthesia  may  be  present  on 
the  outer  part  of  the  leg  and  on  the  dorsum  of  the  foot  and  toes.  The 
explanation  of  this  affection  lies  in  the  fact,  that  the  external  popliteal  or 
peroneal  nerve  is  a  continuation  of  the  lumbosacral  cord  in  the  pelvis, 
and  that  this  lumbosacral  cord  is  particularly  exposed  to  injury  by  pres- 
sure where  it  runs  over  the  brim  of  the  true  pelvis  in  passing  down  to  the 
sacral  plexus.  In  these  cases  there  may  also  be  some  loss  of  power  in  the 
gluteus  medius  muscle,  which  derives  its  motor  supply  from  a  branch  of  the 
lumbosacral  cord.  In  most  of  these  puerperal  cases  the  affection  is  uni- 
lateral; occasionally,  however,  there  is  a  bilateral  paralysis,  presenting  a 
rather  different  type. 

The  form  of  paralysis  varies.  All  depends  upon  the  particular  nerves 
involved.  Occasionally  the  great  sciatic  nerve  alone  is  impaired  by  some 
intrapelvic  lesion,  and  the  case  then  presents  the  picture  of  an  ordinary 
sciatica.  A  small  ovarian  tumor  has  been  known  to  cause  pain  and  loss 
of  power  in  the  buttock.  In  some  of  the  post-partum  cases  pain  is  the 
chief  or  only  symptom. 

Diagnosis.  —  It  is  of  first  importance  that  the  practitioner  should 
determine  the  cause.  When  this  has  once  been  done  the  nature  of  the 
case  usually  becomes  clear. 

The  chief  difficulty  is  to  distinguish  these  cases  from  affections  of  the 
Cauda  equina.  The  history,  however,  usually  points  to  an  intrapelvic 
lesion,  as  in  the  puerperal  and  gynaecological  cases,  and  an  expert  investi- 
gation  'per  vaginam  or  yer  rectum  will  generally  detect  a  local  cause  if  it 
is  present.  The  examination  by  the  rectum  is  especially  important,  as  by 
this  means  the  nerve-trunks  can  be  palpated.  Affections  of  the  cauda 
equina  are  usually  bilateral;  while  those  of  the  sacral  plexus  are  often, 
unilateral;   but  this  latter  rule  is  not  absolute. 

Hysteria  may  simulate  these  affections,  but  this  psychoneurosis  is  to 
be  recognized  by  the  mental  state,  history,  and  peculiar  hysterical  stigmata. 

Cancer  of  the  rectum,  as  well  as  ovarian  tumor,  has  been  mistaken 
for  sciatica  or  some  form  of  pelvic  neuralgia. 

XVI.  THE  SCIATIC  NERVES. 

The  great  sciatic  arises  from  the  sacral  plexus  and  passes  out  of 
the  pelvis  by  the  sacrosciatic  foramen,  where  it  is  readily  accessible  to 
pressure  between  the  great  trochanter  and  the  tuberosity  of  the  ischium. 
It  supplies  in  the  thigh  the  hamstring  muscles — the  biceps  femoris,  the 
semimembranosus,  and  semitendinosus — and  divides  just  above  the  pop- 
liteal space  into  two  main  branches,  the  internal  popliteal  and  exter- 
nal popliteal  (or  peroneal)  nerves.  These  two  branches  supply  all  the 
muscles  below  the  knee  (both  extensor  and  flexor)  and  give  sensation  to 
most  of  the  leg  and  foot,  the  parts  not  supplied  by  it  being  a  strip  along 
the  inner  side  of  the  leg  which  is  supplied  by  the  long  saphenous  nerve, 
and  the  upper  part  of  the  calf  which  is  supplied  by  the  small  sciatic. 


1366  MEDICAL  DIAGNOSIS. 

The  small  sciatic  also  arises  from  the  sacral  plexus  and  passes  out  of 
the  pelvis  alongside  of  the  great  sciatic;  it  supplies  the  gluteus  maximus 
muscle  (through  the  inferior  genital  nerve),  and  a  well-defined  area  of 
the  skin  which  includes  the  buttock,  the  perineum,  and  a  strip  running 
down  the  back  of  the  thigh  to  and  including  the  upper  part  of  the  calf. 

Pathology.  — -  The  great  sciatic  nerve  may  be  the  seat  of  wounds, 
inflammation,  and  tumors.  It  is  sometimes  injured  in  dislocations  of 
the  hip,  also  in  forceps  deliveries,  and  hy  pelvic  tumors  and  even  masses 
of  faeces.  Inflammation  of  the  nerve  constitutes  the  disease  known  as 
"sciatica."  Opportunities  to  examine  the  nerve  are  rare  in  sciatica,  but 
in  a  few  instances  on  record  the  nerve-trunk  has  been  found  swollen  and 
congested.  In  the  operation  for  stretching,  a  similar  state  has  been 
found.  Gout,  rheumatism,  syphilis,  alcoholism,  and  lead  have  all  been 
assigned  as  causes  of  sciatica.  Exposure  to  cold,  especially  after  great  or 
prolonged  muscular  effort  or  a  wetting,  may  cause  the  attack.  Fournier 
said  that  it  may  follow  gonorrhoea. 

Symptoms. — In  organic  lesions,  such  as  injury  or  tumor,  the  symp- 
toms are  characteristic.  Pain  is  an  early  symptom,  sometimes  with 
twitching  of  the  muscles  and  drawing  up  of  the  leg.  If  the  nerve  is  sev- 
ered or  in  any  way  completely  paralyzed,  there  is  loss  of  power  in  the 
hamstring  muscles  and  in  all  the  muscles  below  the  knee,  with  anaesthesia 
on  the  outer  side  of  the  leg,  dorsum  of  the  foot,  the  toes,  the  sole,  and  a 
portion  of  the  inner  and  back  part  of  the  leg.  The  regions  that  are  exempt 
are  a  narrow  strip  on  the  inner  side  of  the  leg,  supplied  by  the  long  saphe- 
nous nerve,  and  the  upper  part  of  the  calf,  supplied  by  the  small  sciatic. 
The  muscles  atrophy,  and  reactions  of  degeneration  are  present.  The 
knee-jerk  may  not  be  lost.     Trophic  ulcers  sometimes  occur. 

Pain  is  the  common  and  sometimes  the  only  symptom  in  sciatica. 
This  pain  is  severe  and  neuralgic  in  type,  especially  felt  about  the  upper 
and  back  part  of  the  thigh.  It  may  also  extend  down  along  the  course  of 
the  nerve  and  be  particularly  intense  in  the  calf  of  the  leg  and  even  in  the 
foot  and  toes.  Any  unusual  motion  in  the  leg  may  aggravate  it,  as 
suddenly  bending  the  thigh.  In  such  cases  the  forcible  action  of  the 
pyriformis  muscle  probably  causes  pressure  on  the  hypersensitive  nerve- 
trunk  at  its  exit  from  the  pelvis.  In  the  earlj^  stages  the  pain  may  be 
paroxysmal;  later  it  is  constant,  dull,  and  aching,  or  even  severe  and 
shooting.  Sensitive  points  are  found  at  the  exit  from  the  pelvis,  behind 
the  knee,  at  the  head  of  the  fibula,  and  on  the  back  of  the  foot.  The  trunk 
of  the  nerve  in  the  thigh  is  usually  extremely  sensitive  to  pressure.  Firm 
pressure  between  the  great  trochanter  and  the  tuberosity  of  the  ischium 
is  usually  most  painful. 

Paraesthesia  is  sometimes  observed,  as  burning  and  tingling  in  the 
areas  of  distribution  of  the  sensory  nerve  endings.  Anaesthesia  is  not  com- 
mon, and  when  present  may  escape  detection  if  not  carefully  sought  for. 

Motor  involvement  is  not  common  in  sciatica.  There  is  usually 
no  true  paralysis  of  muscles,  no  atrophy,  or  reactions  of  degeneration. 
The  knee-jerk,  as  a  rule,  is  not  affected.  The  Achilles-tendon  jerk 
may  be  lost.  Inhibition  of  motion  is  not  uncommon,  but  this  is  due 
to  pain.    The   gait  is   affected  for  the   same  reason,  and  there  may  be 


DISEASES  OF  THE  SPINAL  NERVES.  1367 

sKght  scoliosis.  The  muscles  may  become  flabby  and  wasted  from  dis- 
use.    Trophic  lesions  are  rare.     Herpes  may  occur. 

The  small  sciatic  nerve  may  be  injured  along  with  the  great  sciatic 
at  the  point  where  they  emerge  together  from  the  pelvis.  Instances  in 
which  it  is  injured  alone  must  be  very  rare.  Its  paralysis  causes  loss  of 
power  in  the  gluteus  maximus  muscle,  which  is  shown  in  inability  to 
rise  from  a  sitting  position.  This  paralysis,  however,  is  due  to  involve- 
ment of  the  inferior  gluteal  nerve,  which,  according  to  Gray,  is  closely 
associated  with,  rather  than  a  branch  of,  the  small  sciatic.  Anaesthesia  is 
present  on  the  buttock,  the  perineum,  and  the  back  part  of  the  thigh  and 
popliteal  space  as  far  as  the  upper  third  of  the  calf. 

Diagnosis. — If  there  is  some  organic  cause,  as  injury  or  tumor,  the 
history  of  the  case^  and  a  careful  physical  examination  usually  reveal  it, 
and,  with  the  characteristic  motor  and  sensory  symptoms,  disclose  the 
nature  of  the  case. 

It  is  easy,  as  a  rule,  to  recognize  sciatica.  Pelvic  abscesses,  disease 
of  the  uterus  and  ovaries,  large  fecal  accumulations,  and  especially  cancer 
of  the  rectum  have  been  mistaken  for  sciatica.  Bone  disease  in  the  lum- 
bosacral spine  may  simulate  sciatica  by  irritating  the  nerve-roots.  Hip- 
joint  disease  is  to  be  distinguished  by  the  pain  on  moving  the  joint, 
restriction  of  motion,  alteration  in  the  length  and  position  of  the  limb, 
tilting  of  the  pelvis,  and  the  other  classical  symptoms.  Obscure  cases 
always  call  for  a  rectal  examination  or  vaginal  examination.  Appendicitis 
may  cause  deep-seated  pains  in  the  pelvis,  but  is  not  likely  to  be  mis- 
taken for  sciatica.  In  sciatica  the  most  distinctive  symptom  is  the  pain 
on  pressure  on  the  nerve-trunk.  A  sign  pointed  out  by  Lasegue  is  of  diag- 
nostic value — when  the  patient  lies  on  his  back  and  the  extended  limb  is 
elevated,  pain  is  not  felt  until  an  angle  of  about  90°  is  reached,  and  this 
pain  is  then  relieved  by  bending  the  leg  at  the  knee.  The  disease  is 
unilateral  in  the  vast  majority  of  cases,  bilateral  sciatica  being  usually 
symptomatic  of  organic  disease,  such  as  myelitis,  tumor,  spinal  caries, 
or  affections  of  the  cauda  equina.  Still,  cases  of  genuine  bilateral  sciatica 
have  been  seen,  especially  in  constitutional  diseases,  as  gout  and  diabetes. 

XVII.   THE  INTERNAL  POPLITEAL  NERVE. 

This  nerve  is  a  continuation  of  the  great  sciatic.  It  supplies  the 
flexors  of  the  foot  and  toes  (the  calf  muscles  and  muscles  of  the  sole),  and 
gives  sensation  to  the  outer  part  of  the  back  of  the  leg,  to  the  sole,  and 
in  part  to  the  toes. 

Pathology. — The  internal  popliteal,  or  posterior  tibial  nerve  as  it  is 
called  in  its  extension  down  into  the  leg,  is  so  deeply  situated  that  it  is 
but  seldom  injured.  It  shares,  however,  in  some  diseases  with  other 
nerves,  especially  such  affections  as  cause  muscular  atrophy  and  club- 
foot. In  many  of  these  cases,  however,  the  seat  of  the  lesion  is  in  the 
anterior  gray  matter  of  the  cord  rather  than  in  the  nerve  itself. 

Symptoms. — Paralysis  of  the  flexor  muscles  of  the  foot — the  soleus, 
gastrocnemius,  and  plantaris — which  are  supplied  by  this  ner^^e,  causes 
the  form  of  club-foot  known  as  valgus,  sometimes  associated  with  cal- 


1368  MEDICAL  DIAGNOSIS. 

caneiis.  Thus  flexion  of  the  foot  is  impaired,  and  the  unopposed  pero- 
neus  longus  pulls  the  outer  edge  of  the  foot  upward.  The  patient  tends 
to  walk  on  the  inner  edge  of  his  foot  and  on  the  heel,  and  he  cannot  lift 
himself  on  his  toes.  When  the  nerve  is  injured,  loss  of  sensation  is  found 
on  the  lower  part  of  the  back  of  the  leg  and  on  the  sole. 

Diagnosis. — The  diagnosis  is  easily  made  from  the  characteristic  dis- 
tribution of  the  paralysis  and  anaesthesia. 

XVIII.  THE  PERONEAL  NERVE. 

The  peroneal  or  external  popliteal  nerve  is  in  appearance  a  branch  of 
the  great  sciatic  arising  in  or  just  above  the  popliteal  space,  but  accord- 
ing to  some  observers  its  fibres  are  really  derived  from  the  lumbosacral 
cord  in  the  pelvis,  as  is  proved  by  the  occasional  high  division  of  the 
great  sciatic  within  the  pelvis,  in  which  cases  the  peroneal  is  seen  to  be  a 
continuation  of  one  of  these  branches,  which  itself  is  a  continuation  of 
the  lumbosacral  cord.  It  passes  into  the  leg  behind  the  head  of  the 
fibula,  where  it  may  easily  be  palpated  and  where  it  is  especially  exposed 
to  injury.  It  supplies  the  extensor  muscles  of  the  foot  and  toes,  and  gives 
sensation  to  the  lower  and  outer  part  of  the  leg,  the  inner  and  outer  parts 
of  the  ankle  and  foot,  the  dorsum  of  the  foot,  the  inner  side  of  the  great 
toe,  and  the  adjoining  sides  of  the  other  toes. 

Pathology. — This  nerve  is  sometimes  paralyzed  by  trauma  acting 
upon  it  near  the  head  of  the  fibula.  It  may  also  be  involved  in  fracture 
of  the  fibula.  The  peroneal  is  particularly  liable  to  involvement  in  cases 
of  alcoholic  multiple  neuritis  in  association  with  other  nerves;  and  in  the 
polyneuritis  following  typhoid  fever  this  nerve,  as  well  as  the  ulnar,  is 
apt  to  be  conspicuously  affected.  There  is  also  a  form  of  muscular  atro- 
phy— the  so-called  Charcot-Marie-Tooth  type — in  which  the  muscles  sup- 
plied by  the  peroneal  nerve  suffer  especially.  The  disease  is  likely  to- 
begin  in  these  muscles,  but  later  the  hands  and  forearms  become  affected. 
It  probably  depends  upon  a  peripheral  neuritis,  and  is  sometimes  a 
familial  affection.  Thus  Ormerod  observed  three  cases  of  this  disease 
following  measles  in  one  family.  The  distal  muscles  are  more  affected 
than  the  proximal.  In  puerperal  palsy  the  fibres  going  to  form  the  pero- 
neal nerve  may  suffer  from  pressure  of  the  child's  head  on  the  lumbosacral 
cord  and  sacral  plexus.  Among  rare  causes  of  peroneal  palsy  are  the 
application  of  an  Esmarch  tourniquet,  and  the  pressure  of  stilts.  It  is  a 
curious  fact  that  for  some  obscure  reason  potato-pickers  and  others  who  work 
in  a  stooping  position  sometimes  get  paralysis  of  this  nerve  (Oppenheim). 

Symptoms. — There  is  loss  of  power  of  extension  of  the  foot  and  toes, 
with  consequent  foot-drop  in  walking.  The  first  phalanges  of  the  toes 
may  be  flexed  by  contracture  of  the  interossei.  The  ansesthesia  is  on  the 
outer  side  of  the  lower  leg  and  ankle,  the  dorsum  of  the  foot,  and  the  toes. 
According  to  some  observers  the  inner  side  of  the  ankle  is  anaesthetic. 

Diagnosis. — The  diagnosis  is  easily  made  from  the  characteristic  dis- 
tribution of  the  symptoms.  The  paralysis  of  this  nerve  is  distinguished 
from  that  of  its  main  trunk,  the  sciatic,  by  the  escape  of  the  parts  supplied 
by  the  internal  popliteal,  and  of  the  hamstring  muscles. 


CHOREA.  1369 

GENERAL  NERVOUS  DISEASES. 

I.  CHOREA;  SYDENHAM'S  CHOREA. 

St.  Vitus' s  Dance. 

A  disease  of  children  and  young  adults,  characterized  by  continuous, 
irregular,  involuntary  muscular  contractions  and  psychical  derangements. 

This  substantive  affection  has  nothing  in  common  with  a  number  of 
other  diseases  unfortunately  described  as  chorea  or  choreiform,  except 
abnormal  muscular  movements. 

Etiology.  —  Predisposing  Influences.  —  The  disease  appears  in 
successive  generations  in  certain  families.  The  readily  transmitted  neu- 
rotic constitution  plays  a  more  important  role.  The  nervous,  excitable 
children  of  nervous  parents  are  especially  liable  to  chorea.  Chorea 
is  particularly  a  disease  of  childhood  and  adolescence.  It  is  rare  before 
the  fifth  year  and  after  the  fifteenth.  The  cases  in  early  adult  life 
almost  always  occur  in  women.  The  disease  occurs  about  three  times  as 
often  in  females  as  in  males.  Chorea  is  more  common  among  the  chil- 
dren of  the  poor,  but  is  frequently  observed  among  those  living  in  afflu- 
ence. It  is  rare  amo-ng  negroes.  The  disease  is  relatively  frequent  among 
bright,  intelligent  school  children,  especially  girls,  between  ten  and  fifteen, 
who  are  encouraged  by  their  teachers  to  unreasonable  and  unnatural  appli- 
cation to  study.  Anaemia  and  general  poor  health  often  precede  the 
attack,  but,  on  the  other  hand,  it  frequently  occurs  in  well-nourished  chil- 
dren. The  disease  frequently  develops  in  chlorotic  girls.  Scarlet  fever  is 
sometimes  followed  by  chorea.  This  sequence  also  occurs  as  regards 
whooping-cough  and  other  diseases  of  childhood;  but  there  is  no  satisfac- 
tory evidence  of  a  causal  relation  between  these  infections  and  chorea. 
In  older  persons  chorea  has  been  observed  after  gonorrhoea  and  sepsis. 
Chorea  frequently  develops  shortly  after  an  attack  of  acute  rheumatism, 
and  in  a  group  of  cases  the  arthritis  is  so  mild  and  the  choreic  symptoms 
are  so  prominent  as  to  justify  a  doubt  as  to  whether  or  not  rheumatic 
fever  has  actually  been  present.  In  other  cases  there  is  a  history  of  rheu- 
matic fever  months  or  years  before  the  development  of  the  chorea.  Under 
either  of  these  conditions  the  evidences  of  endocarditis  or  chronic  val- 
vular disease  may  or  may  not  be  present.  The  endocardial  murmurs 
present  in  a  case  of  chorea  may  be  due  to  actual  valvular  lesions,  to 
irregular  action  of  the  heart,  or  to  anaemia.  A  woman  suffering  from 
chorea  may  become  pregnant;  and  the  disease  may  develop  during  preg- 
nancy or  after  parturition.  It  has  been  observed  in  repeated  pregnan- 
cies. It  begins  more  frequently  in  the  early  than  in  the  later  months 
and  is  often  of  the  severe  type — chorea  insaniens.  About  twenty  per 
cent,  of  the  cases  in  pregnant  women  terminate  in  death.  The  causal 
relation  of  pregnancy  is  shown  by  the  fact  that  the  chorea  ceases  upon 
the  occurrence  of  abortion  or  miscarriage,  or  delivery  at  full  term. 

The  Exciting  Causes.  —  In  the  present  state  of  knowledge  it 
must  be  assumed  that  various  pathogenic  agencies  act  as  the  immediate 
exciting  cause  of   chorea.     Among  these  are:    emotional  shock,  especially 


1370  MEDICAL  DIAGNOSIS. 

fright;  mental  shock,  particularly  in  young  women;  and  some  conditions 
associated  with  rheumatic  fever  and  acute  or  chronic  endocarditis,  the 
nature  of  which  is  not  understood.  The  attack  has  followed  a  slight  injury 
or  a  surgical  operation  and  has  been  attributed  to  reflex  causes,  as  intes- 
tinal worms  or  genital  irritation.  It  has  been  stated,  but  not  substan- 
tiated, that  ocular  defects  may  cause  the  disease.  Finally,  the  disease 
frequently  develops  in  the  absence  of  any  noticeable  cause. 

Hypotheses  of  Chorea. — The  view  that  it  is  a  pure  neurosis  appears 
to  be  widely  accepted.  The  embolic  view  has  some  basis  of  support 
in  the  experimental  chorea  produced  in  animals  by  the  injection  of 
indifferent  substances  in  fine  particles.  Cases  occur  in  the  absence  of 
endocarditis  and  without  embolism,  and  with  endocarditis  but  without 
embolism.  That  chorea  is  an  infectious  disease  is  an  opinion  which  has 
the  support  of  many  observers.  The  fact  that  the  attack  in  an  impor- 
tant proportion  of  the  cases  directly  follows  fright  or  other  profound 
emotional  disturbance,  and  the  prominent  psychical  derangements  militate 
against  this  view. 

Symptoms. — Two  forms  may  be  recognized:  (1)  the  ordinary  form 
in  which  the  symptoms  are  of  variable  intensity,  and  (2)  the  maniacal 
form — chorea  insaniens. 

(1)  The  Ordinary  Form. — The  onset  of  the  disease  is  insidious. 
The  child  gradually  becomes  awkward,  clumsy,  and  restless.  He  cannot 
sit  still.  There  is  a  marked  change  in  disposition.  He  appears  to  be  care- 
less and  indifferent,  and  upon  correction  has  spells  of  crying  or  becomes 
sullen.  In  the  course  of  some  days  the  characteristic  involuntary  move- 
ments begin.  In  the  mild  cases  only  one  hand  or  the  side  of  the  face  is 
affected — hemichorea;  in  the  more  severe  cases  both  sides  are  involved, 
but  one  side  to  a  greater  degree  than  the  other.  In  a  well-marked  case, 
the  child  cannot  remain  quiet,  but  is  in  continual  motion.  The  face 
twitches,  the  arms  are  abducted,  adducted,  rotated,  the  hands  extended, 
the  fingers  separated  and  at  once  withdrawn  and  flexed;  the  head  and 
trunk  are  rotated  and  alternately  flexed  and  extended.  The  gait  may  be 
disordered  so  that  progression  is  unnatural  and  difficult.  These  and  other 
movements  are  rapidly  repeated  in  the  most  bizarre  and  disorderly 
manner,  and  often  with  convulsive  suddenness.  They  are  manifestly  pur- 
poseless and  constantly  vary  in  extent  and  direction — ''insanity  of  the 
muscles."  The  hands  and  arms  are  most  affected,  the  face  next,  and 
to  a  less  extent  the  trunk  and  lower  extremities.  The  tongue  is  pro- 
truded and  withdrawn  with  a  jerking  movement;  words  are  uttered 
with  an  irregular,  jerking  cadence,  and  in  grave  cases  the  patient  often 
does  not  talk  at  all  for  hours  or  even  days  together.  The  diaphragm 
may  be  involved,  a  condition  which  is  manifest  by  irregular,  spasmodic 
breathing.  Attempts  at  voluntary  movements  increase  the  involuntar}'- 
twitchings.  There  may  be  transient  loss  of  power  in  a  limb  or  the  entire 
side.  This  is  usually  a  mere  paresis,  but  in  certain  cases  it  is  marked 
— paralytic  chorea. 

Emotional  influences  increase  the  muscular  movements.  The  con- 
sciousness of  being  under  observation  almost  always  intensifies  them.  As  a 
rule  they  cease  during  sleep. 


CHOREA.  1371 

Sensory  derangements  are  not  common.  In  certain  cases  of  hemi- 
chorea  there  is  tenderness  on  pressure  and  spontaneous  pain.  Tender 
points  in  the  line  of  nerve  trunks  are  rare. 

Psychical  derangements  occur  in  a  majority  of  the  cases.  They  are 
usually  moderate;  sometimes  intense.  The  antecedent  neurotic  element 
is  to  be  considered.  Irritability,  peevishness,  and  weakness  of  memory 
are  present.  These  symptoms  often  increase,  especially  in  adults,  until  a 
condition  of  mania  is  established.  There  is  no  distinct  line  of  separation 
between  the  ordinary  forms  and  those  which  are  most  severe. 

(2)  Chorea  Insaniens. — This  most  intense  form  does  not  often 
occur  in  children,  but  is  not  very  rare  in  young  women,  and  especially  in 
pregnancy.  The  muscular  movements  are  excessive  and  continuous. 
The  patient  cannot  remain  standing  or  lie  in  bed.  There  is  an  uncon- 
trollable jactitation,  movement  of  the  eyes  and  lips,  inability  to  pause 
to  take  food  or  for  any  purpose,  associated  with  a  veritable  psychosis 
with  mental  confusion,  maniacal  excitement,  and  hallucinatory  delirium. 
After  a  time  the  patient  falls  into  a  state  of  profound  exhaustion,  with 
apathy  or  melancholia.  The  temperature  may  rise  to  102°-104°  F. 
(38°-40°   C.)  and   in  fatal  cases  hyperpyrexia  has  been  observed. 

The  muscles  do  not  waste,  their  electric  excitability  is  not  affected, 
and  the  deep  reflexes  remain  normal. 

Ocular  Phenomena. — The  pupils  are  often  dilated,  but  the  light  reflex 
is  retained.  The  muscular  twitchings  may  give  rise  to  transient  strabis- 
mus. A  concentric  contraction  of  the  visual  field  has  been  observed. 
The  ophthalmoscopic  findings  are  mostly  negative,  though  a  few  cases  of 
optic  neuritis  have  been  reported. 

Course  of  the  Attack. — The  duration  of  the  disease  in  children  varies 
usually  between  six  and  twelve  weeks.  There  is  a  remarkable  tendency 
to  recurrence,  which  often  takes  place  in  the  spring  of  the  year.  Two  or 
three  attacks  are  common;  as  many  as  five  or  six  have  been  noted.  The 
tendency  to  recovery  appears  to  be  spontaneous.  The  chorea  of  adults 
runs  a  longer  course.     A  chronic  intermittent  form  has  been  described. 

Diagnosis. — Direct. — This  is,  as  a  rule,  made  without  difficulty.  It 
rests  upon  the  character  of  the  muscular  movements,  their  distribution, 
the  age  of  the  patient,  the  psychical  phenomena,  the  frequent  coincidence 
of  rheumatic  arthritis,  endocarditis,  or  chronic  valvular  disease,  and  the 
tendency  to  spontaneous  recovery.  The  absence  of  the  signs  of  organic 
disease  of  the  nervous  system  is  of  diagnostic  importance. 

Differential. — There  are  several  affections  occurring  in  children 
which  present  superficial  resemblances  to  Sydenham's  chorea. 

Multi'ple  Cerebral  Sclerosis. — Weakness,  incoordination,  tremor,  and 
ataxia  are  characteristic.  The  gait  is  spastic  paretic;  the  course  chronic, 
with  little  tendency  to  improvement.  The  reflexes  are  increased  and  the 
intelligence  is  impaired.     Has  been  described  as  chorea  spastica. 

Certain  Disorders  of  Motility  Associated  with  Hemiplegia.  —  Post- 
hemiplegic hemichorea  is  a  term  used  to  designate  the  involuntary  move- 
ments on  one  side  of  the  body  which  manifest  themselves  in  one  muscular 
group  after  another  and  give  rise  to  coarse  trembling  and  awkwardness. 
A  prehemiplegic  chorea  may  occur  but  is  much  more  rare. 


1372  MEDICAL  DIAGNOSIS. 

Athetosis  or  hemiathetosis  consists  in  slow  involuntary  movements 
chiefly  affecting  the  muscles  of  the  fingers  and  toes.  There  are  movements 
of  flexion  and  extension,  adduction  and  abduction,  which  occur  with  occa- 
sional interruptions  both  during  the  waking  hours  and  in  sleep,  or  only 
upon  attempts  to  use  the  member,  or  under  excitement.  The  fingers 
may  be  over-extended  and  spread  apart  while  the  hand  remains  flexed, 
or  some  fingers  may  be  flexed  and  others  extended  at  the  same  moment. 

Hereditary  Ataxia;  Friedreich's  Disease. — The  chronic  nature  of  the 
affection,  its  occurrence  in  several  members  of  a  family,  the  ataxia, 
tremor,  scoliosis,  and  talipes,  together  with  the  nystagmus,  the  scanning 
speech,  and  the  slow,  irregular  muscular  movements,  render  the  recogni- 
tion of  this  disease  a  comparatively  easy  matter. 

Hysteria. — The  movements  of  so-called  hysterical  chorea  are  usually 
rhythmical  and  wholly  different  from  those  of  acute  chorea.  The  stigmata  of 
hysteria  are  present  and  the  psychical  derangements  are  more  marked  than 
in  the  chorea  of  childhood.    The  two  affections  are  sometimes  associated. 

Prognosis. — In  children  the  outlook  is  good.  Most  of  the  cases  ter- 
minate in  complete  recovery.  Death  may  result  from  exhaustion  in  the 
severest  cases.  The  mortality  is  from  2  to  3  per  cent.  Chorea  in  adults, 
and  especially  chorea  insaniens,  is  a  much  more  serious  affection.  In 
the  chorea  of  pregnancy  the  death-rate  is  about  25  per  cent.  Rapid  loss 
of  flesh,  delirium,  and  a  rise  of  temperature  are  ominous  symptoms. 

THE  CHOREIFORM  AFFECTIONS. 

Several  affections  characterized  by  irregular,  involuntary  muscular 
movements  are  described  as  chorea.  This  nosological  error  is  extremely 
unfortunate  and  misleading,  since  these  diseases  not  only  have  no  etio- 
logical and  but  little  clinical  relationship  among  themselves,  but  also  none 
whatever  to  Sydenham's  chorea. 

Chorea  Major ;  Epidemic  Chorea. — It  is  a  matter  of  history  that  at 
times  of  religious  excitement  in  the  Middle  Ages  there  were  extensive 
popular  outbreaks  marked  by  great  excitement,  gesticulations,  and  danc- 
ing. Under  such  circumstances  pilgrimages  were  made  in  the  Rhine 
provinces  to  the  shrine  of  Saint  Vitus  at  Zebern.  This  martyr  as  a  saint 
of  succor  was  invoked  for  protection  against  sudden  death  and  against 
many  diseases  and  distempers,  notably  chorea,  which  thus  came  to 
be  called  Saint  Vitus's  dance.  Limited  outbreaks  of  a  similar  character 
occurred  in  the  nineteenth  century  and  in  this  country  in  Kentucky.  The 
fantastic  pilgrimages  of  the  Doukhobors  in  Manitoba  are  of  this  nature. 
These  folk  uprisings  under  the  stimulus  of  religious  fervor  are  hysterical 
manifestations  and  have  nothing  to  do  with  Sydenham's  chorea. 

Habit  Chorea ;  Habit  Spasm ;  The  Tics. — These  affections  have  been 
misnamed   chorea.     They  have  no  relationship  with  Sydenham's  chorea. 

Momentary  grimaces  or  twitchings  of  bundles  of  facial  muscles  are  not 
uncommon  in  otherwise  healthy  adults  and  are  of  no  clinical  significance. 

Tic  Convulsive ;  Gilles  de  la  Tourette's  Disease. — A  psychosis  char- 
acterized by  involuntary  violent  muscular  movements  affecting  certain 
muscle  groups,  as  the  facial  and  brachial,  or  generalized;    explosive  utter- 


CHOREA. 


1373 


'ances,  which  may  be  inarticulate,  sometimes  resembling  the  bark  of  a  dog, 
or  the  repetition  of  words  (echolalia),  accompanied  by  involuntary  move- 
ments, or  the  repetition  of  obscene  words  (coprolalia),  or  the  spasmodic 
and  involuntary  imitation  of  movements  (echokinesis),  and  in  many  of 
the  cases  by  curious  mental  impulses  or  fixed  ideas,  as  the  impulse  to  touch 
certain  objects  {folie  de  toucher),  or  the  obsession  of  names  (onomoto- 
mania);  or  the  insane  habit  of  counting  with  worriment  about  numbers 
(arithmomania) . 

The  affection,  as  a  rule,  begins  in  childhood  about  the  time  of  the 
second  dentition  and  affects  neurotic  individuals.  The  outlook  is  not 
favorable,  but  some  of  the  cases  recover.  Allied  to  tic  convulsive  is  the 
affection  known  as — 

Saltatory  Spasm  ;  Static  Reflex  Spasm  of  Bamberger ;  Palmus. — 
This  is  probably  not  an  independent  disease  but  in  some  cases  a  form 


Fig.  401. — Gilles  de  la  Tourette's  disease  in  four  phases. — Pennsylvania  Hospital. 


of  tic;  in  others  a  manifestation  of  hysteria;  and  again  a  manifestation  of 
increase  in  the  skin-  and  deep-reflexes.  The  spasms  do  not  occur  when 
the  patient  is  at  rest  or  in  the  recumbent  posture.  When  he  touches  the 
floor  with  his  feet  he  begins  to  hop,  Jump^  and  dance  about  as  the  result 
of  clonic  convulsive  contractions  of  the  muscles  of  the  legs  and  feet,  and 
in  particular  of  the  muscles  of  the  calves  of  the  legs.  It  occurs  in  both 
sexes  and  at  any  age;  in  many  cases  without  obvious  cause;  in  others 
after  emotional  disturbance  or  in  the  convalescence  from  an  infection. 
It  has  been  observed  in  dancers  as  an  occupation  neurosis.  The  prog- 
nosis is  favorable;  recovery  usualh^  takes  place  in  the  course  of  a  few 
months.    The  condition  occasionally  persists  for  years. 

Jumpers. — This  form  of  saltatory  spasm  has  been  observed  as  a 
local  or  family  neurosis  in  Maine  and  parts  of  Canada.  It  is  characterized 
by  sudden  jumping,  with  outcries,  echolalia,  and  echokinesis.  A  similar 
affection  has  been  observed  in  parts  of  Siberia — myriachit — and  in  Java, 
where  it  is  known  as  latah. 


1374  MEDICAL  DIAGNOSIS. 

Chronic  Progressive  Chorea;  Hereditary  Chorea;  Huntingdon's 
Disease. — An  affection  of  early  middle  life,  mostly  hereditary,  charac- 
terized by  irregular  muscular  movements,  disorders  of  speech,  and  irri- 
tabihty  and  mental  weakness  gradually  leading  to  dementia.  This  affec- 
tion was  first  described  by  Huntingdon,  of  Long  Island,  who  observed 
it  in  famihes  in  whom  it  has  occurred  for  four  or  five  generations.  The 
part  played  by  heredity  is  a  conspicuous  feature,  though  cases  have  been 
observed  in  which  this  etiological  factor  was  absent.  Men  and  women 
alike  suffer.  The  onset  is  usually  between  the  thirtieth  and  fortieth  years, 
and  is  insidious,  without  apparent  exciting  cause.  In  rare  instances  it  has 
followed  profound  and  depressing  emotion. 

The  symptoms  are  motor  and  psychical.  The  motor  phenomena  con- 
sist of  involuntary,  purposeless  movements,  manifest  at  first  in  slight 
degree  in  hmited  muscle-groups,  as  the  hands  or  face,  but  gradually  in- 
creasing in  force  and  extent  until  all  the  voluntary  muscles  are.  involved. 
These  movements  are  disorderly  and  irregular,  of  wider  excursus  and  less 
abrupt  than  in  chorea,  and  cause  almost  continuous  grimaces  and  gestic- 
ulations, increased  by  excitement  and  interrupted  only  during  sleep. 
At  first  and  to  some  extent  throughout  the  course  of  the  disease  they  are 
capable  of  some  degree  of  temporary  control  by  the  force  of  the  will,  but 
presently  recur  again  with  renewed  violence.  In  the  later  stages  the  gait 
is  much  impaired.  The  body  is  inchned  forward,  the  trunk  sways,  and 
the  movement  of  the  legs  is  irregular,  uncertain,  and  staggering — often 
arrested  for  a  moment  after  a  few  steps.  Muscular  power  is  retained 
until  toward  the  end,  when  palsies  may  occur.  The  deep  reflexes  are 
usually  increased.     Sensation  and  the  special  senses  are  not  affected. 

Psychical  phenomena  are  irritabihty,  excitabihty,  and  depression. 
Suicide  is  not  uncommon.  As  the  disease  advances  there  are  periods  of 
apathy  and  progressive  dementia.  Speech  is  slow,  hesitating,  and  indis- 
tinct, the  words  being  slurred  and  ill-pronounced. 

The  prognosis  is  invariably  unfavorable.  The  disease  is  incurable. 
Its  duration  varies  from  ten  to  twenty  or  thirty  years.  ^  The  termination 
is  usually  caused  by  some  intercurrent  disease  or  a  progressive  cachexia. 

II.   EPILEPSY. 

A  disease  of  the  nervous  system  characterized  by  attacks  of  uncon- 
sciousness, with  or  without  convulsions,  recurring  at  irregular  periods. 
In  very  rare  instances  consciousness  is  not  wholly  lost. 

The  following  phases  occur,  independently  or  in  association: 
L  Grand   Mai. — Loss   of   consciousness  with   general  convulsions,   at 
first  tonic,  then  clonic. 

2.  Petit  Mai. — Momentary  loss  of  consciousness  without  convulsions. 

3.  Status  Epilepticus. — Convulsive  attacks  recur  in  rapid  succession, 
consciousness  not  being  regained  in  the  intervals  between  them. 

4.  The  Psychical  Epileptic  Equivalent. — Outbreaks  of  mania  or  other 
mental  symptoms,  as  automatism,  take  the  place  of  the  fit. 

5.  Jacksonian  Epilepsy. — The  convulsive  attack  begins  in  a  hmited 
muscle  group  and  may  be  unilateral  and  unattended  by  loss  of  conscious- 
ness;  later  consciousness  may  be  lost  and  the  convulsions  general. 


EPILEPSY.  1375 

Etiology.  —  Predisposing  Influences.  —  Age  plays  an  important 
role.  In  a  large  proportion  of  the  cases  the  first  attack  occurs  in  early 
childhood;  in  the  majority  before  the  twentieth  year.  Many  but  by  no 
means  all  of  the  cases  occurring  in  adult  life  are  symptomatic  of  a  local 
lesion.  In  rare  instances  the  disease  begins  in  old  persons.  Sex  is  with- 
out influence.  In  children  males  appear  to  be  slightly  more  liable;  in 
adults  there  are  more  cases  among  males  than  females.  Direct  inheri- 
tance is  comparatively  infrequent,  but  the  children  of  neurotic  families,  in 
which  neuralgias,  palsies,  hysteria,  and  insanity  have  occurred,  are  more 
liable  to  become  epileptic  than  the  descendants  of  healthy  stock.  Pater- 
nal or  maternal  intemperance,  especially  when  associated  with  syphilis 
or  insanity,  is  frequently  found  in  the  anamnesis.  Epileptic  convulsions 
are  not  very  uncommon  in  the  subjects  of  chronic  alcoholism.  Epilepsy 
may  occur  in  syphilitic  subjects;  more  commonly  the  convulsive  seizures 
are  epileptiform  and  symptomatic  of  syphilitic  disease  of  the  brain.  The 
general  convulsions  which  occur  in  pathological  primary  dentition,  or  in 
children  at  the  onset  of  acute  infections,  in  uraemia,  in  pregnancy,  and  in 
chronic  lead  poisoning  cannot  in  all  instances  be  distinguished  from 
idiopathic  or  essential  epilepsy. 

Exciting  Causes.  —  The  first  attack  sometimes  follows  fright; 
sometimes  an  injury;  less  frequently  one  of  the  acute  febrile  infections. 
Masturbation  has  been  regarded  as  a  common  cause  of  epilepsy  upon 
insufficient  evidence.  The  fact  that  certain  local  irritants  give  rise  to 
epilepsy,  which  ceases  upon  their  removal,  is  incontestably  established. 
Among  them  are  preputial  adhesions,  collections  of  smegma  behind  the 
corona,  intestinal  worms,  a  foreign  body  in  the  ear  or  nose,  an  irritable 
scar,  phimosis,  and  a  testicle  retained  in  the  inguinal  canal.  It  is  neces- 
sary to  assume  a  strong  predisposition  in  such  cases.  In  some  of  them 
the  attacks  persist  after  the  correction  of  the  offending  condition.  Over- 
eating and  indigestion  are  very  often  followed  by  a  fit,  and  a  seizure  may 
follow  trauma,  gall-stone,  or  renal  colic,  or  a  trifling  surgical  operation. 
Epileptiform  convulsions  occur  in  heart  block — Stokes-Adams  disease. 

Symptoms. — The  recurring  fits  are  the  characteristic  and  in  many 
cases  the  only  feature  of  the  disease.  In  the  intervals  the  health  of  the 
patient  is  often  excellent;  in  certain  cases  and  in  the  later  stages  it  may  be 
much  impaired. 

1.  Grand  Mai;  Major  Epilepsy. — The  attack  is  frequently  preceded 
by  a  localized  sensory  manifestation  called  an  aura.  Aurte  may  be:  (a) 
Psychical. — The  patient  experiences  a  sensation  of  strangeness  or  terror, 
or  a  feehng  of  confusion,  or  he  may  fall  into  a  vague,  dreamy  state,  or 
become  extremely  gay  or  furious,  (b)  Visceral. — In  this  form  of  aura  the 
sensation  is  referred  to  various  organs.  It  is  described  as  the  pneumo- 
gastric  aura.  Uneasy  sensations  in  the  epigastrium  are  more  common. 
Sometimes  the  disagreeable  sensation  may  be  intestinal.  In  other  cases 
it  is  precordial  and  attended  by  anxiety  and  palpitation,  (c)  Pe7Hpheral. 
— The  sensation  may  begin  in  the  hand  or  in  a  finger  and  extend  toward 
the  body  before  consciousness  is  lost,  (d)  Visual. — The  aura  may  take 
the  form  of  phosphenes  or  color  sensations  or  in  rare  cases  of  particular 
objects,      (e)   Auditory. — Noises  or  ringing  in  the  ear,  curious  sounds  diffi- 


1376  MEDICAL  DIAGNOSIS. 

cult  to  describe,  musical  tones,  or  voices.  (f)  Olfactory  or  Gustatory. — 
These  are  rare.  They  consist  of  strong  odors,  almost  always  unpleasant 
or  disagreeable,  or  foul  tastes  and  the  like.  The  aura  is  usually  of  short 
duration,  the  attack  coming  on  in  a  few  seconds.  In  other  cases  it  may 
be  prolonged. 

Premonitory  Forced  Movements. — In  some  cases  the  aura  does  not 
occur,  but  in  its  place  there  are  definite  forced  movements.  The  patient 
turns  rapidly  or  twirls  upon  his  toes,  or  runs  a  few  steps  or  even  to  and  fro 
a  number  of  times. 

The  Epileptic  Cry. — At  the  onset  of  the  attack  the  patient  very  often 
utters  a  loud  scream  or  yell. 

The  attack  is  instantaneous.  Consciousness  is  at  once  completely 
lost  and  the  patient  falls  as  if  shot.  Slight  injuries  are  common,  and 
grave,  even  fatal  accidents,  as  fracture  of  the  skull,  sometimes  occur. 
The  FIT  consists  of  three  stages, — (1)  tonic  spasm,  (2)  clonic  convulsions, 
and  (3)  coma. 

(1)  Tonic  Spasm. — There  is  a  spastic  rigidity  of  the  muscles,  includ- 
ing the  respiratory  muscles,  so  that  respiration  is  at  once  arrested.  The 
face  is  at  first  pale,  then  red,  and  directly  bloated  and  cyanotic;  the  eyelids 
are  closed  or  open,  the  eyes  fixed,  the  pupils  dilated,  and  the  iris  is  irre- 
sponsive to  light.  At  the  very  first  there  may  be  a  momentary  contrac- 
tion of  the  pupil,  but  this  soon  gives  place  to  dilatation.  The  head  is 
forcibly  extended  or  turned  to  one  side,  the  arms  are  rigidly  extended  or 
flexed,  the  thumbs  adducted,  and  the  fingers  clinched.  The  legs  may  be 
rigidly  extended,  or  flexed.  The  tongue  may  be  protruded  and  caught 
between  the  fixed  jaws.  The  fseces  and  urine  may  be  discharged.  This 
period  lasts  from  a  few  seconds  to  half  a  minute.  Toward  its  close  there 
is  tremor,  which  ushers  in  the  second  stage. 

(2)  Clonic  Convulsions.  —  The  muscular  contractions  now  intermit. 
Tremor  gives  way  to  rapid  and  violent  spasms.  The  limbs  are  tossed 
about  with  force.  The  muscles  of  the  face  are  violently  contracted;  the 
eyes  roll  from  side  to  side  or  are  turned  up,  and  the  eyelids  open  and  close 
forcibly.  The  jaw  muscles  are  in  violent  clonic  spasm  and  the  tongue 
is  lacerated  by  the  teeth,  A  frothy  saliva,  often  stained  with  blood,  is 
discharged  with  the  violent  respiratory  movements.  Further  discharges 
of  urine  and  fseces  may  now  occur  and  there  is  occasionally  an  ejaculation 
of  semen.  This  period  lasts  from  one  to  three  or  four  minutes.  The  con- 
vulsions become  less  violent  and  gradually  subside  and  the  patient  passes 
into  the  third  stage  of  the  attack. 

(3)  Coma. — The  limbs  are  relaxed  and  the  unconsciousness  is  pro- 
found. The  breathing  is  stertorous  and  the  face  flushed  but  no  longer 
cyanosed.  After  a  time  the  patient  may  be  aroused,  but  is  dazed  and 
confused  and  relapses  into  a  deep  sleep  which  lasts  for  hours. 

The  following  clinical  phenomena  occur,  but  are  not  constant: 
Vomiting  after  the  attack.  Slight  rise  of  temperature, — one  to  two 
degrees  of  Fahrenheit's  scale.  In  the  status  epilepticus  higher  tempera- 
tures are  observed.  Abohtion  of  the  reflexes.  The  conjunctival,  corneal, 
and  pupillary  reflexes  are  all  abohshed  during  the  attack.  The  deep  reflexes 
may,  however,  be  increased  and  ankle  clonus  evoked.     Subcutaneous  and 


EPILEPSY.  1377 

subconjunctival  extravasations  of  blood;  the  former  chiefly  about  the 
face  and  neck.  Albuminuria  during  the  attack;  polyuria  subsequently; 
■occasionally  an  increased  urea  output. 

The  aura  is  not  always  followed  by  the  fit.  When  it  begins  in  an 
extremity,  particularly  in  the  hand,  the  attack  may  be  prevented  in  some 
cases  by  immediate  compression  of  the  member  by  a  string  or  ligature  or 
by  energetic  pulling  or  rubbing  of  the  part. 

2.  Petit  Mai ;  Minor  Epilepsy.  —  Momentary  loss  of  consciousness  is 
the  chief,  often  the  only  symptom.  The  unconsciousness  usually  is  so 
brief — a  few  seconds  to  half  a  minute — that  the  patient  does  not  fall,  but 
•directly  resumes  his  occupation  or  conversation  as  if  nothing  had  occurred 
to  interrupt  it.  The  face  usually  becomes  pale,  the  eyes  are  set  and  staring, 
and  anything  in  the  hands  may  be  dropped.  The  tongue  is  not  bitten  and 
involuntary  discharges  do  not  occur.  In  many  of  the  cases  shght  spas- 
modic movements  of  the  facial  muscles  may  be  noticed. 

The  attack  may  take  the  form  of  transient  vertigo,  the  true  nature 
of  which,  in  the  absence  of  unconsciousness  and  twitchings  of  the  Hps, 
tongue,  or  eyehds,  cannot  be  recognized.  Following  the  attack  of  petit 
mal  there  may  be  slight  incoherency  or  automatic  actions,  such  as  begin- 
ning to  undress,  spitting,  or  rubbing  the  face  or  head.  The  patient  may 
in  other  cases  fall  without  the  occurrence  of  convulsions.  There  may  be 
jerking  of  the  limbs,  tremor,  or  sudden  visual  sensations.  The  significance 
of  these  phenomena  is  revealed  by  their  occurrence  in  persons  who  mani- 
fest well-characterized  attacks.  An  aura  is  rare  and  many  patients  are 
unaware  of  the  occurrence  of  the  attacks.  As  a  rule  convulsions  gradually 
develop,  and  in  many  of  the  cases  petit  mal  and  grand  mal  are  associated. 

3.  Status  Epilepticus. —  The  patient  passes  from  one  convulsive  seiz- 
ure into  another,  consciousness  not  being  regained  in  the  intervals.  The 
pulse  and  respiration  are  rapid,  the  temperature  rises,  and  the  attack 
frequently  terminates  in  death.  Hyperpyrexia  is  not  uncommon  and 
temperatures  of  107°-111°  F.  (41.7°-43.9°  C.)  have  been  observed.  Status 
epilepticus  may  last  two  or  three  days. 

4.  Psychical  Epileptic  Equivalents.  —  Remarkable  psychical  disturb- 
ances sometimes  take  the  place  of  the  fits  or  alternate  with  them. 
The  patients  perform  extraordinary  and  apparently  premeditated  acts  of 
which  they  have  no  knowledge  or  subsequent  recollection.  They  run 
about,  wander  away,  throw  away  their  clothing,  commit  violent,  even 
murderous  assaults  without  motive  and  without  self-restraint.  These 
psychical  states  are  not  easily  distinguished  from  the  maniacal  states 
which  sometimes  follow  the  attacks  —  postepileptic  delirium.  These 
conditions  may  last  for  hours  or  for  several  days.  They  usually  come  on 
suddenly  without  premonitory  symptoms. 

Other  derangements  which  are  regarded  as  equivalents  are  sudden 
and  profuse  sweating,  sudden  sleep  (narcolepsy),  the  automatic  repe- 
tition of  meaningless  words  or  phrases  (verbigeration),  and  attacks  of 
general  tremor  with  impaired  consciousness. 

5.  Jacksonian  Epilepsy ;  Cortical,  Partial,  or  Symptomatic  Epilepsy. 
— Consciousness  is  not  at  first  lost.  It  may  be  preserved  throughout 
the  attack.     The  attacks  are  the  result  of  irritative  lesions  of  the  motor 

87 


1378  MEDICAL  DIAGNOSIS. 

zone,  as  tumor,  inflammatory  softening,  acute  and  chronic  meningitis,  hemor- 
rhage, abscess,  and  trauma.  They  occur  also  in  general  paresis.  The  spasm 
begins  in  a  limited  group  of  muscles  of  the  face,  arm,  or  leg.  Numbness 
or  tingling  is  followed  by  limited  spasm,  which  extends  and  involves  a  limb 
or  the  side  of  the  face.  The  spasms  may  be  localized  for  a  long  time; 
but  ultimately  tend  to  become  general.  Posthemiplegic  epilepsy  is  of  the 
Jacksonian  type.  The  convulsions  may  for  a  long  time  be  confined  to  the 
paralyzed  side,  beginning  in  the  hand  or  foot  without  unconsciousness. 

The  mental  state  of  the  epileptic  is  often  normal.  More  commonly 
there  is  absence  of  self-control,  associated  with  depression  and  irritability. 
As  the  disease  progresses  there  is  often  impairment  of  intelligence  and 
memory.  The  seizures  may  occur  daily  for  a  period  and  then  at  longer 
intervals;  in  other  cases  they  may  occur  only  once  in  many  months. 
It  is  common  for  them  to  recur  at  irregular  intervals  of  two  or  three  weeks. 
The  attacks  of  petit  mal  may  occur  many  times  a  day.  The  attacks  are 
more  common  by  day  than  at  night.  Nocturnal  epilepsy  may  go  on  for 
a  long  time  without  being  recognized.  In  women  the  attacks  frequently 
occur  at  or  near  the  menstrual  period. 

Diagnosis. — Direct. — Major  epilepsy  declares  itself  by  the  aura,  the 
cry,  the  instant  loss  of  consciousness,  and  the  consecutive  tonic  and  clonic 
spasm  followed  by  coma  or  stupor.  The  relaxation  of  the  sphincters  and 
the  bitten  tongue  are  distinctive.  The  recurrence  of  the  fits  at  irregular 
periods  is  an  essential  feature. 

The  minor  attacks  are  characterized  by  momentary  loss  of  consciousness 
or  vertigo.  Twitching  of  the  facial  muscles  is  suggestive.  Their  frequent 
recurrence  and  association  with  grand  mal  are  diagnostic.  Status  epilep- 
ticus  occurs  as  a  culminating  condition  to  be  known  not  only  by  the  recur- 
ring convulsions  and  intervening  coma,  but  also  by  the  history  of  the  case. 
Psychical  equivalents  of  the  attack  can  only  be  recognized  in  the  light  of 
the  anamnesis.  There  is  nothing  distinctive  in  the  delirium,  mania,  or  delu- 
sions. The  diagnosis  of  Jacksonian  epilepsy  rests  upon  its  characteristic 
symptoms,  local  spasm,  and  retention  of  consciousness.  The  recognition 
of  the  peculiar  condition  of  which  it  is  symptomatic  is  often  difficult. 

Differential. — The  importance  of  the  distinction  between  true  epi- 
lepsy— the  so-called  idiopathic  form — and  symptomatic  or  epileptiform 
convulsions  cannot  be  over-estimated.  To  the  latter  belong  convulsions 
of  the  Jacksonian  type.  The  diagnosis  of  epilepsy  can  never  be  made 
from  a  single  attack,  particularly  when  it  has  not  been  seen  by  the  phy- 
sician. Syncope  may  be  mistaken  by  the  untrained  for  epilepsy.  The 
unconsciousness  is  not  so  complete  as  in  epilepsy,  nor  is  it  preceded  by  an 
aura,  accompanied  by  tonic  and  clonic  convulsions,  involuntary  dis- 
charges, or  followed  by  coma  or  automatic  actions.  Meniere's  disease 
may  simulate  an  epileptic  seizure,  but  aural  phenomena  are  present  and 
the  characteristic  symptom-complex  of  epilepsy  is  absent.  Toxic  Condi- 
tions.— The  general  convulsions  of  pathological  puerperal  states,  uraemia, 
lead  intoxication,  and  other  toxic  conditions  are  not  to  be  confounded 
with  epilepsy.  The  underlying  causes  of  these  symptomatic  seizures  are 
usually  plainly  manifest.  When  they  occur  in  individuals  previously 
epileptic,  their  essential  nature  may  remain  in  doubt. 


EPILEPSY.  1379 

General  Convulsions  of  Infancy;  Eclampsia. — These  are  due  to  direct 
irritation  of  the  cerebral  cortex,  reflex  irritation,  and  toxic  influences. 
In  early  infancy  epilepsy  is  the  least  obvious  diagnosis  and  should  never 
be  made  until  other  causes  have  been  excluded.  In  older  children  the 
seizures  may  be  symptomatic  of  peripheral  irritation  or  intestinal  worms, 
or  they  may  replace  the  chill  which  in  adults  marks  the  onset  of  an  acute 
infectious  disease.  When  they  are  repeated,  only  prolonged  observation 
will  justify  a  positive  diagnosis.  Complete  restoration  to  the  usual  health 
in  the  course  of  a  few  hours,  especially  in  a  child  who  presents  the  stigmata 
of  degeneration,  is  an  important  point  in  favor  of  a  diagnosis  of  epilepsy. 

Coarse  Cerebral  Lesions. — Cerebral  focal  disease  and  meningocortical 
lesions  may  cause  symptomatic  or  partial  epilepsy.  When  the  convul- 
sions rapidly  become  general  they  may  closely  simulate  general  epilepsy. 
In  truth  the  border  line  between  the  two  forms  is  not  always  sharply 
drawn.  The  symptomatic  convulsive  seizures  that  occur  in  general  paresis 
are  commonly  unilateral  and  not  attended  by  loss  of  consciousness. 

Hysteria.— {^ee  p.  1384.) 

Hystero-epilepsy. — The  rare  forms  of  major  hysteria  are  attended  with 
recurrent  convulsions,  which  may  be  readily  distinguished  from  repeated 
epileptic  seizures  or  the  status  epilepticus  by  the  emotional  prodromes, 
the  hysterogenetic  points,  globus,  contortions,  histrionic  poses,  and  hallu- 
cinations. There  are  mixed  forms  of  hysteria  and  epilepsy  and  transitional 
forms.     In  other  words  the  hysterical  person  may  be  also  an  epileptic. 

Simulated  Epilepsy. — The  normal  light  reflex,  absence  of  dilatation 
of  the  pupil,  the  absence  of  instantaneous  pallor  at  the  onset  of  the 
attack,  the  lack  of  the  characteristic  cyanosis  and  flushing,  and  the 
condition  of  the  patient  after  the  attack  are  of  diagnostic  value.  The 
convulsion  may  be  feigned,  but  the  tongue  is  not  bitten  and  postepileptic 
coma  and  mental  confusion  cannot  be  imitated. 

Prognosis. — In  the  great  majority  of  cases  epilepsy  is  an  incurable 
disease.  No  case  can  be  looked  upon  as  having  recovered  unless  there  has 
been  complete  freedom  from  the  attack  for  a  period  of  several  years.  The 
outlook  is  less  favorable  when  the  disease  begins  in  infancy  or  childhood 
than  in  the  cases  in  which  it  begins  at  puberty.  When  it  begins  between 
the  twentieth  and  thirty-fifth  years  complete  recovery  is  rare.  The  more 
frequent  the  attacks  and  the  longer  the  period  in  which  they  have  con- 
tinued to  recur,  the  more  unfavorable  the  prospect  of  recovery.  The  prog- 
nosis is  unfavorable  in  degenerates  and  those  suffering  from  inherited  or 
acquired  mental  disease.  Recovery  is  more  rare  in  females  than  in  males. 
The  severity  of  the  individual  attack  has  no  direct  relation  to  the  prog- 
nosis, except  that  the  outlook  is  less  favorable  when  the  disease  begins  as 
petit  mal,  and  that  in  the  status  epilepticus  about  one-half  the  cases  die 
in  the  attack.  Epileptics  are  frequently  short  lived.  The  attack  in  itself 
is  not  especially  dangerous  to  life.  In  very  rare  instances  asphyxia  or 
cardiac  rupture  may  occur.  The  seizure  is  attended  with  the  risk  of  serious, 
even  fatal  injury  which  may  result  from  sudden  loss  of  consciousness. 
The  patient  may  fall  from  a  height  or  under  a  vehicle  or  into  a  fire  or 
water.  The  outlook  is  more  favorable  in  symptomatic  convulsions  than 
in  essential  epilepsy. 


1380  MEDICAL  DIAGNOSIS. 

III.   HYSTERIA. 

Hysteria  is  a  psychoneurosis,  in  which  the  mental  state  induces  and 
dominates  a  great  variety  of  physical  symptoms.  Its  name,  which  is 
derived  from  the  Greek  word  for  the  uterus,  indicates  an  error  which  has 
prevailed  for  more  than  two  thousand  years,  for  hysteria  has  no  neces- 
sary relation  with  the  womb.  It  occurs  in  men  and  in  young  children  as 
well  as  in  women.  Heredity  is  a  common  cause,  as  was  demonstrated  by 
Briquet.  Next  in  importance  is  trauma,  and  then  mental  excitement 
and  moral  shock.  Toxaemia,  metallic  poisoning,  and  acute  disease  all  act 
as  occasional  causes. 

Pathology. — Hysteria  has  no  recognized  pathology.  It  is  a  so-called 
functional  disease.  The  theory  that  it  depends  on  minute  structural 
changes  in  the  neurons  is  possibly  correct,  for  all  function  depends  upon 
structure,  but  we  have  no  way  of  ascertaining  these  changes. 

Symptoms. — Hysteria  is  most  common  in  children  and  young  adults. 
It  rarely  appears  after  middle  life. 

The  French  divide  the  symptoms  into  two  great  classes, — the  par- 
oxysmal and  the  interparoxysmal. 

The  'paroxysm,,  or  fit,  is  divided  into  four  periods.  Prodromes  or  aurse 
may  usher  in  the  first  period;  the  former  usually  are  changes  in  temper 
and  disposition,  the  latter  are  the  clavus,  a  circumscribed  pain  in  the  head, 
the  globus  hystericus,  a  sense  of  a  ball  rising  in  the  throat,  and  ovarian 
hypersesthesia.      Other  and  more  rare  prodromes  and  aurse  are  seen. 

The  first,  or  epileptoid,  period  is  marked  by  a  sudden,  tonic  spasm, 
in  which  the  patient  lies  rigid  or  even  in  opisthotonus,  with  hands  clenched, 
eyes  fixed  or  even  crossed,  and  arms  extended  in  the  position  of  a  cross; 
the  breath  is  labored,  the  pulse  slightly  accelerated,  and  consciousness  is 
obtunded  but  seldom  or  never  entirely  lost.  The  tongue  is  not  bitten, 
the  pupils  are  not  affected,  incontinence  of  urine  does  not  occur,  and  the 
patient  does  not  injure  herself  in  falling.  It  is  this  stage  which  most  closely 
resembles  epilepsy.  But  the  clonic  spasms  which  supervene  are  not  exactly 
like  those  of  epilepsy;  they  are  usually  more  irregular,  and  often  have 
something  of  a  voluntary  aspect.    The  eyelids  present  a  slight  tremor. 

The  second  is  called  by  the  school  of  Charcot  the  period  of  "  clown- 
ism."  The  patient  throws  herself  into  grotesque  attitudes;  she  seems  as 
one  possessed,  and  indeed  she  was  believed,  in  the  Middle  Ages,  to  be 
controlled  by  a  demon.  Extreme  opisthotonus  is  one  of  the  commonest 
positions  assumed  by  the  grand  hysteric. 

In  the  third  period  the  patient  seems  to  act  a  part;  she  is  dramatic, 
sometimes  pathetic,  always  extreme.  This  is  the  histrionic  stage,  in  which 
the  conduct  is  evidently  the  mirror  of  certain  mental  states.  It  has  been 
greatly  elaborated  by  the  French  school,  and  by  means  of  hypnotism  and 
suggestion  has  been  not  a  little  overdone. 

The  fourth  period  is  that  of  delirium — so-called.  The  patient  subsides 
into  a  state  of  weeping  and  declamation;  sometimes  there  are  spells  of 
laughing. 

The  hysterical  fit  is  not  always  typical;  there  are  aberrant  or  abor- 
tive forms.     In  this  country  we  seldom  see  the  Avhole  tableau.     The  first 


HYSTERIA. 


1381 


period  is  the  commonest,  with  a  brief  histrionic  display,  followed  by  a  crisis 
of  weeping  and  laughter.  Among  the  very  rare  aberrant  forms  are  ecstasy, 
somnambulism,  catalepsy,  and  trance.  Tourette  and  Cathelineau  have 
tried  to  show  that  the  nutrition  is  affected  in  a  characteristic  way;  there 
is  loss  of  weight,  with  increased  excretion  of  urea,  but  during  the  lethargic 
trance-like  stage  the  urea  diminishes.  Some  of  the  sensational  stories  of 
the  dead  returning  to  life,  as  in  the  case  of  Lady  Russell,  who  revived  at 
her   own   funeral,  were  doubtless  founded  on  cases  of  hysterical  trance. 

The    inter 'paroxysmal    symptoms    are    motor,    sensory,    and    visceral. 

The  motor  symptoms  are 
paralysis,  contracture,  tremor, 
and  incoordination. 

The  paralysis  may  take  the 
form  of  a  monoplegia,  a  hemi- 
plegia, a  paraplegia,  or  a  total 
palsy.  It  is  sometimes  limited  to 
one  or  a  few  muscles,  as  of  the 
hand,  arm,  face,  tongue,  pharynx, 
or  larynx.  The  paralysis  in  the 
extremities  is  likely  to  be  accom- 
panied with  contracture;  the  deep 
reflexes  are  not  abolished,  nor  is 
there  true  muscular  atrophy,  or 
reactions  of  degeneration.  The 
paralysis  is  not,  as  a  rule,  limited 
to  the  distribution  of  particular 
nerve-trunks;  in  other  words,  it 
is  central,  not  peripheral.  The 
paralyzed  part  may  become 
cedematous,  blue,  and  mottled, 
especially  in  traumatic  cases. 
Hysterical  paralysis  is  usually 
persistent  for  long  periods,  but 
occasionally  it  is  transitory  and 
recurring;    and  mild  grades  may 

f^\T(^-n  l-i(=>  f  rfineffirr-arl  frnm  cnVlp  to  Fig.  402. — Hysterical  hemiplegia,  .showing  glossolabin- 
even    Oe    iransieriea    IlOm    SlUe   to  brachial  spasm  of  left  side.— Stewart. 

side.       Sometimes    a    permanent 

cure  is  effected  suddenly.  In  hemiplegia  the  leg  is  usually  more  paralyzed 
than  the  arm,  and  the  face  and  tongue  are  not  affected.  In  paraplegia 
there  may  be  anuria  but  not  incontinence.  In  total  paralysis  all  four 
limbs  are  involved,  but  the  face  and  trunk  escape.  Chevalier  was  able 
to  find  only  21  authentic  cases  on  record. 

Contracture  sometimes  coexists  with  paralysis,  but  the  rule  is  not 
universal.  The  paralyzed  limb  is  not  always  contractured,  neither  is  the 
contractured  limb  always  paralyzed.  The  contracture  does  not  always 
relax  during  sleep,  but  it  relaxes  under  ether  or  chloroform.  It  may 
come  and  go;  in  some  cases  it  is  painful,  and  it  can  sometimes  be 
re-established  by  pressure  on  the  main  nerve-trunk.  Surprising  cases 
are   on  record  of  long-persisting  hysterical  contractures.     They  sometimes 


1382 


MEDICAL  DIAGNOSIS. 


follow  trauma,  or  the  grand  convulsion,  or  sudden  shock,  and  are  often 
accompanied  with  other  stigmata,   such  as  aphonia,   anaesthesia,   etc. 

Tremor  is  of  several  types:  the  most  common  is  that  which  resembles 
the  intention  tremor  of  multiple  sclerosis;  of  wide  amplitude,  absent 
during  repose,  increased  by  volition,  and  likely  to  be  caused  by  trauma, 
or  by  metallic  poisoning  (lead  and  mercury).  The  'Hype  Rendu"  closely 
resembles  this  tremor,  except  that  it  may  persist  during  repose,  and  is 
merely  aggravated  by  volition.  Dutil  has  also  described  a  very  fine  tremor 
of  from  8  to  12  vibrations  to  the  second.  Westphal's  pseudosclerosis  is 
doubtless  a  form  of   hysterical  tremor. 

Astasia-abasia  is  one  of  the  curios  of  hysteria.  It  consists  of  a  loss 
of  power  of  standing  (astasia)  and  of  walking  (abasia).     There  is  no  true 

loss  of  power  or  any  necessary  loss  of 
sensation,  and  when  the  patient  sits  or 
reclines  there  is  usually  no  incoordina- 
tion. Progression  on  all  fours  is  even 
possible.  The  gait  consists  in  a  series 
of  wild,  incoordinate  movements  of  the 
legs,  with  alternate  bendings  backward 
and  forward  of  the  body.  But  little  prog- 
ress is  made,  and  the  patient  requires 
support  on  each  side.  There  is  some- 
times an  alternate  stiffening  and  relax- 
ation of  the  back  and  legs,  causing  a 
tendency  to  opisthotonus  and  a  rising  on 
the  toes.  Astasia-abasia  is  most  likely 
to  be  caused  by  trauma  and  emotion, 
and  is  most  frequent  in  young  persons. 
Sensory  changes  consist  of  anaes- 
thesia, hyperaesthesia,  and  paraesthesia. 
Anaesthesia  is  of  various  kinds,  such 
as  hemianaesthesia,  segmental  anaes- 
thesia of  a  limb,  and  anaesthesia  in 
patches.  Hemianaesthesia  is  usually 
complete;  that  is,  it  extends  from  the  crown  of  the  head  to  the  sole 
of  the  foot,  and  is  often  accompanied  with  anaesthesia  of  the  mu- 
cous membranes  of  the  eye,  nose,  tongue,  mouth,  and  throat.  It  is 
sharply  delimited  at  the  median  line,  and  can  sometimes  be  transferred 
from  one  side  to  the  other  by  suggestion.  The  special  senses,  sight, 
hearing,  smell,  and  taste,  may  be  involved  on  the  affected  side. 
Segmental  anaesthesia  of  a  limb  is  not  uncommon;  the  area  is  sharply 
delimited  above  by  a  transverse  boundary  line,  thus  presenting  the  shape 
of  a  stocking  or  a  gauntlet.  Irregular  anaesthesia  in  spots  and  curious 
geometrical  figures,  scattered  at  random  over  the  surface  of  the  body, 
and  changing  repeatedly,  is  quite  characteristic.  These  various  sensory 
stigmata  play,  and  have  jDlayed,  an  important  role  in  hysteria.  In  the 
Middle  Ages,  during  the  witchcraft  crazes,  they  were  known  as  the 
"marks  of  the  devil"  {stigmata  diaboli).  The  anaesthesia  of  hysteria,  in 
whatever  form,  is  very  real   and  very  profound,   and  even  involves  the 


Fig.  403.  —  Hysterical  contracture.  —  Lloyd. 


HYSTERIA.  1383 

subcutaneous  tissues  and  the  nerve-trunks.  The  patient  may  not  know  of 
its  existence,  and  it  requires  careful  tests  for  its  demonstration.  Accord- 
ing to  Pitres  hysterical  anaesthesia  is  never  isolated  tactile  anaesthesia; 
in  other  words,  one  or  more  of  the  other  forms  of  anaesthesia — such  as 
analgesia,  thermo-anaesthesia,  and  even  electro-anaesthesia — are  always 
present,  and  in  some  cases  there  is  a  loss  of  sensibility  to  all  modes  of 
sensation.  Loss  of  muscular  sense  is  a  rare  phenomenon.  The  electro- 
anaesthesia  may  be  preserved,  however,  when  all  other  modes  are  lost, 
but  not  inevitably.  Hyperaesthesia  is  found  in  certain  zones  or  terri- 
tories, as  along  the  spine,  and  especiall}^  in  the  ovarian  region,  where 
pressure  may  excite  a  fit  or  cause  other  hysterical  stigmata.  These  are 
the  so-called  hysterogenous  zones.  Paraesthesia,  consisting  of  altered 
sensation,   is  not  so   common  or  significant. 

Of  the  special  senses  the  eyes  present  the  most  important  changes; 
there  is  contraction  of  the  visual  fields,  and  reversal  of  the  color  fields, 
the  red  being  larger  in  extent  than  the  blue.  Hemianopsia  is  rare.  Total 
blindness  or  amaurosis  has  been  noted.  Blepharospasm,  or  spasm  of 
the  orbicular  muscle,  is  seen,  and  may  be  mistaken  for  paralysis  (ptosis), 
but  true  paralysis  of  any  of  the  ocular  muscles  is  extremely  rare.  Lloj'd 
has  seen  true  iridoplegia  in  hysteria.  Spasm  of  one  or  other  ocular 
muscle  may  cause  strabismus,  and  be  mistaken  for  paralysis  of  the 
opposing  muscle. 

Hysterical  deafness,  anosmia,  and  loss  of  taste  are  occasionally  seen. 

Visceral  symptoms  of  various  kinds  are  observed.  Anuria  is  not 
uncommon;  the  patient  may  even  require  to  be  catheterized — a  bad  pro- 
cedure in  hysteria,  since  it  tends  to  confirm  the  weakness.  Incontinence 
is  not  seen.  Hysterical  vomiting — anorexia  nervosa — consists  of  a  regur- 
gitation of  food,  rather  than  a  true  vomiting.  The  food  is  rejected  before 
it  reaches  the  stomach  in  most  cases.  The  curious  habit  known  as 
merycism,  or  chewing  the  cud,  in  which  the  patient  regurgitates  and 
remasticates  the  food,  is  a  closely  allied  symptom.  In  hysterical  vomiting 
there  is  no  nausea,  but  the  patient  may  emaciate  and  present  other  hys- 
terical stigmata;  in  some  cases,  however,  the  nutrition  is  wonderfully 
preserved.  Rapid  respiration  is  sometimes  seen,  the  respirations  running 
as  high  as  seventy  or  more  to  the  minute;  but  the  pulse  is  not  acceler- 
ated, the  color  remains  good,  and  there  is  no  real  dyspnoea.  The  breathing 
is  shallow  or.  panting.  Occasionally,  without  increased  breathing,  there  is 
tachycardia,  wdiich  may  even  persist  in  spite  of  prolonged  rest  in  bed. 
Persistent  cough  is  sometimes  a  perplexing  and  exasperating  symp- 
tom, as  are  also  bouts  of  yawning.  The  cough  is  unattended  with  the 
physical  signs  of  lung  disease;  and  the  yawning  occurs  in  paroxysms, 
much  exaggerated  and  prolonged,  but  not  noisy.  Aphonia  is  not  rare. 
The  patient  may  talk  in  a  whisper,  but  sometimes  is  quite  speechless, 
and  even  voiceless.  Instances  are  reported  of  the  natural  voice  returning 
during  laughter  or  even  during  sleep,  but  a  cure  does  not  necessarily  fol- 
low. Phantom  tumor  can  be  caused  by  contracture  of  the  abdominal 
muscles.  The  French  writers  describe  pyrexia,  or  pseudopyrexia.  Some 
of  the  temperatures  recorded  are  quite  incredible.  The  subject  requires 
further  study. 


1384  MEDICAL  DIAGNOSIS. 

The  'psychical  state  in  hysteria  is  most  important,  for  it  is  the  essential 
one.  To  investigate  it  requires  expert  knowledge  and  skill,  and  it  is  suf- 
ficient here  to  say  that  one  of  its  chief  features  is  suggestibility  (as  the 
French  call  it),  in  which  the  patient's  mind  is  peculiarly  iniiDressionable  to 
outside  influences  and  to  hypnotism. 

Diagnosis. — To  begin  with,  the  practitioner  should  disabuse  his  mind 
of  the  vulgar  prejudice  that  hysteria  is  a  simulated  disease.  The  hysterical 
patient  is  not  a  humbug  or  malingerer.  The  affection  is  very  real,  and 
these  patients  are  genuine  sufferers.  Many  of  them  are  useful  members  of 
society;  some  of  them,  to  be  sure,  are  weaklings,  and  a  few  are  even  degen- 
erates, but  they  are  none  the  less  entitled  to  consideration. 

It  is  commonly  said  that  hysteria  simulates  all  diseases;  but  the 
truth  is  that  it  simulates  none  exactly.  There  is  always  something  sui 
generis  in  the  hysterical  stigmata.  On  the  other  hand,  hysteria  itself  is 
sometimes  simulated  by  designing  persons,  especially  young  women,  but 
the  counterfeit  is  usually  detected  with  ease.  No  person  can  simulate 
successfully,  especially  for  long  periods,  the  paralysis,  the  contracture, 
the  anaesthesia,  or  in  fact  any  of  the  more  important  stigmata  of 
hysteria.  If  any  one  doubts  this,  let  him  try  to  simulate  contracture 
of  the  arm  for  a  week. 

There  is  often  confusion  between  hysteria  and  neurasthenia,  especially 
in  the  traumatic  cases;  and,  in  fact,  many  of  the  so-called  traumatic 
neuroses  are  hysterical.  The  two  conditions  merge  into  each  other,,  and 
the  dividing  line  is  not  easily  determined  in  some  cases.  The  mental  state 
of  suggestibility  is  highly  characteristic  of  hysteria;  also  the  tendency  of 
symptoms  to  come  and  go,  and  to  be  influenced  by  hypnotism.  In  genu- 
ine neurasthenia  this  is  not  so  marked.  Moreover,  in  neurasthenia  we  do 
not  see  the  characteristic  permanent  stigmata  of  hysteria,  such  as  the 
paralyses,   anaesthesias,   aphonia,   anuria,   etc. 

The  hysterical  fit  can  closely  simulate  that  of  epilepsy,  but  there  is 
no  biting  of  the  tongue,  no  frothing  at  the  mouth,  no  injury  to  the  person, 
no  involuntary  passage  of  urine,  and  the  pupils  are  not  affected.  The 
state  of  the  pupils  may  be  a  criterion  of  great  value,  for  in  the  epileptic 
fit  the  pupils  dilate  after  a  momentary  contraction  in  the  tonic  stage. 
In  mild  cases,  however,  such  as  petit  mal,  the  pupil  in  epilepsy  may  respond 
to  light.  The  state  of  the*  consciousness  is  appealed  to  by  many  as 
a  true  test  of  epilepsy,  but  it  is  not  always  reliable.  Doubtless  the  pro- 
found unconsciousness  of  grand  mal  is  not  seen  in  hysteria,  but  in  petit 
mal  the  consciousness  is  often  but  momentarily  confused,  hardly  lost,  and 
these  are  cases  that  might  be  simulated  by  hysteria.  Yet  hysteria  is  not 
usually  so  momentary  as  petit  mal;  and  in  the  hysterical  fit,  it  is  true 
that,  as  a  rule,  consciousness  is  not  so  completely  abolished  as  in  grand 
mal.  The  hysterical  fit  can  sometimes  be  induced  by  pressure  on  the 
ovarian  region,  and  it  is  likely  to  be  followed  by  hysterical  stigmata,  such 
as  anaesthesia  or  even  paralysis.  Finally  the  last  three  periods  of  the 
hysterical  fit  are  determinative,  for  they  are  never  seen  in  epilepsy;  but 
neither  are  they  always  seen  in  hysteria.  It  is  important  to  bear  in  mind 
that  hysteria  and  epilepsy  can  coexist  in  the  same  patient  and  present  a 
confusing  picture,  but  the  crises  are  separate. 


HYPNOTISM.  1385 

The  diagnosis  of  the  various  permanent  stigmata,  such  as  paralysis, 
tremor,  astasia-abasia,  anaesthesia,  vomiting,  phantom  tumor,  etc.,  has  been 
indicated  in  the  description  of  those  symptoms.  Taken  alone,  they  some- 
times closely  simulate  organic  disease,  but  they  are  usually  associated 
with  other  hysterical  stigmata,  and  this  fact  and  the  history  are  determina- 
tive. Ovarian  pain,  hysterical  in  origin,  is  not  seldom  mistaken  for  evidence 
of  organic  disease,  and  women  are  thus  subjected  to  operation  and  needless 
mutilation.  To  guard  against  this  too  common  error  the  practitioner  should 
study  his  case  well  with  reference  to  other  hysterical  stigmata. 

IV.    HYPNOTISM. 

It  is  impossible  to  define  hypnotism,  or  hypnosis,  in  satisfactory 
terms.  It  is  a  mental  state,  resembling,  but  not  identical  with,  sleep,  in 
which  consciousness  is  variously  affected,  but  in  which  the  mind  usually 
remains  open  to  suggestion,  especially  from  the  person  who  stands  in  re- 
lation of  hypnotizer  to  the  patient.  In  the  opinion  of  some  good  observers 
hypnotism  is  merely  a  form  of  induced  hysteria. 

Pathology.  —  Like  all  the  psychoses,  hypnotism  cannot  be  said  to 
have  a  recognizable  pathology.  It  is  common  in  hysterical  patients,  but 
neurotic  and  imaginative  persons  are  also  susceptible.  It  is  rarely  seen 
in  the  insane. 

Symptoms.  • —  We  may  recognize  hei^e  the  three  stages  of  Charcot, 
merely  premising  that  they  are  not  sharply  defined  in  all  cases,  especially 
the  minor  cases. 

In  the  cataleptic  stage  the  patient  assumes  a  statuesque  attitude, 
with  partially  opened  eyes,  blunted  sensibility,  and  a  readiness  to  receive 
and  act  upon  suggestion.  In  many  cases  it  is  not  possible  to  proceed 
beyond  this  stage,  which  may  be  regarded  as  a  minor  form  of  hypnotism. 

In  the  lethargic  stage  the  patient  passes  into  a  more  sleep-like  state. 
The  special  senses  and  general  sensibility  are  much  impaired,  the  muscu- 
lar system  is  relaxed,  and  the  consciousness  is  deeply  affected.  Such 
patients  are  not  as  open  to  suggestion  as  in  the  preceding  stage.  They  are 
usually  highly  neurotic  individuals,  and  in  some  cases  they  may  even 
pass  into  a  trance. 

In  the  somnambulic  stage  we  see  a  state  which  has  often  been  mis- 
called ''double  personality."  The  patient's  special  senses  are  acute, 
but  she  is  oblivious  of  much  that  transpires  about  her,  although  open  to 
suggestion  from  the  hypnotizer.     The  patient  seems  to  be  acting  a  dream. 

Hypnotism  can  usually  be  excited  by  fixing  the  patient's  attention 
on  some  particular  object  and  keeping  the  eyes  in  a  strained  and  fixed 
position.  The  French  use  bright  objects,  revolving  mirrors,  etc.  The 
patient  gradually  becomes  drilled  and  goes  into  the  hypnotic  state  on  the 
slightest  provocation. 

Much  speculation,  and  much  that  is  merel}^  fanciful,  has  been  written 
about  hypnotism,  but  it  is  sufficient  to  bear  in  mind  that  it  is  a  psychosis, 
or  mental  affection,  in  which  the  patient  exists  in  a  sort  of  dream-like 
state,  in  which  suggestion  from  without  can  be  made  to  play  a  prominent 
part,  and  in  which  hysteria  is  always  an  important  factor. 


1386  MEDICAL  DIAGNOSIS. 

V.   NEURASTHENIA. 

Neurasthenia  is  defined  by  Savill  as  a  state  of  irritable  weakness 
of  the  entire  nervous  system,  characterized  by  hypersensitiveness,  head- 
ache, inaptitude  for  mental  work,  disturbed  sleep,  irritability  of  temper, 
restlessness,  nervousness,  vague  pains,  and  affections  of  the  vasomotor 
and  sympathetic  systems.  The  disease  has  been  much  exploited  in  recent 
years,  for  it  is  not  uncommon,  especially  among  the  overworked  popula- 
tions of  our  large  cities. 

Pathology. — There  is  no  recognized  pathology.  The  nerve  centres 
are  at  fault,  and  the  most  plausible  explanation  is  that  these  centres  are 
not  properly  nourished.  There  is,  however,  a  large  mental  element  in 
these  cases,  and,  as  in  all  psychoses  and  neuroses,  the  affection  is  usually 
defined  as  functional.  Among  the  causes,  heredity,  overwork,  trauma, 
and  the  excessive  use  of  alcohol  and  tobacco  are  the  commonest. 

Symptoms. — The  symptoms  are  so  multiform  that  only  a  generalized 
view  will  be  attempted  here  for  purposes  especially  of  diagnosis. 

The  cardinal  symptoms  are  mental  ones — the  despondency,  the 
inability  to  apply  the  mind  and  to  work,  and  the  general  nervous- 
ness. Some  patients  are  not  a  little  hj^pochondriacal,  and  in  others 
an  hysterical  element  is  present,  but  the  disease  is  not  essentially  either 
hypochondria  or  hysteria.  Introspection  and  discouragement  are  promi- 
nent. Upon  this  psychical  state  are  ingrafted  some  characteristic 
bodily  ailments. 

Headache  is  not  uncommon,  and  a  hypersensitive  spine  is  frequent, 
especially  in  traumatic  cases  and  in  women.  There  are  sensitive  point? 
along  the  spine,  and  the  least  exertion  aggravates  these  and  causes  a  sense 
of  exhaustion.  Pain  may  also  be  transmitted  to  the  limbs,  and  sometimes 
there  are  bodily  pains  suggestive  of  visceral  disease.  Disturbance  of  sleep 
is  common;  there  is  either  insomnia  or  broken  and  restless  sleep,  so  that 
the  patient  arises  in  the  morning  unrefreshed.  Ugly  dreams  are  often  a 
feature  of  the  traumatic  cases,  the  patient  seeing  again  the  frightful 
accident  through  which  he  has  passed.  Nutrition  is  sometimes  greatly 
impaired,  the  patients  emaciating  and  becoming  anaemic;  and  they  are  often 
bedridden,  especially  if  they  are  women,  and  present  the  appearance  of 
extreme  illness.  Inability  to  take  and  digest  a  sufficient  c^uantity  of  food 
is  a  troublesome  feature;  and  there  may  even  be  dilatation  of  the  stomach 
or  gastroptosis.  On  the  other  hand,  some  neurasthenics  are  remarkably 
well  nourished;  these  are  the  fat  neurasthenics,  who  are  not  the  least 
troublesome  patients.  Morbid  blushing  and  flushing  are  sometimes  seen; 
and  the  heart  may  be  accelerated  in  spite  of  prolonged  rest.  Palpitation 
annoys  these  patients  on  slight  exertion.  Paralysis  is  not  commonly  seen, 
but  in  the  traumatic  cases  there  may  be  inhibited  or  impaired  movement 
on  account  of  pain.  Genuine  paralysis  points  either  to  hysteria  or  to 
organic  injury.  The  same  is  true  of  anaesthesia;  it  is  rare,  and  its  pres- 
ence is  usually  due  to  an  hysterical  element.  Tremor  is  occasionally  seen, 
and  requires  to  be  carefully  distinguished  fi'om  other  tremors,  such  as 
those  of  alcoholism  and  hysteria.  The  knee-jerks  are  usually  free,  some- 
times exaggerated,  never  lost. 


NEURASTHENIA.  1387 

Of  the  special  senses  the  eyes  suffer  most;  there  may  be  eye-strain 
and  pain  on  using  the  eyes.  Tinnitus,  vertigo,  and  noises  in  the  head, 
or  a  sense  of  fuhiess,  are  present  in  some  cases.  Some  patients  have  a 
strange  sense  of  mental  vacuity. 

Sexual  weakness  is  not  unusual  in  men,  and  the  sexual  act  causes 
profound  exhaustion,  weakness  in  the  back,  and  headache,  which  may 
endure  for  a  day  or  so. 

In  this  connection  it  is  well  to  consider  briefly  the  traumatic  neuroses. 
They  are  in  fact  largely  neurasthenic,  although  a  few  are  purely  hyster- 
ical. It  is  too  much  to  say,  however,  that  all  these  traumatic  cases  are 
purely  functional.  Some  of  these  patients  suffer  from  organic  lesions, 
such  as  bruises,  sprains,  and  wrenches  of  the  muscular  and  tendinous 
attachments,  especially  of  the  spine.  The  so-called  ''railway  spine"  is 
not  always  purely  neurasthenic,  but  may  be  in  part  the  result  of  shock 
and  sprain.  The  same  may  be  said  of  some  of  the  obscure  injuries  to  the 
hip  and  other  joints;  there  is  a  large  neurasthenic  element,  but  it  is  very 
often  not  the  whole  story.  These  cases  are  of  exceptional  importance 
because  they  lead  so  often  to  Htigation;  and  the  controversy  over  them 
is  frequently  acute. 

All  neurasthenics  are  quickly  and  easily  fatigued,  both  by  mental  and 
physical  exertion.  Inability  to  concentrate  the  mind  is  not  uncommon; 
and  of  other  mental  phenomena  the  most  important  are  the  so-called 
obsessions.  They  consist  of  imperative  and  inhibitive  ideas,  and  are  seen 
in  the  state  known  as  psychasthenia,  which  belongs  rather  to  psychiatry 
than  to  clinical  medicine. 

Diagnosis. — Since  Beard  invented  the  term,  neurasthenia  has  been 
used  very  loosely  to  cover  a  wide  variety  of  symptoms.  When  properly 
guarded,  however,  the  term  has  a  legitimate  use,  and,  although  it  is 
hardlj^  capable  of  exact  definition,  it  covers  a  symptom-complex  which  is 
fairly  recognizable;  and  this  has  been  described  above.  The  diagnosis 
must  depend  upon  a  careful  consideration  of  those  symptoms,  and  the 
practitioner  must  not  forget  that  a  neurasthenic  state  often  accompanies 
other  diseases,  even  grave  organic  ones.  The  only  rule  is  to  exercise  care 
and  judgment,  and  to  go  by  a  process  of  exclusion. 

The  most  common  error  is  to  confuse  neurasthenia  and  hysteria; 
in  fact,  some  writers  in  describing  the  traumatic  neuroses  do  not  hesitate 
to  include  hysterical  symptoms  indiscriminately  with  those  of  neuras- 
thenia. This  is  wrong.  Hysteria  is  a  much  more  clearly  defined  disease 
than  is  neurasthenia,  and  it  should  be  kept  apart  whenever  possible.  The 
mental  state,  and  the  various  stigmata,  such  as  paralysis,  anaesthesia, 
contracted  visual  fields,  not  to  mention  the  convulsions,  are  enough  to 
distinguish  it  in  most  cases.  It  is  often  caused  by  trauma,  and  frec^uently 
figures  in  court  in  damage  suits,  as  neurasthenia.  There  is  no  doubt, 
however,  that  hysteria  can  coexist  with  neurasthenia,  just  as  it  can  coexist 
with  epilepsy. 

Hypochondriasis  is  a  state  in  which  there  are  delusions  about  the  health, 
rather  than  real  disorders  of  the  health.  The  hipped  state  of  mind  in  some 
neurasthenics  suggests  a  resemblance,  but  there  are  not  the  deep-seated  hypo- 
chondriacal delusions  in  the  one,  nor  the  genuine  sufferings  in  the  other. 


1388  MEDICAL  DIAGNOSIS. 

In  traumatic  cases  it  is  important  not  to  overlook  organic  injury  and 
to  call  everything  neurasthenic.     Grave  errors  have  thus  been  committed. 

Secret  drug  habits,  especially  the  use  of  morphia^  sometimes  induce 
a  neurasthenic  state,  and  the  true  nature  of  the  case  may  be  overlooked. 
Hence  it  is  important  to  inquire  carefulh'  into  the  habits.  The  same  is 
true  of  alcohol  and  tobacco,  and  even  of  tea  and  coffee. 

Some  of  the  ^actims  of  onanism  can  properly  be  classed  as  neuras- 
thenics, but  in  them  there  is  usually  a  marked  h5'pochondriacal  element. 
These  persons  are  the  easy  prey  of  the  advertising  charlatans,  and  their 
symptoms  are  sometimes  concealed  or  repressed  for  fear  of  exposure. 

VI.   THE  OCCUPATION  NEUROSES. 

These  include  a  variety  of  affections  which  ai'ise  from  overuse  in  the 
course  of  occupation.  They  are  sometimes  called  the  fatigue  neuroses, 
and  are  located  largely  in  the  neuromuscular  apparatus.  The  commonest 
forms  are  scrivener's  palsy,  telegrapher's  cramp,  piano-player's  hand,  and 
some  forms  of  clergj^man's  sore  throat;  and  some  not  so  common  are  seen 
in  fiddlers,  bricklayers,  and  others. 

Pathology. — The  objection  to  the  term  "neurosis"  in  this  connec- 
tion lies  in  its  implied  meaning  that  the  disease  is  functional.  No  disease 
is  purely  functional  in  the  sense  that  it  does  not  depend  on  organic  change, 
for  there  must  be  some  change,  however  slight  and  transient.  In  some  of 
these  cases  we  even  see  evidences  of  structural  change,  such  as  muscular 
atrophy,  persistent  pain,  etc.;  and  we  may  regard  all  of  them  as  instances 
of  disordered  nutrition  both  of  the  nerve-cells  and  of  the  muscular  attach- 
ments.    Farther  than  this  it  is  not  possible  to  go. 

Symptoms. — It  will  be  best  to  consider  a  few  of  these  affections  in 
regular  order. 

Scrivener's  palsy,  or  writer's  cramp,  is  marked  particularly  by  spasm, 
tremor,  and  incoordination.  Pain  and  vasomotor  disorders  are  some- 
times seen.  Paralysis  and  anaesthesia  are  doubtful  symptoms.  Three 
types  are  noted, — the  sjDasmodic,  the  paralytic,  and  the  tremulous, — but 
the  distinction  is  not  always  clear  in  practice.  The  spasm  affects  chiefly 
the  small  muscles  engaged  in  writing,  and  as  a  rule  is  only  manifested  on 
attempts  at  writing — not  in  other  coordinate  movements.  There  are 
exceptions,  however,  to  this  rule.  The  muscles  are  held  in  cramp-like 
rigidity,  wholly  prei^enting  the  act  of  writing.  In  some  cases  the  muscles 
of  the  forearm,  upper  arm,  and  shoulder  are  affected,  and  rare  cases 
are  seen  in  which  even  distant  muscles,  as  those  of  the  foot,  or  of  the 
other  hand  and  arm,  are  involved.  The  spasm  is  not  a  true  cramjD,  for  it 
is  non-painful;  but  exceptions  to  this  rule  occur.  It  is  quite  involuntary, 
and  may  even  persist  for  some  moments  after  the  attempt  at  writing  has 
ceased.  Tremor  and  incoordinate  jerky  movements  are  sometimes  seen. 
Paralysis  is  extremely  rare,  but  a  stage  of  slight  paresis  may  follow  the 
cramp.  Pain,  or  a  painful  sense  of  fatigue,  is  sometimes  present,  together 
with  painful  points  on  the  nerve-trunks.  Neuralgic  pains  are  observed  in 
a  few  cases.  Anaesthesia  is  very  rare.  It  is  probably  an  hysterical  symp- 
tom.    Vasomotor  and  trophic  disorders  are  not  common;   turgescence  of 


OCCUPATION  NEUROSES.  1389 

the  limb  and  flushing  of  the  face  are  among  the  former;  and  such  observ- 
ers as  Eulenburg  and  Gowers  claim  to  have  seen  muscular  atrophy.  It 
has  also  been  seen  in  a  blacksmith,  in  a  saddler,  in  a  tailor,  in  a  dragoon 
(from  holding  the  reins),  in  a  morocco-worker,  and  in  a  player  on  the  bass 
violin.  Atrophy  of  individual  muscles,  or  small  groups  of  muscles,  is 
seen  in  some  artisans  who  overuse  these  muscles,  as  the  small  muscles 
of  the  hand  in  locksmiths;  and  ulnar  paralysis  and  atrophy  in  glass 
blowers  from  pressure  rather  than  overuse. 

Telegrapher^s  cramp  is  closely  allied  to  the  preceding;  in  fact  it  is 
identical  with  it  except  that  the  cause  and  the  seat  of  the  spasm  differ. 
It  was  first  described  by  Onimus  in  1875  and  called  by  him  mal  telegraph- 
ique.  Fulton  studied  the  movements  engaged  in  using  the  Morse  instru- 
ment, which  particular  instrument  has  been  held  most  to  blame.  The 
letters  are  made  by  a  series  of  dots  and  strokes  which  require  a  fine  muscu- 


FiG.  404. — Telegrapher's  cramp. — Lloyd. 

lar  movement,  and  when  the  dispatcher  is  working  rapidly  and  for  long 
stretches  the  strain  on  the  muscular  apparatus  is  great.  Fulton  estimated 
that  an  operator  makes  between  thirty  and  forty  thousand  contractions 
per  hour.  The  word  ''occupation,"  for  instance,  contains  ten  letters 
and  requires  twenty-five  distinct  impressions.  One  of  these  patients 
had  worked  as  long  as  fourteen  hours  a  day.  Another  said  that  his  first 
difficulty  arose  in  making  the  letter  B  ( ) ;  his  hand  would  act  invol- 
untarily and  make  the  dash  and  four  dots  ( )  which  means  the 

numeral  8.     Finally  his  greatest  difficulty  was  experienced  in  maldng  the 

letter  P  ( ),  the  rapid  succession  of  dots  causing  a  cramp.    In  another 

patient  the  cramp  was  painful  and  was  located  in  the  extensors,  pulling 
the  hand  away  from  the  key  (Fig.  404).  Worry  and  discouragement  are 
often  seen  in  these  operators;  it  is  easy  to  make  mistakes  in  transmitting, 
and  these  may  be  serious;  consequently  a  neurasthenic  state  is  often 
present,  which  is  not  improved  by  alcohol  and  tobacco. 

The  telegraph  operator  can  train  his  other  hand  rather  more  easily 
than  the  scrivener,  because  the  movements  are  less  complex;  but  in  time 
the  second  hand  is  likely  to  become  affected  in  both  cases.  It  is  easy  for 
the  disabled  telegrapher  to  become  the  victim  of  writer's  cramp. 


1390  MEDICAL  DIAGNOSIS. 

The  dysphonia  and  aphonia  of  professional  voice-users  have  many 
points  of  similarity  to  writer's  cramp.  There  is  a  spasmodic  type  and  a 
paralytic  type.  In  singers  the  voice  may  break  down  in  the  midst  of 
song,  although  the  natural  voice  for  speaking  may  remain,  thus  showing 
how  a  particular  function  is  involved.  In  the  so-called  clergyman's  sore 
throat  there  may  really  be  some  pharyngitis  or  laryngitis,  but  the  nervous 
element  too  is  usually  well  marked.  There  is  indeed  a  well-marked 
hysterical  element  in  many  of  these  cases  of  aphonia.  Thus  Mackenzie 
reported  the  case  of  a  fish-hawker  who  lost  his  voice  suddenly  while 
crying  his  wares;  he  was  voiceless  for  four  months,  and  was  then  cured 
promptly  with  electricity. 

It  is  needless  to  describe  in  detail  the  long  list  of  the  fatigue  neuroses. 
Among  the  artisans  and  artists  affected  are  grinders,  blacksmiths,  en- 
gravers, cigarette-rollers,  pianists,  violinists,  bricklayers,  tailors,  and  type- 
setters. Milker's  spasm  is  seen  in  this  country  and  is  said  to  be  common 
among  the  cow-herds  of  the  Tyrol.      Miner's  nystagmus  is  a  curious  form. 

Diagnosis. — The  history  and  the  symptoms  are  unmistakable.  It  is 
always  well  to  recall  that  a  neurasthenic  state  is  often  seen  in  these  patients, 
and  that  it  may  complicate  the  clinical  picture.  This  is  still  more  so  of 
hysteria.  Some  of  the  symptoms  seen  are  distinctly  hysterical,  as,  for 
instance,  paralysis  and  anaesthesia  in  writer's  cramp,  for  these  two  symp- 
toms are  probably  never  seen  in  pure  cases.  The  same  is  true  of  aphonia 
in  habitual  voice-users;  it  usually  bears  all  the  marks  of  an  hysterical 
affection.  Still,  these  facts  do  not  necessarily  obscure  the  diagnosis. 
Writer's  cramp  has  been  confused  with  other  diseases  in  which  writing  is 
affected.  Among  such  diseases  are  hemiplegia  with  aphasia  and  agraphia, 
general  paresis,  locomotor  ataxia,  paralysis  agitans,  disseminated  sclerosis, 
chorea,  progressive  muscular  atrophy,  alcohohc  and  metalhc  poisoning, 
and  neuritis. 

VII.   MIGRAINE. 

Hemicrania,  migraine,  or  sick  headache,  is  one  of  the  explosive 
neuroses.  Its  chief  symptoms  are  disorders  of  vision,  pain  in  the  head, 
and  vomiting.  It  is  paroxysmal,  but  has  no  regular  periodicity,  as  a  rule, 
and  it  is  often  hereditary  or  familial.  Mobius  claimed  that  90  per  cent, 
of  the  cases  show  heredity. 

Etiology. — This  is  unknown.  English  physicians  are  fond  of  asso- 
ciating "megrim"  with  gout,  and  in  France  it  was  Trousseau  who  said, 
''migraine  and  gout  are  sisters."  But  these  assertions  are  not  proofs. 
Reflex  causes,  eye-strain,  adenoids,  womb  disease,  and  even  decayed  teeth 
have  been  assigned  as  causes,  without  much  reason.  The  disease  may 
possibly  be  due  to  autoinfection,  and  gastro-intestinal  disorders  some- 
times excite  attacks. 

Symptoms. — Migraine  usually  begins  in  early  life.  The  initial  symp- 
tom of  the  paroxysm  is  an  aura,  usually  sensory,  and  in  the  vast  majority 
of  cases  visual.  The  visual  aurse  consist  of  attacks  of  amblyopia  in  which 
a  part  or  the  whole  of  the  visual  fields  is  obscured;  thus  scotomata  and 
even  hemianopia  occur.  There  are  also  scintillations,  zigzag  hues,  shaped 
like  a  fortification,  flashes  of  light,  blazing  or  flaming  splotches,  and  in. 


MIGRAINE.  1391 

very  rare  cases  illusions,  as  of  the  forms  of  animals  or  terrifying  appari- 
tions. Oscillation  of  the  pupil  (the  so-called  hippus)  is  sometimes  seen. 
Other  sensory  aurae  occur,  as  a  numb  or  tingling  feeling  in  the  face,  tongue, 
or  one  limb.  It  is  characteristic  of  the  aura  of  migraine  to  disappear 
just  before  the  onset  of  pain. 

The  pain  of  migraine  is  an  intense  neuralgia  in  the  distribution  of 
the  fifth  nerve.  It  is  usually  described  as  a  hemicrania,  but  it  is  not 
always  confined  to  one  side.  Occasionally,  however,  it  is  strictly  localized 
in  one  branch  of  the  trigeminus,  especially  the  ophthalmic  division.  The 
pain  increases  gradually,  until  it  reaches  its  acme,  and  it  may  endure  only 
for  a  few  hours  or  even  for  a  day  or  two.  It  is  usually  terminated  by  the 
occurrence  of  vomiting,  which  thus  constitutes  the  third  or  terminal  stage 
of  the  paroxysm. 

Gastric  disorder  is  one  of  the  three  characteristic  symptoms  of 
migraine.  Aversion  to  food,  and  even  nausea,  may  occur  early  in  the 
attack,  and  sometimes  vomiting  begins  early;  but  commonly  vomiting 
is  a  late  or  terminal  symptom.  In  many  cases  the  patient  is  promptly 
relieved  by  emesis. 

Aberrant  types  of  migraine  are  seen,  in  which  one  or  other  of  the 
cardinal  symptoms  is  wanting.  The  commonest  is  the  mild  form  in  which 
the  visual  aura  is  followed  by  slight  headache,  which  is  only  transient, 
and  the  paroxysm  aborts  without  the  third  stage,  or  stage  of  vomiting. 

A  curious  and  rare  form  is  the  psychical  migraine,  in  which  mental 
disorders  of  various  kinds  predominate.  There  is  confusion  of  ideas,  with 
emotional  excitement  or  depression,  attending  the  visual  aura,  and  pain 
may  or  may  not  be  marked.  Incoherence  and  even  aphasia  have  been 
noted,  and  Liveing  attempted  to  show,  with  remarkable  prescience,  that, 
the  aphasia  always  occurs  in  cases  in  which  the  sensory  aura,  as  numb- 
ness of  the  hand,  is  on  the  right  side,  thus  indicating  a  left-sided  cerebral 
lesion.  Genuine  substitutional  attacks  have  been  noted,  just  as  in  epilepsy; 
thus  Sir  George  Airy  observed  in  his  own  person  the  attack  complicated 
with  transient  impairment  of  speech  and  memory  without  either  head- 
ache or  numbness.  Tissot  observed  a  case  in  which  attacks  of  habitual 
migraine  were  at  length  completely  replaced  by  fits  of  disordered  ideation. 
Hysteria  doubtless  complicates  some  cases  of  migraine. 

Ophthalmoplegic  migraine  is  the  form  in  which  the  paroxysm  is  com- 
plicated with  paralysis  of  some  of  the  ocular  muscles.  The  muscles 
involved  are  those  usually  supplied  by  the  third  nerve;  but  occasionally 
the  fourth  or  the  sixth  nerve  is  affected.  The  pain  is  usually  severe, 
and  is  followed  quickly  by  the  paralysis,  which  may  endure  for  days  or 
even  weeks.  The  bout  of  pain  is  commonly  terminated  by  a  crisis  of 
vomiting,  as  in  ordinary  migraine,  but  the  paralysis  constitutes  the 
true  terminal  stage,  and  may  be  total  and  complete  in  the  third  nerve; 
that  is  to  say,  all  the  muscles  supplied  by  that  nerve  are  involved  and  are 
completely  paralyzed.  There  is  ptosis,  external  strabismus,  and  the  pupil 
does  not  react  to  light  or  on  accommodation.  In  some  cases,  however, 
the  paralysis  is  not  total  or  not  complete.  The  duration  varies.  In 
Schilling's  case  the  palsy  lasted  for  from  four  to  six  weeks,  and  in  Pari- 
naud's  case  from  two  to  three  months;   but  in  many  cases  the  duration 


1392  MEDICAL  DIAGNOSIS. 

is  only  for  a  few  days.  The  paralysis,  as  a  rule,  to  which  there  are  few 
exceptions,  always  occurs  in  the  same  eye  in  successive  attacks.  In  some 
cases  the  paroxysms  observe  a  true  periodicity;  in  Suckling's  case  they 
occurred  every  two  weeks.  Many  of  these  cases  date  from  early  childhood. 
Occasionally  a  permanent  palsy  results  after  repeated  seizures.  Paralysis 
of  the  fourth  nerve  has  been  noted  by  Leizenberger;  and  conjoint  paraly- 
sis of  the  third  and  fourth  has  also  been  seen.  Paralysis  of  the  sixth 
nerve,  either  alone  or  in  association  with  some  of  the  fibres  of  the  third 
nerve,  has  been  reported.  De  Schweinitz  saw  a  case  of  abducent  palsy, 
with  migraine,  which  had  begun  in  early  life.  A  very  rare  case  is  that  of 
Possolimo  in  which  a  recurring  paralysis  of  the  seventh  or  facial  nerve 
was  always  ushered  in  by  a  migrainous  attack.  Anaesthesia  of  the  fifth 
nerve  has  been  noted  in  a  very  few  cases,  especially  in  the  first  and 
second  divisions,  or  even  in  the  supra-orbital  branch  alone.  Troemer 
has  reported  a  case  of  ophthalmoplegia  interna  following  severe  attacks 
of  migraine.  The  pupil  was  widely  dilated  and  immobile  to  light,  but 
the  other  ocular  muscles  were  not  affected. 

All  forms  of  migraine  tend  to  grow  less  or  even  to  disappear  in 
middle  life. 

Diagnosis. — The  ordinary  migraine  is  easily  recognized;  in  fact,  the 
patient  usually  knows  well  enough  himself  what  he  has.  The  beginning 
in  early  life,  and  the  peculiar  evolution  of  the  paroxysm,  from  the  aura 
to  the  critical  vomiting,  are  unmistakable.  Simple  neuralgic  attacks, 
which  are  not  uncommon,  are  known  by  the  absence  of  the  true  migrain- 
ous symptoms,  such  as  the  aura,  the  explosive  onset,  and  the  crisis  of 
vomiting. 

Migraine  has  been  likened  to  epilepsy,  especially  by  Hughlings  Jackson 
and  his  followers,  the  resemblance  being  based  largely  on  the  abrupt  onset 
with  an  aura;  but  the  likeness  is  superficial.  In  migraine  there  are  no 
convulsions,  and  the  disease  does  not  merge  into  epilepsy.  Migraine 
and  epilepsy  may  however  coexist  in  the  same  person,  but  the  attacks 
are  separate. 

Ophthalmoplegic  migraine  simulates  organic  disease,  especially  tumor 
and  syphilis  of  the  brain.  The  paroxysmal  nature  of  the  attack,  however, 
and  the  tendency  for  the  paralysis  of  the  third  nerve  to  disappear  are 
against  brain  tumor,  as  is  also  the  history  of  the  case.  In  brain  tumor, 
moreover,  there  are  usually  other  symptoms,  such  as  choked  disk  and 
other  and  more  wide-spread  paralysis,  and  the  course  is  progressive. 

Syphilitic  meningitis  between  the  peduncles  causes  paralysis  of  one 
third  nerve,  sometimes  of  both  third  nerves,  and  this  paralysis  may  even 
be  evanescent,  with  severe  headache;  but  the  history  is  not  that  of 
migraine,  nor  is  the  onset  so  abrupt,  the  cure  so  complete,  and  the 
headache  so  paroxysmal,  with  a  crisis  of  vomiting,  as  in  migraine. 
Moreover,  there  are  likely  to  be  other  nerves  involved  in  syphihs, 
such  as  the  optic  nerves,  or  even  a  hemiplegia,  and  the  symptoms  are 
irregular.  Ophthalmoplegic  migraine  is  always  unilateral;  syphilis  may 
or  may  not  be  so.  One  of  Charcot's  cases  of  migraine  had  paralysis 
first  of  the  sixth  nerve  on  one  side,  then  of  the  third  nerve  on  the 
other,  but  the  case  was  unique. 


PARALYSIS  AGITANS.  1393 

Paroxysmal  or  recurrent  palsy  of  the  oculomotor  nerve  has  been 
noted  also  in  tubercular  meningitis,  in  otorrhoea,  and  in  nasal  catarrh, 
but  the  history  in  these  cases  and  the  associated  symptoms  are  against 
mere  migraine. 

Some  observers  claim  a  relationship  between  tabes  dorsalis  and  migraine 
— suggested  by  the  recurrent  palsy  of  the  third  nerve,  sometimes  seen  in 
tabes.  But  it  is  not  scientific  to  call  the  recurrent  palsy  of  the  third  nerve 
in  tabes  migrainous;  for  this  palsy  is  probably  due  to  nuclear  disease, 
and  it  is  to  be  known  by  its  association  with  other  tabetic  symptoms. 
The  same  may  be  said  of  the  association  of  migraine  and  general  paresis. 

Hysteria  may  unquestionably  complicate  or  simulate  migraine, 
especially  in  the  emotional  and  psychic  symptoms,  and  in  the  contraction 
of  the  visual  fields,  which  might  suggest  scotoma.  But  genuine  paralysis 
of  the  third  nerve  is  probably  never  seen  in  hysteria,  although  it  is  some- 
times simulated  by  a  blepharospasm. 

VIII.  PARALYSIS  AGITANS. 

This  affection  is  usually  called  a  disease  of  old  age;  nevertheless  it  occa- 
sionally begins  in  comparatively  early  middle  life;  seldom,  however,  before 
the  age  of  forty.    It  is  also  called  shaking  palsy,  or  Parkinson's  disease. 

Pathology. — The  cause  and  pathology  are  obscure.  Recently  C.  D. 
Camp  has  made  an  elaborate  study  of  a  series  of  cases,  many  of  them  from 
the  Blockley  Clinic  in  Philadelphia,  in  which  he  endeavors  to  show  that 
the  essential  changes  are  in  the  muscular  fibres;  and  he  suggests  that 
there  may  be  alteration  in  the  secretion  of  the  parathyroid  glands.  The 
ordinary  changes  of  senility,  such  as  atheroma  of  the  cerebral  blood- 
vessels, are  commonly  found  in  these  patients,  but  it  does  not  follow,  as 
Dana  and  a  few  observers  have  suggested,  that  these  changes  are  causative. 
Some  sclerosis  of  the  posterior  and  lateral  tracts  of  the  cord  is  occasionally 
observed;  also  some  atrophy  of  the  cerebral  convolutions,  pigmentation 
of  the  motor  neurons,   and  increase  of  interstitial  tissue. 

Symptoms. — The  disease  is  of  gradual  onset  and  chronic  course,  and 
it  is  rather  more  common  in  men  than  in  women.  The  chief  symptoms 
are  tremor,  rigidity,  paralysis,  and  affection  of  the  gait.  It  usually  begins 
with  tremor  in  the  hands,  sometimes  more  marked  at  first  in  one  hand. 

The  tremor  is  a  regular  to  and  fro  or  up  and  down  movement,  especi- 
ally marked  in  the  hands,  persisting  during  repose,  and  temporarily  arrested 
by  voluntary  motion.  The  amplitude  varies;  sometimes  it  is  slight,  at 
others  wide  and  violent,  particularly  if  the  patient  is  aroused  or  excited. 
The  arrest  on  volition  is  but  for  a  moment;  the  tremor  then  returns  in 
spite  of  the  patient,  and  may  even  be  aggravated  for  a  short  period.  This 
is  seen  on  attempts  at  writing.  In  the  lower  limbs  the  tremor  is  usually 
not  so  marked,  and  is  sometimes  even  absent.  It  is  seen  occasionally  in 
the  facial  muscles,  and  in  the  tongue,  especially  when  it  is  protruded. 
The  statement  that  the  head  is  not  involved  is  not  correct  for  all  cases. 
Nystagmus  is  not  present.     The  tremor  cea.ses  during  sleep. 

Rigidity  is  usuall}^  most  marked  in  the  hands,  arms,  back,  neck,  and 
face,  and  its  effect  is  to  give  the  patient  a  peculiar  attitude  and  expression. 
88 


1394  MEDICAL  DIAGNOSIS. 

Later  the  lower  limbs  are  involved.  The  hands  are  held  in  the  position 
known  as  the  ''obstetric  hand/'  the  fingers  partly  extended,  the  finger- 
tips approximated;  and  the  thumb  held  close.  The  constant  slight  move- 
ment of  the  end  of  the  thumb  and  tips  of  the  fingers  gives  the  appearance 
in  some  cases  of  rolling  pills.  The  arms  are  generally  flexed  at  the  elbows; 
the  back  is  bent  forward,  the  head  is  bowed,  and  the  face  has  a  character- 
istic mask-like  expression.  In  those  rare  cases  in  which  the  tremor  is 
lacking  this  mask-like  expression  and  statuesque  attitude  are  enough  to 
establish  the  diagnosis.  The  active,  intelligent  expression  of  the  eyes  is 
sometimes  in  marked  contrast  with  the  expressionless  face.  The  rigidity 
of  the  limbs  is  very  noticeable  on  attempts  at  passive  motion.  The  speech 
is  often  low  and  feeble  but  not  characteristically  changed. 

Paresis,  or  weakness  of  the  muscles,  is  not  uncommon  as  the  case 
advances;  it  is  doubtless  due  in  part  to  the  embarrassment  caused  by  the 
tremor  and  rigidity,  but  that  there  is  true  loss  of  power  there  can  be  no 
doubt.  In  advanced  cases  a  genuine  paralysis  exists,  and  the  patient  is 
confined  to  a  chair,  or  is  even  bed-ridden.  The  knee-jerks  may  be  increased, 
but  there  is  not  usually  a  true  paraplegia,  for  the  bladder  is  not  involved. 
Sensation  is  not  affected,  as  a  rule;  but  some  patients  complain  of  a  sub- 
jective sense  of  heat  or  cold;  and  the  surface  temperature,  according  to 
Gowers,  may  be  increased. 

Alteration  in  the  gait  is  shown  in  the  condition  known  as  propulsion 
or  festination.  The  patient  seems  to  be  propelled  forward.  With  head 
bowed  and  back  bent  forward  he  goes  at  a  shuffling  gait  or  a  jog  trot,  grad- 
ually increasing  until  he  brings  up  against  some  person  or  thing  which  is 
his  objective  point.  It  seems  as  though  he  must  inevitably  fall,  which, 
however,  he  seldom  does.  Trousseau  said  that  the  patient  seemed  to  be 
chasing  his  centre  of  gravity.  Sometimes  there  is  retropulsion;  and  very 
rarely  lateropulsion. 

The  mental  faculties  are  not  affected  except  by  the  changes  incident 
to  old  age.  Parkinson  made  the  curious  observation  that  in  a  hemiplegic 
attack  the  tremor  in  the  paralj^zed  limb  was  arrested,  sometimes,  however, 
to  return.  When  the  disease  begins  in  early  middle  life  the  patient  often 
looks  prematurely  senile.     Very  rarely  the  disease  is  unilateral. 

Diagnosis. — This  is  not  difficult,  for  paralysis  agitans  apes  no  other 
malady  unless  it  be  some  forms  of  senile  tremor;  but  senile  tremor  is 
usually  coarser,  it  is  almost  always  of  the  intention  type,  it  involves 
the  head;  and  the  characteristic  attitude,  expression,  and  gait  are 
wanting.  In  elderly  men,  given  to  the  overuse  of  alcohol  and  tobacco, 
a  tremor  sometimes  develops  which  it  not  so  much  senile  as  toxic.  It  is 
worse  on  voluntary  movement,  and  is  not  associated  with  the  character- 
istic symptoms  of  paralysis  agitans.  There  should  be  no  confusion  between 
Parkinson's  disease  and  multiple  sclerosis;  the  intention  tremor,  the 
nystagmus,  the  scanning  speech,  the  onset  in  earlier  life,  are  not  seen  in 
the  former. 

There  are  a  few  other  tremors  which  it  is  well  to  recall  in  this  connection. 

A  coarse  tremor  sometimes  occurs  in  the  traumatic  neuroses  and  in 
hysteria.  The  French  describe  all  these  neurotic  tremors  as  hysterical, 
and  they  are  probably  correct.    The  cases  of  pseudosclerosis,  described  by 


TETANY.  1395 

Westphal,  were  doubtless  of  the  same  class.  In  most  of  these  traumatic 
and  hysteroidal  cases  the  tremor  is  usually  of  the  intention  type,  that  is, 
it  is  worse  on  voluntary  movement,  and  it  is  rather  coarse;  moreover  the 
history  and  progress  are  suggestive.  These  cases  often  occur  in  young 
persons;  the  attitude,  gait  and  expression  are  not  those  of  Parkinson's 
disease;  and,  finally,  hysterical  stigmata  are  often  present.  In  an 
occasional  case  the  tremor  may  be  fine. 

The  tremor  due  to  metallic  poisoning  (by  lead  and  mercury  especi- 
ally)  is  similar  to  the  hysterical  tremor. 

The  tremor  of  alcoholism  is  also  largely  of  the  intention  type  and  is 
coarse  and  irregular;   it  is  easily  known  by  the  history. 

IX.  TETANY. 

This  disease  is  characterized  by  tonic,  cramp-like  spasms,  especially 
in  the  fingers,  hands,  and  upper  limbs.  It  occurs  in  epidemics  in  some 
countries,  especially  in  and  about  Vienna,  Northern  Italy  and  Sweden. 
The  cause  is  obscure.  Tetany  may  be  of  infectious  origin,  and  it  is  also 
seen  in  ergotism,  in  the  diarrhoea  and  rickets  of  young  children,  in 
nursing  women,  after  extirpation  of  the  thyroid  gland,  and  in  dilata- 
tion of  the  stomach.  Chvostek  advances  the  theory  that  the  real  cause 
is  a  defective  action  of  the  parathyroid  glands.  According  to  the  statistics 
of  Frankl-Hochwart,  shoemakers  and  tailors  seem  peculiarly  vulnerable. 
The  disease  is  rare  in  America. 

Pathology. — This  is  quite  unknown,  for  post-mortem  findings  have 
not  been  uniform  or  characteristic. 

Symptoms. — The  tetanic  spasms  are  oftenest  seen  in  the  small  muscles 
of  the  fingers  and  hands,  causing  flexion  of  the  basal  phalanges,  extension 
of  the  distal  phalanges,  and  turning  in  of  the  thumb.  This  is  sometimes 
called  the  "obstetric  hand."  The  wrist  and  elbow  are  flexed.  The  toes 
may  be  similarly  affected;    also  the  calf  muscles. 

The  spasms  are  often  painful,  and  usually  intermittent.  They  can 
sometimes  be  excited  by  pressure  on  the  nerve-trunks  or  main  vessels — 
Trousseau's  sign. 

There  is  increase  of  the  mechanical  and  electrical  irritability.  Tapping 
on  nerve-trunks  causes  a  lively  contraction  (Chvostek's  sign),  often  well 
marked  in  the  face;  and  the  galvanic  current,  even  of  mild  power,  causes 
active,  even  tetanic,  responses,  which  may  increase,  rather  than  diminish, 
with  repeated  stimulation.     The  nerves  may  be  hypersensitive  to  pressure. 

Other  muscles,  such  as  of  the  trunk,  tongue,  and  respiration,  are 
involved  in  severe  cases,  and  the  ocular  muscles,  according  to  Kunn,  may 
be  affected.  Nystagmus  has  been  seen.  Other  ocular  symptoms  noted 
by  a  few  observers,  and  which  are  evidently  very  rare,  if  they  belong  to 
the  disease  at  all,  are  neuroretinitis,  optic  atrophy,  unequal  pupils, 
diplopia,  cramp  of  the  eye-muscles,  especially  blepharospasm,  reddening 
of  the  conjunctivae,  and  lachrymation.  Slight  paresis  and  anaesthesia  (or 
hypsesthesia)  are  present  in  the  limbs  after  severe  attacks  of  the  cramps. 

There  is  no  affection  of  consciousness,  as  a  rule,  but  in  severe  cases 
constitutional  reaction,  such  as  fever,  accelerated  pulse,  etc.,  is  seen. 


1396  MEDICAL  DIAGNOSIS. 

Sometimes  the  disease  ends  fatally,  especially  when  caused  by  some 
of  the  more  serious  conditions  mentioned  above.  A  patient  in  the  Phil- 
adelphia Hospital  died  of  exhaustion  and  pulmonary  oedema;  but  the 
prognosis  appears  to  be  good  in  the  majority  of  simple  cases. 

Diagnosis. — The  tetanic  symptoms  are  so  characteristic  that  the 
diagnosis  is  easy. 

The  cramps  seen  in  chronic  uraemia  are  not  to  be  mistaken  for  tetany. 

The  French  describe  an  hysterical  type  of  tetany,  but  it  cannot  be 
made  to  cover  all  cases;  when  the  disease  is  truly  hysterical  the  mental 
state  and  the  presence  of  other  stigmata  suggest  the  right  diagnosis,  and 
such  signs  as  Trousseau's  and  Chvostek's  are  wanting. 

It  is  probable  that  a  variety  of  affections  cause  tetanoid  symptoms, 
and  further  study  is  necessary  to  shed  light  on  these  obscure  cases, 
Tetany  has  no  relation  to  true  tetanus,  and  does  not  resemble  it. 

X.  THE  TICS. 

The  tics,  or  maladie  des  tics,  or  habit  spasms,  are  peculiar  motor  dis- 
orders in  which  one  or  more  groups  of  muscles  are  thrown  into  regular 
and  oft-repeated  contractions,  resembling  a  voluntary  act.  The  muscles 
most  frequently  affected  are  those  of  the  eyes,  face,  mouth,  tongue,  and 
neck,  but  in  some  cases  the  muscles  of  the  limbs  are  involved. 

Pathology. — The  French,  who  have  described  the  tics  most  carefully, 
point  out  the  underlying  mental  state.  The  tic  has  a  quasi-voluntary 
character,  and  in  its  origin  it  is  volitional  or  impulsive.  Gradually  the 
movement  becomes  fixed  as  a  motor  habit,  and  can  no  longer  be  con- 
trolled, or  only  imperfectly  controlled,  by  the  patient,  and  then  at  the 
cost  of  mental  distress  and  anxiety.  Usually  there  is  no  very  distinct 
motive  or  associated  idea  in  the  mind;  the  tic  is  merely  an  impulse,  which 
grows  into  a  habit.  In  proof  of  its  psychic  character,  however,  is  the  fact 
that  in  some  rare  cases  the  movements  are  thus  associated  with  definite 
ideas  in  the  patient's  mind,  emotional  or  otherwise,  of  which  the  tic  is 
the  facial  expression;  and  in  extreme  cases  there  may  be  obsessions, 
especially  of  speech,  the  patient  being  impelled  to  give  utterance  to  some 
set  of  words,  even  an  indecency — the  so-called  coprolalia.  In  fact,  the 
tics  are  closely  allied  to  the  obsessions;  they  are  due  to  a  sort  of 
imperative  motor  impulse,  and  they  are  usually  found  in  neurotic  and 
degenerate  patients. 

Symptoms. — As  no  two  cases  are  exactly  alike  it  is  difficult  to  give  a 
brief  description  of  the  tics.  Blepharospasm  is  common,  and  with  it  is 
often  seen  an  associated  movement  of  the  face  and  even  of  the  tongue  and 
larynx.  Odd  grimaces  are  the  result,  and  these  may  even  be,  or  seem  to 
be,  the  expressions  of  various  mental  states,  as  grief,  surprise,  pain,  or 
joy.  When  unilateral,  as  is  often  the  case,  the  one-sided  expression  can 
best  be  interpreted  by  covering  the  sound  side  of  the  face.  In  many  cases, 
however,  there  is  no  such  expression,  but  merely  a  distortion  of  the  fea- 
tures. When  the  neck  muscles  are  affected  there  are  various  move- 
ments simulating  torticollis.  Sometimes  associated  movements  of  the 
arm,  hand,  leg,  or  foot  are  seen. 


RAYNAUD'S  DISEASE.  1397 

The  tics  occur  in  regularly  recurring  bouts,  the  intervals  varying 
from  a  few  minutes  to  much  longer  periods.  They  can  sometimes  be  con- 
trolled for  a  time  by  an  effort  of  will,  but  the  effort  causes  mental  discom- 
fort, and  the  patient  seeks  relief  in  what  Church  has  called  a  "spasmodic 
debauch,"  in  which  for  a  time  the  tic  is  repeated  rapidly  and  frequently. 

The  tics  commonly  begin  in  childhood  or  in  young  persons.  Occasion- 
ally they  appear  later  in  life;  and  blepharospasm  may  have  its  origin 
in  some  affection  of  the  eye,  and  gradually  become  fixed  as  a  habit. 

Diagnosis. — As  already  said,  the  tics  are  allied  to  the  obsessions  and 
to  various  neuroses.  They  are  easily  recognized  by  the  conspicuous  motor 
disorder;  j^et  they  have  sometimes  been  confused  with  forms  of  epidemic 
hysteria,  such  as  in  the  "jumpers"  of  Maine  and  Canada,  and  the  disease 
known  as  "latah"  among  the  Malays,  and  "  myreachit"  in  Siberia,  in  which 
imitation  and  suggestion  are  prominent  factors.  But  the  tics  are  not  a 
form  of  hysteria;  they  do  not  occur  in  epidemics;  they  are  but  little  influ- 
enced by  suggestion;  and  they  are  too  apt  to  be  incurable.  It  is  likewise  an 
error  to  describe  this  disease,  as  some  authors  do,  under  the  head  of  chorea. 
There  is  nothing  choreic  about  it.  In  young  children  these  habit  spasms  in 
the  face,  neck,  and  shoulders,  at  the  very  beginning,  may  suggest  St.  Vitus's 
dance,  but  the  tic  is  more  localized,  more  habitual,  and  more  persistent 
than  the  movements  in  chorea,  and  there  is  always  a  volitional  element  in 
it.     There  is  a  mild  grade  of  tic  in  children  which  tends  to  recover. 

The  true  tics  are  to  be  distinguished  from  the  spasmodic  form  of 
tic  douloureux,  which  is  a  form  of  facial  neuralgia  in  which  the  facial 
muscles  are  thrown  into  spasm  by  the  action  of  pain.  In  the  habit  tics 
pain  is  absent. 

Stammerers  sometimes  develop  a  kind  of  associated  spasm  in  the  face 
or  even  in  a  limb.  When  the  embarrassment  of  speech  is  great  the  facial 
muscles  are  contorted,  and  even  the  hand  and  arm  may  be  moved  spas- 
modically.    This  cannot  be  called  a  tic  in  the  proper  sense  of  the  word. 

The  tics  differ  from  mere  spasm  by  the  psychic  element  in  them.  In 
pure  spasm  the  affection  is  in  the  neuromuscular  apparatus,  and  there 
is  no  mental  collaboration.  Such  a  spasm,  purely  local,  oft  repeated,  and 
not  involving  consciousness,  is  sometimes  seen  in  some  isolated  muscle- 
groups,  as,  for  instance,  in  the  head  and  neck,  constituting  the  disease 
known  as  torticollis.  It  is  usually  not  controllable  by  the  patient's  will, 
and  the  cause  and  pathology  are  obscure. 

VASOMOTOR  AND  TROPHIC  DISEASES. 

I.  RAYNAUD'S  DISEASE. 

This  is  a  trophic  disease  in  which  the  extremities,  especially  the  fingers 
and  toes,  are  the  seat  of  recurring  pallor,  congestion,  and  even  gangrene. 
The  affection  was  first  described  by  Raynaud  in  1862.  It  is  apparently 
of  vasomotor  origin,  and  has  three  types  or  stages — local  syncope,  local 
asphyxia,  and  local  gangrene. 

Pathology. — The  disease  seems  to  be  essentially  due  to  vasomotor 
disorder.      Neuritis   and   arterial  sclerosis,   or  endarteritis  obliterans,   are 


1398  MEDICAL  DIAGNOSIS. 

not  necessary  parts  of  the  process,  although  they  may  be  present  as  sec- 
ondary phenomena  in  late  stages.  This  whole  subject  of  the  pathology, 
however,  is  still  obscure. 

Symptoms. — In  local  syncope  the  parts  become  blanched,  shrivelled 
and  cold;  the  appearance  is  similar  to  that  caused  by  exposure  to  cold, 
as  in  the  so-called  "dead  fingers."  The  parts  affected  are  usually  the 
fingers  and  toes,  and  the  affection  is  symmetrical.  The  fingers  feel  numb, 
and  there  are  anaesthesia  and  analgesia,  but  as  a  rule  no  loss  of  the  sense 
of  heat  and  cold.  The  affection  is  most  common  in  cold  weather,  and  it  is 
paroxysmal  and  recurrent,  the  attacks  lasting  from  a  few  minutes  to 
several  hours.  There  is  no  real  paralysis,  but  the  fingers  may  be  awkward 
or  even  powerless  from  the  numbness  and  stiffness.  There  is  usually  no 
pain;    merely  tingling  and  numbness. 

In  local  asphyxia  the  reverse  of  the  preceding  picture  is  seen;  it  is  a 
stage  of  reaction,  apparently,  although  it  is  not  necessarily  preceded  by 
a  well-marked  stage  of  syncope.  The  skin  becomes  dusky,  red,  purplish, 
or  even  almost  black;  the  parts,  as  the  fingers,  are  congested;  the  surface 
is  cold;  the  tactile  sense  is  impaired;  and  the  members  may  be  most  pain- 
ful. The  radial  pulse  remains  unchanged.  As  in  syncope,  the  attacks  are 
paroxysmal  and  recurrent,  and  even  occur  in  cycles.  The  affected  fingers 
are  usually  involved  in  turn,  and  the  congestion  disappears  first  from  one 
part  and  then  another.    Occasionally  the  nose,  ears,  and  face  are  invaded. 

The  local  or  symmetrical  gangrene  may  follow  either  the  syncopal  stage 
or  the  asphyxial  stage.  The  parts  are  cold,  usually  shrivelled,  and  bullse 
form;  these  break  and  reveal  black  spots,  which  result  in  localized  destruc- 
tion. The  ends  of  the  fingers  are  destroyed,  or  the  under  parts  of  the  toes. 
The  spots  sometimes  heal,  leaving  a  healthy  scar.    The  pain  is  often  severe. 

Among  accessory  sj^mptoms  should  be  mentioned  haemoglobinuria, 
which,  being  associated  with  chill  and  slight  fever,  and  having  a  paroxys- 
mal course,  has  led  to  the  suspicion  of  malaria;  an  idea  which  seems  to 
find  some  favor  with  Barlow.  Amblyopia  is  also  occasionally  seen,  and 
may  depend  on"  alteration  in  the  calibre  of  the  retinal  vessels,  as  verified 
by  Galezowski.  Temporary  changes  in  the  joints  have  been  noted,  also 
hemiplegia  and  aphasia,  and  in  rare  cases  even  mental  symptoms.  Epilepsy, 
or  attacks  suspiciously  like  it,  has  been  reported. 

Diagnosis. — There  are  various  forms  of  gangrene  which  must  not  be 
mistaken  for  Raynaud's  disease.  The  disorder  closely  resembles  chil- 
blain or  frost  bite,  but  the  history  is  sufficient  to  prevent  error.  Raynaud's 
disease  is  a  recurring  affection,  whereas  frost  bite  is  a  simple  and  soHtary 
accident,  and  by  no  means  always  symmetrical. 

It  also  resembles  ergotism,  but  the  history  alone  should  distinguish 
the  two. 

So  also  of  the  gangrene  of  diabetes,  in  which  the  glycosuria  and  the 
asymmetrical  character  of  the  gangrene  are  significant. 

Erythromelalgia  resembles  the  asphyxial  stage  of  Raynaud's  disease, 
but  in  the  former  the  affected  limb  is  hot,  pulsating,  and  more  uniformly 
painful  than  in  the  latter;  moreover,  it  does  not  present  sensory  changes, 
and  gangrene  does  not  result.  Nevertheless,  the  two  affections  have  some 
affinity.     It  has  been  claimed  that  they  are  identical. 


ERYTHROMELALGIA.  1399 

Morvan's  disease  closely  simulates  the  late  or  gangrenous  stage,  of 
Raynaud's  disease;  but  the  former  is  closely  allied  to  syringomyelia  or 
central  gliomatosis,  and  there  is  a  peripheral  neuritis  and  thickening  of 
the  arterial  coats.  Hence  in  Morvan's  disease  there  is  usually  seen  muscu- 
lar atrophy  in  the  extremities,  anaesthesia  of  all  the  modes  of  sensation, 
changes  in  the  deep  reflexes,  and  possibly  scoliosis  or  kyphosis.  The 
history  is  not  that  of  recurring  paroxysms,  and  the  whitlows  are  painless. 

Injury  to  a  nerve,  especially  the  median  nerve,  may  cause  gangrene 
of  the  finger-tips,  as  in  a  case  lately  recorded  by  Sneve,  but  the  history 
usually  is  clear,  the  affection  is  unilateral,  and  the  paralysis  and  anaesthesia 
are  characteristic. 

Local  gangrene  may  result  from  the  obstruction  of  an  artery,  as 
in  the  condition  called  endarteritis  obliterans,  the  pathology  of  which 
is  obscure. 

We  do  not  agree  with  Oppenheim  in  confusing  the  various  trophic 
lesions  of  tabes,  syringomyelia,  and  even  hysteria  with  those  of  Raynaud's 
disease.  The  associated  symptoms  of  these  diseases  are  sufficient  to  dis- 
tinguish them. 

Barker  has  recently  called  attention  to  the  subject  of  acrocyanosis 
in  which  there  is  anaesthesia  with  gangrene  of  the  toes.  It  seems  to  be  a 
vasomotor  affection  and  may  have  to  be  distinguished  from.  Raynaud's 
disease  by  the  difference  in  the  state  of  sensation. 

II.  ERYTHROMELALGIA. 

The  affection  to  which  Weir  Mitchell  gave  this  name  in  1878  is  de- 
scribed by  that  author  as  a  chronic  disease  in  which  a  part  or  parts  of  the 
body,  usually  one  or  more  extremities,  suffer  with  pain,  flushing,  and  local 
fever,  made  far  worse  if  the  parts  hang  down. 

Pathology. — The  disease  has  often  been  ascribed  to  vasomotor  dis- 
order. Lately,  however,  the  tendency  has  been  to  attribute  it  to  a  periph- 
eral neuritis;  although  careful  examination  has  not  always  supported 
this  view.  In  most  cases  changes  in  the  blood-vessels,  as  atheroma  and 
arterial  sclerosis,  have  been  present.  Finally  it  has  been  suggested  that 
there  is  a  central  or  cord  lesion,  and  cases  have  been  reported  by  Collier  in 
multiple  sclerosis,  tabes,  and  myelitis.  It  is  also  seen  in  hemiplegia.  The 
disease  has  been  observed  not  infrequently  in  workmen  who  do  heavy 
labor  and  stand  for  long  periods;  and  Sturgis  suggests  that  it  has  points 
of  resemblance  to  the  occupation  neuroses,  such  as  writer's  cramp.  On 
the  whole  the  question  of  the  pathology  is  still  an  open  one.  The  weight 
of  evidence  seems  in  favor  of  a  conjoint  arterial  sclerosis  and  peripheral 
neuritis;   while  a  central  influence  may  also  act. 

Symptoms. — When  the  limb  hangs  down  it  becomes  congested  and 
rose-red,  or  even  of  a  dark  violaceous  hue;  the  arteries  throb;  and  the 
local  temperature  of  the  skin  rises.  Pain  is  usually  present,  and  may  be 
severe,  of  a  burning  or  neuralgic  kind,  worse  on  pressure,  and  generally 
relieved  when  the  limb  is  again  elevated;  but  sometimes  it  persists  in  a 
minor  degree  even  then.  It  is  worse  in  summer,  and  is  relieved  by  the 
apphcation  of  cold.    Sensation  of  all  kinds  is  preserved.    The  disease  may 


1400  MEDICAL  DIAGNOSIS. 

be  asymmetrical,  and  is  not  followed  by  gangrene,  although  a  somewhat 
similar  condition  has  been  seen  to  precede  senile  gangrene.  The  symp- 
toms, when  in  the  feet,  are  usually  provoked  by  walking  and  standing. 
It  may  be  questioned  whether  erythromelalgia  is  a  distinct  disease,  or 
anything  more  than  a  symptom  of  various  diseases. 

Diagnosis. — The  distinction  from  senile  gangrene  is  sufficiently  shown 
in  the  account  of  the  symptoms.  In  erythromelalgia  the  painful  swelling 
is  not  constant,  but  is  aggravated  by  the  dependent  position,  and  it  does 
not  lead  to  destruction  of  tissue. 

Raynaud's  disease  is  not  dependent  on  position;  it  begins  as  an  ischae- 
mia;  pain  is  inconstant;  there  is  anaesthesia,  analgesia,  and  lowered  tem- 
perature; and  there  is  a  local,  and  usually  a  symmetrical,  gangrene.  But 
Voorhees,  in  a  recent  paper,  maintains  that  the  two  diseases  are  merely 
different  phases  of  the  same  condition. 

The  disease  has  some  resemblance  to  neuritis  and  injury  to  the  nerves, 
but  there  are  not  the  objective  symptoms,  such  as  paralysis,  anaesthesia, 
and  trophic  changes;  when  these  occur  it  is  doubtful  whether  the  case  is 
one  of  pure  erythromelalgia. 

It  is  well  to  recall,  however,  that  some  of  the  above  data  for  differ- 
entiation are  not  entirely  reliable,  for  pallor,  ischaemia,  sensory  changes, 
etc.,  have  been  noted  in  cases  closely  resembling  erythromelalgia,  and  gan- 
grene has  even  followed  in  some  of  them,  as  in  one  of  Mitchell's  cases. 

The  blue  oedema  of  hysteria  is  usually  confined  to  one  limb;  it  is 
likely  to  be  associated  with  loss  of  power,  and  it  is  often  non-painful; 
moreover,  the  history  and  other  hysterical  symptoms  are  significant. 
These  hysterical  cases  usually  follow  trauma. 

III.  ANGIONEUROTIC    (EDEMA. 

This  is  a  sort  of  pseudo-urticaria,  occurring  usually  in  weakened  or 
neurotic  persons.     It  is  also  called  giant  urticaria,  or  Quincke's  disease. 

Pathology. — The  affection  is  probably  of  vasomotor  origin,  although 
the  essential  cause  and  its  mode  of  action  are  obscure.  Several  instances 
are  given,  as  by  Osier  and  by  Milroy,  of  hereditary  transmission  through 
five  and  six  generations. 

Symptoms. — Locahzed  swellings  occur  on  the  skin  in  various  regions. 
These  are  somewhat  like  wheals,  or  hives,  but  they  are  painless,  and  do 
not  itch.  They  are  at  first,  as  a  rule,  sHghtly  pale,  but  flushing  soon  follows. 
The  subcutaneous  tissue  is  involved  in  the  oedema,  and  sometimes  the 
mucous  membranes  are  invaded.  Thus  croupy  symptoms  have  been  caused, 
and  death  has  even  been  ascribed  to  angioneurotic  oedema  of  the  glottis. 
Gastro-intestinal  symptoms,  such  as  colic  and  vomiting,  are  sometimes  seen. 

Cerebral  symptoms  are  caused  by  these  angioneuroses.  Thus  we 
sometimes  see  flushing  of  the  face  and  head,  palpitation,  throbbing  in  the 
temples,  tinnitus,  dimness  of  vision,  confusion,  and  emotional  disorder. 
Such  cases  are  not  uncommon  in  neurasthenic  and  hysterical  patients. 

Diagnosis. — The  disease  looks  a  little  Hke  urticaria,  but  there  is  no 
burning  or  itching.  Some  authors,  however,  incline  to  identify  the  two, 
and  claim  that  itching  occurs,  but  this  is  doubtful  of  real  cases. 


HEMIFACIAL  ATROPHY.  1401 

When  marked  cerebral  symptoms  occur,  as  m  tne  cases  of  ''rush  of 
blood  to  the  head/'  there  may  be  some  remote  resemblance  to  epilepsy, 
but  the  history  of  the  case  and  the  well-marked  vasomotor  disorder  should 
prevent  error. 

Similar  phenomena  are  sometimes  seen  in  old  alcoholic  cases,  and  in 
exophthalmic  goitre.  Purpura,  with  urticaria  and  haemoglobinuria,  is 
doubtless  a  different  disease. 

IV.  HEMIFACIAL  ATROPHY. 

This  is  an  affection  in  which,  as  the  name  signifies,  atrophic  changes 
on  one  side  of  the  face,  brow,  and  skull  are  seen. 

Pathology. — Autopsies  have  been  rare;  probably  the  most  instruc- 
tive was  one  by  Mendel,  in  which  he  found  neuritis  of  the  left  trigeminal 
nerve,  most  marked  in  the  second  division,  with  atrophy  of  the  descending 
root  and  of  the  substantia  ferruginea.  Homen  found  a  dural  tumor  com- 
pressing the  Gasserian  ganghon.  The  disease  is  a  trophic  one,  probably 
depending  on  changes  in  the  fifth  nerve,  although  operations  on  the  Gas- 
serian ganglion  have  not  fully  sustained  this  theory.  Some  ascribe  it  to 
changes  in  the  sympathetic  nerves.     The  subject  is  still  obscure. 

Symptoms. — The  changes  are  in  the  skin,  subcutaneous  tissue,  and 
bone.    The  muscles  supplied  by  the  seventh  nerve  escape. 

The  initial  symptom  is  changed  color  in  a  limited  area  of  the  skin; 
this  may  spread  until  it  involves  the  entire  side  of  the  face.  The  atrophy 
of  the  skin  follows,  but  it  may  be  very  slow.  Atrophy  of  the  bones  is  more 
rare.  The  color  of  the  hair  of  the  beard,  eyebrows,  and  head  is  sometimes 
changed  to  white.  The  affected  part  does  not  sweat  in  some  cases;  and 
some  writers  have  observed  lowered  temperature  (tq-  of  a  degree).  Taste 
is  sometimes  involved;  hearing  seldom;  sight  never.  The  facial  muscles 
are  not  paralyzed,  but  the  masticatory  muscles,  supplied  by  the  motor 
branch  of  the  fifth  nerve,  have  been  found  wasted,  according  to  some 
authors.    Twitching  of  the  facial  muscles  is  sometimes  seen. 

The  above  are  the  essential  features  of  the  disease.  In  some  cases 
trigeminal  neuralgia  is  present,  and  there  may  be  parsesthesia,-  as  numb- 
ness and  tingling,   but  objective  anaesthesia  is  uncommon. 

In  a  few  cases  hemifacial  atrophy  has  appeared  in  the  chronic  insane: 
and  in  a  few  instances  a  hemilingual  atrophy  has  appeared  along  with  a 
hemiplegia. 

Diagnosis.  —  This  presents  no  difficulty.  The  appearance  of  the 
atrophied  tissue  is   unmistakable. 

In  morphoea  the  bones  are  not  involved;  and  in  scleroderma,  accord- 
ing to  Duhring,  there  is  an  hypertrophy  rather  than  atrophy,  and  the 
tissue  is  hardened. 

In  Bell's  palsy  the  facial  muscles  are  atrophied,  and  there  is  paralysis 
with  reactions  of  degeneration,  but  the  skin  and  bones  are  not  affected. 
Turner  says  that  the  faradic  excitability  of  the  facial  muscles  in  hemi- 
atrophy is  increased  and  that  this  arises  from  lessened  resistance  owing  to 
the  disappearance  of  the  subcutaneous  fat.  The  history  in  Bell's  palsy 
is  usuallv  clear   the  affection  is  acute,  and  the  muscles  alone  are  involved. 


1402 


MEDICAL  DIAGNOSIS. 


So,  too,  in  progressive  muscular  atrophy  and  in  muscular  dystrophy, 
when  the  face  is  invaded,  the  muscles  alone  are  involved,  the  affection  is 
bilateral,  and  the  course  and  appearance  are  entirely  different. 

V.  OSTEITIS  DEFORMANS:   PAGET'S   DISEASE. 

Definition. — A  rare  disease  of  the  bones,  characterized  by  the  absorp- 
tion and  new  formation  of  bone  tissue,  which  remains  for  a  time  uncalcified 
and  leads  to  curvatures,  over-growth  and  other  deformities  of  the  skeleton. 

Up  to  1900  only  66  undoubted  cases  had  been  reported  and  in  1902 
onlv  11  cases  had  been  observed  in  North  America. 


Fig.  405. — Osteitis  deformans. — Jefferson  Hospital. 


Etiology.  —  Predisposixg  Ixfluexces.  —  Both  sexes  are  liable  to 
the  disease.  Of  the  reported  cases  about  twice  as  many  occurred  in  males 
as  in  females.  Age  is  more  important.  The  first  symptoms  have  com- 
monly shown  themselves  after  the  fortieth  year.  The  onset  of  the  disease 
in  one  instance  occurred  about  the  age  of  twenty-one.  As  the  disease  is 
chronic  and  progressive  and  in  most  instances  unattended  by  subjective 
symptoms,  the  cases  have  usually  come  under  observation  at  a  period 
more  or  less  remote  from  the  time  of  onset.  In  the  majority  of  instances 
the  first  symptoms  have  been  observed  in  middle  rather  than  in  advanced 
life.  The  influence  of  heredity  is  uncertain.  In  three  instances,  however, 
cases  have  occurred  in  two  members  of  the  same  family.  Occupation  is 
altogether  without  influence  in  predisposing  to  the  disease. 

Association  with  Other  Diseases. — It  has  been  assumed  that  there  is 
some  causal  relation  between  lesions  of  the  nervous  system  and  osteitis 


OSTEITIS  DEFORMANS. 


1403 


deformans.  No  constant  relationship  has,  however,  been  estabhshed  and  in 
the  greater  number  of  the  cases  there  has  been  an  entire  absence  of  phe- 
nomena indicating  nervous  or  visceral  disease.  Arthritis  deformans  has  in  a 
few  instances  coexisted  with  osteitis  deformans.  This  association  appears 
to  have  been  a  coincidence  and  there  is  no  reason  to  believe  that  there  is 
any   causal    relationship   or  interdependence  between  the  two   affections. 

The  EXCITING  CAUSE  of  the  disease  remains  wholly  unknown. 

Symptoms. — The  manifestations  of  osteitis  deformans  are  chiefly  objec- 
tive. The  onset  is  insidious,  sometimes  involving  a  single  bone  or  a  limited 
number  of  bones,  but  in  the  course  of  time  showing  a  tendency  to  symmetri- 
cal involvement  of  the  skeleton.     Individuals  suffering  from  this  disease 


Fig.  406. — Skiagram  showing    deformity  of  radius 
and  ulna. 


Fig.  407.— Skiagram  showing  deformity  of  tibia 
and  fibula. 


present  as  the  result  of  definite  skeletal  deformities  a  remarkable  resem- 
blance to  each  other.  There  is  thickening  of  the  bones  of  the  skull  and  an 
alteration  in  its  shape.  The  calvarium  becomes  flattened,  the  brow  broad, 
the  parietal  regions  prominent.  The  general  circumference  is  increased  so 
that  the  patient  has  to  wear  a  larger  hat  than  formerly.  The  face  is  irregu- 
larly egg-shaped  or  triangular,  the  base  being  at  the  forehead  and  the  apex 
at  the  chin.  The  head  is  carried  forward  with  the  chin  sunk  upon  the 
breast.  There  is  cervicodorsal  kyphosis,  flattening  of  the  thorax  at  the 
upper  part,  spreading  at  its  base,  the  abdomen  is  diamond-shaped  and 
shows  a  deep  transverse  sulcus,  the  hips  are  increased  in  width  and  the 
lower  extremities  markedly  curved  outward  and  forward,  while  owing  to 
the  decrease  in  height  amounting  in  some  instances  to  several  inches,  the 
arms  appear  disproportionately  long — like  those  of  the  anthropoid  apes. 


1404  MEDICAL  DIAGNOSIS. 

Pain  in  the  bones  is  noted  in  the  early  course  of  many  of  the  cases. 
In  some  instances  it  has  been  intense.  In  others  it  has  occurred  chiefly 
at  night  or  after  fatigue.  As  the  disease  progresses  the  pains  have  become 
less  severe.  In  a  large  proportion  of  the  cases  pain  has  not  been  observed. 
The  absence  of  pain  may  be  explained  by  the  very  insidious  development 
of  the  process. 

General  muscular  atrophy  is  characteristic  of  the  advanced  disease. 
This  is  doubtless  to  some  extent  due  to  senile  changes  in  the  muscles. 
There  appears,  however,  to  be  a  definite  relationship  between  the  osseous 
deformities  and  the  muscular  atrophy. 

Diagnosis. — The  direct  diagnosis  in  well-developed  cases  is  unattended 
by  difficulty.  The  changes  in  the  shape  of  the  head  and  in  the  long  bones, 
the  diminution  in  stature,  the  kyphosis  and  the  peculiar  deformities  of 
the  thorax  and  abdomen  make  up  a  definite  clinical  picture  not  seen  in 
other  maladies.  The  absence  of  causally  related  visceral  disease  and  in 
most  instances  the  absence  of  the  manifestations  of  lesions  of  the  nervous 
system  and  the  unimpaired  general  health  are  to  be  noted. 

The  differential  diagnosis  involves  the  consideration  of  the  following 
diseases: 

1.  Osteomalacia. — In  this  affection  there  is  gradual  softening  and 
subsequent  bending  of  the  bones  in  which  spontaneous  fractures  frequently 
occur.  There  is  a  feeling  of  weakness  in  the  lower  extremities  so  that 
the  patient  walks  with  difficulty  and  requires  support.  There  seems  to 
be  some  relationship  between  osteomalacia  and  osteitis  deformans,  the 
essential  distinction  consisting  in  the  fact  that  in  the  latter  there  is  a  ten- 
dency to  the  irregular  and  eccentric  formation  of  new  bone. 

2.  Leontiasis  Ossea. — In  this  rare  affection  there  is  hyperostosis 
of  the  bones  of  the  skull  and  face.  Osteophytes  develop  upon  the  lower 
jaw  and  at  the  margins  of  the  orbits  and  upon  the  outer  and  inner  table 
of  the  skull.  In  the  latter  situation  they  may  cause  symptoms  of  menin- 
gitis or  tumor.  The  narrowing  of  the  canals  of  exit  for  the  cranial  nerves 
may  give  rise  to  blindness,  deafness,  anosmia  and  peripheral  derangements 
of  sensation  and  loss  of  motion. 

3.  Rickets. — This  disease  of  early  life  presents  changes  in  the  bone 
and  other  associated  symptoms  that  are  characteristic.  The  bending 
of  the  ribs,  enlargement  of  the  wrists,  squareness  of  the  forehead,  open 
fontanelles  are  derangements  of  early  developmental  processes,  not  modi- 
fications of  mature  structures.  The  deformities  produced  by  rickets  bear 
only  a  superficial  resemblance  to  those  caused  by  osteitis  deformans. 

4.  Acromegaly. — The  thick,  heavy  lips,  protruding  under  jaw  and 
broad  deformed  face  and  the  enlargement  of  the  head  in  its  anteroposterior 
diameter  bear  no  resemblance  to  the  cranial  and  facial  changes  in  osteitis 
deformans.  In  acromegaly  the  bones  of  the  hands  and  feet  and  in  some 
instances  the  epiphyses  of  the  long  bones  are  involved,  while  in  osteitis 
deformans  the  changes  in  the  long  bones  mainly  involve  the  diaphysis, 
and  the  bones  of  the  feet  commonly  escape. 

5.  Pseudohypertrophic  pulmonary  osteo-arthropathy — a  dis- 
ease characterized  by  enlargement  and  deformity  of  the  fingers,  hands, 
wrists,  feet  and  ankles,  occurring  in  patients  suffering  from  certain  chronic 


ACHONDROPLASIA.  -  1405 

pulmonary  affections.  This  deforming  affection  of  the  osseous  system  bears 
only  a  remote  resemblance  to  osteitis  deformans.  The  absence  of  changes 
in  the  cranium,  the  escape  of  the  shafts  of  the  long  bones  and  the  constant 
presence  of  intrathoracic  lesions  constitute  points  of  radical  difference. 

Prognosis. — Osteitis  deformans  is  slowly  progressive  and  requires 
a  number  of  years,  varying  from  five  to  fifteen,  to  attain  its  maximum 
development.  It  has  little  influence  upon  the  general  health  and  is  not  a 
direct  cause  of  death. 

VI.  ACHONDROPLASIA:  CHONDRODYSTROPHIA 

FGETALIS. 

Definition. — A  form  of  dwarfism  characterized  by  micromyelia  and 
macrocephalia,  the  trunk  being  of  about  the  normal  size.  This  remark- 
able disease  of  fetal  life  was  first  described  by  Virchow  (1858)  who  regarded 
it  as  a  form  of  fetal  or  congenital  rhachitis.  Parrot  (1878)  suggested 
the-  name  achondroplasia.  The  most  satisfactory  account  is  that  of  P. 
Marie  (1900). 

Etiology. — Predisposing  influences  and  the  exciting  cause  are  alike 
wholly  unknown. 

Patliology. — There  is  a  dystrophy  of  the  epiphyseal  cartilages  from  the 
earliest  period  of  osteogenesis.  The  growth  of  the  bones  of  the  extremi- 
ties at  the  epiphyseal  cartilages  is  defective  or  arrested  so  that  they 
do  not  normally  increase  in  length.  The  bones  which  develop  from  a 
primitive  membranous  matrix,  without  passing  through  the  stage  of  car- 
tilaginous formation,  as  the  clavicle,  ribs  and  certain  of  the  cranial  bones, 
are  not  involved  in  the  dystrophy,  a  fact  which  accounts  for  the  great 
difference  in  the  development  of  the  extremities  and  that  of  the  trunk 
and  head.  The  dystrophy  has  been  ascribed  to  the  action  of  an  unknown 
toxic  agent  circulating  in  the  blood  to  which  the  epiphyseal  cartilage  sub- 
stance is  peculiarly  obnoxious — perhaps  a  vitiated  internal  secretion 
having  to  do  with  the  regulation  of  the  normal  growth  of  the  bod3\ 

Clinical  Characteristics. — The  disease  is  essentially  an  affection  of 
fetal  life.  By  far  the  greater  number  of  cases  die  in  iitero  or  shortly  after 
birth.  Most  of  those  who  survive  die  in  childhood.  A  few  reach  adult 
life.  In  a  limited  number  of  cases  the  disease  has  appeared  to  commence 
shortly  after  birth.     These  constitute  the  dwarfs  known  as  micromelic. 

The  deformities  are  characteristic.  Both  the  upper  and  the  lower 
extremities  are  symmetrically  shortened.  The  arm  is  shorter  than  the 
forearm;  the  thigh  shorter  than  the  leg.  The  lower  limbs  are  bent,  an 
exaggeration  of  normal  curves.  The  development  of  the  trunk  is  about 
normal.  The  enlargement  of  the  head  is  characteristic.  It  may  suggest 
hydrocephalus.  The  head  is  not  only  large;  it  is  also  rounded  with  exag- 
gerated parietal  and  frontal  bosses.  The  features  are  large  and  coarse, 
especially  the  nose,  which  is  depressed  at  its  root  and  rounded  at  its  point 
with  flaring  nostrils.  There  is  lordosis  affecting  the  lumbar  vertebra  and  in 
females  contraction  of  the  pelvis.  The  hand  is  small  and  square,  the  fingers 
short,  of  about  the  same  length  and  spreading — a  deformity  which  has 
been  designated  the  trident  hand.  The  scapulae  are  short.  The  muscles  are 
usually  well  developed.    The  genital  organs  are  normal.    Many  of  the  sub- 


1406  MEDICAL  DIAGNOSIS. 

jects  of  this  disease  are  obese.  The  mental  powers  are  as  a  rule  good;  in 
some  of  the  reported  cases  defective.  Comby  thinks  it  probable  that  the 
court  dwarfs  were  achondroplasiacs  as  they  are  apt  to  be  very  intelligent. 

The  direct  diagnosis  of  achondroplasia  is  unattended  with  difficulty. 

It  is  to  be  differentiated  from  rickets,  of  which  it  was  at  one  time 
regarded  as  a  prenatal  type  by  the  skeletal  changes  which  do  not  involve 
the  trunk  and  are  wholly  dissimilar  in  the  extremities  and  from  cretinism, 
of  which  it  was  formerly  considered  a  fetal  form  by  the  higher  degree  of 
intelligence,  the  peculiar  deformities  of  the  long  bones  which  are  shortened 
and  of  I'elatively  great  thickness  in  the  shaft  and  by  the  fact  that 
improvement  does  not  follow  the  administration  of  thyroid  extract. 


XV. 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  MUSCLES. 

I.  MYOSITIS. 

Definition. — Inflammation  of  the  skeletal  muscles. 
Primary  inflammation  of  the  muscles  may  occur  as  an  acute,  subacute 
or  chronic  disease.     The  following  forms  are  recognized: 

1.  Infectious  Myositis. — This  form  is  very  common  in  Japan.  It 
may  affect  one  or  many  muscles.  Of  32  cases  studied  bacteriologically 
by  Miyake,  2  yielded  negative  results;  27  yielded  a  pure  culture  of  the 
staphylococcus  pyogenes  aureus;  2  the  cultures  of  the  albus  and  aureus 
and  1  the  streptococcus.  The  onset  is  sudden.  There  is  fever  often  high, 
great  depression,  induration  of  the  muscles  followed  by  abscesses  and, 
unless  the  pus  is  completely  evacuated,  sepsis. 

2.  Dermatomyositis. — Many  muscles  are  usually  affected.  The 
overlying  skin  is  inflamed  and  oedematous.  The  muscles  are  tender, 
painful  and  stiff  and  upon  palpation  feel  inelastic  and  dough-like.  The 
affection  progressively  involves  new  groups  of  muscles.  Upon  post-mortem 
examination,  the  muscle  substance  is  firm  but  fragile  and  the  seat  of 
serous  infiltration,  fatty  degeneration  and  proliferation  of  the  interstitial 
connective  tissue.  This  form  of  myositis  resembles  trichinosis,  from  which 
it  cannot  be  differentiated  except  by  the  microscopical  examination  of 
a  bit  of  the  affected  muscle. 

3.  Neuromyositis. — This  name  was  suggested  by  Senator  for  a 
group   of  cases   characterized   by  marked   disorders  of  sensation. 

4.  Polymyositis  Hemorrhagica. — These  cases  present  the  clinical 
phenomena  of  dermatomyositis  but  to  these  are  added  grave  circulatory 
symptoms  due  to  the  implication  of  the  myocardium  in  the  process.  The 
muscles  show  more  or  less  extensive  interstitial  hemorrhages.  This 
variety  is  extremely  rare. 

5.  Myositis  Ossificans. — Two  forms  are  described,  a  local  and  a 
progressive.  The  first  affects  a  limited  muscle  mass  and  is  stationary. 
The  second  develops  early  in  life,  advances  by  irregularly  recurring 
attacks  and  progressively  involves  many  muscle  groups.     The  number 


THE  MYOPATHIES. 


U07 


of  boys  who  suffer  from  this  affection  appears  to  be  five  times  as  great  as 
that  of  girls.  It  is  commonly  first  recognized  in  late  infancy  or  childhood. 
The  muscles  of  the  neck,  trunk  and  upper  extremities  are  usually  involved, 
the  hands  and  lower  extremities  escaping.  The  masseters  are  sometimes 
affected.  The  other  muscles  of  the  face  escape.  The  process  by  which 
the  ossification  occurs  consists  in  cyanotic  congestion  in  a  localized  area 
of  the  tissues  which  upon  pressure  are  found  to  be  of  doughy  consistency 
and  very  painful.  After  repeated  attacks,  bony  nodules  are  found  within 
the  muscles  at  the  seat  of  the  trouble  and  exostoses  develop.  Impairment 
of  function  follows  and  muscular  movements  are  greatly  restricted.  The 
general  health  is  not  usually  disturbed.    There  is  no  fever.    Developmental 


Fig.  408. — Showing  exostoses,  and  full  amount  of  abduction — Walker. 

defects  are  common.  They  include  microdactylia,  ankylosis  of  the  inter- 
phalangeal  articulations,  hallus  valgus  and  other  deformities  of  the  great 
toe  and  malformations  of  the  genital  organs.  Warren  Walker,  to  whose 
article  I  am  indebted  for  some  of  the  above  facts,  has  recently  reported 
a  most  interesting  case.     The  disease  is  very  rare. 


II.  THE    MYOPATHIES. 

By  this  term  we  understand  essential  changes  in  the  muscles,  marked 
by  atrophy  and  loss  of  power,  and  not  depending  on  changes  in  the  central 
or  peripheral  nervous  system. 

Pathology. — In  the  pure  myopathies  the  changes  are  confined  to 
the  muscles.     There  is  atrophy  of  the  muscular  fibres,  sometimes  asso- 


1408  MEDICAL  DIAGNOSIS. 

ciated  with  or  preceded  by  swelling  in  some  of  them.  The  nuclei  of  the 
fibres  may  increase,  and  there  is  proHferation  of  the  fibrous  tissue.  Fatty 
deposits  occur,  and  ultimately  the  muscular  fibres  show  spHtting  and 
longitudinal  striations,  with  the  formation  of  vacuoles.  The  cause  is  not 
definitely  known,  but  there  is  probably  a  congenital  defect  of  development 
or  of  nutrition  of  the  essential  elements  of  the  muscles.  As  a  rule  the 
spinal  cord  and  nerves  are  normal,  although  is  some  cases  the  motor  nerve- 
endings  are  involved;  and  a  question  arises  whether  indeed  there  is  not 
a  juvenile  type  which  is  not  a  pure  myopathy,  but  depends  upon  a  periph- 
eral neuritits  or  nerve  dystrophy.  The  form  known  as  the  Charcot- 
Marie-Tooth  type  is  apparently  not  a  pure  myopathy  at  all,  but  rather 
a  muscular  atrophy  dependent  upon  a  degeneration  of  the  peripheral 
nerves — a  so-called  primary  neuritic  atrophy,  as  shown  in  autopsies  made 
by  Virchow  and  others.  A  well-marked  type  is  that  in  which  some  of  the 
muscles  undergo  an  increase  in  bulk,  but  this  is  a  pseudohypertrophy, 
in  which  the  over-growth  is  not  in  the  muscular  elements  proper.  Various 
other  types  of  the  affection  occur,  which  are  rather  clinical  than  anatom- 
ical; in  fact,  these  types  are  probably  only  varieties  of  the  same  degen- 
erative process.  It  is  proper  to  note  that  some  observers  believe  that 
most  of  these  cases  are  dependent  upon  a  dystrophy  of  the  nerve-endings. 
The  pathology  of  the  myopathies  is  still  somewhat  obscure. 

Symptoms. — The  onset  usually  occurs  early  in  life,  and  may  be  hered- 
itary or  familial.  The  trunk  muscles  are  affected  early  in  the  disease, 
and  the  arms  and  thighs  also  suffer.  There  is  an  absence  of  fibrillary 
twitching  in  the  muscles,  and  the  complete  reactions  of  degeneration  are 
not  seen.  Much  refinement  of  description  has  been  indulged  in.  The 
commonest  types  are  as  follows: 

A  juvenile  type,  or  scapulohumeral  form,  which  appears  in  children, 
and  in  which  the  muscles  of  the  shoulder  and  arm  are  first  affected. 

The  facio-scapulo-humeral  type,  in  which,  as  the  name  implies,  the 
muscles  of  the  face,  shoulder  and  arm  are  especially  involved.  It  differs 
little  from  the  former,  chiefly,  in  fact,  in  the  affection  of  the  face. 

The  peroneal  or  leg  type,  in  which  the  lower  extremities,  especially 
the  peroneal  muscles,  are  implicated. 

Pseudomuscular  hypertrophy,  in  which  some  of  the  muscles,  espe- 
.cially  those  of  the  calf,  are  enlarged,  while  others,  especially  of  the  back 
and  arms,  are  atrophied.  The  enlargement  of  the  calf  muscles  is  not  a 
true  hypertrophy,  but  is  due  largely  to  a  deposit  of  fat. 

The  Charcot-Marie-Tooth  type,  or  primary  neuritic  atrophy,  in 
which  the  distal  muscles  of  the  arms  and  legs  especially  suffer,  and  in 
which  there  is  fibrillation  along  with  the  atrophy,  often  with  preservation 
of  the  knee-jerks,  without  contractures  and  occurring  as  a  familial  affec- 
tion.    As  already  said,  this  type  is  not  a  pure  myopathy. 

The  results  of  these  various  atrophies,  or  dystrophies,  are  various 
forms  of  paralysis.  Wasting  may  become  extreme,  with  consequent  com- 
plete loss  of  power.  The  trunk  muscles  are  so  affected  in  some  cases  that 
extreme  lordosis  occurs.  When  the  face  is  attacked  we  see  the  so-called 
''myopathic  face,"  in  which  the  oral  muscles  are  especially  involved. 
The  muscles  of  mastication  and  deglutition,  as  well  as  of  the  eye,  are  not 


THOMSEN'S  DISEASE.  1409 

affected.  When  the  arm  and  shoulder  muscles  are  involved  there  results 
great  weakness  in  the  upper  extremities,  with  some  deformities  of  the 
hands.  In  the  lower  limbs  the  thigh  muscles  may  be  so  wasted  and  weak- 
ened that  the  patient  cannot  stand,  much  less  walk;  and  in  the  legs  the 
destruction  of  the  muscles  causes  various  forms  of  club-foot.  In  extreme 
cases  no  particular  "type"  is  presented,  but  the  patient  has  extensive 
atrophy  of  all  the  limbs  and  of  many  of  the  trunk  muscles,  and  may 
become  a  so-called  ''living  skeleton."  In  the  pseudohypertrophic  form  the 
enlarged  calves  stand  out  conspicuously,  and  are  hard  and  brawny  to  the 
touch;  but  the  patient  usually  presents  wasting  of  the  arms  and  trunk. 
He  shows  a  special  difficulty  in  rising  from  the  floor,  climbing  with  his 
two  hands,  as  it  were,  up  his  legs.  In  the  myopathies  there  is  no  involve- 
ment of  sensation,  nor  of  the  bladder  or  bowel,  nor  of  the  mental  faculties. 
The  affection  is  chronic  and  incurable. 

Diagnosis. — The  student  or  practitioner  need  not  be  so  much  con- 
cerned to  make  out  ''types"  or  varieties  as  to  establish  a  general  diagnosis 
of  muscular  dystrophy.  For  this  purpose  the  history  of  the  case  is  first 
considered,  and  then  the  peculiar  atrophy,  associated  perhaps  in  some 
muscles  with  pseudohypertrophy,  without  fibrillation,  reactions  of  degener- 
ation, sensory  changes  or  incontinence.  These  points,  some  or  all, 
serve  to  distinguish  the  affection  from  the  progressive  muscular  atrophy 
of  adults,  or  from  acute  multiple  neuritis,  or  from  myelitis  as  the  case  may 
be.  From  infantile  paralysis  or  acute  anterior  poliomyelitis  the  disease 
is  distinguished  by  the  slow  onset,  its  progressive  character  and  wide 
extent,  the  preservation  of  the  electrical  responses  to  an  advanced  stage, 
and  the  general  history. 

The  primary  neuritic  atrophy  of  Charcot,  Marie,  and  Tooth  presents 
some  special  points  which  give  it  a  place  almost  unique.  It  somewhat 
resembles  progressive  muscular  atrophy,  also  multiple  neuritis.  It  is  dis- 
tinguished, however,  by  being  often  a  familial  affection,  beginning  rather 
early  in  life,  very  chronic,  and  the  wasted  muscles  are  the  distal  groups 
of  the  extremities.  Fibrillation  is  common  and  foot-drop  is  seen.  The 
knee-jerks  may  be  preserved,  and  sensory  symptoms  are  wanting. 

In  the  cerebral  palsies  of  children  we  see  hemiplegia,  diplegia,  para- 
plegia and  rarely,  monoplegia.  The  paralysis  is  spastic,  with  exaggerated 
tendon  reflexes  and  without  true  muscular  atrophy;  and  in  some  cases 
there  are  cerebral  symptoms,  as  epilepsy  and  various  grades  of  idiocy. 

III.  THOMSEN'S  DISEASE:   MYOTONIA. 

This  is  a  bizarre  affection,  seen  by  but  few  persons,  and  described 
by  most  writers  in  terms  exactly  alike.  It  was  first  reported  by  a  Dr. 
Thomsen,  for  whom  it  is  named,  and  in  whose  family  it  seems  to  have 
prevailed  to  an  unprecedented  extent.  As  it  is  claimed  to  be  congenital, 
hereditary,  and  familial  it  is  sometimes  called  7nyotonia  congenita. 

Pathology. — The  disease  has  no  pathology  that  anyone  has  yet  dis- 
covered.    But  little  significance  is  to  be  attached  to  such  slight  changes 
as  are  reported  by  Erb,  Dejerine,  and  a  few  others,  and  which  seem  to 
consist  in  nothing  but  a  little  increase  in  size  of  the  muscle  fibres. 
89 


1410  MEDICAL  DIAGNOSIS. 

Symptoms. — Muscular  rigidity,  or  cramp,  occurring  on  voluntary- 
movements  or  attempts  at  such  movements,  is  the  chief  symptom,  A 
condition  of  tonic  spasm  sets  in  when  the  patient,  especially  after  a  long 
rest,  attempts  to  use  certain  muscles  or  groups  of  muscles.  These  spasms 
do  not  seem  to  be  painful;  at  least,  pain  is  not  insisted  on  by  some  writers. 
In  some  cases  a  few  muscles  only  are  involved;  in  others  almost  the  whole 
musculature  of  the  body  is  thrown  into  tonic  spasms.  There  is  no  loss  of 
consciousness. 

Some  effort  has  been  made  to  show  that  the  muscles  present  a  special 
or  so-called  "myotonic  reaction"  to  electricity.  This  consists  in  a  state, 
more  or  less  transient,  of  slight  contracture  and  tonic  spasm,  which  varies 
somewhat  with  the  kind  of  current  used  and  with  its  strength.  With 
faradism  there  is  a  tonic  contracture  of  long  duration;  with  galvanism 
only  labile  currents  produce  contractures,  which  are  sluggish  in  character. 
There  is  also  increase  of  mechanical  irritability,  which  is  shown  by  the 
muscle  giving  a  sluggish  tonic  contraction  on  percussion,  especially  at 
the   point   struck. 

Diagnosis. — This  is  not  difficult,  for  the  disease  is  like  none  other. 
An  attempt  should  always  be  made  to  exclude  hysteria. 

IV.  PARAMYOCLONUS  MULTIPLEX. 

Friedreich,  in  1881,  described  a  disease  which  has  been  dubbed  with 
this  cumbersome  name.  Few  persons  seem  to  have  seen  it,  or  anything 
like  it;  and  some  good  authorities  deny  its  existence.  It  has  no  recognized 
cause  or  morbid   anatomy. 

Symptoms. — As  described  by  most  writers,  the  disease  is  manifested 
by  a  series  of  short,  quick,  irregular,  shock-like  contractions  of  the 
muscles  of  the  extremities  and  trunk.  The  face  usually  escapes.  The 
contractions  are  not  unlike  those  caused  by  electric  shocks.  The  intelli- 
gence, the  sensory  system,  and  the  sphincters  are  not  involved. 

Diagnosis. — Hysteria  is  not  to  be  ignored.  Lloyd  refers  to  aggra- 
vated cases  of  hysterical  tremor,  with  coarse  irregular  jerkings,  which 
suggested  to  him  the  picture  of  paramyoclonus  as  drawn  in  some  books. 
These  are  probably  the  patients  who  get  well. 

The  chorea  electrica  of  Bergeron,  Henoch  and  others  is  probably  a 
true  chorea,  although  cases  of  it  have  been  described  as  paramyoclonus 
multiplex.  Dubini's  chorea,  also  called  electrical,  is  very  rare,  and  is 
said  to  be  associated  with  fever,  muscular  atrophy,  and  paralysis.  It  is 
an  infectious  disease,  seen  mostly  in  Italy. 

V.   MYASTHENIA  GRAVIS. 

The  disease  to  which  Jolly  gave  this  name  may  be  said  to  be  still  on 
trial.  Both  clinically  and  pathologically  it  is  as  yet  a  subject  of  dispute. 
It  may  be  defined  as  a  syndrome  in  which  there  is  rapid  exhaustion  of  the 
muscles  supplied  by  the  bulb,  as  well  as  of  some  of  the  eye  muscles  and 
muscles  of  the  extremities.  The  tendency  is  towards  a  fatal  termination. 
The  disease  is  also  called  asthenic  bulbar  palsy. 


MYASTHENIA  GRAVIS.  1411 

Pathology. — Almost  by  unanimous  consent  the  Germans,  who  have 
done  most  to  secure  the  recognition  of  this  syndrome,  declare  that  the 
anatomical  examinations  in  the  brain  and  cord  are  negative.  Maier  claimed 
to  have  found  alterations  in  the  anterior  roots  of  the  spinal  nerves,  and 
Marinesco  and  Widal  reported  changes  in  the  ganglion  cells^  but  Oppen- 
heim  denies  the  validity  of  these  findings.  In  America,  anatomical 
studies  have  been  made  by  Hun,  Burr  and  McCarthy,  and  others,  and 
there  is  a  disposition  to  see  changes  in  the  thymus  gland  and  lymphoid 
infiltration  in  the  muscles  as  the  true  causes  of  the  disease.  The  subject 
is  still  far  from  settled. 

Symptoms. — Rapid  exhaustion  of  certain  muscles  or  groups  of  muscles 
seems  to  be  the  cardinal  symptom.  The  patient  may  begin  using  the 
muscles  with  normal  vigor,  but  they  rapidly  exhaust,  sometimes  with 
alarming  results.  Thus  there  occur  dysarthria,  dysphonia,  dysphagia, 
dyspnoea,  ptosis,  in  short,  the  evidences  of  paralysis  of  muscles  supplied 
by  the  third,  fifth,  seventh,  tenth  and  twelfth  nerves.  Along  with  this 
the  extremities  are  often  involved,  and  the  respiratory  muscles  weak- 
ened, so  that  the  prostration  of  the  patient  may  be  extreme  and  danger- 
ous. These  attacks  may  be  paroxysmal,  excited  especially  by  voluntary 
use,  and  in  fact  the  progress  of  the  disease  is  often  by  stages. 

Jolly  observed  the  "myasthenic  reaction"  to  faradic  stimulation,  by 
which  is  meant  the  rapid  exhaustion  of  the  muscles  by  the  faradic  current. 
This  reaction  is  claimed  by  some  to  be  pathognomonic.  There  is  no  mus- 
cular atrophy;  no  fibrillation;  no  involvement  of  sensations;  no  optic 
atrophy;  no  paralysis  of  the  bladder  or  bowel;  no  abolition  of  the  tendon 
reflexes  (as  a  rule) ;  no  affection  of  consciousness.  Hun's  patient,  however, 
had  attacks  of  extreme  weakness,  or  collapse,  in  which  the  mind  was  not 
clear  and  the  heart's  action  was  depressed.  The  attacks  resembled  angina 
sine  dolore,  or  even  heart  block. 

Cases  vary  in  the  distribution  of  the  symptoms.  In  some  patients 
the  bulbar  symptoms  are  the  most  marked;  in  others  the  exhaustion  is 
more  wide-spread.  Some  cases  extend  over  a  period  of  years,  and  the 
disease  may  have  marked  remissions  and  exacerbations.  A  fatal  result 
is  to  be  apprehended. 

Diagnosis. — The  disease  resembles  Landry's  paralysis,  except  in  its 
tendency  to  remission  and  in  the  absence  of  evidence  of  organic  central 
disease.  It  is  probable,  however,  that  some  reported  cases  are  allied  to, 
if  not  identical  with,  Landry's  disease. 

In  acute  anterior  poliomyelitis  the  evidence  of  organic  central  disease 
is  clear;  as  for  instance,  a  flaccid  paralysis  with  loss  of  the  tendon  reflexes 
and  with  the  reactions  of  degeneration.  The  disease  is  ushered  in  as  an 
acute  febrile  affection;  it  is  not  one  of  remissions  and  exacerbations,  and 
the  paralysis  is  obstinately  located,  as  a  rule,  in  one  limb  and  even  in  one 
set  of  muscles.  Bulbar  symptoms  are  not  common,  although  not  unnoted 
especially  in  epidemic   anterior  poliomyelitis. 

From  true  bulbar  palsy  the  asthenic  form  is  distinguished  especially 
by  the  history  and  the  absence  of  evidence  of  nuclear  disease.  In  the 
former  there  is  an  insidious  onset,  a  slow  course,  and  the  affected  muscles 
slowly  waste,  and  present  fibrillation  and  gradual  loss  of  power. 


1412  MEDICAL  DIAGNOSIS. 

Hysteria  may  closely  simulate  myasthenia  gravis.  The  exhaustion 
symptom  and  the  myasthenic  reaction  to  faradism  should  serve  to  dis- 
tinguish the  two  affections.  Hysteria  seldom  presents  bulbar  symptoms, 
although  there  may  be  aphonia,  globus,  oesophagismus,  and  retching. 
Hysterical  ptosis  is  not  unheard  of. 

It  is  necessary  to  utter  a  warning  against  placing  too  much  confidence 
in  the  exhaustion  symptom.  Something  very  like  it  can  be  seen  in  neuras- 
thenia; and,  in  fact,  a  weakened  muscle  from  whatever  cause  (as  in 
neuritis  or  dystroph}'-)  exhausts  rapidly  on  being  used.* 

'See  Campbell  and  Bramwell  for  a  critical  digest  of  myasthenia  gravis,  Brain,  1900. 


INDEX. 


A. 

Abdomen,  21 

imaginary  or  conventional  lines  of,  21 

natural  lines  of,  21 

palpation  in  examination  of,  97 

percussion  in  examination  of,  143 

quadrants  of,  23 

visceral  regions  of,  23 
Abdominal  dropsy,  1021 

viscera,  32 

topographical  anatomy  of,  32 
Abscess,  atheromatous,  1240 

in  appendicitis,  970 

mediastinal,  1084 

of  brain,  1262 

of  kidney,  1123 

of  liver,  999 

of  spleen,  1166 

pancreatic,  1016 

perinephric,  1123 

perirenal,  1123 

pulmonary,  1079 
Accessory  spasm,  1316 
Acetone,  292 

tests  for,  292 
Achondroplasia,  927,  1405 
Acidosis,  898 
Acrocyanosis,  1399 
Acromegaly,  1181,  1404 

shape  of  head  and  face  in,  396 

skeletal  changes  in,  403 
Acroparsesthesia,  584 
Actinomycosis,  773 

cutaneous,  775 

gastro-intestinal,  774 

joints  in,  408 

respiratory,  775 
Acute  polyarthritis  (see  Rheumatic  fever), 
746 

yellow  atrophy,  982 
Addison's  disease,  1178 
Adenolipomatosis,  932 
Adiposis  dolorosa,  932 

tuberosa  simplex,  931 
Adrenal  bodies,  diseases  of,  1178 
^gophony,  165 
Affenhand,  1325 
Agglutination  reaction,  246 
Agoraphobia,  596 
Aichmophobia,  596 
Albinism,  535 
Albuminuria,  285 

accidental,  286 

renal,  285 
Albumose,  287 
Alcoholic  intoxication,  876 

neuritis,  1350 
Alcoholism,  876 


Alcoholism,  acute,  877 

chronic,  876 

diagnosis  of,  878 

in  aged,  1288 

symptoms  of,  877 
Alkaptone  bodies,  293 
Alopecia,  547 
Amaurosis,  369 

hysterical,  373 
Amblyopia,  369 
Amenorrhoea,  556 
Amoebic  dysentery,  842 
acute  form,  843 
chronic  form,  843 
Amyloid  disease,  932 

of  intestines,  934 
of  kidney,  933 
of  liver,  934 
of  spleen,  934 
Amyloidosis,  932 

Amyotrophic  lateral  sclerosis,  1327 
Anacidity,  949 
Anaemia,  1133 

aplastic,  1139 

general,  1134 

idiopathic,  1137 

local,  1134 

pernicious,  1137 

post-hemorrhagic,  1142 

primary,  1134 

progressive,  1137 

pseudo-,  1133 

renal,  1110 

secondary  or  symptomatic,  1141 

splenic,  1141,  1165 
Anaemic  headache,  569 
Anal  fistula  in  tuberculosis,  799 
Anamnesis,  the,  39 
Anasarca,  537 
Anencephalia,  10 
Aneurism,  1244 

arteriovenous,  1259 

cirsoid,  1244 

congenital,  1259 

cylindroid,  1244 

dissecting,  1244 

false,  1244 

fusiform,  1244 

headache  in  intracranial,  571 

intracranial,  1278 

of  abdominal  aorta,  1257 

of  aorta,  1244 

of  coeliac  axis  and  its  branches,  1258 

of  heart,  1196 

of  thoracic  aorta,  1246 
cough  in,  1248 
course  of,  1256 
diagnosis  of,  1253 

1413 


1414 


INDEX. 


Aneurism  of  thoracic  aorta,  dysphagia  in, 
1249 
dyspnoea  in,  1248 
hemorrhage  in,  1247 
pain  in,  1248 
physical  signs  of,  1249 
prognosis  of,  1256 
symptoms  of,  1246 
sacculated,  1244 
true,  1244 
Aneurismal  varix,  1244 
Angina,  crural,  1243 
Ludovici,  495 
pseudodiphtheritic,  713 
Vincent's,  713 
Angina  pectoris,  1233 

functional,  1234 
neurotic,  1234 
pseudo-,  1234 
toxic,  1235 
vera,  1233 
Angina  sine  dolore,  1234 
Angiocholitis,  chronic,  985 
Angiomata  of  liver,  1009 
Angioneurotic  oedema,  1400 
Anidrosis,  536 
Ankylostomiasis,  870 
Anorexia,  500 
Anterior  crural  nerve,  1363 

thoracic  nerves,  1356 
Anthrax,  776 

diagnosis  of,  779 
external,  777 
internal,  778 
Anuria,  551 

Aorta,  aneurism  of,  1244 
Aortic  incompetence,  1214 
insufficiency,  1214 
obstruction,  1217 
regurgitation,  1214 
stenosis,  1217 
Aphasia,  326 

Aphonia  of  professional  voice-users,  1390 
Aphthous  fever.  839 
Apoplexy,  1268' 

pulmonary,  1063 
Appearance,  390 
Appendicitis,  964 
abscess  in,  970 
course  of,  970 
diagnosis  of,  971 

nature  of  pathological  process  in,  965 
prognosis  of,  972 
symptoms  of,  965 
table  of  natural  history  of,  966 
Appendix  vermiformis,  33 
Appetite,  500 

loss  of,  500 
Aran-Duchenne  type  of  muscular  atrophy, 

1325 
Arcus  senilis,  359 

Argyll-Robertson  symptom  in  general  pare- 
sis, 1286 
Arithmomania,  1373 
Arrhythmia,  1237 
Arsenical  poisoning,  884 
Arteries,  diseases  of,  1239 


Arteries,  tuberculosis  of,  802 
Arteriosclerosis,  376,  1239 
Arteriovenous  aneurism,  1259 
Arthritis,  gonorrhoeal,  407 

infective,  406 

in  hemorrhagic  diseases,  407 

primary,  405 

tuberculous,  407 
Arthritis  deformans,  406,  908 
diagnosis  of,  910 
Heberden's  nodes  in,  909 
in  children,  910 
monarticular  form,  909 
morbid  anatomy  of,  908 
progressive  polyarticular  form,  909 
vertebral  form,  910 
Ascariasis,  866 
Ascaris  lumbricoides,  866 
Ascites,  539,  1021 
Ascitic  fluid,  adiposus,  1022 
characters  of,  1021 
chylous  and  chyliform,  1022 
inflammatory,  1022 
milky,  non-fatty,  1022 
Astasia-abasia,  416,  1382 
Asthenic  bulbar  palsy,  1410 
Asthma,  bronchial,  1058 

hay,  1037 

nervous,  1058 
Ataxia,  cerebellar  hereditary,  1296 

hereditary,  1334 

locomotor,  1328 
Ataxic  gait,  1329 

paraplegia,  1333 
Atheromatous  abscess,  1240 
Athyria,  1174 

Atrophic  paralyses,  the,  412 
Atrophy,  acute  yellow,  982 

degenerative  muscular,  410 

hemifacial,  1401 

infantile  nuclear,  1292 

of  hair,  547 

of  heart,  1197 

of  muscles,  409 

of  thymus,  1168 

progressive  muscular,  1325 
Attitude,  415 
Auditory  irritation,  1313 

nerve,  1312 
Auscultation,  147 

methods  of,  147 

of  circulatory  organs,  166 

of  oesophagus,  495 

of  veins,  192,  193 

of  voice,  164 

technic  of,  149 
Auscultatory  percussion,  130 
Autointoxication,  896 

from  extensive  abolition  of  function  of 
skin,  898 

gastro-intestinal,  896 

retention,  898 

B. 

Babinski  reflex,  1327 
Bacelli's  sign,  166,  1095 
Bacillary  dysentery,  756 


INDEX. 


141") 


Bacillus,  anthracis,  776 

Eberth's,  715 

fusiformis,  713 

Klebs-Loffler,  706 

leprae,  780 

mallei,  771 

pestis,  757 

tuberculosis,  784 

typhosus,  606 

xerosis,  706 
Backache,  574 
Bacterismia,  263 
Banti's  disease,  1165 
Barlow's  disease,  925 
Basedow's  disease,  1171 
Bednar's  aphtha,  491 
Belching,  503 
Bell's  mania,  1288 

palsy,  1310 
Beri-beri,  761 

diagnosis  of,  763 

forms  of,  762 
Bile-ducts,  cancer  of,  989 
Bile-passages,  diseases  of,  983 
Bilharziasis,  856 
BiHary  colic,  992 
BiUous  typhoid,  836 
Black  vomit  in  yellow  fever,  751 
Bladder,  38 

tuberculosis  of,  801 
Bleeders'  disease,  1158 
Blepharospasm,  357 
Blood,  229 

bacteriological  examination  of,  245 

character  of,  in  chlorosis,  1135 
in  dengue,  704 
in  diabetes,  917 
in  Hodgkin's  disease,  1151 
in  lymphatic  leukaemia,  1146 
in  myelogenous  leukaemia,  1145 
in  pernicious  anaemia,  1138 

ductless  glands  and,  diseases  of,  1133 

estimating  specific  gravity  of,  243 
time  of  coagulation  of,  243 

examination  of,  general  results  of,  252 
in  malarial  fever,  263 
methods  of,  229 

in  stools,  520 

opsonic  index  of,  249 

tests  for  diabetes,  251 
Blood-cells,  differential  counting  of,  233 

red,  in  urine,  272 
nucleated,  256 
number  of,  254 
Blood-platelets,  257 

enumeration  of,  237 
Blood-vessels  of  hver,  affections  of,  997 
Blue  line  on  gums  in  lead  poisoning,  882 
Body,  398 

form  and  nutrition  of,  398 

weight  of,  399 
Bones,  402 
Brachial  plexus,  1355 
Bradycardia,  467,  1238 
Brain,  abscess  of,  1262 

diagnosis  of  echinococcus  of,  865 

diseases  of,  1260 


Brain,  parasites  in,  1283 

syphilis  of,  1284 

tumors  of,  1279 

headache  in,  570 
Break-bone  fever,  702 
Breast,  chicken,  403 
Breathing,  152 

bronchial,  in  disease,  155 
in  health,  152 

bronchovesicular,  154 

tracheal,  152 

vesicular,  in  disease,  156 
in  health,  153 
Bremer's  test  for  diabetes,  251,  917 
Bright's  disease,  acute,  1114 

chronic,  1117 
Broadbent's  sign,  1205 
Bronchi,  diseases  of,  1051 
Bronchial  asthma,  1058 
Bronchiectasis,  1055 
Bronchitis,  1051 

acute,  1051 

capillary,  1051,  1071 

chronic,  1053 

dry,  1053 

fibrinous,  1054 

plastic  or  croupous,  1054 

putrid,  1054 
Bronchocele,  1170 
Bronchopneumonia,  1071 
Bronchorrhagia,  1063 
Bronchorrhoea,  1054 
Bronchorrhoea  serosa,  1054 
Brown-Sequard  paralysis,  1340 
Bruit  de  diable,  1135 
Bubonic  plague,  757 
Buhl's  disease,  1160 
Bulbar  palsy,  1298 

asthenic  form,  1410 
pseudo-,  1300 


Cachexia,  392 

Cachexia  strumipriva,  1177 

Caecum,  33 

Caisson  disease,  1346 

Calculi,  binary,  522 

pancreatic,  523,     1018 

renal,  1124 

ureteral,  1125 

urinary,  277 
Cammidge's  test,  294 
Cancer  (see  Carcinoma) 
Capillary  pulse,  473 
Capsular  cirrhosis  of  authors,  1008 
Caput  Medusae,  545 

succedaneum,  9 
Carcinoma  hepatis,  1010 

intestinal,  975 

of  bile-ducts,  989 

of  stomach,  944 

renal,  1131 

ventriculi,  944 
Cardiac  cycle,  168 

inadequacy  of  the  obese,  1193 

neuroses,  1235 


1416 


INDEX. 


Cardiac  cycle,  orifice,  spasm  of,  950 
Carphologia,  598 
Case-taking,  39 

analytical  method,  40 

synthetic  method,  39 
Catalepsy.  599 
Cataract',  369 
Catarrh,  acute  nasal,  1035 

autumnal,  1037 

chronic  gastric,  938 

chronic  nasal,  1036 

dry  nasal,  1037 

suffocative,  1074 

summer,  1037 
Catarrhe  sec,  1053 
Catarrhus  aestivus,  1037 
Cauda  equina,  affections  of,  1347 
Causalgia,  1350 
Cellulitis  of  the  neck,  495 
Cephalalgia,  568 
Cephalhaematoma,  9 
Cerebellar  hereditary  ataxia,  1296 
Cerebellum,  diseases  of,  1295 
Cerebral  abscess,  headache  in,  570 

disease,  regional  diagnosis  of,  324 

hemorrhage,  1267 

parsesthesise,  583 

softening,  1271 
Cerebrospinal  fever,  730 

anomalous  forms  of,  733 
complications  and  sequels  of,  734 
diagnosis  of,  735 
prognosis  of,  737 

symptoms  of  ordinary  forms  of,  731 
Cerebrospinal  fluid,  304 
Cer\ical  nerve,  1353 

plexus,  1353 
Cestodes,  diseases  due  to,  858 

intestinal,  858 

^dsceral,  862 
Chalazion,  356 
Charcot-!^Iarie-Tooth     type     of     muscular 

atrophy,  1368 
Charcot's  joints,  580 
Chattering  teeth,  1310 
Chejme-Stokes  respiration,  439 
Chicken  breast,  403 

in  rickets,  928 
Chicken-pox  (see  Varicella),  668 
Chills  in  typhoid  fever,  611 
Chloroma,  1147 
Chlorosis,  1134 

florida,  1135 

rubra,  1135 
Cholangitis,  chronic  catarrhal,  985 

suppurative,  985 
Cholecystitis,  acute,  987 

chronic,  988 
Cholelithiasis,  989 

diagnosis  of,  996 

prognosis  of,  997 

symptoms  of,  991 
Cholera,  752 

Asiatic,  752 

complications  and  sequels  of,  755 

diagnosis  of,  755 

infectiosa,  752 


Cholera,  sicca,  754 

symptoms  of,  754 

typhoid,  755 
Chondrodvstrophia  fcetalis,  927,  1405 
Chorea,  1369 

chronic  progressive,  1374 

course  of  attack,  1371 

Dubini's,  1410 

electrica,  1410 

epidemic,  1372 

habit,  1372 

hereditary,  1374 

hypotheses  of,  1370 

insaniens,  1371 

major,  1372 

ocular  phenomena  in,  1371 

ordinary  form,  1370 

paralytic,  1370 
Choreiform  affections,  the,  1372 
Chromidrosis,  536 

Chronic  intoxications,  diagnosis  of,  876 
Chvostek's  symptom,  591 
Chylous  fluids,  304 
Cicatrices,  489,  543 
Circulation,  460 

Circulatory  derangements  in  exophthalmic 
goitre,  1173 
of  kidneys,  1110 
of  lungs,  1061 
Circulatory  organs,  auscultation  of,  166 

diseases  of,  1183 
Circumflex  nerve,  1357 
Cirrhosis  of  liver,  1005 

of  lung,  1075 
Clasp-knife  rigidity,  1328 
Claustrophobia,  596 
Clavdcles,  12 
Cla\nas  in  hysteria,  1380 
Claw  hand  (main  en  griffe),  1325 
Clinical  charts,  58 
Cocaine-bug,  881 
Cocainism,  881 
Cocomania,  881 
Coin  percussion,  140 
Cold,  "hay"  or  "rose,"  1037 

in  head,  1035 
CoUc,  biliary,  992 

renal,  1126 
Colica  pictonum,  882 
Colitis,  mucous,  516 
Colon,  33 

idiopathic  dilatation  of,  963 
Color  index,  242 
Coma,  598,  599 

from  poisonous  gases,  601 

in  apoplexy,  600 

in  cerebral  disease,  600 

in  convulsions,  601 

in  diabetes,  601 

in  epilepsy,  602 

in  hj-steria,  602 

in  infective  diseases,  600 

in  narcotic  poisoning,  601 

in  traumatism  of  head,  600 

in  uraemia,  601 
Coma  vigil,  598 
Common  bile-duct,  36 


INDEX. 


1417 


Common  bile-duct,  obstruction  of,  994 
Congenital  aneurism,  1259 

cystic  kidneys,  1130 

lesions  of  the  heart,  1230 
Conjunctiva,  357 

diphtheria  of,  358 

elevation  of,  358 

hemorrhage  beneath,  358 

inflammation  of,  357 

roughness  of,  358 

tumors  and  cysts  in,  358 

uric  acid  deposits  in,  358 
Consciousness,  derangements  of,  595 
Constipation,  512 

associated  symptoms  of,  515 

causes  of,  512 

constitutional  derangements  of,  515 
Constitutio  lymphatica,  1168 
Consumption  (see  Tuberculosis),  802 
Contracted  kidney,  1118 
Convulsions,  588 
Coprsemia,  897 
Coprolalia,  1373 
Cor  adiposum,  1193 

bovinum,  182,  1191 

villosum,  1198 
Cornea,  358 

Coronary    arteries,    embolism    and    throm- 
bosis of,  1188 
sclerosis  of  in  myocarditis,  1187 
Corpuscles,  estimation  of  the  relative  vol- 
ume of,  242 
Corrigan's  disease,  1214 

pulse,  1138 
Coryza,  1035 

periodic,  1037 
Cough,  444 

chnical  varieties  of,  448 

ear,  447 

in  aneurism  of  thoracic  aorta,  1248 

in  dentition,  448 

in  hysteria,  1383 

in  pneumonia,  719 

in  pulmonary  emphysema,  1067 

liver,  448 

mediastinal,  448 

nervous,  448 

pharyngeal,  447 

significance  of,  in  diagnosis,  446 

stomach,  447 
Courvoisier's  law,  995 
Cowpox,  663 

Cramp,  telegrapher's,  1389 
Cranial  nerves,  diseases  of,  1302 
Craniotabes,  in  rickets,  928 
Crepitant  rales,  160 
Crepitation,  94 
Crepitus  indux,  160 

redux,  160 
Cretinism,  1175 

shape  of  face  in,  396 
Croup,  false,  1041 

membranous,  1044 

spasmodic,  1041 

true,  1044 
Croupous  pneumonia,  714 
abscess  in,  724 


Croupous  pneumonia,  clinical  varities  of,  725 

complications  and  sequels  of,  722 

convalescence  in,  724 

delayed  resolution  of,  724 

diagnosis  of,  727 

endocarditis  in,  722 

gangrene  in,  724 

gastro-intestinal  and  other  abdom- 
inal complications  in,  723 

immunity  from,  715 

jaundice  in,  724 

meningitis  in,  723 

metapneumonic  empyema  in,  722 

meteorism  in,  724 

pathological  anatomy  of,  716 

pericarditis  in,  722 

physical  examination,  721 

pleurisy  in,  722 

prognosis,  728 

resolution  of,  724 

sjmiptoms  of,  717 

thrombosis  in,  723 
Crural  angina,  1243 
Cryoscopy,  294 
Curschmann's  spirals,  297 
Cutaneous  hemorrhages,  542 
Cyanosis,  441,  528 

in  pulmonary  emphysema,  1067 
Cyrtometry,  106 
Cystic  duct,  36 

obstruction  of,  994 
Cysticercus  cellulosae,  862 
Cysts,  305 

hydatid,  306 
of  kidney,  1129 
ovarian,  306 
pancreatic,  305,  1018 
Cytodiagnosis,  303 

D. 

Dalrymple's  sign,  1172 
Dare's  method,  237 

technic  of,  238 
"  Dead  fingers,  "  1398 
Deafness,  1312 
Decubitus,  412 
Defecation,  511 

painful,  518 
Degeneration,  senile,  1287 

stigmata  of,  346 
Delirium,  596 

acute,  1288 

grave,  1288 
Delirium  potu  suspenso,  877 

tremens,  597,  877 
Dengue,  702 
Dercum's  disease,  932 
Dermacentor  andersoni,  835 
Dermatographism,  528 
Desquamation,  543 
Dextrocardia,  1183 
Diabete  bronze,  918 
Diabetes,  912 

an  autointoxication,  898 

pancreatic,  1017 
Diabetes  insipidus,  921 


1418 


INDEX. 


Diabetes  mellitus,  913 
blood  in,  917 

carbohydrate  metabolism  in,   914 
coma  in,  918 
complications  of,  917 
diagnosis  of,  919 
multiple  neuritis  in,  1352 
pancreatic,  914 
phosphatic,  916 
pneumaturia  in,  916 
prognosis  of,  920 
symptoms  of,  915 
test  for  detection  of,  251 
tests  for  glucose  in,  915 
urine  in,  915 
Diacetic  acid,  292 
Diagnosis,  1 

definition  of,  1 
methods  of,  3 
object  of,  3 
requirements  of,  2 
Diaphragm  phenomenon,  69 
Diarrhoea,  515 

associated  symptoms  of,  517 
forms  of,  516 
Diarrhoeal  disorders  of  children,  954 
chronic,  955 
dietetic,  955 
inflammatory,  955 
toxic  and  bacterial,  955 
Diastasis  recti,  951 
Diathesis,  391 
Dicrotism,  471 
Dietl's  crises,  578,  1108 
Digestive  system,  477 

diseases  of,  935 
Diphtheria,  105 

antitoxin  treatment  of,  712 
complications  and  sequels  of,  711 
diagnosis  of,  712 
faucial,  707 
laryngeal,  708 
nasal,  708 
prognosis  of,  713 
symptoms  of,  707 
toxins  of,  707 
Diphtheritic  toxsemia,  710 
Diplegia  in  children,  1274 
Diplococcus  intracellularis  meningitidis,  730 

pneumoniae,  300,  714 
Dipsomania,  878 
Disease,  Addison's,  1178 
amyloid,  932 
Banti's,  1165 
Barlow's,  925 
Basedow's,  1171 
bleeder's,  1158 
Bright' s,  1114 
Buhl's,  1160 
caisson,  1346 
cerebral,  324 
chronic  valvular,  1214 
Corrigan's,  1214 
Dercum's,  932 
gall-stone,  989 
Gilles  de  la  Tourette's,  1372 
Glenard's,  972 


Disease,  Graves's,  1171 

Gull's,  1174 

Hanot's,  1008 

Hodgkin's,  1149 

hook-worm,  870 

Huntingdon's,  1374 

Little's,  1276 

Meniere's,  1313 

Mikulicz's,  1149 

Morvan's,  1337 

Paget's,  1402 

Parkinson's,  1393 

Parrv's,  1171 

Quicke's,  1400 

Raynaud's,  1397 

Schonlein's,  1155 

Thomsen's,  1409 

Werlhof's,  1154 

Winckel's,  1160 
Diseases     characterized     by     hemorrhage, 
1153 

combined  valvular,  1229 

constitutional,  904 

general  nervous,  1369 

hemorrhagic,  of  the  new-born,  1160 

nutritional,  922 

of  adrenal  bodies,  1178 

of  arteries,  1239 

of  bile-passages  and  gall-bladder,   983 

of  blood,  1133 

of  brain,  1260 

of  bronchi,  1051 

of  cerebellum,  1295 

of  circulatory  system,  1183 

of  cranial  nerves,  1302 

of  endocardium,  1207 

of  heart,  1183 

of  hepatic  artery,  999 

of  hepatic  veins,  999 

of  intestines,  952 

of  kidneys,  1107 

of  larynx,  1040 

of  liver,  977 

of  mediastinum,  1083 

of  muscles,  1406 

of  myocardium,  1183 

of  nervous  system,  1260 

of  nose,  1035 

of  pancreas,  1013 

of  pericardium,  1197 

of  peritoneum,  1021 

of  pleura,  1088 

of  pons,  1296 

of  portal  vein,  998 

of  pulmonary  tissue,  1061 

of  respiratory  system,  1035 

of  spinal  cord,  1318 

of  spinal  nerves,  1349 

of  spleen,  1161 

of  stomach,  935 

of  thymus  gland,  1167 

of  thyroid  gland,  1169 

vasomotor  and  trophic,  1397 
Dissecting  aneurism,  1244 
Distomiasis,  855 

hsemic,  856 

hepatic,  855 


INDEX. 


1419 


Distomiasis,  intestinal,  850 

pulmonary,  856 
Dittrich's  plugs,  1054 
Diverticula  of  oesophagus,  498 
pulsion,  499 
traction,  499 
Dracontiasis,  875 
Dracunculus  medinensis,  875 
Dreams,  603 
Dropsy,  537 

abdominal,  1021 

in  acute  nephritis,  1115 

in  chronic  nephritis,  1117 
Drusenfieber  of  Pfeiffer,  837 
Dubini's  chorea,  1410 

Dulness,  normal  and  abnormal  paraverte- 
bral triangles  of  relative,  1094 
Dum-dum  fever,  845 
Duodenal  ulcer,  956 

following  extensive  burns  of  skin, 
957 
Duroziez's  murmur,  1217 
Dysbasia  angiosclerolica,  1243 
Dyscrasia,  392 
Dysentery,  amoebic,  842 

bacillary,  756 
Dysmenorrhoea,  557 
Dysphagia  in  aneurism  of  thoracic  aorta, 

1249 
Dysphonia  of  professional  voice-users,  1390 
Dyspnoea,  440 

facies  of,  440. 

forms  of,  441 

from  aneurism  of  thoracic  aorta,  1248 

in  bronchial  asthma,  443 

in  bronchitis,  443 

in  emphysema,  443 

in  pneumonia,  719 

of  anaemia,  444 

in  pulmonary  emphysema,  1067 

of  fever,  444 

so-called  ursemic,  443 
Dysuria,  549 

E. 

Ear:  Eustachian  tube,  228 

external  auditory  canal,  227 

pharynx,  228 

tympanic  membrane,  228 
Eberth's  bacillus,  715 
Ecchymoses,  542 
Echinococcus  disease,  862 
Echokinesis,  1373 
Echolalia,  1373 
Ectopia  cordis,  1183 
Eczema  of  tongue,  489 
Ehrlich's  diazo  reaction,  293 

triple  stain,  231 
Einhorn's  bead  test  of  digestive  activity,  209 
Electric  strike,  900 
Electro-diagnosis,  337 
Elephantiasis  graecorum,  780 
Ellis  s  line  of  flatness,  1093 
Embolism,  air,  1065 

fat,  1065 
Embryocardia,  176 


Emotional  states,  595 

Emphysema,  collateral  vicarious,  1076 

pseudohypertrophic,  1066 

pulmonary,  1066 

subcutaneous,  542 

substantive,  1066 

vesicular,  1066 
Emprosthotonos,  415 

in  tetanus,  765 
Empyema,  1096 

necessitatis,  1097 
Encephalitis,  acute  hemorrhagic,  1261 

purulent  meningo-,  1262 
Encephalocele,  10 
Encephalopathy,  lead,  883 
Endarteritis  obliterans,  1240 
Endocarditis,  1207 

acute,  1208 

cerebral  form,  1210 

chronic,  1212 

fetal,  1230 

in  pneumonia,  722 

in  rheumatism,  748 

malignant,  1210 

mural,  1207 

recurrent  form,  1210 

septic  form,  1210 

simple,  1209 

typhoid  form,  1210 

valvular,  1207 

vegetative  or  verrucose,  1208 
Endocardium,  diseases  of,  1207 
Enteric  fever  (see  Typhoid  fever),  605 
Enteritis,  952 

catarrhal,  952 

diphtheritic,  953 

phlegmonous,  953 
Enteroliths,  523 
Enteroptosis,  972 
Ephemeral  fever,  833 
Epidemic  cerebrospinal  meningitis,  730 

parotitis  (see  Miunps),  694 

roseola,  687 
Epilepsy,  1374 

as  result  of  alcoholism,  878 

cortical,  partial,  or  symptomatic,  1377 

diagnosis  of,  1378 

Jacksonian,  1377 

major,  1375 

minor,  1377 

premonitory  forced  movements  in,  1376 

prognosis  of,  1379 

senile,  1287 

symptoms  of,  1375 
Epileptic  cry,  1376 

fit,  1376 
Epistaxis,  1039 
Erb's  paralysis,  1338 
Ergotismus,  895 
Eructations,  503 
Erysipelas,  737 

of  eyelids,  356 
Erysipeloid  of  Rosenbach,  840 
Erythema  infectiosum,  841 
migrans,  840 
serpens,  840 
variolosa,  650 


1420 


INDEX. 


Erythrocytes,  233,  253 

abnormal,  255 

enumeration  of,  233 
Erythromelalgia,  1399 
Ewald's  test  breakfast,  200 
Exanthemata,  the,  394 
Exophthalmic  goitre,  354,  1171 

tremor  in,  592 
Exophthalmos,  1172 
Exploratory  puncture,  300 
External  antipyretics,  435 
Extrahepatic  bile-passages,  36 
Extremities,  changes  in,  in  rickets,  929 
Exudates,  301 

bacteriological  examination  of,  302 

cytological  examination  of,  302 
Eye,  examination  of,  351 

motor  nerves  of,  1306 
Eyeball,  353 

protrusion  of,  353 

retraction  of,  354 

tension  of,  355 
Eyelids,  355 

marginal  inflammation  of,  355 

oedema  of,  355 


Face,  9 

regions  of,  9 
Facial  nerve,  1310 

spasm,  1311 
Facies,  392 

Hippocratica,  537,  1028 

myopathica,  411 

of  acute  peritonitis,  393 

of  enteric  fever,  393 

of  exophthalmic  goitre,  396 

of  hepatic  disease,  395,  1008 

of  leprosy,  397 

of  malaria,  395 

of  mental  and  nervous  disease,  397 

of  mumps,  394 

of  pneumonia,  393 

of  renal  disease,  395 

of  rickets,  395 

of  syphilis,  395 

of  tetanus,  394 
Fseces,  214 

chemical  examination  of,  219 

fermentation  of,  216 

microscopical  examination  of,  217 
Fallopian  tubes,  tuberculosis  of,  802 
Farcy,  771 
Farcy-buds,  772 
Farcy-pipes,  772 
Farre's  tubercles,  1010 

Fatty  degeneration,  acute,  of  the  new-born, 
1160 

heart,  1193 

infiltration,  1193 

hver,  1003 

overgrowth,  1193 
Febricula,  833 
Fetal  movements,  103 
Fever,  421 

aphthous,  839 


Fever,  atypical,  426 

bed,  431 

break-bone,  702 

causes  of,  421 

cerebrospinal,  730 

dum-dum,  845 

emaciation  of,  423 

ephemeral,  833 

estivo-autumnal,  852 

glandular,  837 

hay,  1037 

idiopathic,  424 

in  appendicitis,  969 

in  Hodgkin's  disease,  1152 

in  pneumonia,  717 

in  pyelitis,  1122 

in  typhoid  fever,  609 

lung,  714 

malarial,  846 

Malta,  759 

miliary,  838 

paratyphoid,  639 

paroxysmal,  431 

periodical,  431 

pulse  in,  422 

quartan,  852 

relapsing,  644 

respiration  in,  423 

rheumatic,  746 

Rocky  Mountain  spotted,  834 

scarlet,  670 

simple  continued,  833 

stages  of,  427 

symptoms  of,  422 

tertian,  851 

tick,  834 

type  in,  424 

typhoid,  605 

typhus,  641 

varieties  of,  424 

yellow,  750 
Fibrillation,  593 
Fibrinous  pneumonia,  714 
Fibromata  of  liver,  1009 
Fievre  charbonneuse,  777 
Fifth  cranial  nerve,  diseases  of,  1308 
Filaria,  forms  of,  872,  874,  875 
Filariasis,  872 
First-rib  sign,  1202 
Fish  poisoning,  893 
Flexner's  researches  i\i  cirrhosis  of  the  liver, 

1007 
Flint's  murmur,  1216 
Fluid  veins,  theory  of,  152 
Flukes,  diseases  due  to,  855 
Folie  de  toucher,  1373 
Fontanelles,  8 
Food  poisoning,  892 

examination  of  food  in  cases  sus- 
pected of,  896 
Foot-and-mouth-disease,  839 
Foreign  bodies  in  heart,  1195 
Fourth  disease,  689 
Fremitus,  95 

friction,  96,  162 

hydatid,  864 

rhonchal,  97 


INDEX. 


1421 


Fremitus,  vocal,  95 
Friction,  pericardial,  189 

pleuropericardial,  189 
Friction  fremitus,  96,  162 

sounds,  162 

subpleural,  164 
Friedreich's  ataxia,  1334 

sign,  in  adherent  pericardium,  1205 
Furunculosis,  543 

Gait,  417 

ataxic,  418,  1329 

festinating,  418 

hemiplegic,  417 

in  chorea,  418 

in  hereditary  ataxia,  1334 

of  sciatica,  418 

paraplegic,  417 

reeling  or  staggering,  418 

spastic,  417 

steppage,  417 

waddling,  417 
Gall-bladder,  36 

atrophy  of,  994 

cancer  of,  989 

diseases  of,  983 

dropsy  of,  994 

inflammation  of,  987 
Galloping  consumption,  804 
Gallop  rhythm,  176 
Gall-stone  disease,  989 
Gall-stones,  chemical  and  physical  charac- 
ters of,  990 

in  intestines,  996 

origin  of,  990 

quiescent  in  gall-bladder,  991 

symptoms      attending      passage      of, 
through  ducts,  992 

symptoms   caused   by   permanent   ob- 
struction of  ducts  by,  994 

ulcerative  lesions  caused  by,  995 
Gangrene  of  lung,  1080 
Gastralgia,  947 
Gastrectasis,  939 
Gastric  atony,  950 

catarrh,  chronic,  938 

neuroses,  946 

disorders  of  secretion,  947 
disorders  of  motor  functions,  949 
disorders  of  sensation,  946 

ulcer,  942 
Gastritis,  acute,  935 

chronic,  938 

diagnosis  of,  937 

dietetic,  937 

diphtheritic,  936 

infectious,  936 

parasitic,  936 

phlegmonous,  936 

toxic,  935 
Gastrodynia,  947 
Gastro-enteritis,  acute,  955 
Gastro-intestinal  symptoms  in  appendicitis, 
969 
in  pernicious  ansemia,  1138 


Gastroptosis,  950 
Gastrorrhagia,  509 
Gastroscopy,  197 
Gastrosuccorrhoea,  947 
Gastroxynsis,  nervous,  947 
General  nervous  diseases,  1369 

paresis,  1285 
Genito-urinary  system,  548 

tuberculosis  of,  800 
Gerhardt's  sign,  818 
German  measles,  687 
Gilles  de  la  Tourette's  disease,  1372 
Glanders,  771 
Glandular  fever,  837 
Glaucoma,  acute,  369 
Glenard's  disease,  972 
Globus  hystericus,  1380 
Glosso-pharyngeal  nerve,  1314 
Glossy  skin,  544 
Glycosuria,  290 

an  autointoxication,  898 
Goitre,  1170 

endemic,  1170 

exophthalmic,  1171 

facies  of  exophthalmic,  396 

sporadic,  1170 
Gonorrhoea,  831 
Gonorrhoeal  arthritis,  832 

endocarditis,  832 

infection,  832 

sepsis,  832 
Gout,  904 

acute,  905 

an  autointoxication,  898 

association  of,  with  plumbism,  884 

chronic,  905 

diagnosis  of,  906 

irregular,  906 

joints  in,  406 

poor  man's,  905 

retrocedent,  905 

suppressed,  905 

visceral,  915 
Gouty  kidney,  1118 
Gowers  haemocytometer,  137 
Graefe's  sign,  1172 
Grain  poisoning,  895 
Grand  mal,  1375 
Granular  kidney,  1118 
Graves's  disease,  1171 
Great  vessels,  30 
Grocco's  sign,  1094 
Guinea-worm  disease,  875 
Gullet,  26 
Gull's  disease,  1176 
Gummata  in  acquired  syphilis,  824 

of  Hver,  826 

of  lungs,  826 
Gums,  481 


H 


Habit  spasm,  1372 
Habitus  phthisicus,  810 
Hsematemesis,  509 
Hsematidrosis,  536 
Hsematocrit,  Deland's,  242 


1422 


INDEX. 


Hsematoma,  542 
Hsematuria,  552 
Haemocytometer,  237 

Gowers's,  237 

OUver's,  237 

Thoma-Zeiss,  233 
Hsemogenesis,  253 
Haemoglobin  estimation,  237.  255 
Hsemoglobina^mia,  255 
Haemoglobinometer,  Powers's,  240 

Meischer's,  239 

Oliver's,  240 

Tallqvist's,  238 
Hsemoglobinuria,  552 

epidemic,  1160 

infectious,  of  the  new-born,  1160 
Hsemokonia,  257 
Haemolysis,  253 
Haemometer,  Sahli's,  241 

Von  Fleischl's,  238 
Haemopericardium,  1207 
Haemoperitoneum,  1022 
Haemophilia,  1158 
Haemopneumothorax,  1104 
Haemoptysis,  1063 
Haemothorax,  1104 
Hair,  547 

Hammerschlag's  method,  243 
Hanot's  disease,  1008 
Harrison's  groove  in  rickets,  928 
Hay  cold,  1037 

fever,  1037 
Head,  9 

changes  of,  in  rickets,  928 

defonnities  of,  9 
Headache,  567 

anaemic,  569 

associated  symptoms,  572 

distribution  of,  568 

functional,  568,  572 

in  intracranial  aneurism,  571 

organic,  568,  572 

reflex,  571 

significance  of,  569 

varieties  of,  568 
Heart,  28 

abnormal  positions  of,  1183 

aneurism  of,  1196 

atrophy  of,  1197 

congenital  lesions  of,  1230 

dilatation  of,  1192 

direct    effect     of    aortic    insufficiency 
upon,  1214 

diseases  of,  1183 

fatty,  1193       _ 

foreign  bodies  in,  1195 

functional  affections  of,  1235 

hypertrophy  of,  1190 

in  pleurisy,  1095 

new  growths  in,  1195 

parasites  of,  1195 

percussion  of,  in  disease,  141 

rapid,  1238 

relation  of,  to  anterior  wall  of  chest,  29 

rupture  of,  1195 

slow,  1238 

syphilis  of,  1188  ^ 


Heart,  various  degenerations  of,  1195 

wounds  of,  1195 
Heart-block,  1231 
Heart-burn,  503 

Heart-muscle,  chronic  insufficiency  of,  1185 
Heart^sounds,  accentuation  of,  174 

in  disease,  172 

normal,  168 
Heat  exhaustion,  899 
Heat-stroke,  899 
Heberden's  nodes,  909 
Hegar's  sign  in  pregnancy,  902 
Heller's  test,  283 
Hemianopsia,  371 
Hemicrania,  1390 
Hemifacial  atrophy,  1401 
Hemiplegia,  attitude  in,  416 

in  children,  1274 
Hemorrhage,  bronchopulmonary,  1063 

cerebral,  1267 

diseases  characterized  by,  1153 

in  aneurism  of  thoracic  aorta,  1247 

in  spinal  cord  and  membranes,  1343 

into  pancreas,  1013 

pulmonary,  1063 
Hemorrhagic  diathesis,  1153 

diseases  of  the  new-born,  1160 

infarct,  1063 
Hepar  mobilis,  978 
Hepatic  artery,  diseases  of,  999 

duct,  36 

veins,  diseases  of,  999 
Hepatitis,  chronic  interstitial,  1005 

suppurative,  999 
Hepatoptosis,  978 
Hereditary  ataxia,  1334 
Herpes  zoster,  356 
Herzfehlerzellen,  1221 
Hiccough,  445 

Hick's,  Braxton,  sign  in  pregnancy,  902 
Hippocratic  facies,  537 

fingers,  546 

succussion,  1105 
Hippus,  1391 
Hodgkin's  disease,  1149 
Hook-worm  disease,  870 
Huntingdon's  disease,  1374 
Hutchinson  pupil,  1307 

teeth,  480,  825 
Hydatid  disease  (see  Echinococcus) 
Hydraemia,  539 
Hydrarthrosis,  539 
Hydrocephalic  cry,  791 
Hydrocephalus,  10,  539,  1277 

shape  of  head  and  face  in,  395 
Hydro-encephalocele,  10 
Hydronephrosis,  306,  1127 
Hydropericardium,  538,  1206 
Hydroperitoneum,  1021 
Hydrophobia,  767 
Hydropneimiothorax,  1104 
Hydrops  acUposTis,  1098 

chylosus,  1103 

pericardii,  1206 

vesicae  felleae,  994 
Hydrothorax,  539,  1102 
Hyperacidity,  948 


INDEX. 


1423 


Hypersemia  of  liver,  997 
Hyperaesthesia,  gastric,  946 
Hyperchlorliydria,  948 
Hyperidrosis,  535 
Hypernephroma,  1131 
Hyperpyrexia,  433 
Hyperthyrea,  1171 
Hypertrichosis,  547 
Hypertrophy,  congestive,  1163 

of  adenoid  tissue  of  pharynx,  396 

of  heart.  1190 

of  muscles,  409 

of  spleen,  1163 

of  tonsils,  396 
Hypnosis,  1385 
Hypnotism,  1385 
Hypoacidity,  949 
Hypochlorhydria,  949 
Hypochondriasis,  1387 
Hypoglossal  nerve,  1317 
Hypoparathyreosis,  1177 
Hypostatic  congestion  of  lungs,  1061 
Hypothermia,  433 
Hysteria,  1380 

in  alcoholism,  878 
Hysterical  fit,  1384 


Ichthyismus,  893 
Ichthyotoxismus,  893 
Icterus,  530,  979 

acute  febrile,  836 

gastroduodenalis,  983 

gravis,  982 

infectiosus,  836 

neonatorum,  981 

physiological,  981 

simplex,  983 
Idiocy,  amaurotic  family,  1276 
Idiopathic  fever,  424 

Illuminating  gas,  acute  and  chronic  poison- 
ing by,  890 
blood  tests  in  diagnosis  of,  891 
Impotence,  554 
Incontinence,  fecal,  518 

of  urine,  550 
Indican,  281 

Indigestion,  intestinal,  973 
Infantile  eclampsia,  601 

paralysis,  1322 
Infants,  posture  and  movements  of,  418 
Infection,  definition  of,  742 
Inflation  of  the  stomach,  196 
Influenza,  697 

complications  and  sequels  of,  700 
Inoscopy,  302 

Insanity,  chronic  alcoholic,  878 
Insomnia,  603 
Inspection.  62 

of  abdomen,  74 

of  thorax,  62 
Intercostal  nerves,  1361 
Intermittent  claudication,  1243 
Internal  popliteal  nerve,  1367 
Intestinal  cestodes,  858 

indigestion,  973 


Intestinal  neoplasms,  975 

neuroses,  974 

obstruction,  958 

symptoms  of  autointoxication  in, 
897 

stenosis,  958 
Intestines,  33 

amyloid  disease  of,  934 

dilatation  of,  963 

diseases  of,  952 

examination  of,  209 

tuberculosis  of,  798 

ulceration  of,  956 
Intracranial  aneurisms,  1278 
Intussusception,  521 
Iodine  test  in  tuberculosis,  816 
Iris,  pigmentation  of,  359 
Iritis,  362 

J. 

Jacksonian  epilepsy,  1377 
in  uraemia,  1112 
Jaundice,  530,  979 

black,  530 

catarrhal,  983 

forms  of,  979 

in  pneumonia,  724 

malignant,  982 

obstructive,  530 

toxsemic,  5.32 
Joffroy's  sign,  1172 
Joints,  403 
Jumpers,  1373 

K. 

Kakke,  761 

Kala-azar,  845 
Kenophobia,  596 
Keratitis,  interstitial,  359 

ulcerative,  358 
Kernig's  sign,  643 
Kidney,  abscess  of,  1123 

amyloid,  933 

contracted,  1118 

cysts  of,  1129 

floating,  1108,  1109 

gouty, Ills 

granular,  1118 

hemorrhagic  infarct  of,  1110 

movable,  1 108,  1109 

palpable,  1109 

sarcoma  of,  1131 

«clerosis  of,  1118 

surgical,  1122 

tumors  of,  1131 

wandering,  1109 
Kidneys,  38 

anatomical  anomalies  of,  1107 

circulatory  derangements  of,  1110 

congenital  cystic,  1130 

congestion  of,  1110 

diagnosis  of  echinococcus  of,  865 

diseases  of,  1107 

in  diabetes,  918 

inflammation  of,  1114 


1424 


INDEX. 


Kidneys,  palpation  in  examination  of,  102 

syphilis  of,  827 

tuberculosis  of,  801 
Kinepox,  663 
Klebs-Loffler  bacilli.  706 
Koranjd's  sign,  1094 
Korsakoff's  psychosis,  878 
in  myelitis,  1322 
Kyphosis,  15 


Lachrymal  sac,  inflammation  of,  356 

"Lacing"  liver,  978 

Lactose,  291 

Laennec's  cirrhosis,  1007 

Lagophthalmos,  357 

La  grippe  (see  Influenza),  697 

Landry's  paralysis,  1324 

Lardaceous  disease,  932 

Laryngeal  muscles,  paralysis  of,  1048 

phthisis,  1045 
Laryngismus  stridulus,  1047 
Laryngitis,  acute  catarrhal,  1040 

acute,  in  children,  1041 

chronic,  1042 

fibrinous,  1044 

oedematous,  1043 

pseudomembranous,  1044 

subacute,  1042 

syphihtic,  1046 

tuberculous,  1045 
Laryngoscopy,  224 
Larynx,  11 

diseases  of,  1040 

examination  of,  225 
Latah,  1373 
Lateral  sclerosis,  amyotrophic,  1327 

primary,  1328 
Lathyrismus,  895 
Lead  neuritis,  1352 

poisoning,  881 
Le  coeur  medicale,  166 
Leontiasis  ossea,  1404 
Lepra,  780 
Leprosy,  780 

anaesthetic,  782 

diagnosis  of,  784 

mixed  or  complete,  784 

prognosis  of,  784 

shape  of  face  in,  397 

symptoms  of,  781 

tuberculous,  781 
Leptomeningitis,  1260 
Lethargy,  599 
Leucocytes,  257 

development  of,  259 

enumeration  of,  233 

in  urine,  272 

mast-cells,  258 

number  of,  260 

technic  of  counting,  236 
Leucocytosis  in  appendicitis,  969 

pathological,  261 

physiological,  260 
Leucopenia,  262 
Leucoplakia,  489 


Leucorrhoea,  555 
Leuksemia,  1143 

lymphatic,  1146 

myelogenous  or  splenomedullary,  1144 

pseudo-,  1149 
Leukansemia,  1147 
Lien  mobilis,  1162 
Lienteric  diarrhoea,  517 
Lipomata,  932 
Lips,  477 

tuberculosis  of,  797 
Litten's  sign,  69 
Little's  disease,  1276 
Liver,  34 

abscess  of,  999 

acute  yellow  atrophy  of,  982 

amyloid,  934 

anatomical  anomalies  of,  977 

angiomata  of,  1009 

cirrhosis  of,  1005 

congestion  of,  997 

"corset"  or  "lacing,"  978 

diagnosis  of  hydatids  of,  864 

diseases  of,  977 

fatty,  1003 

movable,  978 

new  growths  in,  1009 

pulsation  of,  476 

syphilis  of,  826 

tuberculosis  of,  802 
Lobar  pneumonia,  714 
Lobstein's  cancer,  1034 
Lockjaw,  763 
Locomotor  ataxia,  1328 

relation  of  syphilis  to,  1338 
Locomotor  pulsation,  1215 
Lordosis,  15 
Ludwag's  angina,  495 
Lumbago,  912 
Lumbar  plexus,  1362 
Lung,  cirrhosis  of,  1075 

collapse  of,  1070 

gangrene  of,  1080 
Lung  fever,  714 
Lungs,  26 

diagnosis  of  hydatids  of,  865 

diseases  of,   characterized  by  changes 
in  vesicular  structure  of,  1066 
characterized  by  interstitial  inflam- 
mation, 1075 
due  to  suppuration  and  necrosis, 
1079 

in  diabetes,  918 

new  growths  in,  1082 

syphilis  of,  826 

tuberculosis  of,  802 
Lupinosis,  895 
Lymphatism,  1168 
Lymphocytes,  258 
LymphcBdema,  541 
Lyssa,  767 

M. 

Madura  foot,  776 

Magnan's  sign  in  cocainism,  881 

Maidismus,  895 


INDEX. 


1425 


"Main  de  singe,"  1325 
"Main  en  griffe,  1325 
Maladie  des  tics,  1396 
Malarial  cachexia,  854 
fevers,  846 

algid  form  of,  854 

comatose  form  of,  854 

continued  and  pernicious  forms  of, 

852 
diagnosis  of,  854 
estivo-autumnal,  852 
hemorrhagic  form  of,  854 
irregular  remittent,  852 
parasite  in  man,  847 
parasite  in  mosquito,  849 
prognosis  of,  855 
quartan,  852 
regularly    intermitting    forms    of, 

850 
symptoms  of,  850 
tertian,  851 
Malingering,  6 
Malta  fever,  759 
Mai  telegraphique,  1389 
Mania  a  potu,  877 
Mania,  Bell's,  1288 
Mannkopf's  svmptom,  581 
"Marks  of  the  devil,"  1382 
Masticating  spasm,  1310 
McBurnev's  point,  969 
Measles,  681 
black,  684 

complications  and  sequels  of,  685 
German,  687 
Meat  poisoning,  894 
Mechanical  congestion  of  lungs,  1061 
Median  nerve,  1359 
Mediastinitis,  indurative,  1084 
Mediastinum,  28 

abscess  of,  1083 
diseases  of,  1083 
emphysema  of,  1084 
new  growths  of,  1084 
suppurative  lymphadenitis  in,  1083 
^ledical  thermometry,  53 

topography,  8 
Melancholia,  alcohohc,  877 
Melanoderma,  533 
Menidrosis,  536 
Meniere's  disease,  1313 
Meningitis,  1260 

in  pneumonia,  723 
septic,  1261 
serous,  1260 
spinal,  1318 
Meningocele,  10 
Menorrhagia,  556 
Menstrual  derangements,  550 
Mensuration,  105 
Mercurv,  poisoning  by,  887 
Merycism,  503,  1383 
Metailophobia,  596 
Metasyphilitic  diseases,  826 
Meteorism  in  pneumonia,  724 
Methannoglobin,  255 
Method  of  Russell  and  Brodie,  244 
Metrorrhagia,  557 
90 


Micrococcus  melitensis,  759 
Micturition,  548 

freqvient,  550 

slow,  550 
Mid-brain,  diseases  of,  1290 
Migraine,  1390 

ophthalmoplegic,  1391 

psychical,  1391 
Mikulicz's  disease,  1149 
Miliarv  fever,  838 
Milk-leg,  580 
Mitral  incompetence,  1220 

insufficiency,  1220 

regurgitation,  1220 

stenosis,  1224 
Moebius's  sign,  1172 
Monoplegia  in  children,  1275 
Morbid  sleep,  604 
Morbilli,  681 
Morbus  cseruleus,  529 

maculosus,  1154 

neonatorum,  1161 
Morc's  test  in  tuberculosis,  815 
Morphinism,  879 
Morvan's  disease,  1337 
Motor  nerves  of  eye,  1306 

symptoms,  320 

system,  308 
Mouth,  477 
Movable  kidney,  1108 

Hver,  978 
Mucous  colitis,  516 
Multiple  sclerosis,  1289 
Mumps,  694 

complications  and  sequels  of,  696 
Murmur,  humming-top,  1135 

Nun's,  193,  1135 
Murmurs,  cardiopulmonary,  189 

endocardial,  177 

of  aneurisms,  190 
Muscles,  diseases  of,  1406 

ocular,  paralysis  of,  363 
Muscular  atrophy,  degenerative,  410 
progressive,  1325 

rigidity  in  appendicitis,  969 

sense,  345 
Musculature,  409 
Musculospiral  nerve,  1358 
Myalgia,  911 
Myasthenia  gravis,  1410 
Mycetoma,  776 
Myelajmia,  262 
Myelitis,  1319 
Myelocytes,  259 
Myocarditis,  acute,  1183 

chronic,  1185 

form  due  to  diseases  of  the  coronary 
arteries,  1187 

general  arteriosclerosis  in,  1188 

inflammatory  form,  1187 

in  rheumatism,  748 

nutritional  disorders  and,  1188 
Myocardium,  diseases  of,  1183 
Myodegeneratio  cordis,  1185 
Myoidema,  410 
Myomalacia  cordis,  1187 
Myopathies,  the,  1407 


1426 


INDEX. 


Myositis,  1406 

dermato-,  1406 

infectious,  1406 

neuro-,  1406 

ossificans,  1406 
Myotonia,  1409 

congenita,  1409 
Myotonic  reaction,  1410 
Mvriachit,  1373 
Mytilotoxin,  893 
Myxcedema,  1174 

of  adults,  1176 

postoperative,  1177 

shape  of  face  in,  396 

N. 

Nails,  546 

Narcolepsy,  604 

Naunyn's   theory  of  origin  of    gall-stones, 

990 
Nausea,  503 

Nematodes,  diseases  due  to,  866 
Neoplasms,  intestinal,  975 
Nephritis,  acute,  1114 

dropsy  in,  1115 
parenchymatous,  1114 
urine  in,  1115 
chronic,  1114 

desquamative,  1117 
dropsy  in,  1117 
interstitial,  1118 
parenchymatous,  1117 
tubal,  1117 
urine  in,  1117,  1119 
Nephrolithiasis,  1124 
Nephroptosis,  1108 
Nerve,  anterior  crural,  1363 
circumflex,  1357 
internal  popliteal,  1367 
median,  1359 
musculospiral,  1358 
obturator,  1364 
peroneal,  1368 
phrenic,  1354 
posterior  thoracic,  1356 
ulnar,  1360 
Nerves,  anterior  thoracic,  1356 
cervical,  1353 
cranial,  diseases  of,  1302 
eighth  (auditory),  1312 
eleventh  (spinal  accessory),  1316 
fifth  (trigeminal),  1307 
first  (olfactory),  1303 
ninth  (glosso-pharyngeal),  1314 
second  (optic),  1304 
seventh  (facial),  1310 
tenth  (pneumogastric),  1315 
third,    fourth,    and    sixth    (motor 

nerves  of  eye),  1306 
twelfth  (hypoglossal),  1317 
intercostal,  1361 
sciatic,  1365 
Nei'vous  diarrhoea,  516 
dyspepsia,  946 
system,  diseases  of,  1260 
divisions  of,  304 


Nervous  system,  examination  of  patient,  319 
in  diabetes,  918 

preliminary  consideration  of,  306 
Neurasthenia,  1386 

in  alcoholism,  878 
Neuritis,  alcoholic,  1350 

lead,  1352 

multiple,  1349 

optic,  374,  1306 

peripheral,  1349 
Neuron,  306 

Neuropathic  joint  affections,  408 
Neuroses,  gastric,  946 

in  peritoneum,  1032 

intestinal,  974 

occupation,  1388 

traumatic,  1387 
New  growths  in  heart,  1195 
in  liver,  1009 
in  lungs,  1082 
mediastinal,  1084 
Nightmare,  603 
Night-sweats,  535 
Night-terrors,  603 
Ninth  nerve,  1314 
Noguchi  butyric  acid  test,  the,  for  syphilis, 

829 
Normoblasts,  256 
Nose,  diseases  of,  1035 

examination  of,  222 
Nose-bleed,  1039 
Nucleo-albumin,  286 
Nun's  murmur,  193,  1135 
Nutritional  diseases,  922 
Nylander's  bismuth  test  in  diabetes,  919 
Nystagmus,  354 

in  multiple  sclerosis,  1289 

O. 

Obesity,  930 

Obsessions,  596 

"  Obstetric  hand,  "  1394,  1395 

Obstruction,  intestinal,  958 

complete,  961 
Obturator  nerve,  1364 
Occupation  neuroses,  1388 
Ocular  muscles,  363 

paralysis  of,  363 
(Edema,  537 

acute  laryngeal,  1043 

angioneurotic,  1400 

of  glottis,  1043 

pulmonary,  1062 
(Esophageal  sound,  496 
OEsophagismus,  498 
CEsophagoscopy,  496 
(Esophagus,  26,  495 

alterations  in  calibre  of,  497 

auscultation  of,  496 

diverticula  of,  498 

inflammation  of,  499 

malignant  stricture  of,  497 

obstruction  of,  498 

paralysis  of,  500 

pressure  of,  498 

spasmodic  stricture  of,  498 


INDEX. 


1427 


Q^lsophagus,  stenosis  of,  497 

symptoms  of  disease  of,  497 

tuberculosis  of,  798 

X-ray  examination  of,  497 
Olfactory  nerves,  1303 
Oligochromsemia,  525 
Oliguria,  548 

Oliver's  hiemocytometer,  237 
Onomotomania,  1373 
Onychia,  546 

Ophthalmoplegia,  nuclear,  1291 
Ophthalmotuberculin  test,  812 

Baldwin's    scheme    for    recording 
reactions,  813 
Opisthotonos,  414,  415 

in  tetanus,  765 
Opium  poisoning,  879 

Opsonic  method,  the,  in  diagnosis  of  tuber- 
culosis, 815 
Optic  nerve,  1304 

atrophy  in  tabes,  1330 
primary,  375 
secondary,  375 
Optic  neuritis,  1306 
Organs  of  respiration,  diagnosis  of  in  disease, 

151 
Orthodiagraphy,  386 
Orthopnoeaj  413 
Orthotonos,  415 

in  tetanus,  765 
Osteitis  deformans,  1402 
Osteomalacia,  403,  1404 

of  puberty,  927 
Otoscopy,  226 

Ovaries,  tuberculosis  of,  802 
Oxyuris  vermicularis,  867 
Ozajna,  1037 


Pachymeningitis,  1260 

externa,  1260 

haemorrhagica  of  Virchow,  1260 
Paget's  disease,  1402 

skeletal  changes  in,  413 
Pain,  558 

distribution  of,  565 

etiology  of,  559 

feigned,  565 

in  alcoholic  neuritis,  1350 

in  aneurism  of  thoracic  aorta,  1248 

in  appendicitis,  968 

in  body,  574 

in  caisson  disease,  1346 

in  ear,  574 

in  extremities,  579 

in  eye,  573 

in  face,  573 

in  head,  567 

in  locomotor  ataxia,  1329 

in  pneumonia,  718 

in  scalp,  572 

in  tumors  of  spinal  cord,  1339 

localization  of,  567 

mode  of  expression  of,  560 

modifications  by  physical  and  psychical 
causes,  564 


Pain,  referred,  566 

to  mouth,  574 
significance  of,  566 
sinus,  574 
varieties  of,  562 
Painful  crises,  567 
Palate,  491 
Pallor  of  skin,  525 
Palmus,  1313 
Palpation,  90 

in  examination  of  abdomen,  97 
of  stomach,  194 
of  thorax,  90 
Palsies,  cerebral,  of  children,  1273 
Palsv,  Bell's,  1310 
bulbar,  1298 
pseudobulbar,  1300 
scrivener's,  1388 
shaking,  1393 
Pancreas,  37 

diseases  of,  1013 
hemorrhage  into,  1013 
hyaline  degeneration  of,  1017 
tumors  of,  1020 
Pancreatic  abscess,  1016 
calculi,  523,  1018 
cysts,  1018 
diabetes,  1017 
Pancreatitis,  acute,  1013 

acute  hemorrhagic,  1013 
acute  suppurative,  1016 
chronic,  1017 
gangrenous,  1016 
Papillitis,  374,  1306 
Paracentesis  abdominis,  1023 
Paracolons,  639 
ParsBsthesia,  582 
cerebral,  583 
forms  of,  583 
Paralysis,  acute  ascending,  1324 
agitans,  1393 

attitude  in,  416 
Brown-Sequard,  1340 
Erb's,  1338 
infantile,  1322 
in  lead  poisoning,  882 
Landry's,  1324 

of  associated  movements  of  eyes,  1293 
of  laryngeal  muscles,  1048 
Paramyoclonus  multiplex,  1410 
Paranephritis,  1123 
Paraplegia,  ataxic,  1333 
in  Children,  1275 
senile,  1288 
Parasyphilitic  diseases,  826 
Parathyroids,  1171 
Paratyphoid  fevers,  639,  617 
"  Paratyphoids,"  639 
Parchment  crackling  in  rickets,  928 
Paresis,  alcoholic  general,  878 

general,  1285 
Parkinson's  disease,  1393 
Parry's  disease,  1171 
Pavor  nocturnus,  603 
Pectoriloquy,  165 
Peliosis  rheumatica,  1155 
Pellagra,  875  8!»5 


1428 


INDEX. 


Pelvis,  changes  of,  in  rickets,  929 
Peptic  ulcer  of  jejunum,  956 
Percussion,  120 

auscultatory,  130 

methods  of,"^  129 

of  chest,  130 

of  heart,  141 

of  stomach,  195 

si2;ns  elicited  upon,  126 

te'chnic  of,  122 

theory  of,  121 
Perforating  ulcer  in  tabes,  1331 
Perforation,  intestinal,  in  typhoid  fever,  614 
Periarteritis  nodosa,  1259 
Pericardial  sac,  obliteration  of,  1205 
Pericarditis,  1197 

dry,  1198 

exudative,  1200 

fibrinous,  1198 

in  pneumonia,  722 

in  rheumatism,  748 

plastic,  1198 

sicca,  1198 

with  effusion,  1200 
Pericardium,  28 

adherent,  1205 

calcification  of,  1207 

diseases  of,  1197 

tuberculosis  of,  795 
Perinephric  abscess,  1123 
Perirenal  abscess,  1123 
Perisplenic  peritonitis,  1166 
Peritoneum,  diseases  of,  1021 

new  growths  in,  1032 

tuberculosis  of,  795 
Peritonitis,  acute  circumscribed,  1029 

acute  general,  1024 

appendicular,  970,  1029 

bacteriology  of  acute,  1024 

chronic,  1031 

chronic  proliferative,  1031 

clinical  etiology  of,  1024 

diagnosis  of,  1028 

diffuse  adhesive,  1031 

in  acute  infectious  diseases,  1026 

in  foetus  and  new-born,  1026 

local  adhesive,  1031 

pelvic,  1029 

perisplenic,  1166 

primary,  1024 

secondary,  1024 

subphrenic,  1030 

symptoms  of,  1026 

tuberculous,  1032 
Peroneal  nerve,  1368 
Peroneal  type  of  paralysis,  1364 
Pertussis  (see  Whooping-cough),  689 
Petechias,  542 
Petit  rnal,  1377 

Peyer's  patches  in  typhoid  fever,  614 
Pharynx,  493 

cyanosis  of,  493 

innervation  of,  495 

pulsation  of,  4^3 

tuberculosis  of,  798 

ulceration  of,  494 
Phobias,  596  - 


Phosphorus  poisoning,  889 

resemblance  of  acute  yellow  atro- 
phy to,  889 
Phrenic  nerve,  1354 
Phthisis,  acute  pneumonic,  803 
bronchopneumonic  form,  803 
chronic  ulcerative,  805 

"  closed  "  and  "  open,  "  808 
diagnosis  of  advanced,  818 
diagnosis  of  incipient,  810 
modes  of  onset,  806 
physical    signs    in    advanced, 

817 
physical  signs  in  incipient,  809 
prognosis  of,  819 
stages  of,  807 

symptoms  of  incipient,  808 
symptoms  of  moderately  and 
far  advanced,  816 
fibroid,  819 
florida,  804 
pneumonic  form,  803 
Physical  diagnosis,  61 
Pica,  502 
Pigmentation,  533 

in  Addison's  disease,  534 
in  hepatic  disease,  534 
Plague,  757 

bubonic,  757 

modes  of  transmission,  758 
pneumonic,  759 
septic,  759 
Plasma,  253 

estimation  of  relative  volume  of,  242 
Plasmodium  immaculaturn,  848 
malarite,  848 
vivax,  847 
Pleura,  diseases  of,  1088 
Pleura;,  26 

.  diagnosis  of  hydatids  of,  865 
Pleural  effusion,  chyliform,  1098 
.  !  chylous,  1103 

.  encysted  or  circumscribed,  1097 
hemorrhagic,  1097 
pulsating,  1097 
purulent,  1096 
serofibrinous,  1091 
Pleural    sac,    morbid    states    characterized 
by   transudation   of  serum   or  chyle,   or 
eruption  of  pus,  blood,  or  air  into,  1102 
Pleurisy,  1088 

acute  dry,  1088 

adhesive,    following    removal    of    exu- 
dates, 1090 
chronic  dry,  1090 
diagnosis  of,  with  effusion,  1098 
exudative,  1091 
fibrinous,  1088 
hemorrhagic,  1097 
plastic,  1088 
primitive  dry,  1090 
purulent,  1096 
serofibrinous,  1091 
tuberculous,  794 
tuberculous  dry,  1090 
with  effusion,  1091 
Pleuritis  sicca,  1088 


INDEX. 


1429 


Pleurodynia,  912 
Pleuropericardial  friction,  1089 
Pleuropneumonia,  714 
Pleurothotonos,  415 

in  tetanus,  765 
Pleximetrv,  123 
Plumbisni,  881 

Pneumococcus  septicsemia,  715 
Pneumogastric  nerve,  1315 
Pneumonia,  abortive,  726 

anaesthesia,  727 

apex,  725 

asthenic,  726 

catarrhal,  1071 

central,  725 

chronic  interstitial,  1075 

contusion,  727 

crossed,  717 

croupous,  714 

disseminated  interstitial,  1076 

double,  725 

ether,  1074 

fibrinous,  714 

in  emphysematous  persons,  725 

intense,  726 

lobar,  714 

lobar  interstitial,  1076 

lobular,  1071 

masked  forms,  1074 

massive,  725 

migratory,  725 

postoperative,  727,  1074 

primary  form,  1073 

rudimentary,  726 

secondary  forms,  1074 

toxic,  726 

typhoid,  726 
Pneumonoconiosis,  1078 
Pneumopericardium,  1207 
Pneumorrhagia,  1063 
Pneumothorax,  441,  1104 

masked,  1107 
Podagra,  904 
Poikilocytes,  256 
Poisoning,  arsenical,  884 

by  cocaine,  881 

by  fish,  893 

by  food,  892 

by  grain,  895 

bv  illuminating  gas,  890 

by  lead,  881 

by  meat,  894 

by  mercury,  887 

by  milk  and  milk  products,  894 

by  opium,  879 

by  phosphorus,  889 

by  potatoes,  896 

by  vegetables,  895 

ptomaine,  893 

vetch,  895 
PolioencephaUtis  inferior,  1300 

superior,  1290,  1291 
Poliomyelitis,  anterior,  1322 
Polygraph,  clinical,  112 
Polymyositis  hemorrhagica,  1406 
Polyneuritis,  1349 
Polynuclear  eosinophiles,  258 


Polynuclear  neutrophiles,  258 

Polyphagia,  501 

Polyuria,  548 

Pons,  diseases  of,  1296 

Portal  vein,  diseases  of,  998 

occlusion  or  narrowing  of,  998 
thrombosis  of,  998 
Postepileptic  mania,  597 
Posterior  thoracic  nerve,  1356 
Posture,  412 

dorsal,  413 

lateral,  413 

sitting,  413 

ventral,  414 
Potato  poisoning,  896 
Pregnancy,  901 

diagnosis  of,  902 
Priapism,  553 
Primary  bronchi,  25 
Progressive  muscular  atrophy,  1325 
Prostate,  tuberculosis  of,  802 
Proteus  fiuorescens,  836 
Protozoa,  diseases  due  to,  842 
Pruritus  vulvae,  555 
Pseudobulbar  palsy,  1300 
Pseudochlorosis,  1136 
Pseudodiphtheria,  712 

Pseudohypertrophic   paralysis,  attitude  in, 
416 

pulmonary  osteo-arthropathy,  1404 
Psorospermiasis,  842 
Psychasthenia,  1387 
Psychical  conditions,  593 
intelligence,  593 
memory,  594 
Psychical  epileptic  equivalents,  1377 
Ptomaine  poisoning,  893 
Ptosis,  357 
Pulmonary  abscess,  1079 

apoplexy,  1063 

atelectasis,  1070 

congestion,  1061 

emphysema,  1066 

hemorrhage,  1063 

insufficiency  and  stenosis,  1226 

oedema,  1062 

osteo-arthropathy,  403 

tissue,  diseases  of,  1061 
Pulsation,  100,  460 

of  Uver,  476 
Pulse,  463 

anomalies  of,  472 

capillary,  473 

celerity,  470 

collapsing,  1216 

frequency  of,  464 

irregularity  of,  469 

rhythm,  4*68 

tension,  470 

venous,  474 

volume,  469 
Pulsus  paradoxicus,  1201 
Puncta  maxima,  169 
Puncture,  exploratory,  300 
Pupil,  360 

abnormal  reactions  of,  361 

normal  reactions  of,  360 


1430 


INDEX. 


Pupillary  tract,  mydriatic,  360 

myotic,  360 
Purpura,  1153 

abdominalis,  1156 

and  visceral  symptoms,  1156 

cachetic,  1157 

fulminous,  1155 

hsemorrhagica,  1154 

Henoch's,  1156 

infectious,  1157 

neurotic,  1157 

rheumatica,  1155 

simplex,  1154 

symptomatic,  1157 

toxic,  1157 

traumatic,  1157 

variolosa,  656 
Purpuric  oedema,  febrile,  1155 
Pustule,  malignant,  776 
Pyaemia  (see  Sepsis),  742 
PyeUtis,  1121 
Pylephlebitis,  adhesive,  998 

suppurative,  998 
Pylorus,  hypertrophic  stenosis  of,  945 

relaxation  of,  950 

spasm  of,  950 
Pyopneumothorax,  1104 
Pyopneumothorax  subphrenicus,  1030 
Pyothorax,  1103 
Pyrexia  a  symptom  of  fever,  423 
Pyrhophobia,  596 
Pyrosis,  503 

Q. 

Quantitative  tests,  204 
Quicke's  disease,  1400 

R. 

Rabies,  767 

Rag-picker's  disease,  780 
Railwav  spine,  1387 
Rales,  159 

crepitant,  160 

dry,  159 

moist,  159 

varieties  and  significance,  160,  161 
Rapid  heart,  465,  1238 
Rash  in  typhoid  fever,  612 
Raynaud's  disease,  1397 
Records,  41 

scheme  for,  41 
Redness  of  skin,  527 

from  drugs,  528 
in  fever,  527 
Reflexes,  331 
Regurgitation,  503 
Relapsing  fever,  644 

complications  and  sequels  of,  646 
Renal  ansemia,  1110 

calculus,  1124 

chemical  composition  of,  1125 
immediate  effects  of,  1125 

colic,  symptoms  of,  1126 

infarct,  1124 
Ren  mobilis,  1108 


Rennin,  test  for,  203 

Reproductive  organs,  553 

Resonance,  vocal,  varieties  and  significance 

of,  164,  165 
Respiration,  436 

Cheyne-Stokes,  439 

jerking,  440 

meningeal,  439 

type  in,  438 
Respiratory  movements,  438 

characteristic  derangements  of,  439 
oligopnoea,  438 
polypnoea,  439 
Respiratory  system,  diseases  of,  1035 
Restlessness,  414 
Retinal  hemorrhage,  375 

obstruction  of  vessels,  376 
Retinitis,  375 
Rhachialgia,  574 
Rhachitic  hand,  929 

rosary,  928 
Rhachitis  (see  Rickets),  927 
Rheumatic  fever,  746 

hyperpyrexia  in,  747 
joints  in,  405 
Rheumatism,  acute,  746 

cerebral,  747 

chronic,  405,  911 

muscular,  911 
Rheumatoid  affections,  the,  910 
Rhinitis,  acute,  1035 

atrophica,  1037 

hypertrophica,  1036 

simplex,  1036 
Rhinoscopy,  anterior,  222 

posterior,  223 
Rickets,  927,  1404 

cause  of,  927 

fetal,  927^ 

skeletal  changes  in,  403 
Riegel's  test-meal,  201 
Riga's  disease,  488 
Risus  sardonicus,  765 
Rivalta's  test,  302 
Rocky  mountain  spotted  fever,  834 
Romberg's  symptom,  416,  1329 
Rontgen  rays,    examination    of    intestines 
with,  213 
examination  of  stomach  with,  197 
Rose  cold,  1037 
Roseola  variolosa,  650 
Rossbach's  disease,  947 
Rotch's  sign,  1202 
Rotheln,  687 
Rubella,  687 
Rubeola,  681 
Rumination,  503 


Sacral  plexus,  1364 

Sahli's  desmoid  test,  206 

Salol  test,  for  motor  power  of  stomach,  207 

Saltatory  spasm,  1373 

Sarcoma  of  kidney,  1131 

of  liver,  1011 

retroperitoneal,  1034 


INDEX. 


1431 


Sarcomata,  intestinal,  977 
Sausage  poisoning,  894 
Scapulae,  the,  17 
Scarlatina,  670 
Scarlet  fever,  670 

complications  and  sequels,  677 
diagnosis  of,  679 
prognosis  of,  680 
symptoms  of,  672 
varieties,  675 
Scars,  543 

Schachtelton  percussion  sound,  1068 
Schizogonous  cycle,  847 
Schmidt's     nucleus     test     for     pancreatic 

disease,  218 
Schonlein's  disease,  1155 
Sciatica,  1366 
Sciatic  nerves,  1365 
Sclera,  inflammation  of,  358 
Sclerema  neonatorum,  542 
Scleroderma,  541 
Sclerosis,  amyotrophic  lateral,  1327 

multiple,  1289 

of  coronary  arteries,  1187 

primary  lateral,  1328 
Scoliosis,  15 

in  chronic  sciatica,  416 
Scorbutus,  922 
Scrivener's  palsy,  1388 
Scrofula,  792 
Scurvy,  922 

infantile,  925 
Sclerosis,  542 
Seat  worm,  867 
Senile  degeneration,  1287 
Senile  heart,  the,  1197 
Sensory  symptoms,  322 
Sensory  system,  314 
Sepsis,  742 

symptomatology  of,  743 
Septicaemia  (see  Sepsis),  742 

pneumococcus,  715 
Septicopyaemia  (see  Sepsis),  742 
Serum  globulin  in  urine,  286 
Serum  test,  macroscopical,  248 

microscopical,  246 
technic  of,  246 
Sexual  organs  in  diabetes,  918 
Shaking  palsy,  1393 
Sick  headache,  1390 
Sign,  Bacelli's,  166 
Signs,  389 

Simple  continued  fever,  833 
Sinus  thrombosis,  1265 
Skeletal  changes,  403 

in  acromegaly,  403 
in  Paget's  disease,  403 
in  rickets,  403 
Skin,  524 

collateral  circulation  in,  544 

fulness  of,  536 

moisture  of,  535 

vagabond's,  533 
Skodaic  resonance  in  pneumonia,  721 
Skull,  8 

regions  of,  8 
Sleep  drunkenness,  604 


Sleeping  sickness,  844 

Slow  heart,  1238 

Smallpox,  647 

Softening  of  the  brain,  1271 

Somnambulism,  604 

Somnolence,  598 

Sopor,  598 

Sordes,  481 

Spasm,  accessory,  1316 

habit,  1372 

of  cardiac  orifice,  950 

of  face,  1311 

saltatory,  1373 

static  reflex,  of  Bamberger,  1373 
Speech  (see  Aphasia),  326 
Spermatorrhoea,  555 
Sphygmograms,  diagnostic   significance   of, 

110 
Sphygmograph,  106 

Dudgeon's,  106 
Sphygmomanometer,  115 

technic  of,  115 
Sphygmomanometer,  Beall's,  117 

Janeway's,  117 

Mason's,  117 

Stanton's,  116 
Spina  bifida,  16,  1349 
Spinal  accessory  nerve,  1316 
Spinal  cord,  diseases  of,  1318 
injuries  to,  1341 
softening  of,  1345 
tuberculosis  of,  800 
tumors  of,  1339 
Spinal   cord  and   membranes,   hemorrhage 
in,  1343 
syphilis  of,  1337 
Spinal  localization,  329 
Spinal  meningitis,  1318 
Spinal  nerves,  diseases  of,  1349 
Spirals,  Curschmann's,  297 
Spirochseta  of  Vincent,  713 
Spirochseta  pallida,  822 
Spirometry,  105 
Splanchnoptosis,  972 
Spleen,  37 

abscess  of,  1166 

amyloid,  934 

anatomical  anomalies  of,  1161 

diseases  of,  1161 

hypertrophy  of,  1163 

infarct  of,  1166 

movable,  1162 

palpation  in  examination  of,  102 

rupture  of,  1167 

tuberculosis  of,  802 

wandering,  1162 
Splenic  anaemia,  1165 

capsulitis,  1166 

tumor,  acute,  1162 
chronic,  1163 
with  anaemia,  1165 
with  polycythaemia  and  cvanosis, 
1165 
Splenitis,  suppurative,  1166 
Splenomegaly,  primitive,  1165 
Sputum,  296,  451 

animal  parasites  in,  298 


1432 


INDEX. 


Sputum,  crj'-stals  in,  297 

Curschmann's  spirals  in,  297 

elastic  tissue  in,  297 

epithelial  cells  in,  296 

in  abscess  of  lung,  457 

in  acute  miliary  tuberculosis,  456 

in  bronchiectasis,  458 

in  bronchitis,  455 

in  bronchopneumonia,  457 

in  bronchopulmonary  hemorrhage,  45S 

in  chronic  valvular  disease,  459 

in  croupous  bronchitis,  455 

in  croupous  pneumonia,  456 

in  gangrene  of  lungs,  457 

in  infarcts,  459 

in  oedema  of  lungs,  458 

in  perforating  empyema,  457 

in  pulmonary  tuberculosis,  455 

in  putrid  bronchitis,  458 

leucocytes  in,  296 

microscopical  examination  of,  296 

red  blood-cells  in,  297 

vegetable  parasites  in,  298 
Stains,  EhrHch's  triple,  231 

Jenner's,  231 

Leishman's,  231 

Plehn's,  232 
Static  reflex  spasm  of  Bamberger,  1373 
Station,  416 
Status  epilepticus,  1377 

lymphaticus,  1168 

prsesens,  39 

parathyreoprivus,  1177 

vertiginosis,  587 
Stell wag's  sign,  1172 
Stenocardia,  1233 
Stenosis,  aortic,  1217 

intestinal,  958 

mitral,  1224 

of  duodenum  and  jejunum,    959 

of  ileum,  960 

of  large  bowel.  960 

pulmonary,  1227 

tracheobronchial,  1057 

tricuspid,  1228 
Stereoskiagraphy,  388 
Stertor,  445 
Stethoscope,  148 
"Stiff-neck,"  1317 
Stigmata  of  degeneration,  346 
anatomical,  347 
physiological,  350 
psvchic,  350 
Stigmata  diaboli,  1382 
Stokes- Adams  syndrome,  123 
Stomach,  32 

cancer  of,  964 

dilatation  of,  939 
acute,  940 
chronic,  940 

diseases  of,  935 

examination  of,  194 

inflation  of,  196 

nervous  disorders  of,  946 

tuberculosis  of,  798,  946 
Stomach-tube,  197 

contraindications  for  use  of,  199 


Stools,  518 

abnormal  substances  in,  520 

blood  in,  520 

fatty,  522 

foreign  bodies  in,  524 

gall-stones  in,  522 

gross  physical  characters  of,  518 

intestinal  concretions  in,  523 

intestinal  parasites  in,  524 

intestinal  sand  in,  523 

mucus  in,  520 

pancreatic  calculi  in,  523 

pus  in,  522 

sloughs  in,  524 
Strangury,  549 

Streptococcus  erysipelatis,  738 
Streptothrix  actinomyces,  773 
Striations,  543 

Stridor,  chronic  infantile,  1048 
Stroke,  apoplectic,  1268 

electric,  900 

heat,  899 
Stupor,  598 
St.  Vitus's  dance,  1369 
Succussion,  94 
Suggillation,  542 
Supersecretion,  947 
Suppurative  hepatitis,  999 
Suprarenal  capsules,  801 
Surface  thermometry,  57 
Surgical  kidney,  1122 
Sutures,  8 

Sweating  sickness,  838 
Sydenham's  chorea,  1369 
Symptoms,  389 
Syncope,  598 
Syndrome,  389 

dissociation,  1336 
Svnechia  pericardii,  1205 
Syphilis,  821 

acquired,  822 

and  locomotor  ataxia,  1338 

cerebrospinal,  1285 

diagnosis  of,  828 

fades  of,  395 

gummata  in,  824 

hereditary,  824 

of  brain,  1284 

of  circulatory  sj'stem,  827 

of  digestive  tract,  827 

of  eyelids,  356 

of  heart,  1188 

of  joints,  407 

of  kidneys,  827 

of  liver,  826 

of  lungs,  826 

of  spinal  cord  and  membranes,  1337 

of  testicles,  828 

prognosis  of,  831 

therapeutic  diagnosis  rt^   S30 

visceral,  826 
Syringomyelia,  1335 


Tabes,  juvenile,  1331 
pseudo-,  1332 
sensory  type,  1331 


INDEX. 


1433 


Tabes  dorsalis  (see  Locomotor  ataxia),  1328 

niesenterica,  794 
Tache  cerebrale,  527 
Tachycarciia,  467,  1238 

paroxysmal  or  essential,  1238 
T«nia,  varieties  of,  859,  860,  861 
Tapeworms,  858 
Tarry  stools,  217 
Teeth,  479 

caries,  481 

first  dentition,  479 

Hutchinson's,  480 

second  dentition,  480 

shape  and  structure  of,  480 
Teichmann's  disease,  947 
Telegrapher's  cramp,  1389 
Temperament,  391 
Temperature,  419 

abnormal,  421 

action  of  drugs  upon,  434 

heat  mechanism  of,  419 

in  disease,  55 

significance  of  abnormal,  435 

subnormal,  433 
"  Temperature  charts,  "  58 
Tenderness,  580 

abdominal,  582 

in  appendicitis,  969 

in  extremities,  584 

in  face,  head,  neck,  and  thorax,  581 
Tenesmus,  564 

rectal,  517 
Tenth  nerve,  1315 
Test  meals,  200 
Testes,  tuberculosis  of,  802 
Tests  for  free  HCl,  202 

for  lactic  acid,  202 
Tetanus,  763 

cephalic,  766 

facies  of,  394 

neonatorum,  766 

puerperal,  766 
Tetany,  1395 

from  autointoxication,  897 
Therapeutic  test  in  diphtheria,  712 
Thermogenesis,  419 
Thermolysis,  420 
Thermotaxis,  420 
Thirst,  502 

Thoma-Zeiss  hajmocytometer,  the,  233 
Thomsen's  disease,  1409 
Thoracic  organs,  25 

percussion  of,  in  disease,  134 
topographical  anatomy  of,  25 
Thoracometry,  105 
Thorax,  13 

changes  of,  in  rickets,  928 

landmarks  of,  13 

lines  and  spaces  of,  17 

regional  divisions  of,  19 
Thread  worm,  867 
Thrills,  94 

Throat  consumption,  1045 
Thrombosis  in  pneumonia,  723 
Thynms  gland,  25 

atrophy  of,  1168 
diseases  of,  1167 


Thymus  gland,  hemorrhages  of,  1168 
hypertrophy  of,  1168 
persistence  of,  1168 
tumors  of,  1168 
Thyroid  body,  11 

enlargement   of,   in  exophthalmic 
goitre,  1172 

gland,  diseases  of,  1169 
Thyroiditis,  acute,  1169 
Thyroids,  accessory,  1171. 
Tic  convulsive,  1312 

douloureux,  1309 
Tick  fever,  834 
Tics,  the,  1372,  1396 
"  Tobacco  heart,  "  1235 
Tongue,  482 

coating  of,  485 

eczema  of,  489 

fissures  of,  487 

moisture  of,  484 

motihty  of,  482 

mucous  membrane  of,  484 

mucous  patches  on,  488 

size  of,  483 

tuberculosis  of,  797 

tumors  of,  489 

ulcers  of,  487 
Tonsils,  492 
Torticollis,  912,  1316 

false,  1317 
Toxaemia,  definition  of,  742 

headache  in,  570 
Trachea,  25 
Tracheal  tugging,  97 
Tracheobronchial  stenosis,  1057 
Transillumination,  196 
Transudates,  301 
Tremor,  592 

forms  of,  592 

in  exophthalmic  goitre,  1173 

in  hysteria,  1382 

senile,  1288 
Treponema  pallidum,  822 
Trichinella  spiralis,  867 
Trichiniasis,  867 
Trichocephalus  dispar,  876 
Tricuspid  insufficiency  and  stenosis,  1227 
Trident  hand,  1405 
Trismus,  765 
Trophic  diseases,  1397 

disturbances,  341 
Trousseau's  symptom,  591 
Trypanosoma  gambiense,  844 
Trypanosomiasis,  844 
Tube-casts  in  urine,  273 

clinical  significance  of,  275 
Tubercle  bacillus,  298 

methods  of  examination  for,  299 
Tuberculin  innunction,  815 

test,  812 
Tuberculosis,  784 

acute  miliary,  788 

generalized,  788 
meningeal  form,  790 
pulmonary  form,  790 

modes  of  infection,  787 

of  alimentary  canal,  797 


1434 


INDEX. 


Tuberculosis  of  arteries,  802 

of  bladder,  801  .  , 

of  brain  and  spinal  cord,  800 
of  Fallopian  tubes,  802 
of  genito-urinary  organs,  800 
of  kidnevs,  801 
of  liver,  802 
of  lungs,  802 
of  lymph-nodes,  792 
of  myocardium,  802 
of  ovaries,  802 
of  pericardium,  795 
of  peritoneum,  795,  1032 
of  prostate  and  seminal  vesicles,  802 
of  serous  membranes,  794 
of  spleen,  802 
of  stomach,  798 
of  testes,  802 
of  ureters,  801 
pathogenic  organism  of,  786 
pulmonary,  802 
Tumor  of  brain,  headache  in,  570 
Tumors,  benign,  977 
of  brain,  1279 
of  spinal  cord,  1339 
of  tongue,  489 
Turban's  scheme,  820 
Turgor,  536 
Tussis  convulsiva    (see    Whooping-cough), 

689 
"  Typhoid  carriers,  "  620 
Typhoid  fever,  605 

agglutination  test  in,  628 
association  of  other  diseases  with, 

625 
chills  in,  611 

complications  and  sequels  of,  619 
course  of  disease,  607 
definition  of,  605 
diagnosis  of,  627 

of  intestinal  perforation,  637 
effect     of,    upon    certain    chronic 

diseases,  625 
etiology  of,  605 
exciting  cause  of,  606 
fever  in,  609 
in  aged,  619 
in  children,  618 
in  pregnancy,  619 
nervous  system  in,  609 
ophthalmic    reaction   in   diagnosis 

of,  629 
period  of  incubation,  607 
prognosis  of,  637 
pulse  in,  612 
rash  in,  612 
relapse,  625 

stage  of  prodromes,  607 
symptoms  of  especial  importance 
in  diagnosis,  609 
relating  to  abdominal  organs, 
612 
varieties  of,  616 
Typhoid  spine,  625 
Typhus  biliosus,  836 
Typhus  fever,  641 

complications  and  sequels  of,  643 


Typhus  fever,  prognosis  and  mortality,  644 
Typhus  levissimus,  617 
siderans,  643 

U. 

Uffelman's  test  for  free  lactic  acid,  202 
Ulcer,  duodenal,  956 

gastric,  942 

peptic,  of  jejunum,  956 

perforating,  in  tabes,  1331 
Ulceration  of  intestines,  956 
Ulnar  nerve,  1360 
Uncinariasis,  870 
Uraemia,  1111 

Ureters,  tuberculosis  of,  801 
Uric  acid,  267 
Urinary  calculi,  277 

pigments,  281 
Urination,  548 
Urine,  264 

albumins  in,  282 

animal  parasites  in,  276 

bacteria  in,  276 

cellular  deposits  in,  271 

chemical  examination  of,  277 

fat  in,  294 

in  acute  nephritis,  1115 

in  chronic  nephritis,  1117,  1119, 

incontinence  of,  550 

in  diabetes  insipidus,  921 

in  diabetes  mellitus,  915 

indican  in,  281 

microscopical  examination  of,  266 

oxalates  in,  266 

phosphates  in,  269 

physical  examination  of,  267 

red  blood-cells  in,  272 

retention  of,  551 

sulphates  in,  267 

suppression  of,  551 

tests  for  glucose  in,  288 

tube-casts  in,  273 

urea  in,  278 

uric  acid  in,  267,  279 
Urogenital  tuberculosis,  1122 
Urticaria,  giant,  1400 

V. 

Vaccination,  663 

technic  of,  664 
Vaccinia,  663 
Vagabond's  skin,  533 
Valve  areas,  169 

aortic,  169 

mitral,  169 

pulmonary,  169 

tricuspid,  169 
Valvular  disease,  chronic,  1214 

mitral    insufficiency    due    to, 
1220 
Valvular  diseases,  combined,  1229 
Varicella,  668 
Variola,  647 
Variola  modificata,  657 

complications  and  sequels  of,  658 


INDEX. 


1435 


Variola  pustulosa  hsemorrhagica,  657 
Variola  sine  eruptione,  658 
Variola  vera,  651 

confluent  form,  653 
discrete  form,  651 
hemorrhagic  forms,  656 
stage  of  desiccation  and  decrusta- 
tion,  655 
Varioloid,  657 
Vasomotor  diseases,  1397 
Veins,  auscultation  of,  192,  193 
Venous  hum,  193 
Venous  pulse,  474 

forms  of,  474 
Vertigo,  586 

forms  of,  587 
in  Meniere's  disease,  1314 
Vesical  tenesmus  549 
Vetch  poisoning,  895 
Vibices,  542 
Vincent's  angina,  713 
Msion,  affections  of,  367 
Vitiligo,  535 

Vocal  resonance,  amphoric,  165 
diminished,  165 
increased,  164 
normal,  164 
Voice,  164 

auscultation  of,  164 
Volume  index,  242 
Vomiting,  504 
bilious,  509 
of  blood,  509 
purulent,  511 
stercoraceous,  510 
Vomitus,  508 

gross  characteristics  of,  508 
odor  of,  511 
parasites  in,  511 
quantity  of,  511 
reaction  of,  511 
Von   Pirquet's  cutaneous  tuberculin  reac- 
tion, 813 


W. 


Waking  numbness,  604 
Walking  typhoid,  618 


Wasserman  test,  the,  for  syphilis,  828 
Waxy  or  bacony  infiltration,  932 
Weber's  syndrome,  1307 
Weil's  disease,  836 
Werlhof's  disease,  1154 
Westphal  sign,  1329 
Whip-worm,  876 
Whispering  pectoriloquy',  165 
Whooping-cough,  689 

complications  and  sequels  of,  692 
Widal  test,  628 

Williamson's  test  for  diabetes,  251 
Winckel's  disease,  1160 
Windpipe,  25 
Wintrich's  sign,  818 
Wool-sorter's  disease,  776,  778 
Word-deafness,  1313 
Wounds  of  the  heart,  1195 
Wright's  method,  244 
Wrist-drop  in  lead  poisoning,  882 
Wry-neck,  912,  1316 


X. 

Xanthelasma  of  eyelids,  356 
Xanthin  bases,  279 
Xerostomia,  485 
X-ray,  377 

apparatus  for  use  of,  377 
examination  of  abdomen  with,  384 
of  extremities  with,  386 
of  head,  neck,  and    thorax  with, 
378 
in  diagnosis  of  bronchitis,  384 
of  emphysema,  382 
of  gastroptosis,  951 
of  phthisis,  379 
of     pleurisy     with    effusion     and 

pneumonia,  382 
of  pulmonary  tuberculosis,  816 
technic  in  use  of,  377 


Yellow  fever,  750 

varieties  of,  751 


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rangement with  the  Librarian  in  charge. 

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